What is FAI (Free Androgen Index)?

The Free Androgen Index (FAI) is a calculated ratio that estimates biologically active testosterone levels by comparing total testosterone to sex hormone-binding globulin (SHBG). It helps diagnose hormonal imbalances like PCOS in women and hypogonadism in men more accurately than testosterone alone.

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Understanding the Free Androgen Index

The Free Androgen Index (FAI) is a calculated value that provides insight into how much biologically active testosterone is circulating in your body. Unlike total testosterone measurements, which show all testosterone in your blood regardless of whether it's available for use, FAI gives a more accurate picture of the testosterone that's actually free to interact with your cells and tissues.

Think of FAI as a way to understand your body's true testosterone activity. While total testosterone tells you how much of the hormone is present, much of it may be bound to proteins and unavailable for use. FAI helps clinicians and patients understand what portion of testosterone is genuinely active and influencing bodily functions.

How FAI is Calculated

The Free Androgen Index is calculated using a simple formula that takes into account two key measurements from your blood test:

Normal FAI Reference Ranges

Reference ranges may vary by laboratory and testing method. Always consult with your healthcare provider for interpretation.
PopulationNormal FAI RangeClinical Significance
Women (Premenopausal)Women (Premenopausal)0.4-8.4Higher levels may indicate PCOS or other androgen excess
Women (Postmenopausal)Women (Postmenopausal)0.4-6.0Levels naturally decline after menopause
Men (Adult)Men (Adult)30-150Lower levels may indicate hypogonadism

Reference ranges may vary by laboratory and testing method. Always consult with your healthcare provider for interpretation.

  • Total testosterone levels
  • Sex hormone-binding globulin (SHBG) levels

The formula is: FAI = (Total Testosterone / SHBG) × 100

SHBG is a protein produced by your liver that binds to sex hormones, including testosterone, making them inactive. When SHBG levels are high, more testosterone is bound and unavailable. When SHBG levels are low, more testosterone remains free and active. This relationship makes FAI a valuable tool for understanding hormonal balance.

Normal FAI Ranges

Normal FAI ranges vary significantly between men and women, and can also differ based on age and laboratory methods. Understanding where your FAI falls within these ranges helps identify potential hormonal imbalances.

It's important to note that these ranges can vary between laboratories and testing methods. Your healthcare provider will interpret your results based on the specific reference ranges used by your testing facility, along with your symptoms and overall health picture.

Why FAI Testing Matters

FAI testing provides crucial information that total testosterone testing alone might miss. This is particularly important because two people with identical total testosterone levels can have vastly different amounts of active testosterone based on their SHBG levels.

Diagnosing PCOS in Women

For women, FAI is especially valuable in diagnosing polycystic ovary syndrome (PCOS), a common hormonal disorder affecting 6-12% of women of reproductive age. Women with PCOS often have elevated FAI levels due to increased testosterone production, decreased SHBG, or both. Symptoms of high FAI in women include irregular periods, excess facial or body hair, acne, and difficulty losing weight.

Assessing Hypogonadism in Men

In men, FAI helps diagnose hypogonadism (low testosterone) more accurately than total testosterone alone. A man might have normal total testosterone but low FAI if his SHBG levels are elevated, leading to symptoms like decreased libido, erectile dysfunction, fatigue, and loss of muscle mass. Regular monitoring of FAI can help optimize hormone health and track treatment effectiveness.

Monitoring Hormone Therapy

FAI is also valuable for monitoring hormone replacement therapy effectiveness. As treatments can affect both testosterone and SHBG levels differently, tracking FAI provides a more complete picture of treatment response than monitoring testosterone alone.

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Factors That Affect FAI Levels

Several factors can influence your FAI levels by affecting either testosterone production or SHBG levels:

  • Age: SHBG typically increases with age, potentially lowering FAI
  • Weight: Obesity often decreases SHBG, increasing FAI
  • Insulin resistance: Can lower SHBG and increase FAI
  • Thyroid function: Hyperthyroidism increases SHBG, while hypothyroidism decreases it
  • Liver health: Since SHBG is produced in the liver, liver disease can affect levels
  • Medications: Birth control pills, steroids, and certain other medications can impact SHBG
  • Diet and lifestyle: High-sugar diets and sedentary lifestyles can affect hormone balance

Symptoms of Abnormal FAI

Recognizing the symptoms of abnormal FAI can help you identify when testing might be beneficial. Symptoms vary based on whether FAI is too high or too low, and differ between men and women.

High FAI Symptoms in Women

  • Irregular or absent menstrual periods
  • Hirsutism (excess facial and body hair)
  • Male-pattern baldness or thinning hair
  • Severe acne, especially along the jawline
  • Deepening of the voice
  • Increased muscle mass
  • Difficulty conceiving

Low FAI Symptoms in Men

  • Decreased libido and sexual function
  • Erectile dysfunction
  • Fatigue and low energy
  • Depression or mood changes
  • Loss of muscle mass and strength
  • Increased body fat, especially around the midsection
  • Decreased bone density
  • Hot flashes or night sweats

Testing and Monitoring FAI

FAI testing requires a simple blood draw that measures both total testosterone and SHBG levels. The test is typically performed in the morning when testosterone levels are at their peak, and fasting may be recommended for the most accurate results.

For women, timing of the test during the menstrual cycle can affect results. Many healthcare providers recommend testing during the follicular phase (days 3-5 of the cycle) for consistency. Women on hormonal contraceptives should discuss timing with their provider, as these medications can significantly affect results.

Regular monitoring of FAI can be valuable for tracking hormonal health over time, especially if you're undergoing treatment for a hormonal condition or making lifestyle changes to optimize your hormone levels. Testing every 3-6 months allows you to see trends and adjust interventions as needed.

Optimizing Your FAI Levels

If your FAI levels are outside the optimal range, several strategies can help bring them back into balance. The approach depends on whether your FAI is too high or too low and the underlying causes.

Lifestyle Modifications

  • Maintain a healthy weight: Weight loss can increase SHBG and lower FAI in women with PCOS
  • Exercise regularly: Both resistance training and cardiovascular exercise can optimize hormone levels
  • Manage stress: Chronic stress affects hormone production and balance
  • Improve sleep quality: Poor sleep disrupts hormone production
  • Eat a balanced diet: Focus on whole foods, adequate protein, and healthy fats
  • Limit alcohol: Excessive alcohol can affect both testosterone and SHBG levels

Medical Interventions

When lifestyle changes aren't sufficient, medical treatments may be necessary. For women with high FAI due to PCOS, options include hormonal contraceptives, anti-androgen medications, or insulin-sensitizing drugs. Men with low FAI might benefit from testosterone replacement therapy, though this requires careful monitoring and consideration of risks and benefits.

The Connection Between FAI and Overall Health

FAI levels don't exist in isolation—they're connected to many aspects of your overall health. Abnormal FAI has been linked to increased risk of metabolic syndrome, cardiovascular disease, and type 2 diabetes. In women, elevated FAI is associated with insulin resistance and increased cardiovascular risk factors.

Understanding and optimizing your FAI can therefore have benefits beyond addressing immediate symptoms. It's an important piece of the puzzle for maintaining long-term health and preventing chronic diseases.

Taking Action on Your Hormonal Health

The Free Androgen Index provides valuable insight into your hormonal health that goes beyond simple testosterone testing. By understanding the relationship between total testosterone and SHBG, FAI offers a more complete picture of your body's available androgens and their effects on your health.

Whether you're experiencing symptoms of hormonal imbalance, have been diagnosed with PCOS or hypogonadism, or simply want to optimize your health, FAI testing can provide crucial information. Combined with other hormone tests and a comprehensive health assessment, FAI helps create a roadmap for achieving optimal hormonal balance and overall wellness.

Remember that hormonal health is complex and interconnected with many other aspects of your wellbeing. Working with healthcare providers who understand these connections and can interpret your results in context is essential for developing an effective treatment plan tailored to your unique needs.

References

  1. Rosner W, Auchus RJ, Azziz R, Sluss PM, Raff H. Position statement: Utility, limitations, and pitfalls in measuring testosterone: an Endocrine Society position statement. J Clin Endocrinol Metab. 2007;92(2):405-413.[PubMed][DOI]
  2. Keevil BG, Adaway J. Assessment of free testosterone concentration. J Steroid Biochem Mol Biol. 2019;190:207-211.[PubMed][DOI]
  3. Teede HJ, Misso ML, Costello MF, et al. Recommendations from the international evidence-based guideline for the assessment and management of polycystic ovary syndrome. Hum Reprod. 2018;33(9):1602-1618.[PubMed][DOI]
  4. Bhasin S, Brito JP, Cunningham GR, et al. Testosterone Therapy in Men With Hypogonadism: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2018;103(5):1715-1744.[PubMed][DOI]
  5. Goldman AL, Bhasin S, Wu FCW, Krishna M, Matsumoto AM, Jasuja R. A Reappraisal of Testosterone's Binding in Circulation: Physiological and Clinical Implications. Endocr Rev. 2017;38(4):302-324.[PubMed][DOI]
  6. Vermeulen A, Verdonck L, Kaufman JM. A critical evaluation of simple methods for the estimation of free testosterone in serum. J Clin Endocrinol Metab. 1999;84(10):3666-3672.[PubMed][DOI]

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Frequently Asked Questions

How can I test my FAI at home?

You can test your FAI at home with SiPhox Health's Hormone Focus Program, which includes Free Androgen Index testing along with other key hormone biomarkers. The program provides lab-quality results from a simple at-home blood draw.

What's the difference between FAI and free testosterone?

FAI is a calculated ratio using total testosterone and SHBG levels, while free testosterone is a direct measurement of unbound testosterone. FAI is often more readily available and less expensive than direct free testosterone testing, though both provide information about biologically active testosterone.

Can birth control pills affect my FAI results?

Yes, hormonal contraceptives typically increase SHBG production, which can lower FAI levels. This is why some women on birth control may experience decreased libido or other symptoms related to lower available testosterone. Always inform your healthcare provider about any medications when getting tested.

How often should I retest my FAI levels?

For most people monitoring hormonal health or treatment effectiveness, retesting every 3-6 months is appropriate. However, your healthcare provider may recommend more or less frequent testing based on your specific situation, symptoms, and treatment plan.

Can diet and exercise really change my FAI levels?

Yes, lifestyle factors significantly impact FAI. Weight loss can increase SHBG and normalize FAI in women with PCOS, while resistance training can optimize testosterone levels in men. A balanced diet, stress management, and quality sleep all contribute to healthy hormone balance.

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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View Details
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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.

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Advisor

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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