High SHBG Bloodwork Critique after 10 Weeks on TRT

Howdy folks,

Soliciting feedback on my first follow-up bloodwork after 10 weeks on TRT. After 10 weeks, I may have seen very minor improvements to symptoms but definitely not close to full resolution.

Background:

45 years old, generally good health with clean, lower carb eating (strong family history of diabetes) and consistent but not excessive exercise (mostly interval training and weight training, no chronic cardio). GP referred to an endo several months ago due to multiple classic low-T symptoms despite in-range TT. Onset of low-T symptoms has rolled on slowly over last 3-5 years.

My testosterone has been tested five times in the last 16 months. TT ranged from 353 ng/dL to 955 ng/dL (reference range 264 - 916), with an average result of 671.

SHBG has been tested three times over the last eight months. Average SHBG result was 69 [reference range 16.5 – 55.9]. Highest result was 80. The last two test results (both in 60’s) were months after significant dietary modifications including eating more carbs, not being calorie-restricted, and supplementing with Zinc, Magnesium, Nettle Root, and Boron. The final SHBG result of the three (high 60’s) was higher than the one prior so although the diet and supplementing mods may have helped SHBG a little, the trend was in the wrong direction after some initial improvement and it seemed fairly clear I wasn’t going to see significant SHBG/Free T improvement via diet and supplementation alone.

Thyroid and liver panels all looked very normal.

Pre-TRT:
TT = 353 ng/dl to 955 ng/dl (5 tests over a year) (range 264 - 916)
Free and weakly bound T% = 8% (range 9% - 46%)
Free and weakly bound T absolute = 31 (range 40 - 250)
Estradiol 23.5 (range 7.6 - 42.6 pg/ml)
Hematocrit = 50.9 (range 37.5 -51.0%)

10 weeks into TRT (100 mg Test C IM once weekly; results below at trough):
TT = 804 ng/dl (range 264 - 916)
Free and weakly bound T% = 20.6% (range 9% - 46%)
Free and weakly bound T absolute = 165 (range 40 - 250)
Hematocrit = 52.3 (range 37.5 -51.0%)
Estradiol not tested
SHBG not tested

Lipids pre- and post- are essentially unchanged. My cholesterol has always been high (strong genetic history) but actually got a fair amount better after dietary changes to introduce more carbs (probably the oatmeal breakfasts since oat fiber lowers cholesterol).

Follow-up with endo is next week.

Free T is trending in right direction but given lack of symptom resolution, Free T that’s got some room to move up, and history of high SHBG I’m thinking an incremental bump up in dosage is likely called for.

Questions:

  1. I think I’ve read on here before but can’t remember for sure - is there a metric that gauges how ‘sticky’ a person’s SHBG is?
  2. What’s your read on prudence of bumping up dose?
  3. If you were in my shoes, what would you advocate to bump the dose up to (if you think an increase is called for)?
  4. What other questions or considerations to discuss with my endo?

Thanks much!

Looks like you are headed in the right direction. I would normally say to discuss bumping the dose a bit with your doc. High SHBG guys typically would need slightly higher than 100mg/wk. What concerns me is your hematocrit. Its already now above range and more Test would make it worse. You need to discuss that with your doc.

Agree, and thanks much.

My hematocrit was in range by the narrowest of margins even prior to TRT (50.9, upper bound of range is 51.0)

Is there settled science on what causes higher hematocrit even when natty? Genetics? Environment? Diet? Exercise? Stress? Other?

My issues were similar to yours before I started TRT. High SHBG, lowish TT and very low FT. I’m on 140mg/wk and my FT is in the 2/3 of range while TT is top of range. This works for me. Regarding your hematocrit I don’t know a ton about that to be honest as I never had an issue. I know that being slightly above range is likely not a cause for concern but for you it is because yours will likely go higher with an increase in dose. @highpull What do you recommend for your clients in this scenario?

Hormones don’t always have immediate effects like drugs, tissue needs time to repair, heal for symptom resolution to occur.

Increase testosterone.

1 Like

Thanks much.

How much attention do you pay to hematocrit?

At what level (if any) do you recommend your patients address it?

Do you recommend anything other than therapeutic phlebotomy for patients that have high HCT?

If there is no other cause for high HCT, like sleep apnea, then you will need therapeutic phlebotomy. The TRT guidelines say anything over 55% requires action, but some doctors want it under 52%.

More pressure in the pipes, more wear and tear.

I get therapeutic phlebotomy every month due to hematocrit of 57% and hemoglobin 19.2. My endo isn’t as concerned with my hematocrit as much he is with the hemoglobin levels.

I also take 140mg iron daily split up 3x daily.

CBC is included in every lab order.

Depends on the individual. We have many patients living at altitude. They live at mid to upper 50s. Smokers will run higher, not many of them though. I’ll say 54-55% gets my attention and we start discussing options.

Hydrate, not at all unusual for them to be dehydrated. Decrease testosterone. Occasionally decrease cardio.

2 Likes

Thanks very much.

I’ve considered the hydration piece also and think there may be something to that. I’ve historically just let thirst be my guide but I’ve recently noticed I’ll often go hours during the day without drinking water.

Will definitely be more intentional about my hydration as a first step.

Yep, understood. It’s why you see guidance that some symptoms may take up to 6 months to resolve.

But the intent of the 12-week meeting with the endo was for him to gauge symptom resolution at an intermediate point rather than waiting the full six months to evaluate the efficacy of the initial 100 mg/week protocol. The implication was that he was going to evaluate where symptom abatement stood and potentially adjust dosage if the results were suboptimal relative to reasonable expectations at this juncture.

It has been a frequent thought of mine though - I’m a sample size of one, so I don’t have any context (aside from gleaning it from reading about other experiences on here) to know what “reasonable expectations” are at this stage.

It typically take 4-6 weeks to reach steady states on injections, possibly having to adjust the protocol more than once, and now 6 months has gone by and you’re still tinkering with your protocol.

Jatenzo, an oral T option reaches steady states in 7 days!

Things happen really fast on Jatenzo!

A new oral testosterone undecanoate therapy comes of age for the treatment of hypogonadal men

Clear advantages and disadvantages to each approach I’d say.

The quick feedback of Jatenzo is nice, but the price and convenience of a once a week Test C dose is nice too. Hell I may eventually try once every 10 days or longer and see if I can get away with it; the less often I have to administer the better as far as I’m concerned.

Brief update, met with endo this week and he wants to hold my dose where it is (100/week) for six more months, citing my mildly out of range HCT.

My HCT pre-TRT was 50.9 so it was only in range by the narrowest of margins; on TRT it’s bumped up to 52.3.

As a high-SHBG guy with ongoing libido/sensitivity issues I feel like my dose should be a little higher but I’ll roll with his recommendation for another few months.

If I’m still having sensitivity/libido issues in three months I may reach out and ask him to reevaluate bumping my dose.

My endo and hematologist aren’t concerned with my hematocrit, they are more focused on hemoglobin and as long as this is normal, they are satisfied.

I get phlebotomies so I can have optimal testosterone which is crucial to my glycemic control.

I’m finding extremely consistent levels every time I do labs. I can easily predict when my levels are going to be 4 hours after dosing and 4.5 hours.

How often do you do phlebotomies?

Have you done bloods before and after? Would be curious to know how the phlebotomy affects hematocrit and hemoglobin quantitatively.

I get phlebotomies monthly.

When I used to be at 57% hematocrit and 19.2 for hemoglobin, a phlebotomy would take me to 16.6 hemoglobin and 50% hematocrit.

It takes me a month for my hemoglobin to go from 16.6 → 18. My blood pressure did decrease after the phlebotomy, from 75 bpm 117/79 → 67 bpm 110/67.

My last HCT was 56%, just about 3 weeks ago. Today it is 42-45%, after taking 81mg Aspirin, 2000iu Nattokinase, 10mg Lisinopril all nightly. Test is 100mg/week but was much higher before that test. I bought a home meter to be able to finger prick and see changes more often, try to understand how it fluctuates during the day (it can go down by 6% from the AM first waking up reading to bedtime reading).

Something to look at maybe

Really good information, thank you!