Do you need to draw female hormones when checking testosterone levels in males?

Evaluation of Testosterone Levels in Males

When measuring testosterone levels in males, additional female hormones are not routinely required, but luteinizing hormone (LH) and other specific hormones should be measured based on the initial testosterone results. 1

Initial Testosterone Assessment

• Morning total testosterone level (drawn between 8-10 AM) is the initial test for suspected hypogonadism
• Repeat measurement on a different day is necessary for confirmation 2
• Total testosterone must exceed 350-400 ng/dl to reliably predict normal free testosterone 3

Required Additional Testing After Low Testosterone is Found

Essential Hormones to Measure:

1. Luteinizing Hormone (LH)

   • Strong recommendation (Grade A evidence) to measure LH in all patients with low testosterone 1
   • Helps establish the etiology of testosterone deficiency (primary vs. secondary hypogonadism)
   • Critical for determining if additional testing is needed 1

2. Prolactin

   • Should be measured in patients with low testosterone combined with low or low/normal LH levels
   • Strong recommendation (Grade A evidence) 1
   • Persistently elevated prolactin levels may indicate pituitary tumors requiring endocrinology referral

3. Follicle-Stimulating Hormone (FSH)

   • Should be measured in men with testosterone deficiency who are interested in fertility
   • Helps assess underlying reproductive health status 1

Conditional Hormone Testing:

1. Estradiol
   • Should be measured only in testosterone deficient patients who present with breast symptoms or gynecomastia prior to testosterone therapy
   • Expert opinion recommendation 1
   • Elevated baseline estradiol measurements warrant endocrinology referral

Clinical Decision Algorithm

1. Measure morning total testosterone (8-10 AM)
2. If low, repeat on a different day for confirmation
3. If confirmed low testosterone:
   • Measure LH (mandatory)
   • If LH is low or low/normal, measure prolactin
   • If prolactin is elevated, repeat to confirm and refer to endocrinology if persistently high
   • If patient has breast symptoms, measure estradiol
   • If fertility is a concern, measure FSH

Important Considerations

• Testosterone levels <150 ng/dL with low/normal LH warrant pituitary MRI regardless of prolactin levels 1
• Hemoglobin/hematocrit should be measured prior to initiating testosterone therapy 1
• Cardiovascular risk factors should be assessed in all testosterone deficient patients 1
• SHBG levels affect the interpretation of total testosterone results and may require calculation of free testosterone in certain cases 2

Common Pitfalls to Avoid

• Relying on screening questionnaires instead of laboratory testing (not recommended) 1
• Failing to measure LH, which is essential for determining the cause of hypogonadism
• Overlooking the need for prolactin measurement in secondary hypogonadism
• Not considering fertility implications in men of reproductive age
• Ignoring the pulsatile nature of testosterone secretion, which can cause intermittent declines in testosterone levels 4

Female hormones like estrogen are not routinely needed when measuring testosterone in males unless specific clinical indications (such as gynecomastia) are present.