Testosterone: when to test and how to test properly

Emil Aldyrakov — GP, urologist-andrologist

Testosterone has become a fashionable topic, and with the fashion came two extremes: some men treat symptoms that are not there, others put up with a real deficiency for years. Here is where the line runs, and how not to spoil the test.

Symptoms genuinely linked to deficiency

Reduced libido and erectile dysfunction, loss of muscle mass and strength, increased fat mass, fatigue, low mood and poor concentration, reduced bone density. The difficulty is that all of these are non-specific: depression, disturbed sleep, sleep apnoea, iron deficiency, hypothyroidism and plain chronic sleep restriction look exactly the same. That is why the test is ordered when symptoms are present, not for everyone.

How to test so the result means something

• In the morning, usually between 7 and 11: testosterone varies through the day and is physiologically lower in the evening;
• Fasting — eating lowers the measured level;
• Not during acute illness — levels fall temporarily with illness and stress;
• At least twice on separate days — the diagnosis is not made on a single result.

These rules alone prevent the commonest error: a diagnosis of "low testosterone" based on an evening sample after a working day.

Total, free and SHBG

Most circulating testosterone is protein-bound, chiefly to sex hormone binding globulin. The free fraction is the active one. In obesity, diabetes, liver disease and with age the binding protein changes, and total testosterone stops reflecting the real picture — then free testosterone and SHBG are assessed. The work-up also includes LH and FSH, to establish the level of the problem, and prolactin where indicated.

Who should not be treated

Replacement therapy treats confirmed deficiency; it is not a way to improve athletic performance or general wellbeing at normal levels. It is contraindicated in prostate and breast cancer and requires caution in severe heart failure, significant sleep apnoea and a high haematocrit. Separately: exogenous testosterone suppresses the body's own production and sperm production — men planning children are managed differently.

What often turns out to be the real cause

Weight loss, treating sleep apnoea, restoring sleep and physical activity frequently raise testosterone without any therapy at all. It is the unromantic but most reliable first step, particularly with excess weight — fat tissue actively converts testosterone into oestrogens.

Where to have this done

At GMS a urologist-andrologist consultation is AED 600; the full male hormone profile (total and free PSA, total and free testosterone, SHBG, free androgen index) is AED 900 and free testosterone alone AED 250. Lab tests are taken in the same clinic.

Further reading

• AUA. Testosterone Deficiency Guideline
• Endocrine Society. Testosterone Therapy in Men with Hypogonadism

FAQ

How should I prepare for a testosterone test?

Come in the morning, usually between 7 and 11, fasting and not during acute illness or stress. The diagnosis is not made on a single result: test at least twice on separate days.

Why measure free testosterone and SHBG?

In obesity, diabetes, liver disease and with age the binding protein changes, and total testosterone stops reflecting the real picture. Free testosterone and SHBG are then assessed.

Who should not have testosterone therapy?

Therapy treats confirmed deficiency and is contraindicated in prostate and breast cancer. Exogenous testosterone suppresses the body’s own production and sperm production, so men planning children are managed differently.

This article is for information only and does not replace a consultation. If you have symptoms, see a doctor.

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