Have you been noticing that you have symptoms generally associated with testosterone deficiency; loss of sex drive, depressed mood, anxiety, decreased sense of well being, difficulty concentrating, memory issues, fatigue, and even poor sleep? Then, after being tested you were told that everything was normal? It may be a problem of the testosterone deficiency being masked and your physician just did not appreciate the flaws in the testing.
There is a real prejudice in the medical community toward testosterone and a significant under-appreciation of the benefits of this hormone of vitality. Most physicians fear prescribing it due to its classification as a CIII controlled substance – same category as Lortab and fear that their patients will abuse it. Unfortunately, this tainted view has led to many patients being turned away when they would benefit greatly. We have drifted too far away from the ART of medicine where we truly listen to the symptoms described by our patients and assess their potential issues in a combination subjective and objective ways. Many now rely solely on the objective value of your lab tests. Unfortunately the testing is frequently not understood by the physician ordering it.
The main problem is that we are testing the wrong thing. Most of the time when testing is requested, we order a total testosterone level but only 1-2.5% of this amount is actually free usable testosterone. This means that 97-99% of this value is bound to serum proteins and useless. Very small changes in the percent of free can have a dramatic effect on the usable amount of testosterone.
The bulk of this binding is because of a protein called sex hormone binding globulin or SHBG and the amount of SHBG that each person has can be affected by many things. We are seeing more and more issues with excessive binding due to elevated SHBG in clients coming to see us. Other physicians are also noting this trend in their patients.
The following can cause increased SHBG levels:
- elevated estrogen (from overweight males)
- liver disease (hepatitis, alcohol)
- low insulin levels (healthy people, especially eating paleo)
- calorie restriction
- green tea
- increased protein/carb ratio (paleo eating)
- certain medications
I need to mention one particularly nasty SHBG elevator and that is contraceptives. We have seen huge elevations with oral contraceptives and even the vaginal rings. These levels increase 4-5x over normal range, essentially leaving women with zero free testosterone – talk about birth control…yikes. Interestingly, the elevation observed in women on birth control, though lower, still persists even one year after stopping.
I have seen clients with total testosterones that were in the mid ranges that actually had free testosterones lower than clients that had pathologically deficient levels of total testosterone due to elevated binding. There is not even a consensus on what constitute a normal value. Harvard studied 25 labs that performed testosterone assays and found large variability on what was considered normal ranges and in fact the majority of the lab directors reported that there was no clinical relevance to the reported ranges. (J Sex Med. 2006 Nov;3(6):1085-9). Think about that, clinicians use those ranges to determine whether a person “qualifies” for treatment yet the lab directors say that these values are not clinically relevant.
So what can we do? First, if you are experiencing symptoms that are consistent with low levels, get some comprehensive blood work – free and total testosterone, SHBG, estradiol, and liver studies. Second, talk with a physician that is knowledgeable in testosterone replacement and management. If you do have elevated SHBG, then discuss ways to overcome this issue.
Studies have shown benefit with the following treatments:
- estrogen lowering medication in men
- stinging nettle supplementation
- boron supplementation
- Vitamin D supplementation
For women on birth control, the first step is to get off the medicine but this will also be a gradual process for recovery of healthy levels so discuss options with your physicians. In women with this issue, we have seen dramatic improvements in libido, body composition, mood, and general well being when the SHBG levels normalize.