Interpretation of Testosterone Levels with Low SHBG
Your testosterone levels indicate borderline-low total testosterone (364 ng/dL) with a markedly elevated free testosterone (116.4 pg/mL) and very low SHBG (11.0 nmol/L), which represents functional eugonadism—you do NOT have true testosterone deficiency and should NOT receive testosterone replacement therapy. 1, 2
Understanding Your Laboratory Results
Your pattern reveals a critical diagnostic nuance that is frequently misunderstood:
Low SHBG (11.0 nmol/L) causes your total testosterone to appear falsely low, while your free testosterone—the biologically active form—is actually elevated well above normal ranges (normal free testosterone is typically 50-100 pg/mL) 2, 3
The free androgen index (total testosterone/SHBG ratio) is 33.1, which is markedly elevated and indicates functional hyperandrogenism, not hypogonadism (a ratio <0.3 indicates functional hypogonadism) 2
This pattern is most commonly seen in obesity, metabolic syndrome, and insulin resistance, where increased aromatization of testosterone to estradiol in adipose tissue and low insulin states suppress SHBG production 1, 2, 3
Why Testosterone Therapy is Contraindicated
The European Association of Urology explicitly recommends against testosterone therapy in eugonadal men, even for weight loss, cardiometabolic improvement, cognition, vitality, or physical strength in aging men. 1, 2
Your free testosterone is the bioactive form that drives all physiological effects, including sexual function, muscle mass, bone density, and libido—and yours is elevated, not deficient 2, 3
Testosterone therapy in your situation would cause supraphysiologic free testosterone levels, increasing risks of erythrocytosis (hematocrit >54%), cardiovascular events, and prostate complications without providing any benefit 1, 4, 5
Approximately 20-30% of men receiving testosterone in the United States do not have documented low testosterone levels before treatment initiation, a practice pattern that violates evidence-based guidelines and causes unnecessary harm 1
Recommended Management Algorithm
Step 1: Address Underlying Metabolic Causes
Weight loss through low-calorie diets and regular exercise is the first-line intervention for obesity-associated low SHBG and should be attempted before any hormonal intervention. 1, 3
Optimize metabolic control if diabetes or metabolic syndrome is present, as this can normalize SHBG levels and improve the testosterone/SHBG ratio 1, 3
Evaluate for sleep disorders, thyroid dysfunction, anemia, and vitamin D deficiency, as these conditions can cause symptoms that mimic hypogonadism 1
Step 2: Investigate Reversible Causes of Low SHBG
Check thyroid function tests (TSH, free T4), fasting glucose and HbA1c, liver function tests, and review all medications to identify reversible causes of SHBG suppression 2, 3
Medications that can lower SHBG include glucocorticoids, growth hormone, and certain anticonvulsants—discontinue if possible 2
Chronic liver disease can paradoxically elevate SHBG, but acute hepatic steatosis from metabolic syndrome typically lowers it 2
Step 3: Confirm You Do NOT Have True Hypogonadism
True biochemical hypogonadism requires BOTH total testosterone <300 ng/dL on two separate morning measurements AND low free testosterone by equilibrium dialysis (<50 pg/mL), which you do not have. 1, 3, 4, 5
Your free testosterone of 116.4 pg/mL is more than double the lower limit of normal, confirming you are functionally eugonadal despite borderline-low total testosterone 2, 3
If you have symptoms of fatigue, low energy, or reduced libido, these are NOT due to testosterone deficiency and will not improve with testosterone therapy 1
Expected Outcomes if Testosterone Were Inappropriately Prescribed
Testosterone therapy produces little to no effect on physical functioning, energy, vitality, or cognition, even in men with confirmed hypogonadism—and you do not have hypogonadism. 1, 3
The primary indication for testosterone therapy is diminished libido and erectile dysfunction in men with confirmed biochemical hypogonadism, with small improvements (standardized mean difference 0.35) 1, 3
In your case, testosterone therapy would only increase your already-elevated free testosterone to supraphysiologic levels, causing harm without benefit 1, 2
Critical Pitfalls to Avoid
Never initiate testosterone therapy based on total testosterone alone without measuring free testosterone in patients with suspected SHBG abnormalities. 2, 3
Relying solely on total testosterone without measuring free testosterone misses approximately half of true hypogonadism diagnoses when SHBG is elevated, but in your case, it would cause inappropriate treatment when SHBG is low 2, 3
Never assume symptoms of fatigue, low energy, or reduced motivation are due to testosterone deficiency without confirming both low total AND low free testosterone on two separate morning measurements 1, 3, 4, 5
Never start testosterone without confirming the patient does not desire fertility, as exogenous testosterone suppresses spermatogenesis and causes prolonged azoospermia 1
What Your Provider Should Do Next
Your provider should focus on lifestyle modification (weight loss, exercise, dietary changes) and investigation of metabolic syndrome, insulin resistance, and other reversible causes of low SHBG. 1, 2, 3
Repeat fasting morning total testosterone, free testosterone by equilibrium dialysis, and SHBG in 2-3 months after implementing lifestyle changes to confirm the pattern persists 1, 3
If symptoms persist despite normal free testosterone, evaluate for depression, sleep apnea, thyroid dysfunction, vitamin D deficiency, and other non-hormonal causes 1
Do NOT prescribe testosterone therapy, as you do not meet diagnostic criteria for hypogonadism and treatment would cause harm without benefit 1, 2, 4, 5