A Guide to Sex Hormone Biomarkers

Hormones govern far more than mood swings or hot flashes. They influence energy, drive, fertility, body composition, and even the biology of aging¹ ². When they fall out of balance, the effects ripple across nearly every system in the body. That’s why tracking sex hormone biomarkers reveals imbalances long before symptoms appear, offering a window into prevention rather than late detection².

What Are Sex Hormone Biomarkers?

Sex hormones themselves are chemical messengers that regulate reproductive and metabolic processes throughout the body. Their activity can be tracked through biomarkers measured in the blood ranging from testosterone, estrogen, and progesterone to related markers like sex hormone-binding globulin (SHBG), DHEA-S, and prolactin³ ⁴ ⁵. These values influence sexual function, bone density, muscle strength, mood, and overall well-being.

Think of sex hormone biomarkers as dashboard indicators: when one drifts out of range, it signals a hormonal imbalance that can disrupt the whole system.

The Scale of Hormone Imbalances in the United States

Hormone imbalances aren't rare. According to the HIM Study, about 13.8 million American men over age 45 are estimated to have low testosterone, yet only 25–27% receive treatment⁶ ⁷. This gap highlights how often sex hormone biomarkers are overlooked. Millions walk around with fatigue, weight gain, or low libido without realizing their blood work may already hold the explanation⁸.

But that’s not all. Even after accounting for age and obesity³ ⁴, testosterone levels have been declining across generations, with average levels falling by about 1% per year since the 1980s. This suggests the issue is not only common, but also worsening over time.

Women face similar challenges. Lifestyle and environmental factors such as smoking, nutrition, and toxin exposure can contribute to earlier menopause and perimenopause, driving earlier declines in estradiol and raising long-term risks like osteoporosis and cardiovascular disease¹⁷. At the same time, polycystic ovary syndrome (PCOS) — marked by excess androgens — now affects 11–13% of women worldwide, with prevalence roughly doubling over the past three decades¹⁸ ¹⁹.

These trends show that hormone imbalance is not an isolated issue. It’s a systemic, population-level shift with profound consequences for health, aging, and quality of life.

What Do Sex Hormone Biomarker Levels Mean?

Each biomarker highlights a different aspect of hormone function: whether a hormone is being produced in sufficient amounts, how much is active and available to tissues, or how effectively the brain, glands, and reproductive organs are coordinating regulation⁵. For example, total testosterone measures overall hormone production, while free testosterone shows the fraction actually available to tissues — a critical distinction that can lead to very different, even opposite, clinical conclusions.

Abnormal values can arise from many factors, including chronic stress, obesity, aging, alcohol use, medications, pituitary disorders, or even sleep disruption. These imbalances matter because they are linked not only to symptoms such as fatigue or mood changes, but also to long-term risks including infertility, osteoporosis, metabolic syndrome, cardiovascular disease, and certain cancers⁵ ⁸.

Normal, High, and Low Ranges

Hormone levels are measured against reference ranges, which represent the expected values for age and sex. For example, harmonized reference ranges for testosterone in healthy men aged 19–39 years are approximately 264–916 ng/dL, while total testosterone levels in women are typically only around 15–70 ng/dL, depending on the assay and laboratory⁹.

• Normal range: The “average” range where most individuals fall. However, normal does not always mean optimal; many people experience symptoms even when their values sit within these broad laboratory cutoffs.
• Optimal range: The narrower window where hormone activity best supports energy, fertility, cognition, and long-term health. Functional and longevity-focused medicine often aims for this zone.
• Low range: Suggests underproduction, over-binding, or disrupted signaling. Symptoms often include fatigue, sexual dysfunction, mood changes, and muscle loss.
• High range: Points to overproduction, metabolic dysfunction, or hormone-secreting tumors. In women, elevated testosterone is often seen in PCOS; in men, excess estrogen can cause gynecomastia.

It’s important to remember that numbers don’t exist in isolation. A value that looks “normal” on paper may still be problematic if it doesn’t match symptoms, which is why optimal ranges, not just normal ranges, matter for health and longevity⁹.

Connection to Organs and Body Systems

Hormones are produced and regulated through the hypothalamic-pituitary-gonadal axis. Disruption in one part of this conversation between the brain, pituitary gland, adrenal glands, testes, and ovaries echoes across the whole system⁵. For example, high prolactin from a pituitary tumor can suppress testosterone production, leading to infertility and bone loss⁸.

The liver also plays a vital role: it metabolizes hormones, binds them to proteins, and clears the excess⁵. This underscores that hormone regulation is a whole-body process, involving not only the reproductive organs, but also the brain, liver, bone, muscle, and immune system.

Reference ranges can also be deceptively broad. For example, up to 30% of individuals with TSH levels in the upper-normal range (>3.0 mU/L) have occult autoimmune thyroid disease, highlighting how early dysfunction can fly under the radar¹³. Large population studies likewise show that a substantial proportion of the U.S. population unknowingly has laboratory evidence of thyroid disease¹⁴.

This is why hormone and other biomarker imbalances are so often overlooked: the numbers may be there, but the insight is not.

Key Sex Hormone Biomarkers You Should Know

Here are the most important markers often included in a comprehensive hormone panel:

• Total Testosterone – Measures the overall amount of testosterone in the blood.
• Sex Hormone Binding Globulin (SHBG) – A protein that binds testosterone and estrogen, determining how much is free to act¹⁰.
• Bioavailable Testosterone – Testosterone not bound to SHBG, consisting of free testosterone and albumin-bound testosterone.
• DHEA Sulfate (DHEA-S) – An adrenal hormone precursor that converts into testosterone and estrogen.
• Free Testosterone – The small fraction of testosterone not bound to proteins, representing true active levels.
• Estradiol – The main form of estrogen in both men and women; critical for bone, brain, and cardiovascular health.
• Follicle Stimulating Hormone (FSH) – A pituitary hormone that drives sperm production in men and egg development in women.
• Progesterone – Supports menstrual cycles, pregnancy, and balances the effects of estrogen.
• Luteinizing Hormone (LH) – Signals testes and ovaries to produce testosterone and estrogen.
• Prolactin – Regulates lactation, but can also interfere with reproductive function when elevated.
• Free Androgen Index (FAI) – A calculated ratio of total testosterone to SHBG that is useful for assessing androgen imbalance; elevated values are often seen in polycystic ovary syndrome (PCOS).
• Testosterone / Estradiol Ratio (T:E2) – A marker of balance between testosterone and estradiol, important for metabolic, cardiovascular, and reproductive health.

Practical Concerns of Sex Hormone Imbalances

Low testosterone has been linked to 30–50% higher risks of type 2 diabetes, depression, and osteoporosis⁶ ⁷ ²¹. Insulin resistance, a hallmark of type 2 diabetes, is strongly tied to low testosterone, and men with healthier testosterone levels show about a 40% lower risk of developing type 2 diabetes, underscoring its role in metabolic health²º.

In women, hormone shifts have equally broad consequences. Nearly a third of reproductive-age women experience clinically significant premenstrual syndrome (PMS), while almost half report some premenstrual symptoms. Beyond this, hormonal imbalances contribute to infertility and accelerate bone loss after menopause, with estrogen decline being a primary driver of osteoporosis and fracture risk¹⁷.

Estradiol is a particularly important marker across sexes. In men, low estradiol is linked to higher cardiovascular mortality, while excess estradiol raises risks such as clotting disorders and gynecomastia²² ²³. In women, estradiol decline after menopause drives bone loss and contributes to cardiovascular risk²⁴ ²⁵.

As you can see, these numbers aren’t just lab values. They predict quality of life, shape how we age, and flag disease risk long before symptoms appear. And as hormone assays grow more precise, such as with liquid chromatography-mass spectrometry (LC-MS) testing, research is revealing their cascading effects across metabolism, bone health, cognition, and immunity. Female hormones, in particular, are gaining overdue recognition for roles that extend far beyond reproduction.

Do You Need Testing?

Ask yourself: has your energy, mood, or sexual health shifted in ways that don’t align with your lifestyle? If so, hormone testing may provide useful insight. This isn’t about vanity; it’s about recognizing early changes before they progress into long-term health risks. 

Even if you aren’t experiencing any symptoms, baseline testing can clarify where your levels fall within expected ranges and help track shifts over time. And by understanding your baseline levels, you’ll have the data you need to create a health plan tailored to your body. 

How to Improve Hormone Balance

Lifestyle is the foundation of hormone health:

• Diet: Adequate protein, healthy fats, and key micronutrients support hormone synthesis. Zinc, magnesium, and vitamin D are especially important for converting hormone precursors into their active forms².
• Exercise: Resistance training and regular activity help raise testosterone and improve insulin sensitivity.
• Sleep: Poor sleep lowers testosterone and raises cortisol, while restorative sleep helps rebalance the system.
• Supplements and therapies: In some cases, DHEA, vitamin D, or hormone replacement therapy may be recommended. These require professional guidance, and not everyone with “out-of-range” values needs intervention; lab results and symptoms must be interpreted together.

There is no single fix for biomarker imbalances. Achieving healthy levels usually requires a tailored approach that integrates both biomarker data and your personal lived experience.

Why Biomarker Testing Matters for Longevity

Sex hormones are tightly linked to the biology of aging. Balanced sex hormones help preserve muscle, bone, vascular function, and cognition — all core hallmarks of healthspan. Estradiol supports vascular and brain health in both sexes, progesterone and its metabolites influence sleep and mood through neurosteroid pathways, and testosterone maintains red blood cell production and metabolic flexibility. Together, these hormones act as regulators of resilience across multiple systems.

How Superpower Can Help

Understanding sex hormone biomarkers puts you in control of your healthcare. It takes the guesswork out of your health story and replaces it with clarity. With comprehensive biomarker testing, you see not only where you stand today, but also where your health is headed².

Superpower makes that possible. With a single panel measuring over 100 biomarkers, including the cofactors, binding proteins, and overall metabolic health that affect your sex hormone health, you get functional insights tied directly to longevity and disease prevention. It’s not about reacting once you’re sick. It’s about knowing now, so you can build the healthier future you deserve.

‍