What is the recommended treatment for a patient with elevated FSH (Follicle-Stimulating Hormone) and LH (Luteinizing Hormone), low SHBG (Sex Hormone-Binding Globulin), and low Total T (Total Testosterone)?

Interpretation and Management of Your Hormone Profile

Your laboratory values indicate primary testicular failure (hypergonadotropic hypogonadism), and you require testosterone replacement therapy if you have symptoms of hypogonadism. 1

Understanding Your Results

Your hormone profile shows:

• FSH 10.3 IU/L and LH 7.5 IU/L: These are inappropriately normal-to-elevated relative to your low testosterone, indicating your pituitary is attempting to stimulate testicular function but your testes are not responding adequately 1
• SHBG 92 nmol/L: This is significantly elevated (normal range typically 20-60 nmol/L), which artificially maintains your total testosterone but results in low free (bioavailable) testosterone 1
• Total testosterone 35 nmol/L (approximately 1009 ng/dL): While this appears normal, the elevated SHBG means your free testosterone is likely frankly low despite the normal total testosterone 1

Critical Next Steps

You must obtain a morning (8-10 AM) free testosterone measurement by equilibrium dialysis on at least two separate occasions before any treatment decisions. 1 This is essential because:

• Men with elevated SHBG can have normal total testosterone but low free testosterone, causing symptomatic hypogonadism 1
• Your SHBG of 92 nmol/L is markedly elevated, making total testosterone an unreliable indicator of your true androgen status 1
• The combination of normal-to-elevated gonadotropins (FSH/LH) with low bioavailable testosterone suggests primary testicular dysfunction 1

Additional Required Testing

Before initiating therapy, the following must be assessed 1:

• Repeat morning free testosterone (by equilibrium dialysis, not calculated) on a second occasion 1
• Prolactin level: Required when LH is low or low-normal (though your LH is not suppressed, this helps complete the evaluation) 1
• Hemoglobin and hematocrit: Mandatory pre-treatment assessment 1
• PSA (if age >40 years): To exclude prostate contraindications 2
• Assess for conditions causing elevated SHBG: Hyperthyroidism, liver disease, HIV, aging (you appear to have age-related SHBG elevation) 1, 3

Treatment Recommendation

If your free testosterone is confirmed to be frankly low on two separate morning measurements, testosterone replacement therapy is indicated. 1

Preferred Treatment Options:

Transdermal testosterone gel (1.62%) is recommended as first-line therapy because it provides stable daily testosterone levels and is most convenient for patients 1, 4:

• Starting dose: 40.5 mg daily (two pump actuations) 4
• Titration based on follow-up levels at days 14,28, and 42 4
• Target range: 300-1000 ng/dL average concentration 4
• Monitor testosterone levels 2-3 months after initiation 1

Alternative: Intramuscular testosterone enanthate if cost is prohibitive or patient preference favors less frequent administration 1, 2:

• Provides effective testosterone replacement for primary hypogonadism 2
• Less expensive than transdermal preparations 1
• Requires intramuscular injections every 1-2 weeks 2

Critical Contraindications to Exclude:

• Known or suspected prostate or breast cancer 2, 4
• Uncontrolled heart failure 2
• Untreated severe sleep apnea 2
• Hematocrit >50% 2

Fertility Considerations

If you desire fertility now or in the future, testosterone replacement therapy is contraindicated because it will suppress spermatogenesis 1:

• Your elevated FSH (10.3 IU/L) suggests impaired spermatogenesis 1
• Obtain semen analysis before any testosterone therapy 1
• If fertility is desired, consider referral to reproductive endocrinology for gonadotropin therapy (hCG with FSH) rather than testosterone replacement 5, 6, 7
• Gonadotropin therapy can stimulate both testosterone production and spermatogenesis in appropriate candidates 5

Monitoring During Treatment

Once testosterone therapy is initiated 1, 4:

• Testosterone levels: Check at 2-3 months, then every 6-12 months 1
• Hemoglobin/hematocrit: Monitor at 3,6, and 12 months, then annually (testosterone can increase red blood cell production) 1
• PSA: Annually if age >40 years 1
• Bone density: Consider baseline and follow-up if osteoporosis risk factors present 1
• Metabolic parameters: Testosterone replacement improves insulin resistance, lipids, and body composition in hypogonadal men 1

Common Pitfalls to Avoid

• Do not rely solely on total testosterone when SHBG is elevated—you will miss true hypogonadism 1, 3
• Do not start testosterone if fertility is desired—it will worsen spermatogenesis 1
• Do not use calculated free testosterone—equilibrium dialysis is the gold standard 1
• Do not skip the second confirmatory testosterone measurement—single measurements can be spurious 1