All you need to know about Free and Total Testosterone

The Biomarker Handbook is a curated series that seeks to provide readers with insights on each biomarker we cover in our blood test packages and its relation to our body.


We all know of testosterone as being the “male hormone,” which is true, since it is responsible for the development of male characteristics in the human body. However, it isn’t just things like body hair and muscle mass which testosterone plays a role in — nor is it a male-only hormone.

In fact, testosterone is responsible for such things as bone density, red blood cell production, fat distribution, human reproduction, and mood regulation.

And, there are 2 ways of measuring testosterone in the human body: Free testosterone, and total testosterone.

Here is what you need to know about free testosterone, total testosterone, the importance of having your levels checked, and what to do if they are out of normal range.

What is Free and Total Testosterone?

The male hormone testosterone is produced in the testes and adrenal glands of men. It is known of as an androgen — or male sex hormone — and is responsible for male characteristics such as deep voice, hairiness, and large muscles.

Women also produce testosterone primarily in the ovaries, though in far lower quantities than do men. Women typically do not produce enough testosterone to develop male characteristics, although it does help in maintaining bone density, production of red blood cells, regulate libido and menstrual cycle, as well as a few other organ functions.

Most of your circulating testosterone hormones are attached to two different proteins: Sex hormone binding globulin (SHBG), and albumin. This bound form of the hormone renders it inactive. On the other hand, there is also testosterone in the bloodstream which is unattached to any protein, which is referred to as free testosterone. This is known as the active form of the hormone.

Combined levels of all types of testosterone in the bloodstream (bound and unbound to protein) is the total testosterone.

The Importance of Tracking Free and Total Testosterone

While testosterone production diminishes naturally with age, healthy levels of testosterone are vital to regulate many of our body’s functions.

However, if the body isn’t producing enough testosterone, it can result in a condition known as hypogonadism. Having this condition not only puts the sufferer at risk for brittle bones and anaemia, but reduced sex drive, depression, weakness, lethargy, abnormal menstrual cycles, weight changes, and other signs of poor androgen stimulation of receptors in many cells throughout our body.

By measuring free and total testosterone levels with an annual blood test, many dangerous health conditions related to abnormal testosterone levels can be detected and treated appropriately.

Signs and Symptoms to Watch out For

Both men and women can suffer from symptoms related to testosterone levels, both low and high.

For men, low testosterone can mean:

  • Erectile dysfunction and reduced sexual interest
  • Low sperm count
  • Loss of muscle mass and bone density
  • Increased body fat
  • Low energy
  • Depression and/or lethargy

While in women, symptoms of low testosterone can be:

  • Muscle weakness
  • Lack of sexual desire, or the inability to achieve sexual satisfaction
  • Depression and/or lethargy

However, women can also produce too much testosterone, which can result in:

  • Virilisation: increased facial hair, lowering voice, reduced breast size, increased muscle mass
  • Irregular menstruation (often periods stop- amenorrhoea, or are reduced in frequency- oligomenorrhoea)
  • Male pattern hair loss
  • Acne
  • Imbalanced blood sugar levels

While overproduction of testosterone in men can occur, it is not a likely disorder, nor is it easy to detect. This is because men normally produce enough testosterone that the hormone’s characteristics are considered natural, and more testosterone only means enhanced natural characteristics, which easily go unnoticed.

Consequences of Having Abnormal Free and Total Testosterone Levels

Unfortunately, low testosterone levels in men can lead to osteoporosis, increased body fat ratio, lethargy, depression, lowered libido, and poor mental concentration. However, it should also be noted that many symptoms of low testosterone can appear in men over 50 due to the natural decline in output with age, which is merely part of the aging process. Low testosterone in younger men is not something to ignore. Some of these following health conditions can be associated with low testosterone production in young men: testicular disease or damage from injury; chronic diseases such as type II diabetes, chronic liver or kidney disease, respiratory disease; pituitary disease; HIV; tuberculosis or sarcoidosis.

While symptoms of abnormal testosterone levels in women may be more apparent with overproduction than underproduction, low levels can nonetheless lead to depression, lack of sex drive, and muscle weakness.

Symptoms and signs of abnormal testosterone levels may mask serious illnesses causing or related to this deranged testosterone level.  Having an abnormal testosterone level is always a cause to visit your doctor to have a more comprehensive checkup to find a potential pathologic cause and manage it early.

A high testosterone reading in men can be due to:

  • Hyperthyroidism
  • Grave’s disease
  • Adrenal gland tumors
  • Anabolic steroid use

In women, high levels can be from:

  • Polycystic ovary syndrome
  • Congenital adrenal hyperplasia (CAH), which is a disorder which effects adrenal glands
  • Hirsutism, which is a genetic condition which causes hormone imbalance
  • Adrenal or ovarian tumour
  • Diabetes

Ways to Balance These Levels                      

When necessary, your doctor may decide to treat your low testosterone with testosterone therapy, in which the hormone is simply administered using a skin patch, topical gel, tablet, or injection.

However, testosterone therapy can increase the risk of blood clots and stroke, and there may also be concerns with an elevated risk of prostate cancer, though studies have yet to confirm this. Before resorting to hormone therapy, you should know that once you start, there is a good chance you will need to continue since once your body senses adequate levels of testosterone (or other hormones), it stops producing it on its own. Discuss this with your clinician and consider alternative methods.

There are ways to boost testosterone naturally, such as:

  • Adding zinc-rich foods to the diet, or using a zinc supplement.
  • Ashwagandha, which is a traditional Indian medicine which is shown to increase serum testosterone levels.
  • Malaysian ginseng, which can stimulate the production of testosterone.
  • Yohimbe bark, which is a rare FDA approved herb used as a prescription drug for erectile dysfunction.
  • Dehydroepiandrosterone (DHEA), which is a precursor to testosterone, but results are still inconclusive as well as its safety- reduces your good cholesterol level (HDL).

High levels of testosterone in women are most often treated using medications such as Spironolactone, which blocks the effects of androgens. Weight loss is also recommended, since as many as 65% of all women with high testosterone are overweight, which can lead to hyperandrogenism.

When to see the Doctor

In addition to an annual blood test as part of a routine physical which measures free and total serum testosterone, any ongoing symptoms of low testosterone should be reviewed by your physician—especially for those under age 50.

This is because low testosterone can be associated or caused by disorders which can be better treated if diagnosed early. Early diagnosis of these conditions can make the difference between safe treatment with full recovery, or long-term complications and health deterioration.

Is There Any Further Testing That Should be Done?

When screening and tracking for your testosterone level, it is customary to order the total testosterone as the first measure. When it is low, or if your doctor still suspects hormonal imbalance, then the free testosterone is ordered. Furthermore, other hormonal imbalances can be present either as a complication of the testosterone imbalance or as a compensatory mechanism to the imbalance.

These are some biomarkers that your doctor may consider ordering to check for any presence of chronic disease associated, or complications arising from the abnormal testosterone level.

  • Testing for other hormones produced by the pituitary, adrenal, thyroid or ovarian glands;
  • Sperm analysis;
  • General Metabolic workup including a full blood count, lipid profile, diabetic screen and profile, liver function test for chronic disease, renal function test;
  • Other bone density and bone health biomarkers in vitamin D, calcium, phosphorous

Apart from blood biomarkers, your doctor may also order imaging techniques to study your glands (adrenal, pituitary, ovarian, etc).

 

Even though we may associate testosterone with musclebound athletes and macho men, there is more to this important hormone than just male characteristics.

In fact, without testosterone, neither men or women would be able to produce normal red blood cells, maintain bone density, manage body fat, or reproduce.

So, whether you are male or female, keeping tabs on your free and total testosterone levels with an annual blood test, as well as by addressing any symptoms of too low or too high testosterone levels can not only help improve your quality of life but save it as well!


If you want to find out more about testosterone and how you can balance testosterone levels, take a look at our lifestyle article here!

Interested in other biomarkers? Check out the rest of The Biomarker Handbook.

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