elevated Shbg and Test

[Joseph Guarneri]

Hey Guys i have a patient with an SHBG of 108 and a Total test pf 1038 with an LH of  15.5, we have been trying to figure out why he has such a high SHBG and LH, he complains of low test symptoms. Hes been to many endos and they cant give him an explanation of why his levels are so out of whack. Does anyone have an idea what might be causing this

[Giovanni Silva]

Would probably recommend testing for his free-testosterone. As we know it is the free-testosterone that does the job within the cell receptors (saturation of androgen receptors). Most of total testosterone is bound to albumin 50%, SHBG 44%, and corticotropin-binding globulin 4%. Free testosterone should be at least 2.5% of total testosterone. Also the sensitivity of the androgen receptors (AR); AR genes contain “CAG repeats” that affect receptor function, where fewer repeats leads to increased receptor sensitivity to circulating androgens and more repeats leads to decreased receptor sensitivity.

It has also been postulated that hormone receptors may be saturated with toxins thus free-testosterone is not able to sit on receptor.

SHBG typically goes up with age. Also, too low insulin, high T4, increased estradiol and obesity/metabolic syndrome drives up SHBG.

[Joseph Guarneri]

T4, insulin markers, estradiol are all within normal levels, he’s a 35 year old highly active male with a bmi normal for his age, no signs of metabolic disease. His free test came back at 0.97%.

[tim blend]

!% of 1038 is only about 10, most patients do not feel the bennefits until free T reaches 15-30 ng/dl

[Giovanni Silva]

If his TT is at 1038, his FT should be at least 25.95ng/dl, 0.97 is way too low.  You can calculate FT with the “Free & Bioavailable Testosterone Calculator”, you will need albumin, SHBG, and Testosterone values. This is more accurate than assays. For this type of patient (high SHBG and possibly diminished androgen receptor sensitivity), I really like Biotics “Hormone Balance & Protect” and “Receptor Detox”.

 

[Clyde Boswell]

Something to consider here,

If he is ketogenic then this can drastically increase SHBG if other work up looks normal. I have had multiple patients where this was an issue, however, they are seniors, not younger adults.

[Giovanni Silva]

There is also 2 different trains-of-thought amongst “hormone experts”:

1. One says “continue increasing TT and try to get FT higher”. My concern with this approach would be the possible greater increase in E and DHT.?? This statement from a hormone expert (Harvard Urologist).
2. The other one says “the higher the TT, the body will try to compensate and will produce higher SHBG”. This statement from a a“world-renowned urologist with expertise in sexual medicine and testosterone therapy”.

[tim blend]

my thoughts are in line with the Harvard Urologist, increasing TT will increase all the parameters you mention,E2,DHT and free T however E2 is generally good for the heart preventing plaque build up and dht may cause some hair loss or BPH symptoms but I would try to get the free T higher then deal with elevated E2 or DHT if they are problematic. T will in general lower the SHBG which seems counter intuitive and E2 generally will raise SHBG but there is no consensus as to what levels will do what and appear to be specific per the individual.

As you said correctly the calculated Free T is much more accurate then the assay which is proven by labs like quest diagnostics who use the calculated value which is always in the range of 2-3% however labcorp which uses an assay is ALWAYS off by a factor of 10! I have tried reaching out to their pathology department but my concerns fall on deaf ears.

[Clyde Boswell]

What about lowering SHBG with Danazol?

[tim blend]

why take another medication, high or low shbg is not generally the problem but the way it affects the hormones its carrying like testosterone or estradiol etc

[Caroline Snelwar]

Hi Tim,

How is his stress, sleep and gut function?

Maybe do saliva testing ( cortisol) as he reports still having low T symptoms despite levels.

Keep us posted!

[Lisa Waterman]

Consider DUTCH test …. See how he is metabolizing hormones. Then make the needed adjustments

from above … agree increasing the dose to get symptom relief.

if keto have him cycle or target keto ….

[tim blend]

salivary testing for cortisol and the dutch test are also great ancillary tests if symptoms persist in spite of optimization.

[Linda Kiley]

I didn’t see his DHT level, and agree he should have either DUTCH or Physicians Lab urine hormone metabolic profile.  I find those tests more valuable than saliva.

[Bill Clearfield]

Another calculation not as robust as Bioavailable Testosterone but easier to calculate and readily available here is the “Free Androgen Index” (FAI)

FAI= Total Testosterone/(0.288 x SHBG)

This corrects for units

“Normal” is 30-130

”Optimal” is 55-110

in this case Testo = 1038/(0.288 x 108) 

FAI= 33.44 just barely “Normal”

I agree  with the others about optimizing other parameters.  Our go to is first to lower SHBG with Boron 3 mg at bedtime.

Recheck in monthly by phone esp of symptoms do not improve. Every 4! Weeks can increase Boron by 3 mg to a max of 9 mg

repeat in 3 months with lab

on Average patients only need 3 mg Boron with SHBG decreasing by25-33% creating a rose in free testosterone to relieve the symptoms

my 2 cents for what it’s worth

 

 

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