Overview.
A comprehensive hormone panel evaluates the major endocrine axes simultaneously. Testing testosterone in isolation — or estrogen alone — misses critical context: the same testosterone value means something entirely different depending on SHBG levels, LH drive, prolactin, and thyroid status. The hypothalamic-pituitary-gonadal (HPG) axis operates as a closed feedback loop, and interpreting any single node without the others leads to misdiagnosis.
Shared markers for both sexes: TSH, Free T4, prolactin, DHEA-S, cortisol, and fasting insulin. Male-specific: total and free testosterone, SHBG, estradiol, LH, FSH, inhibin B. Female-specific: cycle-timed FSH/LH/estradiol, AMH, progesterone, total testosterone, and free androgen index (FAI).
What's included.
- Total Testosterone — normal: M: 300-1000 / F: 15-70 ng/dL · Primary androgen — requires SHBG context
- Free Testosterone — normal: M: 45-125 pg/mL pg/mL · Biologically active fraction; more clinically meaningful
- SHBG — normal: M: 10-57 / F: 18-144 nmol/L · High SHBG reduces free testosterone; low in insulin resistance
- Estradiol — normal: M: 10-40 / F: cycle-dependent pg/mL · Men: elevated in obesity; Women: follicular development marker
- FSH — normal: M: 1.5-12.4 / F: 3-10 (Day 3) mIU/mL · Gonadotropin drive for spermatogenesis / follicle development
- LH — normal: M: 1.7-8.6 / F: 2-15 (Day 3) mIU/mL · Gonadotropin drive for testosterone / ovulation
- Prolactin — normal: M: <15 / F: <25 ng/mL · Suppresses GnRH when elevated
- TSH — normal: 0.4-4.0 mIU/L · Thyroid modulates SHBG, prolactin, and all sex hormones
- DHEA-S — normal: M: 80-560 / F: 45-270 μg/dL · Adrenal androgen reserve (age-varies)
- Morning Cortisol (8 AM) — normal: 6-23 μg/dL · Chronic stress suppresses GnRH and reproductive axis
Preparation.
Fasting required.
When: Morning draw is essential for testosterone and cortisol accuracy. Afternoon testosterone can be 20-30% lower than morning values, leading to false 'low testosterone' results.
- Blood draw 7-10 AM (testosterone and cortisol peak in the morning)
- Fasting minimum 8 hours (for insulin and glucose)
- Women: Day 2-5 for FSH/LH/E2; Day 21 for progesterone
- Men: no cycle timing needed
- Stop biotin supplements 2-3 days before (affects thyroid assays)
- Prolactin: avoid breast stimulation and vigorous exercise for 24 hours
- Note all medications — OCPs, TRT, antipsychotics, and steroids affect multiple markers
When it's ordered.
- Symptoms suggesting hormonal imbalance: fatigue, low libido, weight changes, mood changes
- Suspected PCOS (irregular cycles + acne/hirsutism/weight gain)
- Suspected hypogonadism (low energy, erectile dysfunction, decreased muscle mass)
- Fertility evaluation for either partner
- Monitoring hormone replacement therapy (HRT or TRT)
- Perimenopause assessment
- Unexplained hair loss, gynaecomastia, or body composition changes
Interpretation.
What normal means
All endocrine axes are functioning within expected ranges, feedback loops are intact, and binding proteins are not distorting free hormone availability. Normal results with persistent symptoms may warrant investigation of receptor sensitivity, diurnal patterns, or tissue-level effects.
Abnormal patterns
Low testosterone + Elevated LH/FSH (Primary hypogonadism in men)
Possible causes
- Klinefelter syndrome
- Prior chemotherapy or radiation
- Varicocele (severe)
- Undescended testes history
Next steps
- Karyotype if not previously done
- Scrotal ultrasound
- Consider testosterone replacement (if fertility not desired)
Low testosterone + Low/normal LH/FSH (Secondary hypogonadism in men)
Possible causes
- Exogenous testosterone or anabolic steroids
- Prolactinoma
- Obesity (estradiol feedback suppression)
- Opioid use
- Pituitary disorder
Next steps
- Check prolactin and pituitary MRI if elevated
- Discontinue exogenous androgens
- Assess BMI and insulin resistance
Normal total T + High SHBG + Low free T (SHBG trapping)
Possible causes
- Hyperthyroidism (raises SHBG)
- Oral contraceptive pills (in women; can persist months after stopping)
- Liver disease
- Ageing
Next steps
- Treat underlying cause of elevated SHBG
- Check thyroid function
- Free testosterone is the clinical driver, not total
Elevated testosterone + Low SHBG + Elevated insulin (in women)
Possible causes
- PCOS with insulin resistance
- Metabolic syndrome
Next steps
- HOMA-IR calculation
- Apply Rotterdam criteria for PCOS
- Consider metformin or inositol
Cost & access.
Full panel costs $200-500 without insurance depending on which markers are included. Insurance typically covers with clinical indication (hormonal symptoms, infertility). Many components can be ordered by primary care.
FAQs.
Why can't I just test testosterone alone?
Total testosterone without SHBG is like checking a bank balance without knowing what's frozen — high SHBG can make a 'normal' total testosterone functionally low. Without LH/FSH, you can't tell whether low T is from the testes (primary) or the brain (secondary). Without thyroid, you miss a common cause of SHBG distortion.
What is the Free Androgen Index (FAI)?
FAI = (Total testosterone x 100) / SHBG. In women, FAI >4-5 indicates hyperandrogenism even when total testosterone looks normal. It's particularly useful because immunoassay testosterone tests are less accurate at the low concentrations found in women.
Does time of day really matter for testosterone?
Yes — testosterone peaks between 7-10 AM and can be 20-30% lower in the afternoon. An afternoon draw can falsely suggest hypogonadism. Morning fasting blood draw is the standard for accurate results.
How does insulin resistance affect hormones?
Insulin suppresses SHBG, increasing free androgen activity. In women, this drives PCOS symptoms. In men, obesity increases aromatase activity (converting testosterone to estradiol), which suppresses LH/FSH via feedback, worsening hypogonadism. It's a vicious cycle that a comprehensive panel reveals.