My SHBG (sex hormone‑binding globulin) is 95 nmol/L; I have normal total testosterone, LH (luteinizing hormone), FSH (follicle‑stimulating hormone) and sperm count but low libido and erectile dysfunction—what does this indicate and how should I manage it?

High SHBG with Normal Testosterone, LH, FSH, and Sperm Count but Low Libido and Erectile Dysfunction

Your elevated SHBG (95 nmol/L) is likely reducing your bioavailable testosterone despite normal total testosterone, which explains your sexual symptoms—this pattern requires measuring free testosterone and addressing underlying causes of high SHBG rather than starting testosterone therapy. 1

Understanding Your Hormone Profile

Your clinical picture represents functional hypogonadism due to elevated SHBG binding excessive testosterone and reducing the biologically active (free) fraction. 1

• SHBG >60 nmol/L occurs in only 5.6% of men presenting to men's health centers, and your level of 95 nmol/L is markedly elevated. 2
• Normal total testosterone with high SHBG can mask true androgen deficiency because the SHBG-bound fraction is biologically unavailable for tissue effects. 2, 3
• Among men over 60 years with erectile dysfunction, 26.3% have normal total testosterone but low free testosterone due to elevated SHBG—this symptomatic hypogonadism would be missed by screening total testosterone alone. 3

Essential Diagnostic Steps

Measure Free Testosterone Immediately

• Free testosterone by equilibrium dialysis (gold standard) or calculated free testosterone using the Vermeulen formula is mandatory to confirm true androgen status. 1, 4
• Do not use direct immunoassay measurements of free testosterone—these are unreliable and should never guide clinical decisions. 4
• If calculated free testosterone is used, ensure albumin is measured (not assumed at 4.3 g/dL) when SHBG is this elevated. 5

Identify the Cause of Elevated SHBG

Common causes of SHBG elevation include: 1

• Hyperthyroidism—check TSH, free T4, and free T3 immediately. 1
• Hepatic disease—obtain liver function tests (AST, ALT, bilirubin, albumin). 1
• HIV infection—consider HIV testing if risk factors present. 1
• Medications—anticonvulsants, estrogens, thyroid hormone excess. 1
• Aging—SHBG increases with age, and men >60 years have mean SHBG of 36.6 nmol/L with 9% exceeding 60 nmol/L. 1, 2

Treatment Algorithm

If Free Testosterone is Low (<6.5 ng/dL or <65 pg/mL)

Step 1: Address Reversible Causes First 1

• Treat hyperthyroidism if present—correction of thyroid dysfunction normalizes SHBG and improves sexual function. 1
• Optimize liver disease management if hepatic dysfunction is identified. 1
• Discontinue SHBG-elevating medications when feasible (anticonvulsants, excess thyroid hormone). 1

Step 2: Lifestyle Modifications 4

• Weight loss if BMI >25—obesity paradoxically lowers SHBG but metabolic optimization improves overall hormonal function. 4
• Regular physical activity—150 minutes/week moderate-intensity aerobic exercise plus resistance training 2-3 times weekly. 4

Step 3: Consider Testosterone Therapy Only After Above Steps 1, 4

• Testosterone therapy is appropriate if free testosterone remains low after addressing reversible causes and you have confirmed symptoms (diminished libido, erectile dysfunction). 1, 4
• Transdermal testosterone gel 1.62% at 40.5 mg daily is preferred first-line formulation due to stable levels. 4
• Target mid-normal testosterone levels (500-600 ng/dL) when monitoring therapy. 4
• Monitor hematocrit periodically—withhold treatment if >54%. 1, 4

If Free Testosterone is Normal (>6.5 ng/dL)

Testosterone therapy is contraindicated even with sexual symptoms, as you are biochemically eugonadal. 1, 4

Alternative management for erectile dysfunction: 4

• PDE5 inhibitors (sildenafil, tadalafil) as first-line treatment for erectile dysfunction regardless of testosterone status. 4
• Pelvic floor muscle training may improve sexual function. 4
• Psychological evaluation for performance anxiety, relationship issues, or depression contributing to sexual dysfunction. 4

Critical Pitfalls to Avoid

• Never start testosterone therapy based on total testosterone alone when SHBG is elevated—you will miss functional hypogonadism (low free T) or inappropriately treat eugonadal men (normal free T). 1, 3
• Never diagnose hypogonadism without measuring free testosterone when SHBG >60 nmol/L—17.2% of men with erectile dysfunction have normal total testosterone but low free testosterone. 3
• Never skip thyroid function testing—hyperthyroidism is a common reversible cause of elevated SHBG and sexual dysfunction. 1
• Never assume symptoms alone justify testosterone therapy—biochemical confirmation of low free testosterone is mandatory. 1, 4

Expected Outcomes

• If free testosterone is low and testosterone therapy is initiated, expect small but significant improvements in sexual function (standardized mean difference 0.35) and modest quality of life improvements primarily in sexual domains. 4
• Testosterone therapy provides little to no benefit for energy, physical function, or mood even with confirmed hypogonadism. 4
• If hyperthyroidism is the cause, correction of thyroid dysfunction improves semen quality and sexual function without testosterone therapy. 6