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When it comes to testing hormones (which I believe should always be measured with a DUTCH panel—they’re available for men and women you can reach out to me if you’d like to order), there’s a consideration that I’ve known about for a long time and it’s been recently elucidated to me just how important it is.

I’ve done a deep dive on it because I currently have three clients—two women, one man—who are presenting with this situation and as many of you know, my deep dives often end up as blog posts.

We’re talking about a possible hormonal hostage situation.

• Are your hormone levels “within range,” but you’re still symptomatic?
• Are you working to balance your hormones, but it feels like you’re pushing a rock uphill?
• Are you on HRT (hormone replacement therapy), but you’re still symptomatic—and your provider wants to increase your dose?

If so, it’s possible that your SHBG (sex hormone binding globulin) is high. Note the word: binding.

Remember, this isn’t just a problem for women, as men can also be affected…greatly.

Even if you don’t identify with any of the above, it’s important to test SHBG alongside any hormone panel, DUTCH or otherwise. DUTCH = dried urine testing for comprehensive hormones.

Now, the DUTCH doesn’t test SHBG. Why? Because SHBG is a protein found in serum and therefore, cannot be measured via urine.

What is SHBG?

SHBG is a glycoprotein produced primarily by the liver and is the body’s most underappreciated (and possibly the most undertested) molecular babysitter—it binds your sex hormones (primarily testosterone and estrogen) and renders you all dressed up with no hormonal place to go.

And yes, women definitely need testosterone (for mood and mental clarity, muscle mass, cognitive function, bone health, metabolic health) and men definitely need estrogen (for bone health, brain function and mood, cardiovascular health, testosterone balance).

Even if your testosterone and estrogen levels are “normal” on your hormone panel, elevated SHBG has rendered them inactive—it binds tightly to these sex hormones and acts like a bossy hall monitor of your endocrine system. Remember, it’s the availability of free and unbound hormones that keeps our hormonal symphony playing along as it should.

When testosterone is locked up, you’re going to see the classic symptoms of low T: libido, muscle growth, motivation? Sorry, they’re all tied up.

When estrogen is locked up, you’re going to see the classic symptoms of low estrogen: joint pain, forgetfulness, dry skin, sleep issues, mood swings, etc.

Why the vast majority of doctors don’t automatically run this lab, I don’t know. (Ask for it, or I can get it for you for an insanely inexpensive price. You can reach out to me if you’d like to order.)

Yes, high SHBG can make HRT biologically inactive!

Taking HRT with high SHBG is like throwing a party where everyone gets locked in the bathroom—they’re there, but nobody’s having any fun.

As SHBG increases, it can render HRT far less effective, again, despite “normal” labs.

Vicious cycle alert…

High estrogen is one of the primary causes of elevated SHBG. So…estrogen HRT, especially if it’s oral or dosed too high, can keep you stuck in a never-ending cycle of symptoms. Oral estrogen undergoes first-pass liver metabolism and signals the liver to pump out more SHBG, whereas transdermal estrogen (gel, patch, cream) doesn’t pass through the liver and is said to have less impact on SHBG.

Here’s a possible scenario:

• You start estrogen HRT and SHBG increases.
• Your unbound estrogen drops (despite total levels looking okay).
• You’re still symptomatic and your provider invariably increases your dose.
• SHBG rises even higher and you have even less free estrogen.
• You’re left with “normal” labs or high “total estrogen” and little to no symptom relief.

Other causes of elevated SHBG

Hormonal factors
In addition to high estrogen, which also shows up with pregnancy and oral contraceptive use, an overactive thyroid (hyperthyroidism) stimulates SHBG production. Yes, an estrogen-based birth control pill and excessive dosing of thyroid HRT (for underactive thyroid/hypothyroidism) can cause high SHBG.

Additionally, low androgens (DHEA, testosterone), which, in my opinion, is a rampant issue for both men and women and aren’t measured often enough (yes, DUTCH measures them) can cause SHBG to increase. Sufficient androgen levels suppress SHBG, so if they’re low, SHBG often increases as a teeter totter/compensatory mechanism.

Speaking of testosterone, aging can cause SHBG to increase, especially in men. This is one of the primary and most overlooked culprits in “low T” and in fact, high SHBG has been nicknamed “the testosterone handcuffs.”

So men, don’t let your provider simply test your Total T. You need to measure your Free T as well as SHBG. (You’re best off with a DUTCH panel for DHEA, T, and the T metabolites, along with a serum SHBG test.)

Nutritional and metabolic factors
Malnutrition, low protein intake, caloric restriction, low body fat, and anorexia can be a big problem. One popular dietary practice—intermittent fasting—is said to mildly elevate SHBG in some.

Impaired liver health
Mild liver disease, which is often a result of excess alcohol consumption, can increase SHBG, but advanced liver disease actually lowers it. Please don’t start going on benders to lower your SHBG! Some naturally have elevated SHBG because of inherited differences in liver regulation.

What are the reference ranges?

I almost didn’t add this section. I’m not a doctor. And thus, I’m not giving medical advice or assisting you in diagnosing yourself.

As with most reference ranges, there’s nuance. You’re going to get differing opinions, even from medical providers and various labs.

Several years ago, I received a lengthy document with pretty much any lab biomarker you can think of. It’s a side-by-side comparison of conventional/allopathic vs. functional/integrative reference ranges—an amalgamation of notes from several respected doctors. When I received this thing, I thought, this is manna from heaven. I’ve treated it like gold.

Remember, conventional ranges are based on a sick population (“pathology and disease detection”). Functional ranges are based on a healthy population (“optimization”). We want healthy.

It says:

Sex Hormone Binding Globulin (female): 25 - 122 nmo/l
Sex Hormone Binding Globulin (male): 30 - 40 nmo/l

Now…

For the women’s range above, I’ve learned that it’s “broad functional” and with SHBG that high, there are “obvious issues.” And that most integrative providers now consider 30-60 nmo/l to be optimal, especially when using HRT. (Always confirm the units.)

For the men’s range, it’s said that 40 nmo/l is indeed the upper limit from a functional perspective and that 60 nmo/l is “broad functional.” (Remember, confirm the units.)

One of my clients had SHBG of 287 on their last panel. Clearly higher than 60, and clearly higher than 122.

How to lower SHBG

The strategy depends on what’s driving elevated levels in the first place, so some sleuthing is warranted. You’ll want to address the underlying causes that we’ve discussed here while supporting overall hormone balance and metabolic health.

Manage thyroid health
Balance an overactive/hyperthyroid situation, even if it’s subclinical. Remember, overdosing of thyroid HRT if hypothyroid is often a problem.

Very low TSH (thyroid stimulating hormone) is often a telltale sign that thyroid hormone replacement is too high and you’re overmedicated. You can find a one-page functional thyroid panel here. (The DUTCH doesn’t test thyroid hormones, but I can get you a full/functional thyroid panel at a very low cost.)

Speaking of thyroid HRT, as I said in my article, The Risk: Thyroid Hormone Replacement and Osteoporosis…

Seriously consider whether thyroid hormone replacement is right for you. I’m not here to suggest changes to anyone’s prescriptions. But it’s a fact that millions are on Levothyroxine (aka Synthroid, Unithroid, and Tirosint)—it’s the second most prescribed drug, next to statins. It’s estimated the 23 million are on levo. And that 21 million of them don’t need it. 

Manage estrogen
Do a DUTCH panel to measure E1, E2, and E3 and their three metabolites. Additionally, avoid xenoestrogens (plastics, fragrance chemicals, pesticides), and resolve any constipation because estrogen is reabsorbed if things aren’t moving.

Support your liver
Among many other benefits, liver detoxification enhances hormone clearance and estrogen metabolism.

Reconsider the birth control pill
This is worthy of another post, but there are a LOT of issues with BCP use, including nutrient depletion, an altered microbiome, and liver stress. Oh, the issues that so many women see while on BCP—including post-pill syndrome after getting off.

Correct low androgens
Again, I believe that the DUTCH is the clear winner when it comes to testing androgens, but you can ask for these from your provider: Total T, Free T, DHEA-S, estradiol, SHBG.

Low dose DHEA supplementation can help to increase free testosterone and reduce SHBG with two caveats:

1. DHEA should only be taken if it’s is proven to be low.

2. DHEA is a precursor for testosterone (it converts to T, so you’re catching two butterflies with one net), but more so for women. For men, its ability to significantly raise testosterone is limited and highly individualized. Conversion is variable. Belly fat? That DHEA is way more likely to convert to estrogen. Ever heard of moobs? (Male boobs.)

Gain weight
If underweight, improve nutritional density and put some body mass on.

Get adequate protein
We should be getting protein with every meal.

Reduce chronic stress
High cortisol (an adrenal stress hormone) can dysregulate sex hormones and increase SHBG. There’s a very tight relationship between thyroid and adrenal health—you cannot address one without addressing the other.

Limit alcohol intake
Even moderate alcohol can increase SHBG in some (especially women).

Exercise wisely
While resistance training increases Free T and can help to lower SHBG, overtraining may raise SHBG by reducing androgens and increasing stress hormones.

Nutraceutical strategies

These should be used with labs and supervision. Always test before supplementing, especially with hormone-modulating herbs.

• Again, DHEA. See above for caveats.
• Zinc has been shown to provide mild SHBG inhibition.
• Boron lowers SHBG and can help to increase Free T.
• DIM (diindolylmethane) for estrogen detox—should only be used with clear evidence of estrogen dominance or impaired estrogen metabolism. You’ll get some DIM from cruciferous vegetables and no, they’re not going to slow your thyroid. And no, you should not avoid them if you’re unsure if you’re estrogen dominant or have impaired estrogen metabolism.
• Ashwagandha is an adaptogen that helps to manage cortisol and it modestly increases testosterone. Note: ashwagandha is a nightshade, so if sensitive, you’ll want to reverse the sensitivity prior to taking it.
• Nettles binds to SHBG, displacing testosterone. It doesn’t lower SHBG itself, but increases bioavailable testosterone.

For years, my clients have automatically received several labs when they enroll in a private coaching program with me: a DUTCH (again, reach out to me if you’d like to order), a GI Map, a functional thyroid panel, B₁₂, and iron/ferritin.

No, these aren’t all the labs that are often needed. And as of today, an SHBG test is now part of that list. It’s that important—we need it from the get-go.

Again, why the vast majority of doctors don’t automatically run this lab, I don’t know…