How to manage a male patient with low free testosterone, high total testosterone, and high SHBG (Sex Hormone-Binding Globulin), with normal LH (Luteinizing Hormone) levels?

Understanding High SHBG with Normal LH: This Does NOT Represent True Hypogonadism

Your clinical scenario—low free testosterone with high total testosterone and elevated SHBG in the setting of normal LH (7.0 mIU/mL)—represents a binding protein abnormality rather than true testosterone deficiency, and therefore does NOT cause testicular atrophy or warrant testosterone replacement therapy. 1

Why Testicular Atrophy Does NOT Occur

• Normal LH levels (7.0 mIU/mL) indicate intact hypothalamic-pituitary-testicular axis function, meaning your testes are receiving appropriate stimulation and are producing testosterone normally. 1
• Testicular atrophy occurs only when the testes themselves fail (primary hypogonadism with elevated LH) or when pituitary stimulation is inadequate (secondary hypogonadism with low/low-normal LH)—neither of which applies to your situation. 1
• The elevated SHBG is simply binding more of your circulating testosterone, reducing the free (bioavailable) fraction, but your total testosterone production remains normal as evidenced by high total testosterone levels. 2, 3

Diagnostic Clarification

This pattern suggests functional or relative androgen deficiency due to increased binding, not true hypogonadism:

• True testosterone deficiency requires BOTH low total testosterone (<300 ng/dL on two separate early morning measurements) AND clinical symptoms/signs of hypogonadism. 1, 4, 5
• Your high total testosterone excludes the diagnosis of testosterone deficiency by AUA criteria. 1
• Free testosterone measurement is most useful when total testosterone is borderline (near 300 ng/dL) or when SHBG abnormalities are suspected—which applies here, but the normal LH indicates this is a binding issue, not a production problem. 5, 3

Common Causes of Elevated SHBG to Investigate

Before considering any intervention, identify and address the underlying cause of elevated SHBG:

• Hyperthyroidism (most common endocrine cause—check TSH and free T4) 6
• Hepatic dysfunction (check liver function tests) 6
• Aging (SHBG naturally increases with age) 2
• Medications (anticonvulsants, certain HIV medications) 6
• Low body weight or eating disorders (opposite of obesity, which lowers SHBG) 6

Management Algorithm

Step 1: Confirm the Pattern

• Repeat early morning total testosterone, free testosterone (by equilibrium dialysis if available), SHBG, and LH to confirm the pattern is consistent. 1, 6, 5

Step 2: Evaluate for Symptoms

• Assess for genuine hypogonadal symptoms: reduced libido, erectile dysfunction, fatigue, reduced muscle mass, gynecomastia, infertility. 1, 3
• If asymptomatic, no treatment is indicated regardless of free testosterone levels. 1, 4

Step 3: Address Underlying Causes

• Treat any identified cause of elevated SHBG (thyroid disease, liver disease, medication adjustment). 6
• Weight optimization if overweight/obese (though obesity typically lowers SHBG, metabolic optimization improves overall androgen status). 6

Step 4: Treatment Decisions (Only if Symptomatic)

If symptomatic despite normal total testosterone and normal LH:

• DO NOT initiate testosterone replacement therapy—this will suppress your normal LH and cause testicular atrophy, converting you from a man with normal testicular function to one with iatrogenic hypogonadism. 1, 4

• Consider selective estrogen receptor modulators (SERMs) like clomiphene citrate if fertility preservation is desired and symptoms are significant, as these raise endogenous testosterone production without suppressing the HPT axis. 1, 7

• Most importantly: address the root cause of elevated SHBG first, as correcting this may normalize free testosterone without any hormonal intervention. 6, 3

Critical Pitfalls to Avoid

• Never treat based on free testosterone alone when total testosterone is normal and LH is normal—this represents a laboratory finding, not a disease requiring treatment. 1, 3
• Testosterone replacement in your scenario would be inappropriate and harmful, causing testicular atrophy through suppression of your currently normal LH levels. 1, 4
• Validated questionnaires should NOT be used to diagnose testosterone deficiency or guide treatment decisions—they have poor specificity and sensitivity. 1
• Many men with borderline free testosterone but normal total testosterone do not have true hypogonadism—only 24.7% of men with borderline total testosterone have confirmed hypogonadism by free testosterone criteria. 3

Monitoring if No Treatment Initiated

• Recheck testosterone panel (total, free, SHBG, LH) in 6-12 months to ensure stability of the pattern. 6
• Annual monitoring if the pattern persists but remains asymptomatic. 6