got labs back, starting new regimen monday!!!!

[robs2nd75]

Thank you Dr. Saya your input is greatly appreciated. Given all the recent research demonstrating the importance of estrogen in men, what do you consider an ideal range?

 

[JSayaMD]

Although this varies from individual to individual, most males will find their ideal E2 level to be in the range of ~15-35 pg/ml. The recent research mainly points to what most in the field already know...LOW E2 is not ideal nor healthy for a male (or female as can be seen when women go through menopause and develop increased risk of heart disease, osteoporosis, etc). The same can be said of high E2. As with all hormones, it is all about the harmonious balancing of the "hormone symphony."

Dr Saya

 

[Gene Devine]

Hi Dr. Saya and welcome to our forum. It's always great to have such knowledge to share with our members.

Let me address a couple of things if you will.

This a Testosterone Replacement forum. It's where men (and women) can come and discuss any issues regarding TRT for men in a safe and respected community.

The Original Poster posted his lab work and his protocol and specifically asked members for their opinion and feedback. He must know that, like anything else in life, critique is what it is. Everyone has their own opinion and it might not always "jive" with ones own expectations.

In my response to the OP I was very clear that these were my personal opinions and views. I was responding to his request for feedback.

I am not a medical practitioner in any way shape of form. That being said, I have studied TRT for men for years. I have moderated TRT forums on the internet for years. I know some of the top TRT Specialists in the country on a first name basis. I have studied the papers and protocols of some of the leading clinicians in the space ad nauseum. I personally have been on TRT for years and have experimented in many many ways.

My response was just my personal opinion and nothing more.

As far as the E2 sensitive assay is concerned I have seen with my own eyes more than a few labs where the man's E2 was tested concurrently with both the Standard Default and Sensitive assay. In one case that stands out, the Standard lab read 59.2 pg/ml while the Sensitive assay read 24.8 pg/ml...more than a 100% variance. If we were to use just the Default lab this man could end up with a unwarranted prescription for an AI which otherwise would probably tank his E2 serum levels which were near perfect. I know many TRT clinicians who just will not go by the Standard Default lab for just that reason; the Standard Default lab tends to over estimate serum levels. My personal TRT Physicians feels the exact same way and his belief is that the Standard Default assay is junk in accurately determining a man serum levels.

I believe Dr. Crisler says it best in this one short paragraph:
Unless you specify a ‘sensitive’ assay for your male patients, the lab will default to the standard estradiol designed for females, which is useless for our purposes here. I have run the standard assay and the sensitive assay concurrently on a number of my patients, and the two results may be as night and day. However, patient symptomology is best described by the sensitive assay. The reason is the bell curve from which the test is designed sits well within the “normal” range for females; therefore the hormonal concentration range appropriate to adult males falls on a very flat slope of said bell curve. The same holds for Total Estrogens. Laboratory testing is best when small changes in concentrations result in large changes in subsequent reported result.

As for the Thyroid, again my personal opinion; but if I had a TSH level reading over 6 I would personally insist on further diagnosis before planning out a drug protocol. That's just me. For me, TSH is just a marker of Thyroid performance and it's a poor one at that in my opinion. Additionally, we know that Hypothyroidism can and will cause Hypogonadism and for that alone reason I would personally want to know much more before taking any drugs of any sort.

I had no intentions of "freaking out" the OP and causing you any grief whatsoever. I did not tell the OP to change his protocol or adjust dosages or anything of that sort; I just provided my own personal opinion based on my own experiences and learning and the OP's desire for member feedback. But one must remember, this is a Testosterone Forum and discussion and discourse like this will happen.

Again, welcome aboard Doc!

GD

 

[JSayaMD]

Gene,

With regards to E levels and E testing, in cases where there were significant differences side-by-side between the ultrasensitive assay and the standard assay, who's to say which of the two was inaccurate? By the very nature of the sensitivity of the test, a "highly sensitive" assay is more prone to drastic variations and measurement error. In addition, when measurement variation or error do occur they will be much more evident and pronounced in the results on the sensitive assay. As I said, I feel E levels in males are best categorized as very low/low/normal-good/high/very high....and for these general classifications one would not need to pay the extra $ for a sensitive assay as the standard assay does a fine job of telling us this info. As always, side effects and symptoms are used to correlate with the lab results.

Regarding the thyroid testing, we are taught very early in medical school to place importance on cost of care. Many young medical students and even residents are more comfortable with the " shotgun" approach of ordering ALL pertinent labs prior to arriving at a diagnosis or treatment plan. For cost reasons, this is not practical for many patients and decisions are best made based on the preponderance of evidence standard (vs the beyond a reasonable doubt standard...to steal a line of thought from my legal-minded friends). A lot also comes down to the confidence and certainty of the diagnosing physician as well, which in this specific case, I am extremely confident in my diagnosis of hypothyroidism. Had I been less confident in the diagnosis, I would "push" more for additional testing.

I realize this is a discussion forum and discussions are the purpose. However, for some patients, the uncertainty and uneasiness created by critiquing of their management/medical plan (especially negative critiquing) can really undermine their treatment and set them up for failure. I realize the OP requested critique, however be cautious of the tone, recommendations, and ultimate effect on the OP of said critiques going forward.

Dr Saya

 

[Gene Devine]

Regarding the E2 Ultra Sensitive assay...

This one is directly from Quest Diagnostics for their Ultra Sensitive E2 test..they actually print it on their lab analysis report!

http://www.questdiagnostics.com/test...89&labCode=SJC

" For any patients for whom low estradiol levels are anticipated (e.g. males, pre-pubertal children and hypogonadal/post-menopausal females), the Quest Diagnostics Estradiol, Ultrasensitive, LC/MS/MS assay is recommended (order code 30289)."

I wonder why???

 

[JSayaMD]

So that they can influence providers to order a more expensive (and more profitable) test that is likely unnecessary. In general I'm much more fond of LabCorp, I've had quite a few issues with Quest in the past (including me questioning the accuracy of some of their tests). On MULTIPLE occasions I've had testosterone levels run through Quest that have come back ridiculously high based on patient dosing. Due to suspicion on 3 separate occasions I then ran a testosterone level (drawn minutes apart from each other) through both Quest and LabCorp. On each occasion Quest results showed T 2000-2400 while Labcorp showed T 900-1200. I have no doubt the LabCorp readings were the accurate ones as those numbers were more in line with previous labs for those patients and consistent with the patients dosing. The more expensive ultrasensitive E test is more of a marketing ploy than clinically necessary. BTW, a LOW sensitivity test (as you're suggesting the regular estradiol assay is) would NOT OVERESTIMATE low readings, it would actually UNDERESTIMATE low readings due to not being sensitive enough to detect very low levels. Pay more to Quest for the ultrasensitive test if you wish, it's your money. I will continue to save my patients money with the perfectly suitable and practical standard estradiol assay unless they CHOOSE to pay more for the ultrasensitive , which is an option.

Dr Saya

 

[Dr. John Crisler]

The Ultrasentive asaay is, by its very methodology, much more accurate than the standard assays. That is because immunoassay technology has fallen far behind, infavor of the vastly superior LC/MS. In short, if you cannot get LC/MS, you cannot trust a hormonal assay.

That paragraph is there on Quest Diagnostics printouts for a very good reason; after I presented my results to the Nichols Institute.

In literally thousands of patients, when both standard and sensitive assays are concurrently run, the patient's symptoms match the more sensitive methodology. It is far more than an effort to increase laboratory revenues, and physicians who properly order it are not wasting their patient's money.

I just saw a study published which proves this (don't know how to post one on here LOL). Can anyone come up with it?

No sex hormone work-up is valid without SHBG. It sets the sweet spot, within range, via its effects on bioavailable levels.

 

[Dr. John Crisler]

Let's see if this works:

http://www.sciencedirect.com/science/article/pii/S0039128X0700089X

 

[JSayaMD]

Dr John,

Thanks for the input and the study, which is actually suggesting that the RIA method may overestimate E2 levels by cross-reacting with other estrogen metabolites, which it is presumed the LC/MS method does not. The only way to tell clinically how reliable a test is, is to correlate with clinical symptoms. The standard assay has done a great job in my practice of correlating with the symptoms expected for my general classifications of E levels: low/normal/high... Allowing me to make reasonable medical decisions AND save my patients some coin at the same time.

With regards to the SHBG, with measurement of a free T level one can infer the SHBG status.

Dr Saya

 

[Dr. John Crisler]

When you carefully watch SHBG, Total T, Free T and albumin levels, some of us think we are seeing a fair amount of variability in the "stickiness" of the SHBG complex.

While it is an assay of questionable reliability (it's just a tough test for them), I always do get a SHBG; there's a lot more we can draw from this result as well.

I quit being surprised at the variability--hormonally, at least LOL--across the population long ago.

 

[Jasen Bruce]

Gentlemen

Does anyone know the difference between Quest's Ultra Sensitive test and Labcorps Senstive Estradiol (test code 140244)? I have emailed our Labcorp rep and am awaiting a response.

 

[Gene Devine]

Gentlemen

Does anyone know the difference between Quest's Ultra Sensitive test and Labcorps Senstive Estradiol (test code 140244)? I have emailed our Labcorp rep and am awaiting a response.

I think Access Medical Labs has the big 3 beat when it comes to both blood and saliva testing:

http://www.accessmedlab.com/serum_blood_testing.html

 

[Dr. John Crisler]

Access Labs indeed does a very fine job. I have worked with them for years.

They also sponsored me when I spoke at AMMG two years ago.

 

[Dr. John Crisler]

Gentlemen

Does anyone know the difference between Quest's Ultra Sensitive test and Labcorps Senstive Estradiol (test code 140244)? I have emailed our Labcorp rep and am awaiting a response.

Honestly, Quest's Ultrasensitive assay is currently having some issues. I'll keep you all posted on how they are doing.

The Mayo Clinic's "Enhanced Estradiol" # 81816, is okay; and very commonly offered where a hospital contracts for specialty send-out labs.

Even though it is the less preferable RIA methodology, actual clinical experience makes me trust LabCorp's "Sensitive Estradiol" #140244. It is also less expensive than their new one, using LC/MS technology. This one makes my mouth water, directly from my own lab orders: Estradiol #500108 Estrone #500634

Now I am able to do better things for my patients, especially since there is now an E1 I trust (beside the one I get from a 24 hour urine panel). Estrone favors androgens, and Estradiol favors Estrogen. This can help explain subjective response, when relying upon E2 alone fails.

If you have any more questions of a LabCorp Rep, Jasen, please let me know. The one for my area always gets back to me right away.

 

[Dr. John Crisler]

Access Labs indeed does a very fine job. I have worked with them for years.

They also sponsored me when I spoke at AMMG two years ago.

Ryan and Adam were a day late arriving, so I was left trying to hold down the fort in the Exhibition Hall for them.

Never willing to shirk my duties for my Sponsor, at one point I had about 30 attendees packed around their booth. In fact, my neighbor directly across the aisle, for my dear friend Dr. Anna Cabecca (the smartest doctor I ever met), was having to give up space. LOL

Fortunately, my old friend Jerry Kramer, NFL Hall of Fame member (he put the most famous block in NFL history on Jethro Pugh, so Bart Starr could sneak into the end zone during the "Ice Bowl") saw me walking down the hall at the M Resort (conference venue), and snagged me for lunch. He was happy to help out later, and tell old stories at the Access Labs booth. We were all hanging on his every word, like little kids clumped around a TV. Handed out a lot of flyers.

 

[JSayaMD]

As mentioned previously, I share a preference for LabCorp vs Quest (this may have not been completely clear in my previous post, but the discordant T levels I mentioned earlier 2000-2400 (Quest) vs 900-1200 (LabCorp) were drawn from the SAME PATIENT at the SAME TIME)... on three separate occasions, with three different patients.

Curious what you mean when referring that estrone favors androgens and estradiol favors estrogen? Estrone is known to generally carry more carcinogenic risk, that I know.

Dr Saya

 

[Dr. John Crisler]

As mentioned previously, I share a preference for LabCorp vs Quest (this may have not been completely clear in my previous post, but the discordant T levels I mentioned earlier 2000-2400 (Quest) vs 900-1200 (LabCorp) were drawn from the SAME PATIENT at the SAME TIME)... on three separate occasions, with three different patients.

Curious what you mean when referring that estrone favors androgens and estradiol favors estrogen? Estrone is known to generally carry more carcinogenic risk, that I know.

Dr Saya

Laboratory methodology is reliant upon statistical analysis. Therefore, the top of "normal range" from one lab is the same for the top of "normal range" at another--no matter what the actual numbers.

To illustrate, guys will try to use laboratories where the top of range is a higher number, thinking they will then get more testosterone. In practice, this does not work, because they just end up at the top of range, again, anyway.

IOW, midrange on one lab is the same as midrange on another. Irrespective of the ranges.

It's a strange concept, but it's just part of getting used to walking on slippery rocks all the time, which is what it is like practicing this field of medicine.

 

[Dr. John Crisler]

As mentioned previously, I share a preference for LabCorp vs Quest (this may have not been completely clear in my previous post, but the discordant T levels I mentioned earlier 2000-2400 (Quest) vs 900-1200 (LabCorp) were drawn from the SAME PATIENT at the SAME TIME)... on three separate occasions, with three different patients.

Curious what you mean when referring that estrone favors androgens and estradiol favors estrogen? Estrone is known to generally carry more carcinogenic risk, that I know.

Dr Saya

Estradiol is proliferative as well, especially with respect to prostate tissue.

Several of the Estrone metabolites are considered cancer protective, at both Phase I and Phase II detoxification.

But to directly answer your question, if a man is estrogen dominant his Estrone will be higher within its range than Estradiol is in its.

When evaluating estrogen effects, and E2 seems fine, E1 provides the answer.

This becomes VERY important when SHBG is lower. More bio T....but also more Bio E at work.

Androgen dominance, conversely, places E2 over E1 withing respective ranges.

Now that I have an E1 I trust (for serums), I am able to do better things for my guys.

 

[Dr. John Crisler]

Here's directly from a set of labs I read yesterday. My third patient of the day, while training a colleague in my techniques (my One-on-One Program), so it was an excellent teaching moment:

Patient "T.E." Serums 10.09.13

Total Testosterone 991 (348-1197)
Free Testosterone 238 (52-280)

If you see where Total T is within its range, and compare to Free T within its range, you would draw the conclusion SHBG must be about midrange.

But what was the actual SHBG?

18.9 (16.5-55.9)

Very low normal.

THIS changes everything, and directs the astute practitioner in a new direction for subsequent TRT regimen. This greatly improves our prospects for optimizing his health and happiness.

Laboratory tests, like each and every point in patient's subjective report, are all but pieces of a much larger puzzle.

 

[JSayaMD]

As I understand estradiol levels (if high) also have a much larger effect on SHBG levels than do T levels in males (although both I've seen both bump SHBG levels when supraphysiologic).

Dr Saya