What to do next for an adult male with low testosterone levels and low Sex Hormone Binding Globulin (SHBG)?

From the Guidelines

For an adult male with low testosterone levels and low Sex Hormone Binding Globulin (SHBG), the next step should be a comprehensive evaluation by an endocrinologist or urologist specializing in male hormonal health, as recommended by the most recent guidelines 1. This evaluation should include a complete medical history, physical examination, and confirmation of low testosterone with a second morning blood test (ideally between 8-10 AM when levels are highest).

• The patient's medical history should be thoroughly reviewed to identify any underlying conditions that may be contributing to the low testosterone levels.
• A physical examination should be performed to assess for any signs of hypogonadism, such as decreased muscle mass or bone density.
• The second morning blood test should be used to confirm the diagnosis of low testosterone, as levels can fluctuate throughout the day.

Treatment options typically include testosterone replacement therapy (TRT), which can be administered as injections (testosterone cypionate 50-100mg weekly or testosterone enanthate 100-200mg every 2 weeks), daily transdermal gels (AndroGel, Testim 50-100mg daily), patches (Androderm 2-6mg daily), or pellets implanted subcutaneously every 3-6 months.

• Low SHBG is significant because it affects how much free testosterone is available in the body, and this should be taken into account when determining the best course of treatment.
• Lifestyle modifications are also important and should include weight loss if overweight, regular exercise, adequate sleep, stress reduction, and limiting alcohol consumption, as recommended by the American Urological Association 1.
• Nutritional support with vitamin D, zinc, and magnesium may help optimize testosterone production. Regular monitoring is essential during treatment, with testosterone levels checked at 3-6 month intervals, along with hematocrit, PSA (prostate-specific antigen), and liver function tests to monitor for potential side effects, as recommended by the Endocrine Society Clinical Practice Guideline 1.
• Treatment should continue as long as symptoms persist and no adverse effects develop. It is also important to note that further tests, such as luteinizing hormone and follicle-stimulating hormone levels, may be needed to determine if the patient has hypogonadism, as recommended by the Diabetes Care guidelines 1.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION Prior to initiating testosterone enanthate injection, confirm the diagnosis of hypogonadism by ensuring that serum testosterone concentrations have been measured in the morning on at least two separate days and that these serum testosterone concentrations are below the normal range Male hypogonadism: As replacement therapy, i.e., for eunuchism, the suggested dosage is 50 to 400 mg every 2 to 4 weeks.

The patient has low testosterone levels and low Sex Hormone Binding Globulin (SHBG). The next step would be to confirm the diagnosis of hypogonadism by ensuring that serum testosterone concentrations have been measured in the morning on at least two separate days. If the diagnosis is confirmed, testosterone replacement therapy may be considered, with a suggested dosage of 50 to 400 mg every 2 to 4 weeks 2. It is essential to note that the patient's age, sex, diagnosis, response to treatment, and appearance of adverse effects should be taken into account when determining the dosage and duration of therapy.

From the Research

Next Steps for Adult Male with Low Testosterone Levels and Low Sex Hormone Binding Globulin (SHBG)

• The patient's low testosterone levels and low SHBG levels should be evaluated in the context of their symptoms and medical history 3.
• The measurement of morning total testosterone level by a reliable assay is recommended as the initial diagnostic test, and confirmation of the diagnosis by repeating the measurement of morning total testosterone and measuring free or bioavailable testosterone level may be necessary, especially if SHBG abnormality is suspected 4.
• Testosterone therapy may be considered to induce and maintain secondary sex characteristics and to improve sexual function, sense of well-being, muscle mass and strength, and bone mineral density, but it is essential to rule out any contraindications such as breast or prostate cancer, palpable prostate nodule or induration, or uncontrolled heart failure 4.
• Gonadotropin therapy, such as human chorionic gonadotropin (hCG) and follicle-stimulating hormone (FSH), may be an alternative treatment option for men with hypogonadotropic hypogonadism, especially if fertility is a concern 5.
• The patient's SHBG levels should be monitored, as low SHBG levels have been associated with erectile dysfunction and may be affected by certain medications, such as oxandrolone 6.
• The feedback inhibition of gonadotropins by testosterone should be taken into account when evaluating the patient's response to treatment, as gonadotropin levels may be suppressed by testosterone replacement therapy 7.