Question about estradiol and the sensitive estradiol test

When evaluating T, we look at the total T, as well as the free T. But when we look at estradiol, there seems to be only one number. Does the estradiol test measure free estradiol, or total?

It would seem to me that if estradiol is bound to SHBG, then it would be of little consequence, and less need to lower it. But if you have low SHBG, more of the estradiol would be active, and therefore it may be affecting you more.

i have read here about the uncertainties regarding lowering estradiol, and am trying to understand it better.

Before TRT my estradiol was about 13. Now it is 39, at the top of the reference range. Not terrible from what I understand. However, in an effort to increase my sex drive, my doc has prescribed an AI. He said since my free T is high, therefore my SHBG is low.

With low SHBG, would estradiol have more effect on a guy?

Yes, I read it like this in Dr Crisler's latest book: low SHBG equates to high Free T. Along with high Free T comes high free E and is tougher for us low SHBG guys to manage that.
I would strongly suggest that you not treat the number of your E2 test, treat your Estrogenic symptom(s) of high E2, if you have any. What is your trough total T like?

Unlike Total and Free T, Estrogen isn't measured that way.

Vince Carter said:

I would strongly suggest that you not treat the number of your E2 test, treat your Estrogenic symptom(s) of high E2, if you have any.

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Sound advice. Lab values are critical, but should be relied on to interpret what your body tells you subjectively.

Remember too that the E2 "reference range" is most often based upon a total T of 6-700 and the E2 of 39 as a max number makes no sense if you have a total T of, say, 1000. Many doctors do not understand that and want to give you an AI regardless if you hit that number.

My body is telling me I have no sex drive. The doc is trying to fix that. He is a reputable TRT doc.

My last lab values were:

Testosterone, Serum 834 ng/dL 348 - 1197 0
Free Testosterone(Direct) 30.4 High pg/mL 7.2 - 24.0 02
Estradiol, Sensitive 34.8 pg/mL 8.0 - 35.0 02 (not 39 as I stated above)

My protocol is daily compounded T gel and daily HCG, and the labs were taken at 8:30 a.m. fasting, before applying treatment for that day.

But my question is a broader one. I'm trying to better understand how all this works, and I realized I don't really know why there is no free E2 number, similar to free T. And I'm not sure whether the sensitive E2 test is measuring total E2. So I thought I'd ask. It's relevant because it would seem to me that total E2 would effect guys very differently depending on their level of SHBG, and we really would want to see a free E2 number. And there isn't one. Why?

Vince,

I am in the low SHBG camp (I take 180 mg a week and total T is 425, free 21). What are symptoms of high E2?

SHBG shouldn't be much of a factor with a daily gel I can see you probably are low SHBG as your free T is off the chart which is a typical indicator. But again, E2 is E2. Its not measured or shown in a total or Free. E2 is simply one of the Estrogens in your body but E2 is the one that is more prevalent and impacts men directly.

I'd rather see your Estrogen higher, considering the ratio of T:E is ~24 and the theory is 14-20 is more ideal. And indeed, Estrogen will affect your sex drive; too little.

Jay said:

Vince,

I am in the low SHBG camp (I take 180 mg a week and total T is 425, free 21). What are symptoms of high E2?

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You've got some sort of issue if you're shooting 180mg and your TT is only 425.

High Estrogen: night sweats, puffy/water retention, bloated, most imoprtant is nipple issues like itchy, senstive, any kind of discharge.
But yeah something is way off with your dosing and numbers. What has your E2 tested at with those T numbers?

E2 is 27 - One .5 Armidex 3 x week

I do 3 shots of 60mg per week. Dunno, it is weird my total T is so low. Dr. says I am a fast metabolizer of T. Kinda sux. Not feeling all the benefits of T.

Vince,

If E2 binds to SHBG in a similar way to T, then that would seem to be a big factor in how guys react to a given E2 number (again total E2, both bound and unbound? I'm not sure what the sensitive E2 test actually measures...) And it does not make sense to me that therefore there is only one E2 number, since from what I understand, some E2 is bound and some is unbound.

I'm just asking questions to help my understanding.

I do understand the ratio theory: That what is important is not the E2 number but the ratio of T to E2. However, according to Dr. John Crisler in his book (Chapter 5), he disagrees with that theory. (Unless he has changed his mind, and I understand that this is a rapidly evolving area as we all continue to learn.)

Dr. Crisler says in his book:

"Some believe it is only the T/E ratio which is significant, and therefore, as long as E only 'appropriately' rises with elevations in T, all is well. This is incorrect, as the absolute concentration of estrogen (actually, all of them) is of concern, too. Now especially so in light of data pointing to elevated estrogen as cause, or adjunctively encouraging, several serious disease processes, including numerous cancers, as well as significant potential for induction of sexual dysfunction (no matter the accompanying androgen load)..."

The practical question is whether lowering my E2 is going to help me with my problem. I guess I will find out in another month or so as the new protocol takes hold.

The ratio theory belongs to Nelson Vergel. Dr Crisler doesn't treat E2 absent symptoms, if you're not aware. I haven't heard him on the ratio business but the forward thinking remains the same.

But anywho, E2 is how your tested and what matters. You can keep on digging a hole with bound and unbound and total Estrogens but that's not how this is done. It's just not. You're not going to find your sex drive by lowering E2 with an AI, not at a 35, anyway.

To add, what is an elevated E2 number? It's not what's on the lab reported ranges, and that's a fact. No one has any data of what is too high an E2 number in men.

Why not simply try to get in the mid 20s and see how you feel? Some guys are very sensitive to E2 and your baseline was bottom range. At 35 you're almost 3x your baseline. That's a big change in E2. Some guys seem to do best 15-25.

Some guys might feel great at 35 and others may not. I look at it the same way as TT. Some guys do well at 1100 or top of the range, but for me I'd go crazy with anxiety. I like around 700. HRT is so individual.

I would listen to your doc and let him use his experience. Until he steers you wrong, why not go with his expertise? You said he's a TRT doc so I imagine he's worked in the trenches with 1000s of guys - right? I'd also start super low, like .25mg 2x a week or E3D and test again in 4 weeks, if he allows.

TRT is a game of elimination for many of us. Try things out and see how you feel. If it doesn't make a difference just drop the AI and you'll float back 35 and look at other hormones, diet, etc.

I also agree with Dr John (he's my TRT doc) about the ratio theory. I defer to his exp. For me I feel better in the 20s than at around 40 and only need .25 a once or twice week to keep it in the 20s.

BTW - my free T is high and my SHBG is low, just like yours. Though my DHT is slightly above range and I'm horn dog lol. I do EOD subq injects at 105mg per week.

Thanks, RoneTone. I'll be starting the AI, as soon as the meds arrive, along with a couple of other changes the doc suggested, and see what happens. Horn dog level is what I'm shooting for, lol.

When you start taking Anastrozole (assuming Anastrozole/Arimidex)...start SMALL, .25mg once a week. I'm presuming your Dr goes full retard and prescirbes .5mg 3x week or .25mg EOD, something stupid like that. An AI is a powerful drug...go SMALL and titrate up, test often even if you have to use discountedlabs and pay for it yourself..

Nickle worth of free advice.

The doc has put me on anastrozole with DIM, .25 mg every other day.

DIM is diindolylmethane, a substance found in cruciferous vegetables. As the doc explained to me, the anastrozole will help prevent conversion of T to estradiol (as everyone who reads these forums knows), and he believes the DIM may help my liver metabolize estradiol, as well as other types of estrogen.

He also upped my HCG from 100 to 150 IU daily, and has added DHEA to my compounded T gel.

My doc is well known in the TRT biz and has a strong reputation for success. I sought him out because of his extensive clinical experience and judgement, to help me with this process, knowing going in that there could be setbacks or complications. But I'm sure he would readily admit that he doesn't know everything, and can't predict exactly how any specific guy is going to respond to a given protocol. So we'll see what happens, and go from there.

The next round of blood work and follow up consult is scheduled in 30 days.

That is a lot of Anastrozole. It is easier to start very low and adjust upward. You really are running the risk of crashing your estradiol.

It seems that my question about about free estradiol, and how it might explain my symptoms, was on track. In recent posts on the Facebook Testosterone Replacement group, Dr. Saya and Dr. Crisler from Defy Medical have discussed the availability of a free estradiol test, and how they are working to bring the cost down, so it can be a practical tool in their work.

My own sex drive has picked up with the addition of anastasol/DIM, even though total E2 was still (barely) in reference range. So I think we should not be so quick to dismiss the use of anastrozole. Dose is currently .15 2x week. I will post test result when I get them.