How to lower elevated Sex Hormone-Binding Globulin (SHBG) levels?

How to Lower Elevated SHBG (95 nmol/L)

Address insulin resistance and metabolic factors through weight loss and dietary modification, as these are the most effective evidence-based interventions for lowering elevated SHBG levels. 1, 2

Primary Interventions to Lower SHBG

Weight Loss and Metabolic Optimization

• Weight reduction is the most effective intervention for lowering SHBG, particularly in individuals with obesity or elevated BMI, as insulin resistance directly suppresses SHBG production. 1, 3
• A low-fat (<10% calories), high-fiber diet combined with daily exercise significantly increases SHBG in the short term but addresses the underlying insulin resistance that chronically suppresses SHBG when present. 2
• After weight loss of approximately 15 kg, SHBG levels normalize even in individuals who remain technically obese, demonstrating the powerful effect of metabolic improvement. 3
• Insulin levels inversely correlate with SHBG (p<0.001), making insulin resistance the primary modifiable factor. 3, 4

Dietary Modifications

• Reduce total caloric intake and dietary fat content, as these directly influence SHBG gene expression in the liver. 5
• Increase dietary fiber intake, which improves insulin sensitivity and can modulate SHBG production. 2, 5
• Protein-rich diets during weight reduction have been shown to normalize SHBG levels. 3

Medication and Hormonal Approaches

Pharmacological Options That Lower SHBG

• Growth hormone, glucocorticoids (such as prednisone), and testosterone/anabolic steroids decrease SHBG levels, but these should only be used when clinically indicated for other conditions, not solely to lower SHBG. 1, 6
• Testosterone replacement therapy (TRT) can reduce elevated SHBG while normalizing free testosterone levels in men with confirmed hypogonadism. 1

Important Caveat

• Do not use medications solely to lower SHBG without addressing the underlying cause, as this approach lacks evidence for improving clinical outcomes. 6

Identify and Treat Underlying Causes

Medical Conditions That Elevate SHBG

Your SHBG of 95 nmol/L requires evaluation for:

• Hyperthyroidism - check TSH and free T4, as thyroid hormone directly stimulates SHBG production. 1, 6, 4
• Hepatic disease/liver cirrhosis - obtain liver function tests (AST, ALT, bilirubin, albumin). 1, 6
• HIV/AIDS - consider testing in appropriate clinical contexts. 1, 6

Medication Review

• Anticonvulsants, estrogens, and thyroid hormone medications increase SHBG; review and adjust if medically appropriate. 1, 6
• Smoking is associated with elevated SHBG; cessation may help normalize levels. 1, 6

Clinical Assessment Strategy

Initial Workup

• Measure morning total testosterone and calculate free testosterone index (total testosterone/SHBG ratio) to determine if you have functional hypogonadism. 1
• A free testosterone index <0.3 indicates hypogonadism despite potentially normal total testosterone. 1
• Check fasting insulin and glucose to assess for insulin resistance. 3, 4
• Obtain liver function tests and thyroid function tests (TSH, free T4). 1, 6
• Measure LH and FSH if hypogonadism is confirmed. 1

Body Composition Assessment

• Calculate BMI and measure waist circumference, as central obesity strongly correlates with metabolic dysfunction affecting SHBG. 3, 7
• SHBG levels correlate negatively with BMI and positively with HDL cholesterol, making cardiovascular risk assessment relevant. 3, 4

Monitoring and Follow-Up

• Reassess SHBG, total testosterone, and free testosterone after 3-6 months of lifestyle intervention or treatment. 1
• Monitor fasting insulin levels as a marker of metabolic improvement. 3, 4
• Track weight, BMI, and waist circumference as surrogate markers for insulin sensitivity changes. 7

Key Clinical Pitfalls to Avoid

• Do not rely solely on total testosterone measurements when SHBG is elevated, as this will miss functional hypogonadism. 1, 8
• Do not ignore the metabolic component - elevated SHBG often coexists with or masks underlying insulin resistance that requires treatment. 4, 7
• Do not prescribe medications to lower SHBG without treating the root cause, as this approach lacks evidence and may cause harm. 6
• Recognize that low GH/IGF-I levels may contribute to elevated SHBG in some populations, though this is not a primary treatment target. 3