Testosterone, Total
Total testosterone is the standard screening test measuring all testosterone in your blood — both the active free form and protein-bound portions. It provides the foundation for evaluating hormonal health in both men and women. In men, total testosterone explains symptoms like low libido, fatigue, difficulty building muscle, or mood changes. In women, it helps diagnose PCOS when elevated. Testing total testosterone regularly catches hormonal decline years before symptoms appear and enables prevention rather than just treatment.
Total testosterone is the standard screening test measuring all testosterone in your blood — both the active free form and protein-bound portions. It provides the foundation for evaluating hormonal health in both men and women.
In men, total testosterone explains symptoms like low libido, fatigue, difficulty building muscle, or mood changes. Low levels affect metabolism, bone health, and cardiovascular risk. In women, total testosterone helps diagnose PCOS when elevated or contributes to understanding low libido and fatigue when low.
Testing total testosterone regularly, even when healthy, catches hormonal decline years before symptoms appear. Regular testing (1-2 times per year) tracks changes over time and enables prevention rather than just treatment. For the most accurate assessment, total testosterone is best combined with free testosterone or SHBG.
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Key Benefits of Total Testosterone Testing
- Screen hormonal status — Get comprehensive overview of testosterone production
- Identify symptom causes — Determine if low testosterone explains fatigue, reduced libido, or difficulty building muscle
- Diagnose androgen excess — In women, detect elevated testosterone indicating PCOS
- Assess reproductive health — Evaluate fertility concerns in both men and women
- Guide treatment decisions — Confirm testosterone deficiency before hormone therapy
- Monitor therapy — Track testosterone replacement effectiveness
- Protect bone health — Identify low testosterone increasing osteoporosis risk
- Most accurate with free testosterone — Combined testing provides complete hormonal picture
What Does Total Testosterone Measure?
Total testosterone measures all testosterone circulating in your bloodstream, regardless of whether it’s bound to proteins or freely available to tissues. It’s a steroid hormone produced primarily in testes (men) and ovaries (women), with small amounts from adrenal glands. Men produce 10-20 times more testosterone than women.
Testosterone circulates in three forms:
SHBG-bound (~60-70%) — Tightly bound to sex hormone-binding globulin, biologically inactive and unavailable to tissues.
Albumin-bound (~30-40%) — Loosely bound to albumin, can dissociate and become available when needed.
Free (~2-3%) — Unbound testosterone that freely enters cells and exerts effects.
Total testosterone is the sum of all three forms, reflecting overall production and transport. However, total alone doesn’t reveal how much testosterone is actually available to tissues. When SHBG changes from aging, obesity, liver disease, or thyroid dysfunction, total testosterone may appear normal even when free (active) testosterone is low, or vice versa. This is why total testosterone is often measured alongside free testosterone or SHBG.
Why Total Testosterone Testing Matters
Foundation of Hormonal Assessment
Total testosterone is the standard first test for evaluating hormonal status. It provides comprehensive overview of testosterone production and serves as the foundation for diagnosing low testosterone (hypogonadism) in men or androgen excess in women. Most clinical guidelines recommend starting with total testosterone screening before additional tests.
Explains Symptoms in Men and Women
Low total testosterone in men causes decreased libido, erectile dysfunction, persistent fatigue, difficulty building muscle, increased abdominal fat, mood changes including depression and irritability, and reduced bone density. In women, elevated total testosterone from PCOS causes hirsutism, acne, irregular periods, and metabolic problems. Testing identifies whether symptoms result from hormonal imbalance.
Reflects Metabolic Health
Total testosterone is closely linked to metabolism. Low testosterone in men promotes insulin resistance, increases visceral fat, and contributes to type 2 diabetes and metabolic syndrome. Conversely, obesity and diabetes suppress testosterone, creating vicious cycles. Testosterone testing is essential for comprehensive metabolic assessment.
What Can Affect Total Testosterone Levels?
Medical Conditions
In Men — Low Total Testosterone: Aging causes 1-2% annual decline after age 30-40. Obesity is the strongest modifiable cause — 10 kg weight loss raises testosterone significantly. Type 2 diabetes affects 30-40% of diabetic men. Chronic opioid use causes severe deficiency in 50-85% of users. Pituitary disorders, testicular conditions (trauma, infections, chemotherapy), and chronic illnesses (kidney disease, liver cirrhosis, HIV, COPD) all suppress levels.
In Women — High Total Testosterone: PCOS is the most common cause, affecting 8-13% of reproductive-age women. Congenital adrenal hyperplasia causes enzyme deficiencies leading to excess androgens. Rarely, ovarian or adrenal tumors produce excess testosterone.
Lifestyle Factors
Lifestyle significantly impacts testosterone. Physical activity matters — resistance training optimizes levels while excessive endurance training can lower them. Sleep is critical since testosterone production occurs during sleep; sleep deprivation (5 hours nightly) reduces testosterone 10-15% within one week, and sleep apnea suppresses levels significantly.
Body weight is crucial — obesity is the strongest lifestyle cause of low testosterone, and weight loss effectively raises levels. Chronic stress suppresses production through elevated cortisol. Very low-fat diets and heavy alcohol consumption also lower testosterone.
Medications
Glucocorticoids like prednisone suppress testosterone. Anabolic steroids suppress body’s own production, sometimes permanently. Chronic opioids profoundly suppress testosterone. Other medications affecting levels include certain antipsychotics, antidepressants, antifungals, and chemotherapy agents.
When Should You Test Total Testosterone?
Preventive Testing: Before Symptoms Appear
Regular testosterone testing (annually or twice yearly) provides valuable information even without symptoms. Establishing your baseline when healthy creates a reference point for future comparison. Tracking trends over years reveals your personal aging trajectory — whether testosterone is stable, declining gradually, or dropping rapidly. This catches decline 5-10 years before symptoms develop, when lifestyle interventions like weight loss, exercise, and sleep optimization are most effective. Prevention is more powerful than treatment.
Men Should Consider Testing For:
Symptoms suggesting low testosterone warrant testing: decreased libido or sexual desire, erectile dysfunction, persistent fatigue despite adequate sleep, difficulty building or maintaining muscle, increased abdominal fat, depression, irritability, reduced motivation, and cognitive difficulties.
High-risk conditions also warrant screening: type 2 diabetes (30-40% have low testosterone), metabolic syndrome, obesity (especially BMI >30), chronic opioid therapy, pituitary disorders, testicular problems, HIV, and chronic kidney disease. Testing is also part of infertility evaluation, osteoporosis assessment, and monitoring testosterone replacement therapy.
Women Should Consider Testing For:
Symptoms of androgen excess: irregular or absent menstrual periods, hirsutism (unwanted facial or body hair), severe or persistent acne, male-pattern hair thinning. Suspected PCOS requires total testosterone as part of diagnostic workup. Fertility evaluation and persistent low libido may also warrant testing, though low testosterone in women is less clinically defined than in men.
Testing Requirements
Morning testing (7-10 AM) is essential for men since testosterone peaks early morning and declines 20-30% by evening. Afternoon testing yields falsely low values. Women don’t have significant diurnal variation, so timing matters less. Abnormal results should be confirmed with repeat testing before diagnosis or treatment decisions, since testosterone naturally fluctuates day to day.
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Understanding Your Total Testosterone Results
Your results will include laboratory-specific reference ranges that vary by age, sex, and testing method. Reference ranges differ between laboratories, so the most meaningful comparisons are your own results over time using the same lab.
Interpreting Results in Context
Low total testosterone in men is generally diagnosed below the laboratory’s reference range with consistent symptoms. However, symptoms matter — some men with “low” numbers feel fine while others with “normal” numbers have significant symptoms. Context is everything.
Important consideration: Total testosterone can be misleading when SHBG is abnormal. High SHBG (aging, liver disease) may show normal total but low free testosterone — explaining symptoms despite “normal” results. Low SHBG (obesity) may show low total but normal free testosterone — explaining minimal symptoms despite “low” results. This is why combining total with free testosterone or SHBG provides more accurate assessment.
Next Steps If Abnormal
Low total testosterone should be confirmed with repeat morning testing. Additional evaluation includes LH and FSH (to distinguish testicular from pituitary causes), prolactin (to screen for pituitary tumors), and assessment of underlying conditions. Free testosterone or SHBG clarifies bioavailable hormone status.
High total testosterone in women requires evaluation for PCOS, adrenal androgens (DHEA-S), and imaging if tumor suspected.
What to Do About Abnormal Total Testosterone
For Men with Low Total Testosterone
Lifestyle interventions are first-line and often remarkably effective. Weight loss is most powerful — 10 kg loss can raise testosterone significantly in overweight men. Resistance training 3-4 times weekly optimizes production. Sleep optimization (7-9 hours nightly, treating sleep apnea if present) directly supports hormone production. Stress management and avoiding excessive alcohol also help. These changes can improve testosterone 10-30%, meaningful for borderline levels.
For confirmed deficiency with persistent symptoms despite lifestyle optimization, testosterone replacement therapy effectively improves libido, erectile function, energy, mood, muscle mass, and bone density. See our Low Testosterone article for comprehensive treatment information.
For Women with High Total Testosterone
Treatment addresses the underlying cause, most commonly PCOS. Effective approaches include weight loss (5-10% significantly improves hormones and metabolic markers), combined oral contraceptives for cycle regulation and androgen reduction, anti-androgens for hirsutism and acne, and metformin for insulin resistance. See our PCOS article for detailed guidance.
Total Testosterone and Related Health Conditions
Total testosterone connects to health conditions across metabolic, hormonal, reproductive, and structural systems.
Metabolic Health
Prediabetes and Type 2 Diabetes: Low testosterone in men increases diabetes risk 2-4 fold through worsened insulin resistance. Diabetes also suppresses testosterone, creating bidirectional harm.
Metabolic Syndrome and Obesity: Each metabolic syndrome component associates with lower testosterone. Obesity is the strongest modifiable cause of low testosterone. Weight loss powerfully improves levels.
Women’s Hormonal Health
PCOS: Elevated testosterone is central to PCOS diagnosis and pathophysiology. Total testosterone testing is essential for diagnosis and monitoring treatment response.
Menopause: Testosterone declines during menopause, contributing to decreased libido and fatigue alongside estrogen deficiency.
Men’s Health
Low Testosterone (Hypogonadism): Total testosterone is the standard screening test for diagnosing male hypogonadism.
Erectile Dysfunction and Infertility: Testosterone is necessary for both erectile function and sperm production. Evaluation of both conditions includes testosterone assessment.
Bone, Muscle, and Aging
Osteoporosis: Low testosterone increases fracture risk. Men with osteoporosis or unexplained fractures should have testosterone assessed.
Sarcopenia: Age-related muscle loss accelerates with declining testosterone. Maintaining adequate levels supports physical function in aging.
Mental Health and Sleep
Depression: Low testosterone independently associates with depression in men.
Sleep Apnea: Bidirectional relationship — sleep apnea lowers testosterone, and low testosterone may worsen sleep apnea.
Why Regular Total Testosterone Testing Matters
Single tests provide only snapshots. Testing 1-2 times per year reveals trends — is your testosterone stable, declining gradually, or dropping rapidly? This trajectory information is far more valuable than any single number.
Regular testing catches decline 5-10 years before severe symptoms develop, when lifestyle changes are most effective. If actively improving health through weight loss or exercise, testing shows whether efforts are working. Tracking testosterone over time transforms it from one-time diagnosis into longitudinal health optimization.
Related Biomarkers Often Tested Together
For most accurate assessment, total testosterone should be tested with:
- Free testosterone or SHBG (bioavailable hormone)
- LH and FSH (identify causes)
- Complete symptom profile
Free Testosterone Measures unbound, biologically active testosterone. When SHBG is abnormal, free testosterone may be more meaningful than total. Testing both provides most accurate assessment.
SHBG Binds testosterone and reduces bioavailability. Measuring SHBG with total allows free testosterone calculation. High SHBG means total may be normal but free is low. Low SHBG means total may be low but free is normal.
LH and FSH Regulate testosterone production. Distinguish primary (testicular failure—high LH/FSH) from secondary hypogonadism (pituitary dysfunction—low/normal LH/FSH). In women, LH/FSH ratio helps diagnose PCOS.
Prolactin Elevated prolactin suppresses testosterone. Screens for pituitary tumors in men with low testosterone and low LH.
Estradiol Testosterone converts to estradiol via aromatase. Very high estradiol from excess conversion suppresses testosterone production.
DHEA-S In women with high testosterone, distinguishes ovarian (PCOS—normal DHEA-S) from adrenal (high DHEA-S) androgen sources.
Insulin and Glucose Insulin resistance and poor glucose control lower testosterone. Reveals whether metabolic dysfunction contributes to hormonal imbalance.
Our Hormone Health Panel and Men’s Health Panel include total testosterone with these complementary markers.
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Note: Information provided in this article is for educational purposes and doesn’t replace personalized medical advice.
Frequently Asked Questions
Total testosterone measures all testosterone — free, albumin-bound, and SHBG-bound combined. Free testosterone measures only the unbound, biologically active form (2-3% of total). While total reflects overall production, free shows what’s actually available to tissues. SHBG variations can make total misleading, which is why testing both provides the most accurate assessment.
Testosterone has diurnal variation in men — highest early morning (7-10 AM), declining 20-30% by evening. Morning testing captures peak levels for accurate baseline. Afternoon testing yields falsely low values. This rhythm diminishes with aging but morning testing remains standard. Women don’t have significant diurnal variation.
Yes, for borderline or mild low testosterone from lifestyle factors. Weight loss is most effective — 10 kg lost can raise testosterone significantly. Resistance training, adequate sleep (7-9 hours), stress reduction, and avoiding excessive alcohol all help. These can raise testosterone 10-30%, meaningful for borderline levels though usually insufficient for severe deficiency requiring medical treatment.
Women should test when experiencing androgen excess symptoms (irregular periods, hirsutism, severe acne, suspected PCOS) or evaluating fertility. Total testosterone is key for diagnosing PCOS. Women with persistently low libido may also benefit. Routine screening without specific symptoms isn’t necessary.
Yes, commonly with elevated SHBG from aging, liver disease, or hyperthyroidism. High SHBG binds more testosterone, reducing free testosterone even though total appears normal. This explains symptoms despite “normal” total testosterone. Measuring free testosterone or SHBG alongside total provides more accurate assessment.
Yes. Regular testing establishes your baseline, reveals your aging trajectory, and catches decline years before symptoms appear — when prevention is most effective. By the time symptoms develop, testosterone may have declined for years. Annual or twice-yearly testing enables prevention rather than just treatment.
For prevention: 1-2 times per year to track trends. During active optimization (weight loss, lifestyle changes): every 3-6 months to measure impact. During testosterone treatment: 3-6 months after starting, then 1-2 times annually.
Levels rise within days to weeks with testosterone therapy. Symptomatic benefits take longer: libido and mood improve in 3-6 weeks, muscle mass over 6-12 months, bone density over 1-2 years.
References
This article provides educational information about Testosterone, Total blood biomarker on current clinical guidelines and peer-reviewed research. It does not replace personalized medical advice. Consult qualified healthcare professionals for diagnosis and treatment decisions specific to your situation.
Key Sources:
- Bhasin S, et al. Testosterone Therapy in Men With Hypogonadism: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2018;103(5):1715-1744.
- Traish AM, et al. Testosterone Deficiency. Am J Med. 2011;124(7):578-587.
- Teede HJ, et al. Recommendations from the international evidence-based guideline for PCOS. Hum Reprod. 2018;33(9):1602-1618.
