Should We Be Managing Estradiol and Hematocrit in Men on Testosterone Replacement?

Interesting discussion. This is one of my original labs after starting with Dr. Saya on 160mg test per week a few years ago, along with .15mg anastrozole 2x per week.

My estrogen was high, my nipples felt itchy, I previously had gyno surgery at 18 from puberty (safe to say high converter) & was concerned it was about to be deja vu.

After we adjusted my anastrozole to .25mg 3x week and got it down to around 30, I felt much better subjectively, and the symptoms I had were resolved.

Medicine & treatment, like most things in life, usually shouldn't have blanket statements attached to them. To say I shouldn't have been treated to reduce my E2 levels because there are no studies to show the benefit seems pretty ridiculous. I think everyone would agree TRT is pretty much in it's infancy in terms of available information from published studies to match the current understanding among specialists. Much of what we have is outdated and poorly executed.

My $.02

Curious to hear if Dr. Nichols would still have an issue prescribing an AI to someone with my background, symptoms, and numbers?

Druboutin said:

View attachment 3652

Interesting discussion. This is one of my original labs after starting with Dr. Saya on 160mg test per week a few years ago, along with .15mg anastrozole 2x per week.

My estrogen was high, my nipples felt itchy, I previously had gyno surgery at 18 from puberty (safe to say high converter) & was concerned it was about to be deja vu.

After we adjusted my anastrozole to .25mg 3x week and got it down to around 30, I felt much better subjectively, and the symptoms I had were resolved.

Medicine & treatment, like most things in life, usually shouldn't have blanket statements attached to them. To say I shouldn't have been treated to reduce my E2 levels because there are no studies to show the benefit seems pretty ridiculous. I think everyone would agree TRT is pretty much in it's infancy in terms of available information from published studies to match the current understanding among specialists. Much of what we have is outdated and poorly executed.

My $.02

Curious to hear if Dr. Nichols would still have an issue prescribing an AI to someone with my background, symptoms, and numbers?

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Interesting, I thought that lab wouldn't show test levels greater than 1500. I've never seen estradiol that high. You noted that your nipples were itchy and that you felt better after increasing the anastrozole, but how exactly did you feel with that much estrogen?

AbsoluteZ3R0 said:

Interesting, I thought that lab wouldn't show test levels greater than 1500. I've never seen estradiol that high. You noted that your nipples were itchy and that you felt better after increasing the anastrozole, but how exactly did you feel with that much estrogen?

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I wasn't totally moody or emotional like some people say. My nipples were definitely itchy and just walking around the office with my shirt moving slightly over them was perpetuating it pretty much all day.

I also noticed I was holding a lot of water, I'd take my socks off after getting home and have huge imprints from the sock lines. I could push my fingers into my calves, and leave an imprint that would take a few minutes to disappear.

As far as sex drive, I was feeling a little better than before treatment, but I couldn't tell if I was "willing it" by watching porn in hopes of capturing that old magic. It wasn't a drastic shift.

Contrast this with my feeling after we bumped up the Anastrozole dose, and it was night and day. Literally like being 15/16 again. Would go out at lunch and meet up with dates in an empty parking lot, no joke. Water retention and nipple issues were resolved. Mood improved to the point I received a few comments.

That may be excessive to some, but I was more than glad to have that sexual urge back after going the previous 6 months without even thinking of sex.

Edit: Short answer to you question is with E2 that high, I didn't feel as terrible as some report, but didn't feel great either. Pretty much a "meh". After making adjustments, I feel like I got my life back.

Druboutin said:

I wasn't totally moody or emotional like some people say. My nipples were definitely itchy and just walking around the office with my shirt moving slightly over them was perpetuating it pretty much all day.

I also noticed I was holding a lot of water, I'd take my socks off after getting home and have huge imprints from the sock lines. I could push my fingers into my calves, and leave an imprint that would take a few minutes to disappear.

As far as sex drive, I was feeling a little better than before treatment, but I couldn't tell if I was "willing it" by watching porn in hopes of capturing that old magic. It wasn't a drastic shift.

Contrast this with my feeling after we bumped up the Anastrozole dose, and it was night and day. Literally like being 15/16 again. Would go out at lunch and meet up with dates in an empty parking lot, no joke. Water retention and nipple issues were resolved. Mood improved to the point I received a few comments.

That may be excessive to some, but I was more than glad to have that sexual urge back after going the previous 6 months without even thinking of sex.

Edit: Short answer to you question is with E2 that high, I didn't feel as terrible as some report, but didn't feel great either. Pretty much a "meh". After making adjustments, I feel like I got my life back.

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It's insane that your estrogen bumped up that high from only 160mg of test per week. It's also interesting that some men go on 200mg a week and still don't reach test levels over 1500. I'm assuming you probably had HCG in there as well. Anyway, the detail is much appreciated. Estrogen seems to play a really convoluted role in sex drive. Unlike testosterone, having too much is deleterious, but "too much" seems incredibly difficult to define.

AbsoluteZ3R0 said:

It's insane that your estrogen bumped up that high from only 160mg of test per week. It's also interesting that some men go on 200mg a week and still don't reach test levels over 1500. I'm assuming you probably had HCG in there as well. Anyway, the detail is much appreciated. Estrogen seems to play a really convoluted role in sex drive. Unlike testosterone, having too much is deleterious, but "too much" seems incredibly difficult to define.

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You are correct, HCG as well. 250-300 IU day prior to injection.

I think based on all the first hand accounts available to us on sites like this, the only blanket statement we can truly make is TRT is not one-size-fits-all.

Some may not need an AI -- more power to you. For someone with symptoms like me, and a history of pubescent gyno, I think an AI can be extremely beneficial to optimizing your treatment and how you feel.

Druboutin said:

You are correct, HCG as well. 250-300 IU day prior to injection.

I think based on all the first hand accounts available to us on sites like this, the only blanket statement we can truly make is TRT is not one-size-fits-all.

Some may not need an AI -- more power to you. For someone with symptoms like me, and a history of pubescent gyno, I think an AI can be extremely beneficial to optimizing your treatment and how you feel.

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Before I started TRT my E2 was over 100 with many symptoms along with all the classic gyno symptoms. Now I'm on HRT ... all hormones and I take .2 mcg AI daily and I feel so much better. Life is great!

Druboutin said:

I think based on all the first hand accounts available to us on sites like this, the only blanket statement we can truly make is TRT is not one-size-fits-all.

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Never a truer statement has been spoken.

Druboutin said:

<snip>

Curious to hear if Dr. Nichols would still have an issue prescribing an AI to someone with my background, symptoms, and numbers?

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I think part of what Dr. Nichols is trying to say, by treating with the creams twice a day there is no need to treat for elevated E2 as it is not a issue with his protocol.

Agreed cja. I wonder and maybe Dr. Saya can chime in if maybe the high dht offsets estradiol. I know Dr Saya mentioned dht being elevated would be a concern of his and that came into my head also. I think that's why many of us were surprised he didn't check dht levels.

Druboutin said:

View attachment 3652

Interesting discussion. This is one of my original labs after starting with Dr. Saya on 160mg test per week a few years ago, along with .15mg anastrozole 2x per week.

My estrogen was high, my nipples felt itchy, I previously had gyno surgery at 18 from puberty (safe to say high converter) & was concerned it was about to be deja vu.

After we adjusted my anastrozole to .25mg 3x week and got it down to around 30, I felt much better subjectively, and the symptoms I had were resolved.

Medicine & treatment, like most things in life, usually shouldn't have blanket statements attached to them. To say I shouldn't have been treated to reduce my E2 levels because there are no studies to show the benefit seems pretty ridiculous. I think everyone would agree TRT is pretty much in it's infancy in terms of available information from published studies to match the current understanding among specialists. Much of what we have is outdated and poorly executed.

My $.02

Curious to hear if Dr. Nichols would still have an issue prescribing an AI to someone with my background, symptoms, and numbers?

Click to expand...

Why did you run labs not in your trough and then make protocol changes? I'm totally with you on the AI, but your's is a curiosity that those aren't trough numbers, was this intentional to see a peak? Or some other strategy.

Vince Carter said:

Why did you run labs not in your trough and then make protocol changes? I'm totally with you on the AI, but your's is a curiosity that those aren't trough numbers, was this intentional to see a peak? Or some other strategy.

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This WAS a trough day, lol... Defy's Nurse (forgot which one) recommended I drop to 120mg per week after this. I guess I metabolize the medicine pretty well? Not sure what the explanation is.

For reference, I had to travel about a month ago. Took a 150mg injection before leaving, came back and had labs done 7 days later...



E2 was 34

Edit: Keep in mind I'm also using HCG 3x week at roughly 300 IU. Could be cause for inflated numbers on trough days?

& in this case, I had injected my regularly scheduled half dose 3.5 days earlier. I did a full dose at one before leaving just so make travel more convenient.

J. Keith Nichols MD said:

The first thing to look for is symptom improvement after starting TRT. The problem recently with labCorp is that they changed the reagent so now when you order a free T you will get a response of "too high to measure". The same thing just happened with the testing of a women's progesterone. I find that my patients are most optimal at a free T level of 30-50 and some even higher (it's just a number and I am treating symptoms ). With the current test it won't give you those numbers so we have to order a equilibrium ultra filtration test which is a more specialized test and will give me the actual free T level no matter what the value. Believe me, we have no complaints when a free T is maintained at a optimal level 24/7. So in summary, the total T is insignificant really. It is the free T you are looking to optimize. If your free T Is in a optimal range don't worry about total. The most simple test that I tell my patients is if they are having consistent morning erections. If you are then you are optimal. This will also start another thread but don't look to lower your SHBG. The higher the better. I can send you all the studies. You don't want to lower SHBG to raise T, you just increase the T dosage. When you increase your T you also increase your E2 which also increases SHBG and all three are beneficial. Just follow your free T and get that 30-50 and I assure you you will not worry about your E2 or SHBG

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Man am I confused! My current Dr has me on 600mg (three clicks of 200mg cream) compounded cream applied to my shoulder daily. Total T around 500, free at 5, SHBG in the 90s. He says even a 10 point reduction in SHBG will make me feel much better. The worst part is for a while I was taking 800mg and my anxiety and BP were going through the roof without feeling the positive effects of the free T. And I have been told by every Dr to never apply T to my scrotum... when I was on ejections My total got above 1500 but free still around 8 and estrogen through the roof. The side effects were horrible including hot flashes, dizzy spells, fat gain, BP reaching 200. And all while on arimidex. My personal experience told me estrogen=bad. I really appreciate this forum for the open discussion of actual Doctors who deal with this stuff everyday. Thanks for your comments and any advice you have for me is very appreciated!

Bnib said:

Man am I confused! My current Dr has me on 600mg (three clicks of 200mg cream) compounded cream applied to my shoulder daily. Total T around 500, free at 5, SHBG in the 90s. He says even a 10 point reduction in SHBG will make me feel much better. The worst part is for a while I was taking 800mg and my anxiety and BP were going through the roof without feeling the positive effects of the free T. And I have been told by every Dr to never apply T to my scrotum... when I was on ejections My total got above 1500 but free still around 8 and estrogen through the roof. The side effects were horrible including hot flashes, dizzy spells, fat gain, BP reaching 200. And all while on arimidex. My personal experience told me estrogen=bad. I really appreciate this forum for the open discussion of actual Doctors who deal with this stuff everyday. Thanks for your comments and any advice you have for me is very appreciated!

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Start a new thread, with detailed labs (including reference ranges), please.

Bnib said:

Man am I confused! My current Dr has me on 600mg (three clicks of 200mg cream) compounded cream applied to my shoulder daily. Total T around 500, free at 5, SHBG in the 90s. He says even a 10 point reduction in SHBG will make me feel much better. The worst part is for a while I was taking 800mg and my anxiety and BP were going through the roof without feeling the positive effects of the free T. And I have been told by every Dr to never apply T to my scrotum... when I was on ejections My total got above 1500 but free still around 8 and estrogen through the roof. The side effects were horrible including hot flashes, dizzy spells, fat gain, BP reaching 200. And all while on arimidex. My personal experience told me estrogen=bad. I really appreciate this forum for the open discussion of actual Doctors who deal with this stuff everyday. Thanks for your comments and any advice you have for me is very appreciated!

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No you're not.

It´s a pity that the real core of some conflicting views of the two doctors seemed to come to an end. It was really interesting to follow. I hope Dr J. Keith Nichols could come back sometimes to this forum.

E2 monitoring is essential

Everyone is different. I have been on trt for about 10 months. So many of those anti aging doctors start you off at extremely high doses (Prime Body and Royal Men's) 200 mg of cypionate a week which I would never go back to! They also have you inject with large needles into your thigh that are absolutely necessary.

High hematocrit feels horrible, like you are about to have a heart attack. What feels even worse is low ferritin, mine tested at 29 on a scale of 30-300 after 3 phlebotomies within the course of 2 months to bring down hematocrit that was +50. I have found out that the side effects were too severe for a younger guy (36yrs) with low T around 400-500 before I started.

I am now following a protocol similar to Nelson's 50 mg every 3.5 days with a painless shoulder injection with a 27 gauge insulin needle, I also use about 250 units of HCG twice a week.

Unfortunately for me if I don't use any AI my estrogen gets too high and my libido and erections disappears. Also if it gets too low my libido and erections disappear.

I have done so many blood work ups I pretty much can guess my e2 levels within 10. I take minor doses of an ai at 100 mg cyp a week. Around .05-.2 mg a week.

When my e2 is around 20 i feel the best. I can last much longer in bed as well. around 30 my **** becomes soft during intercourse and I cannot last long at all in bed. Around 10 I can have sex for a hour if I want but the orgasm almost doesn't exist and its impossible to get aroused.

When I hear these doctors argue about how e2 is irrelevant I feel like they are close minded because I have the personal experience and + 10 lab records over the course of a year and daily spreadsheet entries with my symptoms to confirm how e2 needs to be dialed in.

It is so easy to crash your e on an AI though. Now I use my libido and erection strength as a guide to my e levels, I really don't need to test it anymore. My libido levels are much higher on 100 mg cypionate than it ever was on 200. In my opinion as long as my test is above 600 I feel fine. No need to go over 1000 unless you have no negative symptoms then hell aim as high as you want.

Interesting to read about the compounded cream, perhaps the daily dosing really does prevent too much from over aromatizing, or that method of delivery just affects the body differently.

Who do you work with? I've asked about diabetic gauge needles in the past but every dr I've used said it's not available. I hated the shot in the leg. But I'm type 1 diabetic and those shots are really a breeze.

Question posed to trt. Sorry if I'm not using the message board correctly...

trt1 said:

Everyone is different. I have been on trt for about 10 months. So many of those anti aging doctors start you off at extremely high doses (Prime Body and Royal Men's) 200 mg of cypionate a week which I would never go back to! They also have you inject with large needles into your thigh that are absolutely necessary.

High hematocrit feels horrible, like you are about to have a heart attack. What feels even worse is low ferritin, mine tested at 29 on a scale of 30-300 after 3 phlebotomies within the course of 2 months to bring down hematocrit that was +50. I have found out that the side effects were too severe for a younger guy (36yrs) with low T around 400-500 before I started.

I am now following a protocol similar to Nelson's 50 mg every 3.5 days with a painless shoulder injection with a 27 gauge insulin needle, I also use about 250 units of HCG twice a week.

Unfortunately for me if I don't use any AI my estrogen gets too high and my libido and erections disappears. Also if it gets too low my libido and erections disappear.

I have done so many blood work ups I pretty much can guess my e2 levels within 10. I take minor doses of an ai at 100 mg cyp a week. Around .05-.2 mg a week.

When my e2 is around 20 i feel the best. I can last much longer in bed as well. around 30 my **** becomes soft during intercourse and I cannot last long at all in bed. Around 10 I can have sex for a hour if I want but the orgasm almost doesn't exist and its impossible to get aroused.

When I hear these doctors argue about how e2 is irrelevant I feel like they are close minded because I have the personal experience and + 10 lab records over the course of a year and daily spreadsheet entries with my symptoms to confirm how e2 needs to be dialed in.

It is so easy to crash your e on an AI though. Now I use my libido and erection strength as a guide to my e levels, I really don't need to test it anymore. My libido levels are much higher on 100 mg cypionate than it ever was on 200. In my opinion as long as my test is above 600 I feel fine. No need to go over 1000 unless you have no negative symptoms then hell aim as high as you want.

Interesting to read about the compounded cream, perhaps the daily dosing really does prevent too much from over aromatizing, or that method of delivery just affects the body differently.

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Great post!

2 questions.
What is your test level when you're at an E of 20?
What symptoms do you have when you have low ferritin?

Bnib said:

Who do you work with? I've asked about diabetic gauge needles in the past but every dr I've used said it's not available. I hated the shot in the leg. But I'm type 1 diabetic and those shots are really a breeze.

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I was always given the 1 inch 25 gauge needle which I was never looking forward to doing ever!

When I saw what Nelson Vergel was doing I just bought some 27 gauge 1/2 inch needles online, its totally legal and adjusted my protocol myself, they draw the cypionate perfectly fine, just a tad slowly and injecting to the shoulder is so easy and painless.

Most of the Dr's at the anti aging clinics could care less about you and they use dated methods of administration.

http://www.excelmale.com/showthread....a-prescription