TRT without the use of Aromatase Inhibitors

[Vince Carter]

I think you and I have similar situations. My SHBG is in the low teens, most recently it came in 14 while my ultra sensitive estradiol was at 30. I think I may need to lower mine a bit. I’m going to ask my doctor about the free E test as well

Feel Free to PM to discuss if you like.

 

[bkb33]

I bet your prolactin levels are above normal. That can kill libido. The problem with high T is managing estrodial and prolactin.

That's interesting. I've had a lot of bloodwork done in the past year but haven't had that number tested. I've been told my hormone levels aren't indicative of highly elevated prolactin. My doctor did, however, recommend that I try B6, which I understand lowers prolactin. I started taking 300mg every day a little over a month ago -- obviously, I can't imply correlation from this, but my symptoms have gotten worse in this time, so I'm not certain that lowering prolactin will fix my issues.

I'd like to hear what Dr. Crisler thinks, but my current thought is that I may:
1. Decrease (but not entirely eliminate) my A.I. usage
2. Start a "low and slow" T dose

Thoughts? Good/bad plan? With so much mixed information out there, I'm pretty confused about what's happening in my body.

 

[Dr. John Crisler]

I don't think there is any question aromatase inhibitors are being over prescribed. This has been Nelson's message here for quite some time.

We still do not know if there may be any long term side effects from causing estrogen to rise to two or more times the top of normal range. But we do know for sure low estrogen is always bad for us. So between the two directions, the choice is clear.

For years I have treated, and taught, I do not add an AI in absence of elevated estrogen symptoms. There is just so much we still need to learn.

 

[bkb33]

I don't think there is any question aromatase inhibitors are being over prescribed. This has been Nelson's message here for quite some time.

We still do not know if there may be any long term side effects from causing estrogen to rise to two or more times the top of normal range. But we do know for sure low estrogen is always bad for us. So between the two directions, the choice is clear.

For years I have treated, and taught, I do not add an AI in absence of elevated estrogen symptoms. There is just so much we still need to learn.

@Dr. John Crisler, when you say elevated estrogen symptoms, does low libido fall into that category? Or are you talking more about nipple sensitivity, moodiness, etc.?

 

[Nashtide]

I don't think there is any question aromatase inhibitors are being over prescribed. This has been Nelson's message here for quite some time.

We still do not know if there may be any long term side effects from causing estrogen to rise to two or more times the top of normal range. But we do know for sure low estrogen is always bad for us. So between the two directions, the choice is clear.

For years I have treated, and taught, I do not add an AI in absence of elevated estrogen symptoms. There is just so much we still need to learn.

Interesting. So no AI in the absence of symptoms I even if the E2 is well over the range?

 

[Cips1975]

As an Osteopathic physician, less drugs is better. To be clear, I wish we never had to add an AI to a gentleman's TRT regimen.

Through this thread, let's explore this topic. I am especially interested in hearing from guys who previously were on an AI, then successfully discontinued it.

At a given weekly testosterone dosage, we can often times reduce estrogen and/or elevated estrogen symptoms, by dividing up the individual dosages. Rapid accelerations in serum androgen levels increase the activity of the aromatase enzyme. So smoothing out the dosing lowers subsequent estrogen.

This has the added benefit of retaining more testosterone in the body; rapid accelerations in androgen levels also increase urinary excretion of androgens (but not estrogen, unfortunately). One study concluded 40mg twice per week of test cyp is about the same as 100mg once per week.

Many are finding relief from injecting small daily doses. I am happy to have all my injectable TRT guys do that..IF they have the time. Everything is a negotiation in medicine.

Also, just changing hormone levels can cause effects, both positive and negative, and while a hormone level is both rising or falling. For that reason, I usually have my patients wait a month before doing labs, to let things even out.

From what I have read, some are reporting things got better, but not until the second month. Getting a guy to wait it out is the hard part. Many get quite anxious if they feel even a slight bit of nipple sensitivity.

And there is always the chance to reduce the testosterone dose. But if you have started low/gone slow, you have already been at the lower dose. This strategy works only when a patient presents on a dose of TRT which is too high for them. As we always say, "more is not better", and "every-body is different".

I’ve been on 150-200mg of Test Cyp weekly and 1000 iu of HcG. Both divided into two doses weekly. (100 mg test and 500 iu HcG). I take 0.5mg Arimidex tues, fri and Sunday. I’ve performed blood work 3 times this year and all my Estrogen levels have been normal and where they need to be. So I am fine with taking the AI

 

[Cips1975]

I don't think there is any question aromatase inhibitors are being over prescribed. This has been Nelson's message here for quite some time.

We still do not know if there may be any long term side effects from causing estrogen to rise to two or more times the top of normal range. But we do know for sure low estrogen is always bad for us. So between the two directions, the choice is clear.

For years I have treated, and taught, I do not add an AI in absence of elevated estrogen symptoms. There is just so much we still need to learn.

Hey John. Question I have is that we know that once Testosterone is administered even at TRT doses, some conversion to Estrogen is just gonna happen. So why wait for possible sides? Wouldn’t taking a AI like arimidex as a prophylactic be somewhat sensible. I would rather have that assurance that a AI is on board than get hit with symptoms and try to correct it down the road. I know it can go both ways. Just my personal thought asnIve been running Arimidex for 11 months on TRT and my levels are all solid.

 

[Dr. John Crisler]

@Dr. John Crisler, when you say elevated estrogen symptoms, does low libido fall into that category? Or are you talking more about nipple sensitivity, moodiness, etc.?

All of the above.

EDIT: I now believe these symptoms are transient, and if we give them a little time, they calm down.

 

[Dr. John Crisler]

Those strongly opposed to AI administration are employing studies where invalid estrogen testing and/or dosing protocols averaging at least 7 times a prudent dose were employed as the "evidence-based medicine". In fact, there has never been a study conducted which showed a reasonable dose of an AI hurt any man. Actually, there has never been a study conducted where a prudent dose was even tested.

When estrogen is too low, it seriously damages men's health. That comes when (1) testosterone is lowered--as with aging or other influences, or (2) an aromatase inhibitor is over-prescribed.

No doubt many of the benefits of TRT come from its subsequent elevation of estrogen. It may be that estrogen may be considered more valuable to our health than testosterone. But that does not mean all those androgen receptors are not on every cell in the body (even red blood cells) without good reasons, and they do not need stimulation.

I have heard talk about using estrogen supplementation to treat prostate cancer, as some kind of argument for very high estrogen levels in men. I don't know much about it yet, but am told these patients "are dong just fine". I note that cutting testosterone, and adding estrogen, is what we do for male-to-female sexual reassignment. Just an observation.

 

[Dr. John Crisler]

Hey John. Question I have is that we know that once Testosterone is administered even at TRT doses, some conversion to Estrogen is just gonna happen. So why wait for possible sides? Wouldn’t taking a AI like arimidex as a prophylactic be somewhat sensible. I would rather have that assurance that a AI is on board than get hit with symptoms and try to correct it down the road. I know it can go both ways. Just my personal thought asnIve been running Arimidex for 11 months on TRT and my levels are all solid.

Great question.

IMPO, no. It appears estrogen a bit above range is actually good for us, so I do not add low dose aromatization inhibition unless it is necessary. "Necessary" means because elevated estrogen symptoms will not go away, and the dose of TRT can not be lowered (because we already tried that lower dose, and it wasn't enough.

 

[bkb33]

But we do know, for instance, greatly elevating DHT will cause the hair to fall out. Those applying T cream to their scrotum will necessarily greatly elevate DHT. I've seen this cause anxiety, high blood pressure, urinary voiding symptoms, and hair loss. Not everyone can afford a hair transplant.

I've seen scrotal application of high dose T cream take DHT to 800. That is more than 10 times the top of normal range! No one knows what that does long term. Sure, you may feel good now, but who knows what is going on in the background?

Just wanted to say thank you again, Dr. John, for spending your time educating people like me on these forums. I very much appreciate it!

Can anyone here speak anecdotally to the DHT side effects Dr. John mentions? I don't have a history of hair loss in my family, and I have quite a lot of hair, but I don't want to mess up my health long-term. Given that I am constantly traveling, the allure of a cream (over injections) is undeniable. As many here can attest, transporting medications can be inconvenient.

 

[trt reznor]

I've only tried Anastrozole for a couple of weeks, i felt awful on it, whether it was .25mg or .125mg, I believe my body over responded and my E2 levels dipped too low.

I believe it's imperative, given some recent information I've read attributing prothrombic (promotes blood clotting) qualities to arimidex/anastrozole as well as a correlation between high Estradiol levels and DVT (deep vein thrombosis, blood clotting in the larger veins of the body, which can lead to serious conditions and death, source: Article: Second Interview with Dr Charles Glueck About Testosterone and DVT), that men undergoing TRT do their best to manage E2 levels without the use of AIs. *Small* frequent testosterone doses (somewhere closer to the body's natural production of 7-10mg per day), and low hCG dosage (if any) seems to be the key (edit: at least in low SHBG guys like myself)

 

[bkb33]

*Small* frequent testosterone doses (somewhere closer to the body's natural production of 7-10mg per day), and low hCG (if any) dosage seems to be the key (edit: at least in low SHBG guys like myself)

I think you're right, but I've also seen people say that if estrogen is an issue (ex: in my case, with high SHBG), we should overcome it with large doses (ex: one 200mg injection per week, or two 100mg injections). This method seems to encourage "peaks and valleys," though. Thoughts, all?

 

[trt reznor]

I think you're right, but I've also seen people say that if estrogen is an issue (ex: in my case, with high SHBG), we should overcome it with large doses (ex: one 200mg injection per week, or two 100mg injections). This method seems to encourage "peaks and valleys," though. Thoughts, all?

This is why I had to make that last edit about my post being in regards to low SHBG.

 

[trt reznor]

I think you're right, but I've also seen people say that if estrogen is an issue (ex: in my case, with high SHBG), we should overcome it with large doses (ex: one 200mg injection per week, or two 100mg injections). This method seems to encourage "peaks and valleys," though. Thoughts, all?

I'm also interested in the high dose methodology. I'm thinking it won't work for low SHBG guys, but I've never attempted it personally. Like Dr. Crisler says, the larger t doses may simply steamroll the estrogenic effects out of the equation. But with larger unnatural doses, who knows what else is happening in the background. I've known men in my personal life that have been on some sort of steroid regimen for over 20 years and hasn't shown any negative symptoms that I can see. Would love to hear from someone low SHBG that's tried the high dose approach.

 

[Cips1975]

Great question.

IMPO, no. It appears estrogen a bit above range is actually good for us, so I do not add low dose aromatization inhibition unless it is necessary. "Necessary" means because elevated estrogen symptoms will not go away, and the dose of TRT can not be lowered (because we already tried that lower dose, and it wasn't enough.

Thanks John for the reply. I may consider trying that in a future and see how it works out

 

[Gman86]

I've only tried Anastrozole for a couple of weeks, i felt awful on it, whether it was .25mg or .125mg, I believe my body over responded and my E2 levels dipped too low.

I believe it's imperative, given some recent information I've read attributing prothrombic qualities (aids in blood clotting) to arimidex/anastrozole as well as a correlation between high Estradiol levels and DVT (deep vein thrombosis, blood clotting in the larger veins of the body, which can lead to serious conditions and death, source: Article: Second Interview with Dr Charles Glueck About Testosterone and DVT), that men undergoing TRT do their best to manage E2 levels without the use of AIs. *Small* frequent testosterone doses (somewhere closer to the body's natural production of 7-10mg per day), and low hCG (if any) dosage seems to be the key (edit: at least in low SHBG guys like myself)

Very interesting info. I was not aware that high estrogen levels can increase a male’s risk of DVT/ CVA, and I’m a nurse. So thanks for posting that link.

 

[JimBob]

If you are properly stepping up your TRT dosage, titrating to effect, and you begin feeling high estrogen symptoms, wait a month. You will not grow breasts in that time. But if you still have these elevated estrogen symptoms after a month, add a small dose of anastrozole (dosing per protocol). IF the estrogen symptoms go away, the problem was the estrogen.

It would appear an alternative is just to take a very large dose of testosterone. You can not decrease current dose, because you have already been there, and it did not work. And letting things calm down for a month or so means you are now stabilized (just changing hormone levels, up or down, can cause side effects temporarily). It's looking to me that huge doses of testosterone may ablate the estrogen symptoms. They might be just running right over them.

The problem with the latter approach is no one knows what taking testosterone--or estrogen for that matter--to 2 or more times the top of normal range does to a person (man or woman) long term. There is not one shred of evidence-based medicine to support that strategy.

But we do know, for instance, greatly elevating DHT will cause the hair to fall out. Those applying T cream to their scrotum will necessarily greatly elevate DHT. I've seen this cause anxiety, high blood pressure, urinary voiding symptoms, and hair loss. Not everyone can afford a hair transplant.

I've seen scrotal application of high dose T cream take DHT to 800. That is more than 10 times the top of normal range! No one knows what that does long term. Sure, you may feel good now, but who knows what is going on in the background?

My position has been that it is far better to have added LOW DOSE anastrozole along the way, and maintained T, DHT, and E more near normal range. Then we are taking into account any Endocrine Disrupting Chemicals (EDC), Androgen Receptor Resistance, and the fact mens' T levels, on average, used to be higher (hence the lower "normal ranges").

Again, I do not ever want to prescribe any drug which is unnecessary. But I have also learned we generate health problems when we slam biological systems too far in any direction.

These are simple facts the Anti-AI Crowd cannot overcome.

Please pass this post around the Internet. This is a very important, and currently hot, topic.

Dr. N------will simply say that he doesn't raise T to supraphysiological levels.
As for the invalid estrogen studies you mention, are these the same studies that Dr. Rouzier references? I'm not arguing either way, but how does a doctor with his supposed HRT experience not recognize that these studies are invalid? Really strange.

 

[user_joe]

If you are properly stepping up your TRT dosage, titrating to effect, and you begin feeling high estrogen symptoms, wait a month. You will not grow breasts in that time. But if you still have these elevated estrogen symptoms after a month, add a small dose of anastrozole (dosing per protocol). IF the estrogen symptoms go away, the problem was the estrogen.

It would appear an alternative is just to take a very large dose of testosterone. You can not decrease current dose, because you have already been there, and it did not work. And letting things calm down for a month or so means you are now stabilized (just changing hormone levels, up or down, can cause side effects temporarily). It's looking to me that huge doses of testosterone may ablate the estrogen symptoms. They might be just running right over them.

The problem with the latter approach is no one knows what taking testosterone--or estrogen for that matter--to 2 or more times the top of normal range does to a person (man or woman) long term. There is not one shred of evidence-based medicine to support that strategy.

But we do know, for instance, greatly elevating DHT will cause the hair to fall out. Those applying T cream to their scrotum will necessarily greatly elevate DHT. I've seen this cause anxiety, high blood pressure, urinary voiding symptoms, and hair loss. Not everyone can afford a hair transplant.

I've seen scrotal application of high dose T cream take DHT to 800. That is more than 10 times the top of normal range! No one knows what that does long term. Sure, you may feel good now, but who knows what is going on in the background?

My position has been that it is far better to have added LOW DOSE anastrozole along the way, and maintained T, DHT, and E more near normal range. Then we are taking into account any Endocrine Disrupting Chemicals (EDC), Androgen Receptor Resistance, and the fact mens' T levels, on average, used to be higher (hence the lower "normal ranges").

Again, I do not ever want to prescribe any drug which is unnecessary. But I have also learned we generate health problems when we slam biological systems too far in any direction.

These are simple facts the Anti-AI Crowd cannot overcome.

Please pass this post around the Internet. This is a very important, and currently hot, topic.

On the topic of things unknown long term, what if the effects are POSITIVE? Why make the assumption very high DHT is going to be negative when stating we don’t know the answer?

What do you think about the lab ranges? They keep showing T levels lower and lower to be “in range.” My father in his 60s routinely rests above range for TT now only bc they lowered the range.

I don’t care to debate you per say, bc I only have my own personal experience to draw from. I can say without a doubt using the tiniest dose of ai possible gives me the best therapeutic effects. Interested in you elaborating on large doses as I currently run 300mg/wk. split into 2 doses that was a trough of 1280. I do daily now. AI has been 1/32mg every 7-10 days the past month. I feel great.

 

[trt reznor]

On the topic of things unknown long term, what if the effects are POSITIVE? Why make the assumption very high DHT is going to be negative when stating we don’t know the answer?

What do you think about the lab ranges? They keep showing T levels lower and lower to be “in range.” My father in his 60s routinely rests above range for TT now only bc they lowered the range.

I don’t care to debate you per say, bc I only have my own personal experience to draw from. I can say without a doubt using the tiniest dose of ai possible gives me the best therapeutic effects. Interested in you elaborating on large doses as I currently run 300mg/wk. split into 2 doses that was a trough of 1280. I do daily now. AI has been 1/32mg every 7-10 days the past month. I feel great.

Joe, how about libido or sides?