Help with Labs - High T, Low E2

[jasinc81]

Please excuse me if I'm not following protocol for posting this here. I started in the "introduction" section, but thought I'd re-post here and summarize. Here is the original thread if you want to review.

Here's my situation, I've been on TRT for over 2 1/2 months (Fortesta gel). Pre-TRT labs are here, mostly Total T and Free T. Started the gel on July 5th 2017:

June 5, 2017:
Testosterone Male 294.9 ng/dL 280.0 - 1,100.0 ng/dL
Testosterone Free Males ED 51.7
FSH 5.7 mUnits/mL 1.4 - 18.1 mUnits/mL
LH 1.4 mUnits/mL mUnits/mL
PHOSPHORUS 3.7 mg/dL 2.4 - 4.7 mg/dL

Comprehensive Metabolic Panel:
Fasting Status 13.0 hrs
Sodium 144 mmol/L 135 - 145 mmol/L
Potassium 4.9 mmol/L 3.4 - 5.1 mmol/L
Chloride 109 mmol/L 98 - 107 mmol/L
Carbon Dioxide 25 mmol/L 21 - 32 mmol/L
Anion Gap 15 mmol/L 10 - 20 mmol/L
Glucose 76 mg/dL 65 - 99 mg/dL
BUN 52 mg/dL 6 - 20 mg/dL
Creatinine 1.17 mg/dL 0.67 - 1.17 mg/dL
GFR Estimate, African American >90
eGFR results = or >90 mL/min/1.73m2 = Normal kidney function.
GFR Estimate, Non African American 80
eGFR 60 - 89 mL/min/1.73m2 = Mild decrease in kidney function.
BUN/Creatinine Ratio 44 7 - 25
CALCIUM 9.5 mg/dL 8.4 - 10.2 mg/dL
TOTAL BILIRUBIN 0.4 mg/dL 0.2 - 1.0 mg/dL
AST/SGOT 35 Units/L <38 Units/L
ALT/SGPT 45 Units/L <79 Units/L
ALK PHOSPHATASE 61 Units/L 45 - 117 Units/L
TOTAL PROTEIN 6.8 g/dL 6.4 - 8.2 g/dL
Albumin 4.3 g/dL 3.6 - 5.1 g/dL
GLOBULIN 2.5 g/dL 2.0 - 4.0 g/dL
A/G Ratio, Serum 1.7 1.0 - 2.4

Here are the labs I took earlier this month, after being on 40mg (2 pumps to each leg) of fortesta gel. My symptoms aren't any better, gained 15-20 lbs (mostly around my waist), still have no libido but no symptoms of gyno.

September 2, 2017:
TOTAL TESTOSTERONE 1,440 ng/dL 300 - 1,080 ng/dL
SEX HORMONE BINDING GLOBULIN 30 nmol/L
TESTOSTERONE, FREE 347 pg/mL 47 - 244 pg/mL
% FREE TESTOSTERONE 2.4 %
AUTO HEMOGRAM/PLATE/DIFF
WBC 6.2 K/mcL 4.2 - 11.0 K/mcL
RBC 4.42 mil/mcL 4.50 - 5.90 mil/mcL
HGB 13.8 g/dL 13.0 - 17.0 g/dL
HCT 41.9 % 39.0 - 51.0 %
MCV 94.8 fl 78.0 - 100.0 fl
MCH 31.2 pg 26.0 - 34.0 pg
MCHC 32.9 g/dL 32.0 - 36.5 g/dL
RDW-CV 13.2 % 11.0 - 15.0 %
PLT 187 K/mcL 140 - 450 K/mcL
DIFF TYPE AUTOMATED DIFFERENTIAL
Neutrophil 51 % %
LYMPH 34 % %
MONO 8 % %
EOSIN 6 % %
BASO 1 % %
Absolute Neutrophil 3.1 K/mcL 1.8 - 7.7 K/mcL
Absolute Lymph 2.1 K/mcL 1.0 - 4.8 K/mcL
Absolute Mono 0.5 K/mcL 0.3 - 0.9 K/mcL
Absolute Eos 0.4 K/mcL 0.1 - 0.5 K/mcL
Absolute Baso 0.1 K/mcL 0.0 - 0.3 K/mcL
PSA, Total 0.16 ng/mL <4.01 ng/mL

After receiving advice from the previous forum post, I ordered an Estradiol, sensitive test and a CBC test.
Estradiol:


CBC:


After the high T test, I visited my doctor and he lowered the dose of Fortesta to 1 pump per leg each morning (20mg) and re-ordered tests in 2 months. I've been on that dosage for over a week now and don't feel any different. Do I still not feel right because of low E2? Or do I need to give it more time to stabilize? My biggest concern is the libido and weight gain even though I workout 6 days a week and eat 2000-2300 calories a day. On top of testosterone gel, here are the other supplements I'm taking:

krill oil - 2g daily
Multi-vitamin
Adrenal Support (2x daily)
Metformin 500mg (3x daily w/meals - just started 1 week ago)
DHEA 100mg

Any help would be greatly appreciated! Thanks!

 

[jasinc81]

Just realized the link from my previous thread didn't post..my apologies. Here it is again https://www.excelmale.com/forum/showthread.php?11865-New-to-the-Forum-started-TRT-2-months-ago

 

[Vince Carter]

Are you using anything at all, an AI like Anastrozole or Aromasin to control your E? 7.2 is quite low and is not good.

 

[jasinc81]

No AI...I had ordered some Anastrozole figuring it was high, but after getting the tests back showing low, they're just sitting in the box still.

 

[Vince Carter]

we see that from time-to-time, very low natural E. Given that you've altered your dosing just ride it out till the next set of labs. Low E is bad, would be better to be high(er) E like in the 30-35 range though, if not a bit higher. Low E has all kinds of negatives.

 

[lowe2sucks]

too high dht can supress estradiol.. makes sense if your testosterone delivery is gel or cream they can raise DHT quite high because of 5-AR enzyme in the skin. I know everybody says how dhea raises estrogen but I found one link in google that states dhea inhibits aromatase https://raypeatforum.com/community/...by-35-and-endotoxin-blocks-that-effect.12529/ nobody believes me but I used the DHEA cream and after few months of using it felt same side effects as I got from anastrozole which I used many years ago..

 

[lowe2sucks]

Another reason for lower aromatase in men on TRT is - 0 FSH (https://www.ncbi.nlm.nih.gov/pubmed/3155262) 0 LH (https://www.ncbi.nlm.nih.gov/pubmed/11124864) non-functioning testes (https://www.ncbi.nlm.nih.gov/pubmed/7539819 https://www.ncbi.nlm.nih.gov/pubmed/7956176) too high DHT (Dihydrotestosterone (DHT), a 5&#945; reduced metabolite of testosterone, has been reported to act as a competitive inhibitor of aromatase activity in the ovary (17). - https://academic.oup.com/endo/article/143/8/2930/2989558/Dihydrotestosterone-Inhibits-Granulosa-Cell)
also I found that CRH is involved in aromatase (http://www.sciencedirect.com/science/article/pii/S0143400413007911) and I found a study that shows that testosterone supresses CRH-stimulated cortisol in men (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1470424/)

 

[lowe2sucks]

make sure you are not high in zinc, vitamin d3 and don't take melatonin if you are taking it as these have aromatase inhibiting, antiestrogenic effects

 

[jasinc81]

we see that from time-to-time, very low natural E. Given that you've altered your dosing just ride it out till the next set of labs. Low E is bad, would be better to be high(er) E like in the 30-35 range though, if not a bit higher. Low E has all kinds of negatives.

Ok..I've been on 1/2 dosage for 2 weeks now. Feel worse than I did before, but I'll give it until November when I have my next set of labs. Thanks for the advice!

 

[jasinc81]

make sure you are not high in zinc, vitamin d3 and don't take melatonin if you are taking it as these have aromatase inhibiting, antiestrogenic effects

I appreciate the insight. So, it's possible my DHEA supplement could be contributing to the low E2? I do take a ZMA supplement every night. Should I also forgo that as well?

 

[Vince Carter]

DHEA is far more likely TO aromatase than drive E down...extremely unlikely. Same with DHT.

 

[user_joe]

I had naturally low e2 that took months to creep up on TRT. Where I'd go from here is an increased dose or on to injections. You already have your T quite high though. I think I'd switch to injections. You will never feel great with low e2 for any length of time. I'd start injections at 80mg 2x/wk and not stop the gel for 10-14 days. Just my guess based on personal experience.

Most people shed water weight with low e2. TRT otherwise shouldn't increase your weight if calories are controlled unless your thyroid was affected in a negative way. Apparently, that is an issue for some. Definitely not the majority.

 

[jasinc81]

I had naturally low e2 that took months to creep up on TRT. Where I'd go from here is an increased dose or on to injections. You already have your T quite high though. I think I'd switch to injections. You will never feel great with low e2 for any length of time. I'd start injections at 80mg 2x/wk and not stop the gel for 10-14 days. Just my guess based on personal experience.

Most people shed water weight with low e2. TRT otherwise shouldn't increase your weight if calories are controlled unless your thyroid was affected in a negative way. Apparently, that is an issue for some. Definitely not the majority.

My doctor just lowered my gel applications, so we'll see in November where I sit. I've been on this dosage for 2 weeks now, and don't feel any better. In fact, I feel worse. I would love to switch to injections, but I guess that's up to the doctor and I'm assuming insurance. Applying the gel is a pain every morning because it gives me a rash and takes forever to dry.

I might be the exception, because my weight keeps going up at least a couple pounds a week. It's very discouraging as my calories are controlled and I workout 6 days a week. I know it's water weight/fat because I have lost all vascularity and my waist keeps increasing. I'm creeping into a slight depression where I almost prefer when I was able to stay lean but felt like crap. Now I feel like crap and keep putting on weight no matter what I eat and how much I workout.

 

[jasinc81]

DHEA is far more likely TO aromatase than drive E down...extremely unlikely. Same with DHT.

I was doing 100mg of DHEA daily..should I decrease to 25mg?

 

[Vince Carter]

I was doing 100mg of DHEA daily..should I decrease to 25mg?

Thats a whopper mega dose...25, or less, would be better to see how you tolerate where you can titrate up or down as needed. There's a few guys that just don't tolerate DHEA very well even at 10mg or less. I don't agree with DHEA use a basic must have in TRT.

 

[user_joe]

I personally think you have the wrong attitude. **** the doctor and insurance company. You are going to commit to feeling miserable for additional months to save $100-$200/mo? I went straight to the first clinic I could find when I was getting bad treatment and made another move later once I was feeling better. Would not change that.

I'd try to shed some water weight to see if that's the only thing going on. Could be transient. If it's legit body mass added with low calories you a CBC run and looked at by a competent endo.

There is more knowledge on this forum than your inexperienced doctor has. That may sound strange, but that's the state of hormone treatments and inexperienced/clueless doctors.

My doctor just lowered my gel applications, so we'll see in November where I sit. I've been on this dosage for 2 weeks now, and don't feel any better. In fact, I feel worse. I would love to switch to injections, but I guess that's up to the doctor and I'm assuming insurance. Applying the gel is a pain every morning because it gives me a rash and takes forever to dry.

I might be the exception, because my weight keeps going up at least a couple pounds a week. It's very discouraging as my calories are controlled and I workout 6 days a week. I know it's water weight/fat because I have lost all vascularity and my waist keeps increasing. I'm creeping into a slight depression where I almost prefer when I was able to stay lean but felt like crap. Now I feel like crap and keep putting on weight no matter what I eat and how much I workout.

 

[jasinc81]

Thats a whopper mega dose...25, or less, would be better to see how you tolerate where you can titrate up or down as needed. There's a few guys that just don't tolerate DHEA very well even at 10mg or less. I don't agree with DHEA use a basic must have in TRT.

I only had 100mg capsules, but ordered some 25mg pills so I will give that a shot for a few weeks then maybe switch to 25mg EOD. I had a saliva test done a few months back and it showed my DHEA was very low, so that's why I started taking it, it wasn't related to the low E2. Thanks again for the help!

 

[jasinc81]

I personally think you have the wrong attitude. **** the doctor and insurance company. You are going to commit to feeling miserable for additional months to save $100-$200/mo? I went straight to the first clinic I could find when I was getting bad treatment and made another move later once I was feeling better. Would not change that.

I'd try to shed some water weight to see if that's the only thing going on. Could be transient. If it's legit body mass added with low calories you a CBC run and looked at by a competent endo.

There is more knowledge on this forum than your inexperienced doctor has. That may sound strange, but that's the state of hormone treatments and inexperienced/clueless doctors.

Yeah, I was going to wait until the next labs to see what my next steps are. I've been reading a lot about defy here on the forums, so that may be an option. I did have a CBC test run along with that E test, however the only thing I noticed as a high EOS.

Any suggestions for cutting water weight? I already eat moderate carbs (~150-170g day). I was on keto for 6 months last year and 4 months this year. I generally do well on low carb, but my strength and endurance when training go into the drain so that's why I went back to eating cleaner carbs.

 

[jasinc81]

Update:
I sent my doctor a note this morning asking about my E2 levels being so low. I also asked to include an Estradiol sensitive test in my next set of labs. Here is is response:

"The low E2 results are likely due to lower testosterone levels. So, when the testosterone drops there is less to convert to estradiol, meaning that the estradiol then drops. It rises back to normal after consistent testosterone levels (as usual, these fluctuate during the day). There is no clinical significance to testosterone replacement for this lab, meaning that the results do not change our approach or add anything significant. If the estradiol was extremely high, it can indicate an estrogen-producing tumor. This is obviously not the case for you, but is really the only time we need an estradiol level in men.

If you feeling more fatigued, we should split the difference on dosing or go to 3 pumps daily now so we have time to see it reflected on labs in November. It does not matter which side you place the third actuation. Try this for a couple of weeks and let me know how you are feeling. "

Couple things.

1. This E2 test was taken only 2 days after going from 4 pumps to 2 pumps, and a week after my TT levels were over 1500. So the theory of my low T levels bringing E2 down shouldn't be accurate, right?

2. If I increase my dosage again, won't I just end up right back where I was or close?

Finally, what are other's experience with Defy Medical and what could I expect from a cost/treatment plan? I've been dealing with this endo over a year now and feel like I'm spinning tires. I'd appreciate any feedback or comments on this matter.

Thanks!

 

[user_joe]

My gut reaction is to say your doctor is a moron, but he's probably just inexperienced in the intricacies of TRT. He sure has a lot of patience for the process of getting you on a successful treatment.

Zero experience with Defy here, but the DR posts here frequently and seems to be extremely knowledgeable. The protocols they put people on make sense imo.