This article is for the man or woman who is administering testosterone replacement therapy and is still symptomatic and shows suboptimal free testosterone levels. There is also useful information in here for men who may not be administering testosterone replacement therapy but their bloodwork shows high SHBG and suboptimal free testosterone levels.
Before we break down the components of testosterone and talk about how to maximize free testosterone I want to express that while I am the owner of Steel Health and Hormones Centre, a health optimization clinic in Pittsburgh Pennsylvania, I am not a medical doctor. This article should not be used to treat, diagnose, or prevent disease. This article should not be used to supersede the guidance of the medical professional looking over your personal health. You should always seek the help of a medical professional with sensitive subjects like hormones, and
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Now let’s get into this…
For this article it’s important to understand that testosterone is broken down into 2 different components; total testosterone and free testosterone. Total testosterone includes free testosterone but also includes the testosterone bound by sex hormone binding globulin and albumin. Free testosterone is the unbound version. For simplicity I want you to think about free testosterone as being the primary form of testosterone that people look for when administering testosterone replacement therapy.
As an anecdote, we sometimes see men who come into our clinic who have mediocre total testosterone levels (let’s say in the 300s), but they have all the classical symptoms of androgen deficiency (AD); low sex drive, week erections, increased fat mass, loss of strength, loss of drive etc. When we look at the breakdown of their testosterone, almost always their free testosterone is in the gutter.
Most men, when we administer small doses of testosterone multiple times per week will see a nice bump in total testosterone, and a large rise in free testosterone. Almost always this alleviates the symptoms associated with androgen deficiency. Most men can get away with 2 injections per week to achieve symptom relief.
However, there are other men in our clinic who do not achieve symptom relief for AD on the standard protocol. What usually happens is that we see a man’s total testosterone improve, but their free testosterone remains suboptimal. For these men we have to check out lifestyle factors, liver health, underlying disease, adjust treatment protocols, and add a supplement where necessary.1
The first thing we want to do if a man is still suffering from AD even after administering testosterone replacement therapy is check their liver health. We always do this with our patient intake, but it’s important to leave no stone unturned and multiple tests may be necessary. For the man with elevated liver enzymes, imaging may be essential. If the patient is dealing with liver disease (whether fatty liver or hepatitis), this needs addressed. Sometimes we have to refer out, or sometimes the patient needs to lose significant fat, which we can help the patient do with our GLP-1 Receptor Agonists like Semaglutide and Tirzepatide.
If the patient has a healthy liver and no underlying disease we may increase the frequency of injections. Some men will show increased free testosterone on the same dose if it’s spread out into smaller, more frequency injections. I speculate that this is because there is less variation in
levels throughout the week, which may allow the liver to make less SHBG resulting in higher free testosterone. Relatedly, some men just need a larger dose.2 There is good research to suggest that larger people just need a larger dose to achieve optimal levels of testosterone. This is why individualized patient care is so important, and it’s a cornerstone to our philosophy at Steel Health and Hormones Centre.
Additionally, if we’ve checked the man for liver disease, helped him achieve a healthy body composition, we’ve increased the frequency of injections, and we’ve prescribed a dose that if we were to increase, we believe would result in deleterious outcomes, we can start looking into supplements. A supplement that shows promise is Boron. Boron is a trace mineral that shows tremendous health benefits, and it also shows an ability to lower SHBG and therefore significantly increase free testosterone. The dose used in the study that I’ll link below was 6mg per day.3
If you’re a man on testosterone replacement therapy and you’re still dealing with androgen deficiency caused by low free testosterone, here is the step by step approach we take at Steel Health and Hormones Centre, located in Pittsburgh Pennsylvania.
- Check for underlying disease, particularly in the liver.
- Increase the frequency of injections.
- Increase the dose.
- Supplement with boron.
A note of caution, you DO want healthy SHBG levels. In terms of free testosterone, more is not always better, more could just mean more side effects. You should be working with a clinic that monitors you closely and keeps their fingers on the pulse of your health and treatment protocol. If you’re interest in working with a clinic like ours, fill out the contact form below.
- https://medlineplus.gov/lab-tests/shbg-blood-test/
- https://www.urologytimes.com/view/higher-testosterone-dosing-may-be-required-for- patients-with-a-higher-bmi
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4712861/
