124. SHBG: One Reason Why “Normal” Hormones Can Still Feel Off

What if one overlooked protein quietly shaped your hormones, cycles, and metabolic health? In this episode of Cycle Wisdom, Dr. Monica breaks down Sex Hormone Binding Globulin (SHBG)—what it is, why it matters for both women and men, and how low levels can drive acne, irregular cycles, ovulation issues, insulin resistance, and hormone imbalance. You’ll learn how SHBG affects free testosterone and estrogen, when to test it, and how a restorative approach can improve it by treating root causes like insulin resistance, thyroid dysfunction, and liver health—helping hormones finally align with how you feel.

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Transcript

Speaker 2: 0:02

Welcome back to Cycle Wisdom, where we empower women to restore natural menstrual cycles, to improve health and promote fertility. I'm your host, Dr. Monica Minjeur, and I'm so glad you're listening today. What if a single protein that was made in your liver quietly shaped your entire hormone story? How much estrogen or testosterone is actually available to your tissues? How regular your cycles feel and even your risk for metabolic dysfunction. Today we're going to unpack SHBG or sex hormone binding globulin. We'll discuss what it is, why it matters for both women and men, and most importantly, how to improve it in a restorative evidence-based way to help get your hormones back on track. Let's get started today with a story about a patient who we'll call Michelle now. Michelle came to us at 29 years of age and she was having irregular menstrual cycles anywhere from 40 to 60 days apart. She had a lot of acne on her chin and significant mood disturbances during the middle part of her cycle. After seeing multiple different doctors, she felt dismissed. She was told Your labs are normal. Maybe you should just go on birth control. But Michelle wanted real answers, not just a coverup. And so as with all of our patients, we completed a full lab panel, which includes evaluation for sex hormone binding globulin. And not surprisingly, we found that her SHBG level was quite low. Now, the part that isn't always so obvious is that oftentimes this means that even if you have a normal testosterone level, but your SHBG is low, this means that the amount of free testosterone is quite high in your system, which can explain the increased acne, oily skin, and significant ovulation variability. So Michelle's charting showed that she was indeed ovulating, but it was just happening much later in her cycle. We also revealed elevated fasting insulin levels, normal blood sugars, and a borderline low iron stores. And so as always, we focus on treating what it is that we find. We started with treating her insulin resistance, specifically going through nutrition strategies. Resistance training and specific supplements for her. We also worked through improvements in sleep stress reduction, and over the next four to five months, we found that she had a significant improvement in her sex hormone binding globulin with a decrease in the free testosterone levels, which meant a reduction in her symptoms. And Michelle said to us, I finally feel as good as my labs say that I should. So what is SHBG? What is this? Sex hormone binding globulin that can make such a big difference. SHBG is a protein that is made by your liver that is designed to bind up sex steroids, specifically testosterone and estrogen, and helps to regulate how available it is to the rest of your tissues. I like to describe it in my practice that SHBG is basically the train. That picks up those hormones and takes them where they need to go in your body, but also means that they are not available to do other things in your body. So for example, if you don't have too much excess free testosterone flying around, you have less ability to be able to have significant acne, oily skin and facial hair growth. So it's really important that we focus on this SHBG in helping to improve levels so that we can bind any excess. That may otherwise be causing problems. So why does this matter? The free hormones are only a small percentage of the hormones that are regulating in your cycle, and this is why though that two people with the exact same total testosterone levels can feel and look completely different. Their SHBG level is different. For example, if your SHBG level is really low, even with a normal testosterone level, you can have significant symptoms of excess testosterone because not as much of it is bound to that SHBG or it's not in the train, as we can say. If your SHBG is normal and your testosterone is normal, you are less likely to have excess testosterone symptoms. Now, low sex hormone binding globulin is not just a lab marker that we check off, but low levels also are strongly predictive of future metabolic dysfunction. Findings show that actually having low SHBG can lead to increased risk of type two diabetes in both women and men in the future. So again, very important to pay attention to this, not just from a standpoint of your menstrual cycle. But for your overall health as well. So let's talk specifically about what SHBG means when it comes to women's menstrual cycle health and fertility. Now, in women with irregular cycles, and especially those that have PCOS or polycystic ovarian syndrome, we find that oftentimes the link is elevated insulin levels that directly suppress or decrease sex hormone binding globulin. This in turn, as we mentioned previously. Increases the free testosterone, which then will add to acne, facial hair growth and ovulation dysfunction. The way we fix this, correct, the insulin resistance, this will oftentimes increase sex hormone binding globulin, and help to improve the cycles overall. Now when we find that those free androgens are high, and SHBG is low, ovulation is oftentimes delayed or weaker. That mid luteal phase, progesterone level can be decreased, and this is why it makes all the difference in the world to know when ovulation is happening so that we can assess appropriately if progesterone might be needed for you. Two other quick times that I want to mention that SHBG levels can be off. One is gonna be in perimenopause and menopause transition, and the variability and ovulation can shift that balance of free hormones and SHBG. And then the other time is going to be postpartum. Now, we know that oftentimes your cycles and hormones will do all sorts of wild and crazy things in the postpartum timeframe, but when you have a variable return of ovulation, that can really add to things and throw things off. And so it's not uncommon for women postpartum to develop more significant symptoms of excess testosterone, especially if sex hormone binding globulin isn't keeping up to bind the excess. Now sex hormone binding globulin is not just for females. It is something that men have as well. And low SHBG levels will lead to increased chances of obesity, insulin resistance, and higher cardiometabolic risk, similar to female. So again, it's changing the free testosterone, and this may track with semen quality in some men via that metabolism. So again, same as for women with men, we treat metabolism concerns with making sure we get adequate sleep, plenty of regular exercise, maintaining a healthy weight and insulin levels. And oftentimes this will help to improve the balance of excess androgens and sex hormone binding globulin. So when do we test, or how do we test for this? Sex hormone binding globulin is best tested through a blood test just from a standpoint of ease. We are looking at it in our patients with every single menstrual cycle concern there is, including fertility issues because we need to know if we are fighting an uphill battle with SHBG because it often points to something else that's going on. You especially want to make sure that this is evaluated. If you're somebody that has irregular cycles, signs of excess testosterone, like acne or facial hair growth. If you have suspected polycystic ovarian syndrome, if you're having troubles with your libido. Or if your labs seem to be normal, but you are still having significant symptoms, now it's important to know that you shouldn't just evaluate sex hormone binding globulin independently. You want to look at this as part of a big picture, right? So evaluating total testosterone, estrogen levels, free testosterone levels, and in women, we interpret this alongside with the cycle charting in order to evaluate more consistently. Other things that oftentimes run hand in hand with low sex hormone binding globulin are going to be elevated fasting insulin, or an oral glucose tolerance and insulin test that is abnormal, increased weight, increased liver fat, or non-alcoholic fatty liver disease, or untreated thyroid dysfunction. And in fact, these are oftentimes the things that we're going to look at when it comes to knowing how do we help to improve sex hormone binding globulin? And again, we are looking at what is the underlying cause of that SHBG being low in the first place. So again, the number one most common driver of a low sex hormone binding globulin is going to be insulin resistant. So I would refer you back to episode number 1 0 7, where we talk all about insulin resistance, blood sugar, and hormones. In order to determine how do we need to help improve this, we wanna specifically focus on lower sugar or carbohydrates, higher fiber, higher protein, all with the intention to lower insulin and liver fat. In some cases, if it's appropriate, we also will utilize supplements like Myo acetol or prescriptions like metformin in order to help decrease that insulin sensitivity. And most importantly, focusing on maintaining healthy weight exercise, especially resistance and aerobic training can be a really great combination to utilize in order to help drive down that insulin resistance and help improve weight, which can also help to heal the liver. Lower that liver fat, which correlates with lower SHBG. Something else that's really important to pay attention to is thyroid. As we've discussed so many times, thyroid can hijack all of the other hormones, and we find that thyroid hormones will actually increase production of sex hormone binding globulin. So if you are deficient in thyroid, whether it's T four, T three, or both, we wanna make sure that thyroid hormone is. Optimized in order to improve SHBG function and help to stabilize that free testosterone and estrogen balance. Other more indirect things that can help would be to optimize your iron intake. Make sure that your ferritin levels or your iron stores are in good range. Improve the quality of your sleep and reduce chronic stress where possible. All of these will otherwise aggravate insulin resistance and increase your fatigue and stress response. So fixing these can help to restore an improved balance on sex hormone binding globulin. And finally, correcting underlying dysfunction with medications may be appropriate in your particular situation. So again, this is where it's important to work with somebody who understands the role of SHBG and how it plays a picture in your bigger story. So for example, you may need to be on prescription strength medication to lower your insulin like metformin. Or you may need to be on prescription strength bioidentical estrogen to help improve the sensitivity. Now again, this is not just a blanket prescription. This is looking to see again, what is the underlying cause of that low SHBG and working to fix it. So what are some things that you can do if your symptoms haven't been aligning and you find out, Hey, I've got a low SHBG, I have some insulin dysfunction. So first, as I mentioned, working towards that resistance training, that is really crucial for helping with insulin resistance, building your meals around higher fiber. Good quality, fiber, and balanced carbs also makes a significant change. Again, focusing on that insulin resistance and then considering, am I getting enough sleep? Am I aiming for that eight to nine hours a night? Is my stress well managed? Am I limiting my excess sugars and alcohol? All of those things will spike your insulin if you are not doing them adequately. So again, sleep. Stress and removal of excess sugars in your diet. All of these, in addition to treating the underlying cause, can help to get sex hormone binding globulin back on track, helping to maintain a better balance for the long-term with estrogen, testosterone, and all of the rest of your hormones. Imagine if your hormones finally felt in balance because you addressed the hidden cause of low sex hormone binding globulin at its source. Over a few cycles, ovulation cues can become more pronounced. Acne and oily skin can calm down, and your luteal phase would improve. Your labs can actually reflect how you feel to improve health and promote fertility.

Speaker: 14:15

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