Total Testosterone vs Free Testosterone

[LexiDreamer]

Can someone explain the difference between total T vs free T in terms of MtF HRT, please?

[KayXo]

Free and bio-available T is T that can actually bind to receptors in cells and trigger changes in body. Total T also includes T that is bound to SHBG and that CANNOT bind to receptors. 

[Janes Groove]

Free and bio-available T is T that can actually bind to receptors in cells and trigger changes in body. Total T also includes T that is bound to SHBG and that CANNOT bind to receptors.

That makes sense. I had high T but out of range low free T.  Which I believe suggests mild androgen insensitivity.  I suspect my hormonal feedback system was reading low free T and so my T factories just kept pumping out high levels of T to compensate.

[LexiDreamer]

Thank you ladies!

Well, my latest lab has my FREE T at 0.8 pg/mL. For some reason there was no report for my TOTAL T.
My primary made it sound like the TOTAL T was undetectable.

This was frustrating considering my previous test were for total T.

She is really concerned that my T is too low and wants me to quit the Spiro for two weeks and then start again on a half dose.

I argued with her and told her I don't need the T, since I am taking Prometrium and that has given me desired results (ie. my libido has returned and other positive effects).

Now she's trying to pawn me off on an Endo... I likely think that she decided I'm a pain in the ass.

Any thoughts as to why she keeps pushing to have some T in my system?

[LexiDreamer]

Furthermore my E level came back around 950 pg/mL. I'm concerned it's been running that high and she hasn't suggested lowering my Estradiol dose.

It probably explains why my T is so low though.

[Dena]

By e level, do you mean total estrogen or estradiol? My total estrogen runs about 700 but my estradiol levels are around 50 pg/ml at test time. Total estrogen is the combination of estrone and estradiol with the body converting estradiol to estrone. Estrone is a relatively ineffective estrogen and is something like 14 times less effective than estradiol. 

[kelly_aus]

Thank you ladies!

Well, my latest lab has my FREE T at 0.8 pg/mL. For some reason there was no report for my TOTAL T.
My primary made it sound like the TOTAL T was undetectable.

This was frustrating considering my previous test were for total T.

She is really concerned that my T is too low and wants me to quit the Spiro for two weeks and then start again on a half dose.

I argued with her and told her I don't need the T, since I am taking Prometrium and that has given me desired results (ie. my libido has returned and other positive effects).

Now she's trying to pawn me off on an Endo... I likely think that she decided I'm a pain in the ass.

Any thoughts as to why she keeps pushing to have some T in my system?

Prometrium is not a replacement for T, it just has some similar effects. Women need T too, preferably in the range of 700 pmol/L to 2.5 nmol/L..

So, if your T is low, as it appears to be, then your doctor suggesting you stop spiro briefly and restart again at a lower dose is the correct course of action..

[KayXo]

Some women do very well on very low T, some need a little. It DEPENDS. I think it's important for a doctor to consider individual variability and listen to their patient's feedback.

[LexiDreamer]

By e level, do you mean total estrogen or estradiol? My total estrogen runs about 700 but my estradiol levels are around 50 pg/ml at test time. Total estrogen is the combination of estrone and estradiol with the body converting estradiol to estrone. Estrone is a relatively ineffective estrogen and is something like 14 times less effective than estradiol.

It says "Estrogen,Total,Serum " and the result is "920.5 pg/mL "

These damn blood labs are so confusing!

I'm actually glad she's gonna send me to an Endo, so hopefully someone will prescribe the correct tests.

Quest Diagnostics shows the following ranges for that specific test:

Reference Range(s)
Adult Female   
   Follicular Phase (1-12 days)   90-590 pg/mL
   Luteal Phase   130-460 pg/mL
   Postmenopausal   50-170 pg/mL
Adult Male   60-190 pg/mL

So, it appears I'm still on the high side.

[LexiDreamer]

Prometrium is not a replacement for T, it just has some similar effects. Women need T too, preferably in the range of 700 pmol/L to 2.5 nmol/L..

So, if your T is low, as it appears to be, then your doctor suggesting you stop spiro briefly and restart again at a lower dose is the correct course of action..

But, as I've learned on here, there are plenty of post-op trans-women (GRS or Orchi) that have undetectable levels of T and they do fine with just Progesterone.
So why do "women" need T too?
I think that's the case for cis-women, but trans-women are a whole different case, no?

[KayXo]

Don't focus so much on the numbers. Instead, how you feel and physical results (i.e. breast growth, facial changes, body hair, etc) should matter.

[KayXo]

But, as I've learned on here, there are plenty of post-op trans-women (GRS or Orchi) that have undetectable levels of T and they do fine with just Progesterone.
So why do "women" need T too?
I think that's the case for cis-women, but trans-women are a whole different case, no?

Every woman, whether cis or trans, is different. Some feel better on a little, some just don't need it. Think of CAIS XY women who are completely insensitive to androgen, they do quite well.

[Dena]

It says "Estrogen,Total,Serum " and the result is "920.5 pg/mL "

These damn blood labs are so confusing!

I'm actually glad she's gonna send me to an Endo, so hopefully someone will prescribe the correct tests.

Quest Diagnostics shows the following ranges for that specific test:

Reference Range(s)
Adult Female   
   Follicular Phase (1-12 days)   90-590 pg/mL
   Luteal Phase   130-460 pg/mL
   Postmenopausal   50-170 pg/mL
Adult Male   60-190 pg/mL

So, it appears I'm still on the high side.

Apple and oranges. Total estrogen is estrone+estradiol. The table you displayed is estradiol. My total estrogen off my last test was 740 pg/ml. My estradiol was 45 pg/ml measured about 30 hours after my last dose. This would make my estrone level 695 pg/ml. Estrone has little feminizing power but it can convert back to estradiol if needed. Also, the estrone came from the estradiol being converted to estrone shortly after I took my pill. In my body, it seems like it's really fast to convert to estrone but slow to convert back to estradiol. 

The problem and I have it with my prescriber as well is that they don't always check estradiol levels. Each time I need a blood draw, I call up the office and ask for the paper work but I request that estradiol be added to the list of tests. As the result I can do the calculations because I have total estrogen and estradiol levels.

[KayXo]

In my body, it seems like it's really fast to convert to estrone but slow to convert back to estradiol. 

The problem is not your body but the way you take estradiol. Even if taken buccally, I suspect much of it is swallowed anyways, is converted, as it should, extensively in the gut and in the liver to estrone. Estrone to estradiol conversion occurs to a much lesser degree in anyone's body, also normal.

[LexiDreamer]

Apple and oranges. Total estrogen is estrone+estradiol. The table you displayed is estradiol. My total estrogen off my last test was 740 pg/ml. My estradiol was 45 pg/ml measured about 30 hours after my last dose. This would make my estrone level 695 pg/ml. Estrone has little feminizing power but it can convert back to estradiol if needed. Also, the estrone came from the estradiol being converted to estrone shortly after I took my pill. In my body, it seems like it's really fast to convert to estrone but slow to convert back to estradiol. 

The problem and I have it with my prescriber as well is that they don't always check estradiol levels. Each time I need a blood draw, I call up the office and ask for the paper work but I request that estradiol be added to the list of tests. As the result I can do the calculations because I have total estrogen and estradiol levels.

Here is the page, from Quest Diagnostics, that I got the chart from. I see no mention of Estradiol.

http://www.questdiagnostics.com/testcenter/TestDetail.action?ntc=439


Also, the range displayed on my chart row matches the table for "Adult Male" (60-190), as copied below:

Test                          Date           Test                         Result          H/L   Range
Laboratory test finding  06/07/2017  Estrogen,Total,Serum  920.5 pg/mL  High  60-190


I'll go back and look, but I don't believe I ever saw a test for "Estradiol".

[ainsley]

I got this comment on my T levels one time.  It might help explain a bit:

Free Testosterone concentrations are calculated from total testosterone after measuring the percentage of free testosterone. Since the total testosterone in this patient was below the limit of quantification (<7 ng/dL), the free testosterone concentration could NOT be calculated.

[LexiDreamer]

So I went back and looked at my chart, and once in January they actually tested for Estradiol.

Test                                Date            Test               Result         H/L     Range
Estradiol, Free, LC/MS/MS   01/11/2017   Estradiol,Free   0.51 pg/mL   High   Adults: < Or = 0.45
Estradiol, Free, LC/MS/MS   01/11/2017   Estradiol          33 pg/mL     High    Adults: < Or = 29

Reference Range(s) below from (http://www.questdiagnostics.com/testcenter/TestDetail.action?ntc=36169):
Estradiol, Free       
Female       
  Follicular Stage   0.43-5.03   pg/mL
  Mid-Cycle Stage   0.72-5.89   pg/mL
  Luteal Stage   0.40-5.55   pg/mL
  Postmenopausal   ≤0.38   pg/mL
Adult Male   ≤0.45   pg/mL
Estradiol       
Female       
  Follicular Stage   39-375   pg/mL
  Mid-Cycle Stage   94-762   pg/mL
  Luteal Stage   48-440   pg/mL
  Postmenopausal   ≤10   pg/mL
Adult Male   ≤29   pg/mL


So this is the test I should be having done all along?

[KayXo]

Your estradiol levels are very low, indeed, despite high estrogen levels. This means most your estrogen is estrone, the weaker of the two estrogens. Interestingly, the peak levels of total estradiol according to this lab, in women during a menstrual cycle can go as high as 762 pg/ml, quite high!

[LexiDreamer]

This whole thing has me quite frustrated at the moment. It seems my Primary does not know what the h*ll she's doing. They just blindly follow the "Callen Lorde Protocols" but have no real understanding of what they mean.  Let this be a lesson for all of you other girls transitioning out there.

Here is my full lab history concerning anything Testosterone, Estrogen or Estradiol (all ranges are described as Adult Male ranges):

Baseline:
I was only taking herbal estrogen at this point
Notice the crazy high T levels!
1/11/16 Total Testosterone = 1310 ng/dL         (Range:250-1100)
            Free Testosterone = 59.0 pg/mL         (Range:35.0-155.0)
            Total Serum Estrogen = 188.3  pg/mL  (Range:60-190)

Started dosing myself with Spiro in anticipation of starting Pharma HRT. Plus I didn't like the high T levels that were reported on my baseline test.
7/8/16  Total Testosterone = 37 ng/dL         (Range:250-1100)
            Free Testosterone = 1.3 pg/mL         (Range:35.0-155.0)
            Total Serum Estrogen = 115.1 pg/mL  (Range:60-190)

Last day taking herbals, As I was prescribed Low (starting dose) Estradiol and Spiro this day.
8/9/16  Total Testosterone = 38 ng/dL         (Range:250-1100)
            Free Testosterone = 1.1 pg/mL         (Range:35.0-155.0)
            Total Serum Estrogen = 111.1 pg/mL  (Range:60-190)

One month follow up to see where my levels were at after starting pharma HRT.
Not seeing the results yet, she had me double my Estradiol to "normal" HRT dosage.
All the tests seemed to spike... not sure whats going on here.
9/12/16  Total Testosterone = 916 ng/dL         (Range:250-1100)
            Free Testosterone = 69.6 pg/mL         (Range:35.0-155.0)
            Total Serum Estrogen = 1030.4 pg/mL  (Range:60-190)
After seeing results a week later, she dropped my Estradiol dosage back to low dose and had me double my Spiro since my T was so high.

One month follow up... totally different test for T... WTF? At least is low on this test
10/28/16  Testosterone,Total,Males (Adult),Immunoasay = 38 ng/dL         (Range:250-827)           
            Total Serum Estrogen = 440.8 pg/mL  (Range:60-190)

3 month follow up... Where's my T test?
1/11/17  Free Estradiol = 0.51 pg/mL         (Range:Adults: < Or = 0.45)
                       Estradiol =35 pg/mL         (Range:Adults: < Or = 29)
These levels look low, so she doubles my Estradiol again (to normal HRT strength).

2 month follow up. Using that "alternate" T test again... and back to the Total Serum Estrogen
3/20/17  Testosterone,Total,Males (Adult),Immunoasay = 38 ng/dL         (Range:250-827)
            Total Serum Estrogen = 789.0 pg/mL  (Range:60-190)

3 Month follow up. Only free T... and still using Total Serum Estrogen
6/7/17  Free Testosterone = 0.8 pg/mL         (Range:35.0-155.0)
           Total Serum Estrogen = 920.5 pg/mL  (Range:60-190)


Until reading Dena's post, I started to worry that my estrogen levels are way to high so I cut my night time dose in half. But now, it seems premature since Total Serum Estrogen seems like a useless test for Trans-women.

Can anyone figure out what the h*ll is going on here? I'm feeling so frustrated...

[KayXo]

Estradiol is normal-slightly high for male, low for female
Estrone is high
Free T, the T that can actually do damage and bind to receptors in cells, is normal for male, high for female (1-8.5 pg/ml)

This is reflected in your body hair growth patterns. Not surprised. Your SHBG levels are low, probably.