What Blood Tests Should Men Actually Get? Why a Testosterone Level Alone Isn’t Enough
A man walks into his doctor’s office with fatigue, declining libido, erectile changes, difficulty building muscle, increasing body fat, poor recovery and a general sense that he simply does not feel like himself anymore.
His testosterone is checked.
The result comes back:
Total testosterone: 487 ng/dL
“Normal.”
End of evaluation.
But what if his free testosterone is low because his SHBG is extremely high?
What if his LH is already elevated, suggesting that his testes are working increasingly hard to maintain that “normal” testosterone level?
What if his symptoms are actually being driven by hypothyroidism, anemia, diabetes, sleep apnea or another underlying condition?
What if his cholesterol looks acceptable, but his ApoB or lipoprotein(a) identifies cardiovascular risk that has never been recognized?
And what if testosterone has very little to do with his symptoms at all?
This is why checking a testosterone level and evaluating a man’s health are not the same thing.
A good laboratory evaluation should not simply answer:
“Is your testosterone below the laboratory reference range?”
It should help answer:
Why do you feel the way you do? What physiology might be contributing? Are there underlying health risks we should identify? And what, if anything, should we do next?
Testosterone Is Important. But It Is Only One Piece of the Puzzle.
Testosterone testing is obviously an important component of evaluating a man with symptoms of testosterone deficiency.
But it has to be interpreted correctly.
The American Urological Association considers a total testosterone below 300 ng/dL a reasonable biochemical cutoff to support the diagnosis of testosterone deficiency. Diagnosis should also include compatible symptoms and confirmation rather than relying on a single isolated result.
The Endocrine Society similarly recommends diagnosing hypogonadism only in men who have symptoms or signs consistent with testosterone deficiency and consistently low testosterone concentrations, generally confirmed with repeat morning testing.
That’s important.
A single testosterone value should rarely be interpreted in isolation.
Testosterone changes throughout the day. Sleep, caloric intake, illness, obesity, medications, training and other factors can influence testosterone production.
And even when total testosterone is technically “normal,” there can still be more to understand which is why we always say prescribing testosterone is the easy part while evaluating and managing it well is harder.
Total Testosterone vs. Free Testosterone
Most testosterone circulating in the bloodstream is bound to proteins.
Two of the most important are:
sex hormone-binding globulin, or SHBG
albumin
Only a small percentage circulates as unbound, or free testosterone.
That means two men can have the exact same total testosterone level while having substantially different amounts of biologically available testosterone.
This becomes particularly important when SHBG is unusually high or low.
The Endocrine Society specifically recommends evaluating free testosterone when total testosterone is near the lower end of the normal range or when a condition that alters SHBG is present. Free testosterone can be measured with an appropriate assay or calculated using total testosterone, SHBG and albumin.
When SHBG is high
Imagine two men with a total testosterone of 500 ng/dL.
One has an SHBG of 25.
The other has an SHBG of 90.
Those are not necessarily equivalent hormonal situations.
The man with very high SHBG may have substantially less free testosterone despite what appears to be an excellent total testosterone.
Higher SHBG can be associated with factors such as aging, hyperthyroidism, certain liver conditions, estrogen exposure, some medications and individual genetics.
When SHBG is low
The opposite can happen as well.
A man may have a total testosterone of 280 or 320 and assume that he must have severe testosterone deficiency.
But if his SHBG is extremely low, his free testosterone may be considerably better preserved.
Low SHBG is commonly seen with obesity, insulin resistance, metabolic disease and hypothyroidism, among other conditions.
This is why a comprehensive evaluation often includes:
Total testosterone + free testosterone + SHBG + albumin
rather than simply checking total testosterone and stopping.
LH and FSH: Don’t Just Ask Whether Testosterone Is Low. Ask Why.
Suppose we establish that testosterone production actually is inadequate.
The next question should be:
Why?
This is where luteinizing hormone and follicle-stimulating hormone become extremely helpful.
LH: the signal to produce testosterone
Luteinizing hormone, or LH, is produced by the pituitary gland.
LH essentially tells the Leydig cells in the testes:
Make testosterone.
That gives us an important window into the hypothalamic-pituitary-gonadal axis.
Broadly speaking:
Low testosterone + elevated LH
Suggests that the brain is sending an appropriate signal, but the testes are having difficulty responding.
That points toward primary testicular dysfunction.
Conversely:
Low testosterone + low or inappropriately normal LH
Suggests that the testes may not be receiving enough stimulation from the hypothalamus and pituitary.
That raises the possibility of secondary or central hypogonadism.
The Endocrine Society specifically recommends measuring LH and FSH to distinguish primary from secondary hypogonadism once androgen deficiency has been identified.
There is another interesting situation:
Normal testosterone with an elevated LH
A man can occasionally maintain a normal total testosterone while requiring increasingly strong LH stimulation to do it.
Sometimes referred to as compensated testicular dysfunction, this pattern does not automatically mean that someone needs testosterone treatment.
But it is physiologically different from having a normal testosterone and a completely normal reproductive axis.
It can be worth understanding and following over time.
FSH and fertility
FSH primarily helps regulate spermatogenesis.
It becomes particularly important when fertility matters.
A man with an elevated FSH, for example, may have impaired seminiferous-tubule function even when testosterone production is relatively well preserved.
This becomes even more relevant before starting testosterone therapy because exogenous testosterone can suppress LH and FSH and dramatically reduce sperm production.
For men who may want children now—or even years from now—fertility should be part of the conversation before therapy begins.
Prolactin: Sometimes the Problem Is Upstream
Prolactin deserves attention particularly when testosterone is low and LH is low or inappropriately normal.
Elevated prolactin can suppress the reproductive axis.
Depending on the degree of elevation and clinical circumstances, it may prompt evaluation for medications, thyroid disease or abnormalities involving the pituitary.
Symptoms such as:
low libido
erectile dysfunction
infertility
gynecomastia
headaches
visual changes
can sometimes make prolactin particularly relevant.
Again, the point is not to blindly order every laboratory test available.
The point is to understand the physiology.
Estradiol: Important—But Not an Hormone We Should Automatically Try to Eliminate
Estradiol often gets treated like the villain in testosterone therapy.
It shouldn’t.
Men need estrogen.
Estradiol contributes to:
bone health
libido
sexual function
brain function
metabolic physiology
Some testosterone is naturally converted to estradiol through the aromatase enzyme.
As testosterone rises, estradiol may rise as well.
That does not automatically represent a problem.
Estradiol is particularly useful when breast symptoms, gynecomastia or other clinical concerns are present, and establishing a baseline can sometimes make later interpretation easier.
What I generally don’t favor is treating a laboratory number simply because estradiol falls outside an arbitrary target created by a testosterone clinic.
Hormones should be interpreted in the context of symptoms, physiology and the individual patient.
CBC: More Than Just a Testosterone Safety Test
A complete blood count—or CBC—is one of the most useful baseline tests before testosterone therapy.
Testosterone stimulates erythropoiesis, which means it can increase red blood cell production.
That makes baseline hemoglobin and hematocrit important before treatment and during follow-up.
But a CBC can also tell us something else.
What if the man complaining of fatigue actually has anemia?
Fatigue, poor exercise tolerance, weakness and reduced performance can easily be attributed to “low testosterone” when another explanation is sitting directly in the CBC.
Conversely, if a man’s hematocrit is already elevated before treatment, we need to understand why before potentially raising it further.
Possible contributors could include:
dehydration
smoking
obstructive sleep apnea
pulmonary disease
altitude
other causes of erythrocytosis
Good medicine means asking that question first.
PSA: Establish the Baseline Before Testosterone Therapy
For appropriate men—particularly those entering an age range where prostate screening is relevant—a baseline PSA can be extremely valuable.
As a urologist, I think one of the most important concepts for men to understand is this:
PSA is prostate-specific. It is not prostate-cancer-specific.
PSA can increase for many reasons, including:
prostate enlargement
inflammation
infection
recent instrumentation
ejaculation
prostate cancer
The value of having a baseline PSA before testosterone treatment is that it gives us something meaningful to compare against later.
If PSA changes, we don’t simply panic because a number increased.
We evaluate the magnitude of the change, the man’s age, baseline PSA, prostate history, family history, urinary symptoms and overall risk profile.
That is far more useful than discovering years later that nobody ever obtained a pretreatment baseline.
Don’t Forget the Thyroid
There is tremendous symptom overlap between thyroid disorders and testosterone deficiency.
Consider the common complaints:
fatigue
weight gain or weight loss
changes in mood
brain fog
poor exercise tolerance
weakness
libido changes
sexual dysfunction
sleep problems
Those symptoms do not automatically equal “low T.”
Thyroid disease can also affect SHBG, which can change how total and free testosterone should be interpreted.
For many men, a TSH is therefore an appropriate component of the initial evaluation.
Free T4 and additional thyroid testing can be added when clinically indicated.
If we’re going to talk about “hormone optimization,” we shouldn’t evaluate one hormone system while ignoring another major endocrine organ.
Metabolic Health Is Men’s Health
This may be one of the most commonly overlooked parts of men’s hormone evaluation.
Testosterone does not exist in isolation from metabolic health.
Obesity, insulin resistance, diabetes, sleep apnea, inflammation, nutrition and physical activity all interact with hormonal physiology.
That’s why I generally want to understand a man’s metabolic health as well.
Glucose and hemoglobin A1c
Fasting glucose gives us a snapshot.
Hemoglobin A1c gives us information about average glucose exposure over the preceding several months.
A man coming in because his testosterone is declining may actually be demonstrating early signs of metabolic dysfunction.
Finding that problem may ultimately be more important to his long-term health than the testosterone number that brought him through the door.
Kidney Function and Electrolytes Matter Too
A metabolic panel can provide information about:
creatinine
estimated kidney function
sodium
potassium
calcium
glucose
albumin
Creatinine deserves some nuance in muscular men.
Creatinine is influenced partly by muscle mass and creatine intake.
A muscular man who strength trains and takes creatine may have a serum creatinine that looks somewhat different from that of a sedentary person with less lean body mass.
That doesn’t mean kidney abnormalities should be dismissed.
It means numbers need clinical context.
When uncertainty remains, additional testing such as cystatin C can sometimes help provide another estimate of renal function.
Liver Enzymes: Athletes Can Generate Some Interesting Lab Results
This is another area where context matters enormously.
AST and ALT are often called “liver enzymes.”
But AST in particular is also found in skeletal muscle.
Heavy resistance exercise can therefore produce elevations that look alarming on paper.
In a controlled study of healthy men performing weightlifting, AST and ALT rose significantly and remained elevated for at least seven days. CK, LD and myoglobin also increased substantially, while markers including bilirubin and alkaline phosphatase remained normal.
Imagine the scenario.
You crush legs on Sunday.
You have bloodwork Monday.
Your AST comes back elevated.
Suddenly you’re being told you may have liver disease.
Maybe.
But maybe you simply destroyed your quads 18 hours earlier.
That’s why I ask about:
recent strenuous exercise
alcohol
medications
supplements
acetaminophen
anabolic agents
previous liver tests
When something does not fit clinically, sometimes repeating the laboratory test after several days without strenuous training provides valuable information.
Again:
Treat the patient—not an isolated laboratory number.
Cardiovascular Risk: LDL Cholesterol Isn’t the Whole Story Either
If we’re talking about helping men live longer and perform better, cardiovascular health cannot be an afterthought.
Cardiovascular disease remains one of the dominant threats to men’s long-term health.
A standard lipid panel typically includes:
total cholesterol
LDL cholesterol
HDL cholesterol
triglycerides
Those remain useful.
But modern cardiovascular risk assessment should often go further. More on that later.
ApoB: How Many Atherogenic Particles Are Actually Circulating?
LDL cholesterol tells us approximately how much cholesterol is being transported within LDL particles.
But cholesterol content and particle number are not always equivalent.
Apolipoprotein B—or ApoB—provides a measure related to the number of atherogenic lipoprotein particles.
Every major atherogenic particle carries an ApoB molecule.
That includes LDL, VLDL remnants and lipoprotein(a).
This matters because two men with similar LDL cholesterol can sometimes have different ApoB concentrations—and potentially different atherogenic particle burdens.
The new 2026 ACC/AHA dyslipidemia guideline recognizes ApoB as useful in selected patients for refining cardiovascular risk, particularly in cardiometabolic disease, diabetes, elevated triglycerides and situations where conventional lipid values may underestimate residual risk.
For someone interested in genuinely understanding cardiovascular risk rather than simply checking whether LDL is marked red on a laboratory report, ApoB can provide valuable additional information.
Lipoprotein(a): A Test Many Men Have Never Had
Lipoprotein(a), or Lp(a), may be even more interesting because it is largely genetically determined.
Diet and exercise—which are incredibly important for cardiovascular health—usually have relatively little effect on the actual Lp(a) concentration.
You can therefore be lean, active, metabolically healthy and still carry elevated cardiovascular risk because of Lp(a).
The 2026 ACC/AHA dyslipidemia guideline now recommends that Lp(a) be measured at least once in adulthood for cardiovascular risk assessment.
For many people, once is enough because the level tends to remain relatively stable throughout life.
An elevated Lp(a) doesn’t mean cardiovascular disease is inevitable.
It means we have information that may justify being more aggressive about modifiable risk factors such as:
LDL
blood pressure
smoking
glucose
body composition
exercise
nutrition
This is exactly what good preventive medicine is supposed to do:
Find risk before risk becomes disease.
What About Vitamin D?
Vitamin D is frequently included in “optimization panels.”
There are situations where measuring vitamin D makes sense—particularly in men with bone-health concerns, osteoporosis risk, limited sun exposure, malabsorption or other clinical risk factors.
But I don’t think every micronutrient needs to be checked simply because a test exists.
That’s an important distinction.
The goal of comprehensive laboratory testing isn’t:
Order everything.
The goal is:
Order enough to understand the patient.
Other targeted tests might include:
ferritin and iron studies
vitamin B12
folate
vitamin D
magnesium
hs-CRP
additional pituitary hormones
thyroid antibodies
semen analysis
But these should generally be driven by history, symptoms, risk factors and clinical questions.
So What Does a Comprehensive Men’s Health Lab Evaluation Look Like?
There isn’t one universal laboratory panel that every man on Earth needs.
But depending on symptoms, age, history and goals, a comprehensive baseline evaluation might include:
Hormonal Assessment
Total testosterone
The starting point—but rarely the entire story.
Free testosterone
Particularly important when total testosterone and symptoms don’t seem to match.
SHBG
Helps us understand the relationship between total and free testosterone.
Albumin
Useful when calculating free testosterone.
LH
Helps distinguish testicular from central causes of testosterone deficiency.
FSH
Provides additional information about testicular function and becomes particularly important when fertility is relevant.
Estradiol
Useful in appropriate circumstances and valuable as part of individualized hormonal interpretation.
Prolactin
Particularly important when testosterone is low with low or inappropriately normal LH or when symptoms suggest pituitary involvement.
General Health and Treatment Safety
CBC
Evaluates hemoglobin, hematocrit and other blood-cell parameters.
Comprehensive metabolic panel
Provides information about kidney function, electrolytes, glucose, albumin and liver-related markers.
PSA
When appropriate for age, risk and prostate-health evaluation.
Metabolic Health
Fasting glucose
Provides a snapshot of glucose physiology.
Hemoglobin A1c
Helps evaluate longer-term glucose regulation and diabetes risk.
Cardiovascular Risk
Lipid panel
Total cholesterol, LDL, HDL and triglycerides.
ApoB
Provides additional information about atherogenic particle burden.
Lipoprotein(a)
A largely genetically determined cardiovascular risk marker that current cardiovascular guidelines recommend measuring at least once in adulthood.
Thyroid
TSH
A reasonable starting point when symptoms potentially overlap with thyroid dysfunction.
Free T4 and other thyroid testing
Added when appropriate based on TSH, symptoms and clinical history.
Individualized Testing
Depending upon the patient, I may also consider:
vitamin D
ferritin
iron studies
B12
folate
hs-CRP
CK
cystatin C
additional pituitary evaluation
fertility testing
semen analysis
other targeted studies
The key word is:
Individualized.
Guidelines Are a Starting Point. A Comprehensive Evaluation Can Ask More Questions.
Clinical guidelines are incredibly useful.
They establish evidence-based standards for diagnosis, treatment and safety.
The AUA provides practical recommendations surrounding testosterone diagnosis, including the use of a total testosterone below 300 ng/dL as a reasonable diagnostic threshold.
The Endocrine Society emphasizes symptoms plus consistently low testosterone, repeat morning testing and further evaluation to determine the cause of androgen deficiency.
Those are important foundations.
But there is a difference between meeting the minimum criteria required to diagnose testosterone deficiency and performing a comprehensive men’s health evaluation.
One asks:
Does this patient meet criteria for testosterone deficiency?
The other asks:
What is happening with this man’s hormonal, metabolic and cardiovascular health—and why?
Those are related questions.
They aren’t identical.
The guidelines have real limitations as well…more on that later.
There is also the question of who should evaluate and treat low testosterone in the first place.
More Testing Isn’t Always Better
There is an important counterpoint to everything I’ve just discussed.
More labs do not automatically equal better medicine.
I’ve seen enormous “optimization panels” containing dozens upon dozens of biomarkers without any clear clinical reason for ordering them.
That creates its own problems.
The more tests you perform, the greater the likelihood that something will fall slightly outside a reference interval simply by chance.
Then people start treating numbers.
Supplements get added.
Hormones get manipulated.
Medications get prescribed.
And eventually nobody remembers what problem they were originally trying to solve.
A laboratory test should ideally answer a question.
That is why I prefer comprehensive but purposeful testing.
Not too little.
Not everything imaginable.
Enough information to understand the physiology and make an intelligent plan.
The Goal Isn’t to Find Something Wrong
This may be the most important point.
A comprehensive men’s health evaluation isn’t about trying to manufacture a diagnosis.
Sometimes the labs look excellent.
That’s good news.
Sometimes the hormonal system looks perfectly healthy and we discover that the man’s symptoms require investigation somewhere else.
That’s also good medicine.
Sometimes we find insulin resistance.
Sometimes thyroid disease.
Sometimes anemia.
Sometimes elevated cardiovascular risk.
Sometimes true testosterone deficiency.
And sometimes we find nothing that requires medical treatment at all.
The goal isn’t testosterone.
The goal isn’t medication.
The goal is understanding what’s happening.
Start With Labs
If you’re trying to understand your testosterone, energy, sexual health, metabolic health or overall men’s health, you don’t necessarily need to start with treatment.
You can start with information (Learn more about our approach to testosterone and hormone health)
At Fit & Fine Health, there are two simple ways to begin.
Already have recent labs?
Send them to us.
We can review the testing you’ve already completed and determine whether it provides enough information or whether important pieces of the evaluation are missing.
Need labs?
We can help arrange laboratory testing close to your home through one of our certified laboratory partners.
Depending upon your history, symptoms and goals, we can build an appropriate men’s health laboratory assessment that evaluates much more than a testosterone number.
That may include evaluation of:
Testosterone and hormonal physiology
Metabolic health
Cardiovascular risk
Thyroid function
Blood counts
Kidney and liver function
Prostate health
Fertility when relevant
The goal is not to order every laboratory test available.
It’s to order the right tests, understand what they mean together and determine the appropriate next step.
Sometimes that next step is treatment.
Sometimes it’s lifestyle change.
Sometimes it’s additional evaluation.
And sometimes the best answer is simply reassurance.
If you want to understand where you stand, start with a FREE ASSESSMENT NOW.
Fit & Fine Health
Physician-led men’s health, hormone, metabolic and performance care.
David Hall, MD, CWC
Board-Certified Urologist
Men’s Health Physician
Certified Wellness Coach
Educational content only. Laboratory testing and treatment decisions should be individualized based on medical history, symptoms, examination when appropriate and physician evaluation.