Testosterone (total, and free/bioavailable), men

Pick Ordered or Not ordered to see the note.

Indicated when

• —Men with symptoms and signs consistent with testosterone deficiency (decreased libido, erectile dysfunction, loss of morning erections, fatigue, mood change, decreased muscle mass), using a morning (7-11 AM) fasting total testosterone as the initial test, confirmed by repeating it [1, 2]
• —Total testosterone near the lower limit of normal, or a condition known to alter SHBG: add a free or calculated bioavailable testosterone [2, 1]
• —Once testosterone deficiency is confirmed: LH, to classify it as primary (high LH) or secondary (low/normal LH) [1]

Not indicated when

• —Asymptomatic men, as a screening test with no symptoms of hypogonadism [3, 4]
• —A single afternoon or non-fasting sample used alone to diagnose deficiency or start treatment

Why not

Testosterone has a pronounced diurnal rhythm, highest in the morning, so a sample drawn later in the day or without fasting can read low in a man who is not actually deficient. Choosing Wisely Canada's urology and endocrinology recommendations both advise against testing or treating in the absence of real symptoms [3, 4]. Testing asymptomatic men, or acting on a single non-morning sample, risks a false 'low T' label and unnecessary therapy, which carries its own monitoring burden and risks (erythrocytosis, prostate and cardiovascular considerations the guideline addresses separately).

Better first step

In a symptomatic man, order a morning (7-11 AM), fasting total testosterone and repeat it to confirm before diagnosing deficiency or starting therapy [1, 2].

Typical ND rationale

An ND may order testosterone, sometimes with SHBG or free testosterone, in a man reporting fatigue, low libido, or difficulty maintaining muscle mass, reasoning that testosterone decline is common with age and is worth checking directly, especially when the patient is already describing classic symptoms.

Ontario coverage & CONO orderability

OHIP status

insured

Testosterone (L340) and testosterone, free (L608) are listed by name in the 2026 Schedule of Benefits for Laboratory Services with no restricting condition noted, so both are insured when a physician orders them after clinically assessing the patient (Reg. 552 s.22). No line item named 'sex hormone binding globulin' or 'SHBG' was found anywhere in the Schedule text on direct review, so SHBG coverage is recorded as unverified; it may fall under the generic 'Ligand assays - not included above' (L585, individually considered) but this was not confirmed by an Ontario source. ND-ordered testing is patient-paid regardless [9].

CONO orderable

Yes — CONO list #113, #115, #116, #182, #183

CONO list items 113 (SHBG, blood), 115 (Testosterone, blood), 116 (Testosterone free, blood), 182 (Testosterone, saliva) and 183 (Testosterone free, saliva). 'Bioavailable testosterone' is not a separate CONO line; it is a calculated value derived from total testosterone, SHBG and albumin, not a distinct assay.

Linked conditions

• Low testosterone (male hypogonadism) ↗
• tired ↗

Counselling script

“With symptoms like low sex drive, erection problems, or loss of morning erections, checking testosterone makes sense, drawn in the morning before eating. A low result is repeated before any decision, because one level can mislead. Without those symptoms I wouldn't test, since a low number on its own usually doesn't mean much.”

Revisit if

• —Initial result is low and needs a confirmatory repeat morning fasting sample
• —Total testosterone is near the lower limit of normal (consider free/bioavailable testosterone)
• —Testosterone deficiency is confirmed (add LH to classify as primary or secondary)

References

1. [1]Canadian Urological Association (2021). Canadian Urological Association guideline on testosterone deficiency in men: Evidence-based Q&A. linkMorning (7-11am) fasting total testosterone is the best initial screening test to diagnose testosterone deficiency; SHBG used to calculate free/bioavailable testosterone in equivocal cases; LH used to classify primary vs. secondary deficiency once confirmed
2. [2]Endocrine Society (2018). Testosterone Therapy in Men With Hypogonadism: An Endocrine Society Clinical Practice Guideline. linkDiagnose hypogonadism only with symptoms/signs plus unequivocally and consistently low serum testosterone, confirmed by repeat morning measurement; add free testosterone near the lower limit of normal or if SHBG is altered
3. [3]Canadian Urological Association / Choosing Wisely Canada (2025). Urology recommendations. linkDon't order serum testosterone in men without symptoms of hypogonadism
4. [4]Canadian Society of Endocrinology and Metabolism / Choosing Wisely Canada (2026). Endocrinology and Metabolism: Seven Tests and Treatments to Question. linkDon't prescribe testosterone therapy unless there is biochemical evidence of testosterone deficiency
5. [5]Ontario Ministry of Health (2026). Schedule of Benefits for Laboratory Services (effective April 1, 2026) — L340 Testosterone. linkTestosterone (L340) listed in the 2026 OHIP Schedule of Benefits for Laboratory Services
6. [6]Ontario Ministry of Health (2026). Schedule of Benefits for Laboratory Services (effective April 1, 2026) — L608 Testosterone, free. linkTestosterone, free (L608) listed in the 2026 Schedule
7. [7]Ontario Ministry of Health (2026). Ontario Health Insurance Plan: Schedule of Benefits for Laboratory Services (effective April 1, 2026). linkDirect review of the full 2026 Schedule text found no line item named SHBG or sex hormone binding globulin
8. [8]Government of Ontario (e-Laws) (2026). Health Insurance Act, R.R.O. 1990, Reg. 552: General, s. 22 (insured laboratory services). linkA lab test is insured only when ordered by a physician, midwife, or NP who has clinically assessed the patient
9. [9]Ontario Ministry of Health (2026). Ontario Health Insurance Plan: Schedule of Benefits for Laboratory Services (effective April 1, 2026). linkTests ordered by anyone other than an authorized provider, including NDs, are not insured services