What does a low Free Androgen Index mean?

A low Free Androgen Index (FAI) indicates reduced levels of biologically active testosterone, which can cause symptoms like fatigue, low libido, and mood changes. Treatment depends on the underlying cause and may include hormone therapy, lifestyle modifications, or addressing conditions like PCOS or thyroid disorders.

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Understanding the Free Androgen Index

The Free Androgen Index (FAI) is a calculated value that estimates the amount of biologically active testosterone circulating in your bloodstream. Unlike total testosterone measurements, which include both bound and unbound forms, FAI provides insight into how much testosterone is actually available for your body to use. This distinction is crucial because only free testosterone can enter cells and exert biological effects.

FAI is calculated using a simple formula: (Total Testosterone / Sex Hormone Binding Globulin) × 100. Sex Hormone Binding Globulin (SHBG) is a protein that binds to testosterone and other sex hormones, essentially making them inactive. When SHBG levels are high or total testosterone is low, your FAI decreases, potentially leading to symptoms of androgen deficiency even if your total testosterone appears normal.

Why FAI matters more than total testosterone

Many people focus solely on total testosterone levels, but this can be misleading. Approximately 98% of testosterone in the blood is bound to proteins like SHBG and albumin, leaving only about 2% as free, bioavailable testosterone. FAI helps bridge this gap by providing a more accurate picture of your hormonal status. This is particularly important for diagnosing conditions like hypogonadism, where symptoms may be present despite normal total testosterone levels.

Free Androgen Index Reference Ranges

FAI ranges vary by laboratory and calculation method. Always interpret results with your healthcare provider.
PopulationNormal FAI RangeLow FAIClinical Significance
Adult MenAdult Men30-150Below 30May indicate hypogonadism
Premenopausal WomenPremenopausal Women0.5-6.5Below 0.5Associated with low libido, fatigue
Postmenopausal WomenPostmenopausal Women0.3-4.0Below 0.3Common but may still cause symptoms
PCOS WomenPCOS WomenOften elevatedBelow normal rangeMay indicate SHBG abnormalities

FAI ranges vary by laboratory and calculation method. Always interpret results with your healthcare provider.

Normal FAI ranges and what low means

FAI reference ranges vary significantly based on sex and age. Understanding these ranges helps contextualize your results and determine whether intervention might be necessary.

A low FAI typically falls below these reference ranges and indicates that your body has insufficient free testosterone available for normal physiological functions. This can occur even when total testosterone levels appear adequate, making FAI a valuable diagnostic tool for identifying subtle hormonal imbalances.

Factors affecting FAI interpretation

Several factors can influence FAI values and their interpretation. Age plays a significant role, as both testosterone production and SHBG levels change throughout life. Body composition matters too - obesity often correlates with lower SHBG and altered FAI values. Additionally, certain medications, liver function, and thyroid status can all impact SHBG production and subsequently affect FAI calculations.

Symptoms of low Free Androgen Index

Low FAI can manifest through various symptoms that affect both physical and mental well-being. The severity and combination of symptoms often depend on how low your FAI is and how long it has been suppressed. Many people initially dismiss these symptoms as normal aging or stress, but recognizing them as potential signs of hormonal imbalance is the first step toward appropriate treatment.

Physical symptoms

  • Persistent fatigue and low energy levels
  • Decreased muscle mass and strength
  • Increased body fat, particularly around the midsection
  • Reduced bone density and increased fracture risk
  • Hair loss or thinning
  • Dry skin and brittle nails
  • Hot flashes and night sweats
  • Decreased exercise tolerance and recovery

Sexual and reproductive symptoms

  • Low libido or complete loss of sex drive
  • Erectile dysfunction in men
  • Vaginal dryness and painful intercourse in women
  • Irregular menstrual cycles or amenorrhea
  • Infertility or difficulty conceiving
  • Reduced sexual satisfaction

Mental and emotional symptoms

  • Depression and mood swings
  • Anxiety and irritability
  • Brain fog and difficulty concentrating
  • Memory problems
  • Lack of motivation and drive
  • Sleep disturbances

Common causes of low FAI

Understanding what causes low FAI is essential for developing an effective treatment strategy. The underlying mechanisms typically involve either decreased testosterone production, increased SHBG levels, or a combination of both. Identifying the root cause helps healthcare providers tailor interventions to address the specific hormonal imbalance.

High SHBG levels

Elevated SHBG is one of the most common causes of low FAI. Several conditions can increase SHBG production, including hyperthyroidism, liver disease, and certain medications like oral contraceptives and anti-seizure drugs. Aging also naturally increases SHBG levels, which partially explains why older individuals often experience symptoms of androgen deficiency despite having normal total testosterone levels.

Low testosterone production

Primary hypogonadism occurs when the testes or ovaries fail to produce adequate amounts of testosterone. This can result from genetic conditions, injury, infection, or autoimmune disorders. Secondary hypogonadism involves problems with the pituitary gland or hypothalamus, which control hormone production. Chronic stress, obesity, and certain medications can also suppress testosterone production through various mechanisms.

Medical conditions affecting FAI

  • Polycystic Ovary Syndrome (PCOS) - paradoxically can cause both high and low FAI
  • Thyroid disorders - both hyper and hypothyroidism affect SHBG
  • Type 2 diabetes and metabolic syndrome
  • Chronic liver disease
  • HIV/AIDS and other chronic infections
  • Eating disorders and malnutrition
  • Cushing's syndrome

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Diagnosis and testing for FAI

Accurate diagnosis of low FAI requires comprehensive hormone testing that goes beyond a simple testosterone measurement. The timing of testing matters, as hormone levels fluctuate throughout the day and, in women, throughout the menstrual cycle. Most experts recommend testing in the morning when testosterone levels are typically highest.

Essential tests for evaluating FAI include total testosterone, SHBG, and albumin levels. Additional tests might include free testosterone (directly measured), luteinizing hormone (LH), follicle-stimulating hormone (FSH), and prolactin to help identify the underlying cause. For a comprehensive hormonal assessment, consider at-home testing options that measure multiple biomarkers simultaneously.

When to get tested

Consider FAI testing if you experience persistent symptoms of androgen deficiency, especially if initial testosterone tests came back normal. Women with PCOS, irregular periods, or fertility issues should also consider FAI testing. Men experiencing erectile dysfunction, low libido, or unexplained fatigue may benefit from comprehensive hormone evaluation including FAI calculation.

Treatment options for low FAI

Treatment for low FAI depends on the underlying cause and individual circumstances. The goal is to restore hormonal balance while addressing any contributing factors. Treatment approaches range from lifestyle modifications to hormone replacement therapy, and often a combination of strategies works best.

Hormone replacement therapy

For individuals with significantly low FAI due to hypogonadism, hormone replacement therapy (HRT) may be appropriate. In men, this typically involves testosterone replacement through gels, injections, or patches. Women might receive testosterone therapy in much lower doses, often combined with estrogen replacement if appropriate. HRT requires careful monitoring and regular blood tests to ensure optimal dosing and minimize side effects.

Lifestyle modifications

Many lifestyle factors can naturally improve FAI levels. Regular resistance training stimulates testosterone production and improves body composition. Maintaining a healthy weight reduces the conversion of testosterone to estrogen in fat tissue. Adequate sleep, stress management, and a nutrient-dense diet rich in zinc, vitamin D, and healthy fats all support optimal hormone production.

Addressing underlying conditions

When low FAI results from conditions like thyroid disorders or PCOS, treating the underlying condition often improves hormone balance. This might involve thyroid medication, metformin for insulin resistance, or specific treatments for liver disease. Working with healthcare providers who understand the complex interactions between different hormonal systems is crucial for successful treatment.

Monitoring and long-term management

Successfully managing low FAI requires ongoing monitoring and adjustment of treatment strategies. Regular testing helps track progress and ensures that interventions are working effectively. Most experts recommend retesting hormone levels every 3-6 months initially, then annually once stable levels are achieved.

Beyond laboratory values, monitoring symptom improvement is equally important. Keep a journal tracking energy levels, mood, libido, and other relevant symptoms. This information helps healthcare providers fine-tune treatment plans and identify any emerging issues early. Regular monitoring through comprehensive hormone panels can provide valuable insights into your treatment progress.

The importance of comprehensive hormone testing

Low FAI rarely exists in isolation - it often reflects broader hormonal imbalances that affect multiple body systems. Comprehensive testing that includes thyroid hormones, metabolic markers, and other sex hormones provides a complete picture of your endocrine health. This holistic approach enables more targeted and effective treatment strategies.

Understanding your FAI in the context of overall health is crucial for long-term wellness. Low FAI can impact cardiovascular health, bone density, cognitive function, and metabolic health. By addressing hormonal imbalances early and comprehensively, you can prevent many age-related health issues and maintain vitality throughout life. Regular monitoring and proactive management of hormone levels represent an investment in your future health and quality of life.

References

  1. Keevil, B. G., & Adaway, J. (2019). Assessment of free testosterone concentration. Journal of Steroid Biochemistry and Molecular Biology, 190, 207-211.[PubMed][DOI]
  2. Goldman, A. L., Bhasin, S., Wu, F. C., Krishna, M., Matsumoto, A. M., & Jasuja, R. (2017). A reappraisal of testosterone's binding in circulation: physiological and clinical implications. Endocrine Reviews, 38(4), 302-324.[PubMed][DOI]
  3. Rosner, W., Auchus, R. J., Azziz, R., Sluss, P. M., & Raff, H. (2007). Position statement: Utility, limitations, and pitfalls in measuring testosterone: an Endocrine Society position statement. The Journal of Clinical Endocrinology & Metabolism, 92(2), 405-413.[PubMed][DOI]
  4. Vermeulen, A., Verdonck, L., & Kaufman, J. M. (1999). A critical evaluation of simple methods for the estimation of free testosterone in serum. The Journal of Clinical Endocrinology & Metabolism, 84(10), 3666-3672.[PubMed][DOI]
  5. Davis, S. R., & Wahlin-Jacobsen, S. (2015). Testosterone in women—the clinical significance. The Lancet Diabetes & Endocrinology, 3(12), 980-992.[PubMed][DOI]
  6. Handelsman, D. J., Hirschberg, A. L., & Bermon, S. (2018). Circulating testosterone as the hormonal basis of sex differences in athletic performance. Endocrine Reviews, 39(5), 803-829.[PubMed][DOI]

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Frequently Asked Questions

How can I test my Free Androgen Index at home?

You can test your Free Androgen Index at home with SiPhox Health's Hormone Focus Program, which includes Free Androgen Index (FAI) testing along with other essential hormone biomarkers. This CLIA-certified program provides lab-quality results from the comfort of your home.

What is the difference between FAI and free testosterone?

FAI is a calculated value using total testosterone and SHBG levels, while free testosterone can be directly measured or calculated. FAI provides an estimate of bioavailable testosterone, whereas free testosterone measures the actual unbound hormone. Both are useful for assessing androgen status, but FAI is often more accessible and cost-effective.

Can women have low FAI?

Yes, women can have low FAI, which may cause symptoms like low libido, fatigue, depression, and decreased muscle mass. Women naturally have lower testosterone levels than men, but adequate levels are still important for health. Low FAI in women often results from high SHBG levels, ovarian dysfunction, or adrenal issues.

How long does it take to improve low FAI naturally?

Natural improvements in FAI typically take 3-6 months of consistent lifestyle changes. Factors like weight loss, exercise, and stress reduction can gradually improve hormone balance. However, the timeline varies based on the underlying cause and individual factors. Regular testing every 3 months helps track progress.

What foods can help increase FAI?

Foods that support healthy testosterone levels and may improve FAI include zinc-rich foods (oysters, beef, pumpkin seeds), vitamin D sources (fatty fish, egg yolks), healthy fats (avocados, olive oil, nuts), and cruciferous vegetables that help balance hormones. Avoiding excessive sugar and processed foods is equally important.

This article is licensed under CC BY 4.0. You are free to share and adapt this material with attribution.

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Director of Clinical Product Operations at SiPhox Health with a background in medicine and a passion for health optimization. Experienced in leading software and clinical development teams, contributing to patents, launching health-related products, and turning diagnostics into actionable tools.

View Details
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Advisor

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Advisor

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His latest book, ‘Lies I Taught In Medical School’ is an instant New York Times bestseller and has re-framed how we think about metabolic health and longevity. In addition to being a practicing physician, he is author of over 200 peer reviewed scientific papers and 14 books that are available in fourteen languages.

View Details
Ben Bikman, PhD

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Advisor

Benjamin Bikman earned his Ph.D. in Bioenergetics and was a postdoctoral fellow with the Duke-National University of Singapore in metabolic disorders. Currently, his professional focus as a scientist and professor (Brigham Young University) is to better understand the role of elevated insulin and nutrient metabolism in regulating obesity, diabetes, and dementia.

In addition to his academic pursuits, Dr. Bikman is the author of Why We Get Sick and How Not To Get Sick.

View Details
Tash Milinkovic, MD

Tash Milinkovic, MD

Health Programs Lead, Heart & Metabolic

Dr. Natasha Milinkovic is part of the clinical product team at SiPhox Health, having graduated from the University of Bristol Medical School. Her medical career includes rotations across medical and surgical specialties, with specialized research in vascular surgery, focusing on recovery and post-operative pain outcomes. Dr. Milinkovic built her expertise in emergency medicine as a clinical fellow at a major trauma center before practicing at a central London teaching hospital throughout the pandemic.

She has contributed to global health initiatives, implementing surgical safety standards and protocols across rural Uganda. Dr. Milinkovic initially joined SiPhox Health to spearhead the health coaching initiative and has been a key contributor in the development and launch of the Heart and Metabolic program. She is passionate about addressing health disparities by building scalable healthcare solutions.

View Details