In an adult male with total testosterone 592 ng/dL, free testosterone 9.9 pg/mL, and estradiol <5 pg/mL, are these hormone levels normal and what is the appropriate next step in management?

Hormone Level Interpretation and Management

Direct Answer

Your testosterone levels are normal and do not indicate hypogonadism; the extremely low estradiol is likely a laboratory artifact, and no testosterone replacement therapy is warranted.

Detailed Hormone Analysis

Total Testosterone Assessment

Your total testosterone of 592 ng/dL falls well within the normal adult male range (264–916 ng/dL for healthy nonobese men aged 19–39 years) 1. This level is comfortably above the diagnostic threshold for hypogonadism, which requires two separate morning measurements both < 300 ng/dL 2, 3. The American Urological Association explicitly states that testosterone > 350 ng/dL typically does not require replacement therapy 3.

Free Testosterone Evaluation

Your free testosterone of 9.9 pg/mL is within normal limits for adult men 2. Free testosterone measurement becomes critical when total testosterone is borderline (231–346 ng/dL) or in men with obesity where SHBG alterations may affect interpretation 2, 4. Since your total testosterone is clearly normal, the free testosterone confirms adequate bioavailable androgen status 4.

Estradiol Interpretation

The reported estradiol < 5.0 pg/mL is almost certainly a laboratory error or assay limitation rather than a true physiologic value 5. In adult men, estradiol is produced through aromatization of testosterone in adipose tissue and other tissues 2. With a normal testosterone level of 592 ng/dL, you should have detectable estradiol in the typical male range (approximately 10–40 pg/mL). Many standard estradiol immunoassays have poor sensitivity at low concentrations and report values as "< 5" when they cannot accurately quantify the hormone 5. This result does not indicate pathology and should not trigger treatment 2.

Clinical Implications

No Indication for Testosterone Therapy

The European Association of Urology explicitly recommends against testosterone therapy in eugonadal men (those with normal testosterone levels), even for complaints of weight loss, fatigue, or other nonspecific symptoms 2. Your testosterone level of 592 ng/dL places you firmly in the eugonadal category 3.

Expected Lack of Benefit

Even if testosterone therapy were initiated inappropriately, the evidence shows it produces little to no effect on physical functioning, energy, vitality, depressive symptoms, or cognition in men without true hypogonadism 2. The primary proven benefit is a small improvement in sexual function (standardized mean difference 0.35) in men with confirmed low testosterone and sexual symptoms 2.

Risks of Inappropriate Treatment

Approximately 25–30% of men receiving testosterone therapy do not meet diagnostic criteria for hypogonadism 2, representing widespread inappropriate prescribing. Testosterone therapy carries risks including erythrocytosis (43.8% with injectable forms), cardiovascular events, and permanent suppression of fertility 2.

Recommended Next Steps

If You Have Symptoms

If you are experiencing fatigue, low energy, mood changes, or other nonspecific symptoms:

• Do not pursue testosterone therapy, as your hormone levels are normal 2, 3
• Evaluate for alternative causes: thyroid dysfunction (measure TSH), vitamin D deficiency, sleep disorders, anemia, metabolic syndrome, or depression 2
• Consider lifestyle modifications: weight loss if obese, structured exercise (≥150 min/week moderate-intensity aerobic activity plus resistance training 2–3×/week), and stress management 2

Regarding the Low Estradiol Result

• Request a repeat estradiol measurement using a high-sensitivity assay (LC-MS/MS method) if clinically indicated 5
• Do not initiate any treatment based on the < 5.0 pg/mL result alone, as this is likely a measurement limitation rather than true pathology 5
• True severe estradiol deficiency in men with normal testosterone is exceedingly rare and would require confirmation with specialized testing 2

Common Pitfalls to Avoid

• Never diagnose hypogonadism on symptoms alone without biochemical confirmation of low testosterone on two separate morning measurements 2, 3
• Never initiate testosterone therapy when total testosterone exceeds 350 ng/dL, regardless of symptoms 3
• Never rely on a single testosterone measurement due to diurnal variation and assay variability 2, 5
• Do not assume low estradiol requires treatment in the setting of normal testosterone; verify with repeat testing using an appropriate assay 5