What is the treatment approach for a patient with low Sex Hormone-Binding Globulin (SHBG) and low bioavailable testosterone?

From the Guidelines

The treatment approach for a patient with low Sex Hormone-Binding Globulin (SHBG) and low bioavailable testosterone typically involves testosterone replacement therapy (TRT), with careful monitoring of both total and free testosterone levels. For most adult men, TRT options include injectable testosterone cypionate or enanthate (typically 100-200mg every 1-2 weeks), daily transdermal gels (50-100mg AndroGel, Testim, or similar products), or testosterone pellets implanted subcutaneously every 3-6 months. When SHBG is low, shorter-acting formulations like daily gels may be preferable to avoid excessive peaks in free testosterone. Lifestyle modifications are equally important, including weight loss for overweight patients, as obesity lowers SHBG levels. Regular exercise, adequate sleep, stress reduction, and limiting alcohol consumption can help optimize testosterone metabolism. Treatment should be monitored with regular blood tests checking total and free testosterone, SHBG, estradiol, complete blood count, and PSA (in men over 40) 1. This comprehensive approach addresses both the hormonal deficiency and underlying factors affecting SHBG levels, which is crucial since low SHBG can amplify testosterone's effects even at lower doses, potentially increasing side effect risks like polycythemia, acne, or mood changes. Some studies suggest that testosterone therapy may provide small improvements in sexual functioning and quality of life but little to no benefit for other common symptoms of aging 1. However, long-term efficacy and safety are unknown, and more research is needed to fully understand the effects of testosterone replacement therapy in men with low SHBG and bioavailable testosterone. In general, the method of testosterone replacement should be individualized for each patient, taking into account factors such as cost, convenience, and potential side effects 1. Ultimately, the goal of treatment is to improve symptoms and quality of life while minimizing risks and side effects.

Some key points to consider when treating patients with low SHBG and bioavailable testosterone include:

• Careful monitoring of testosterone levels and adjustment of treatment as needed
• Lifestyle modifications to optimize testosterone metabolism
• Individualization of treatment to minimize risks and side effects
• Regular follow-up and evaluation to assess treatment efficacy and safety
• Consideration of potential benefits and harms of testosterone replacement therapy in the context of the individual patient's needs and health status.

It is essential to weigh the potential benefits and risks of testosterone replacement therapy and to carefully monitor patients for any adverse effects, particularly in light of the limited long-term safety data available 1. By taking a comprehensive and individualized approach to treatment, clinicians can help patients with low SHBG and bioavailable testosterone achieve optimal outcomes and improve their overall quality of life.

From the FDA Drug Label

The FDA drug label does not answer the question about the treatment approach for a patient with low Sex Hormone-Binding Globulin (SHBG) and low bioavailable testosterone.

The FDA drug label does not provide information on the treatment of low SHBG and low bioavailable testosterone. The labels discuss the administration, dosage, and precautions for testosterone gel 1.62%, but do not address the specific condition of low SHBG and low bioavailable testosterone. Therefore, no conclusion can be drawn from the provided drug labels regarding the treatment approach for this condition 2, 2, 2.

From the Research

Treatment Approach for Low SHBG and Bioavailable Testosterone

• The treatment approach for a patient with low Sex Hormone-Binding Globulin (SHBG) and low bioavailable testosterone typically involves testosterone replacement therapy (TRT) 3, 4.
• TRT can help restore normal serum testosterone concentrations and relieve symptoms in most hypogonadal men 4.
• The selection of the TRT method depends on the patient's preference with advice from the physician, and dose adjustment is possible with most delivery methods 4.
• It is essential to assess testosterone levels when an adult man exhibits signs of hypogonadism, and as part of normal medical screening in men starting at age 40 to 50 years, to establish a baseline 3.
• A physician should discuss the possibility of TRT with symptomatic patients who have a serum total testosterone level < 300 ng/dL 3.

Importance of SHBG in Diagnosis and Treatment

• SHBG plays a crucial role in the diagnosis and treatment of hypogonadism, as it regulates testicular negative feedback and modulates the entry of testosterone or estradiol into cells in the hypothalamus and/or pituitary to control gonadotropin synthesis and secretion 5.
• A low level of SHBG is often associated with adult onset male hypogonadism (AOH), and the level of SHBG is highly positively correlated with the total testosterone level in untreated men presenting for evaluation of AOH 5.
• The use of calculated free testosterone (cFT) and SHBG can help diagnose symptomatic hypogonadism in men, especially in those with HIV infection 6.
• A complete hormonal profile, including SHBG, total testosterone, and luteinizing hormone (LH), is necessary to properly diagnose and classify hypogonadism in men complaining about sexual symptoms 6.

Guidelines for Testosterone Replacement Therapy

• The Society for Endocrinology guidelines for testosterone replacement therapy in male hypogonadism provide a multidisciplinary approach to treating patients with MH, including expertise from endocrine, primary care, clinical biochemistry, urology, and reproductive medicine practices 7.
• These guidelines also provide a patient perspective to help clinicians best manage MH, and emphasize the importance of individualized treatment approaches 7.