How to decrease Sex Hormone-Binding Globulin (SHBG) in a patient with hypogonadism (low Testosterone (T)) and elevated SHBG?

From the Guidelines

To decrease Sex Hormone-Binding Globulin (SHBG) in a patient with hypogonadism and elevated SHBG, consider using metformin (500-1000mg twice daily) as it has been shown to lower SHBG levels, particularly in insulin-resistant patients 1.

Strategies to Lower SHBG

Several strategies can be implemented to lower SHBG levels in patients with hypogonadism and elevated SHBG. These include:

• Dietary modifications: increasing protein intake to 1.2-1.6g/kg/day and moderately increasing carbohydrate consumption, as low-carb diets can elevate SHBG
• Supplementing with boron at 9-12mg daily, as this trace mineral has been shown to reduce SHBG and increase free testosterone
• Vitamin D supplementation of 2000-5000 IU daily may help if levels are deficient
• Medications that can lower SHBG include metformin (500-1000mg twice daily) and danazol (200mg twice daily), though this has more side effects and is less commonly used
• Stinging nettle root extract (120-300mg daily) may also help by binding to SHBG
• Regular resistance training 3-4 times weekly can improve testosterone levels while potentially lowering SHBG
• Adequate sleep (7-9 hours) and stress management are important as cortisol elevation can impact hormone balance

Monitoring Treatment

Treatment should be monitored with follow-up hormone panels every 3-6 months to assess effectiveness. It is essential to individualize treatment and consider the patient's overall health, medical history, and potential interactions with other medications.

Evidence-Based Recommendation

The most recent and highest quality study 1 supports the use of metformin to lower SHBG levels in patients with hypogonadism and elevated SHBG. This study provides evidence for the efficacy and safety of testosterone treatment in men, including the use of metformin to lower SHBG levels.

From the Research

Decreasing Sex Hormone-Binding Globulin (SHBG) in Patients with Hypogonadism

To decrease SHBG in a patient with hypogonadism and elevated SHBG, several factors and interventions can be considered based on available research:

• Weight Reduction: Clinically significant weight loss can substantially reverse obesity-related reductions in serum testosterone and ameliorate non-specific symptoms resembling, but not due to, androgen deficiency 2. This approach may also impact SHBG levels, as obesity is associated with reduced SHBG.
• Management of Co-morbidities: Optimizing the management of type 2 diabetes mellitus, obstructive sleep apnea, depression, and other obesity-related co-morbidities, as well as rationalizing concomitant drug regimens, can help in rectifying the reversible conditions responsible for reduced serum testosterone concentrations and potentially affect SHBG levels 2.
• Discontinuation of Certain Medications: Discontinuation of oxandrolone, an anabolic-androgenic steroid, has been shown to lead to the normalization or improvement of testosterone levels and an increase in SHBG in some cases 3.
• Dietary and Lifestyle Interventions: A high triglyceride to HDL cholesterol ratio is associated with low testosterone and SHBG levels in middle-aged and elderly men, suggesting that dietary interventions aimed at improving lipid profiles could positively impact SHBG and testosterone levels 4.
• Thyroid Hormone Analogues: The effect of D-thyroxine on SHBG levels has been observed, with higher doses increasing SHBG levels in euthyroid subjects, although this may not directly apply to decreasing SHBG in hypogonadal patients 5.
• Anabolic Steroids: The use of anabolic steroids can lead to a decrease in SHBG concentrations, which may remain low even after steroid withdrawal 6. However, this is not a recommended approach for decreasing SHBG due to potential adverse effects.

Considerations

• The relationship between SHBG, testosterone, and various interventions is complex and can be influenced by multiple factors, including the patient's overall health, presence of co-morbidities, and current medications.
• Any intervention aimed at decreasing SHBG should be carefully considered in the context of the patient's hypogonadism and overall health status, and ideally, under the guidance of a healthcare professional.