Have just registered for this forum and will try to be involved as my life schedule permits (with work and three kids at home)...
Hello to everyone!
Marshall and others:
In general, members should be cautious of taking advice and getting all worked up from other members whom are not medical professionals...they are trying to help with advice, but for some people this just breeds anxiety and is more harmful than beneficial.
Regarding the issues posed...
In my experience, the ultra sensitive E test and regular E test are fairly equivalent unless we start talking about VERY low E levels ( <15), which would be too low anyways. At those VERY low E levels the ultra sensitive test is exactly that - more sensitive (this is evidenced by the fact that the regular E test will not detect anything less than 5.1 - it will read <5.1 ... It is not SENSITIVE enough to detect those low levels). The ultrasensitive test is also more expensive and he's welcome to order it, but IMO is a waste of $ that could be better spent elsewhere. In other words, the regular estradiol test will give us a good idea of if E2 is "low", "acceptable/OK", or "high"... which is really what we're interested in anyways. If your interested in knowing EXACTLY how low (ie: 3 vs 10) or EXACTLY how high (ie: 50 vs 65) then the ultrasensitive test would give you that, but at additional cost...
With regards to the thyroid... high TSH, fatigue, being overweight = basically guaranteed hypothyroidism. Sure we can check additional labs (free T3, free T4, reverse T3) but again this is additional cost to the patient and will likely NOT ultimately change our treatment plan as 99% probability with his TSH level (>6) that his T3/T4 will be off. In addition, as I do with most patients, but don't recall specifically my convo with him, I usually give the option of more thorough testing up front (at more cost, with the understanding that it likely will NOT alter the treatment plan) or to empirically start thyroid treatment and monitor on follow-up accordingly... and most patients , Mr Shell included if I recall, choose to start empiric treatment. We ARE monitoring free T3 and free T4 on his 90 day f/ u labs to make sure the armour dosage is dialed in accurately.
Regarding anastrozole, E is 25 (perfect) with total T 400 (fairly high ratio), has history of high E with early breast/gyno symptoms, has relatively high body fat % (= more aromatase activity). He ABSOLUTELY needs an AI. How much?? Well that's the art of it and to be determined through treatment and follow-up. 0.5 mg twice weekly is a good bet of what he'll need ... Maybe a bit more or a bit less, we'll see on follow-up labs. E will begin to rise as soon as T rises (aromatase enzyme doesn't take any vacations), so should start the AI together when starting the T injections ESPECIALLY in patients with a proven history of high E conversion and the related side effects. His current E level is perfect at 25, but it WILL NOT stay there as his T comes up without an AI especially with his high aromatase activity.
I spent over an hour discussing many issues with this patient, once again, he should be cautious of getting worked up or stressed out by posts from forum members that do not know his entire clinical picture, are not medically trained, and have not had an official (1 HOUR) medical consult with him. Some aspects of HRT are more art than exact science, and this is where CLINICAL experience is crucial. Many people have various differing opinions, but I have quite a bit of experience with these and similar hormonal abnormalities and am well versed in the intricacies and caveats of treatment... forum posts by non-medical members should not be taken as the gospel especially if they will breed uncertainty and anxiety.
Good day all!
Dr Saya