Is Testosterone to Estradiol Ratio Important in Men?

[bigfred32]

Couple months ago Nelson had a take on E management and understanding E follows T makes perfect sense and treating symptoms vs numbers on bloodwork.

There was alot of conversation about a ratio of keeping E2 (14-20) using the math of T÷E2.

I recently moved to Nashville from So Cal and starting to interview doctors in the area and wanted to go in with some added info as I feel fantastic and keep my E2 ratio around 18 on Nelsons scale. In reality its total T: 740 and E2 ultra sensitive is 39. (740÷39=18)

Im in the process of compiling all the questions regarding my treatment, and want to back up my E2 management. Its taken over a year to get to this point and I dont want to go backwards.

Question: is this an educated belief about ratios or is there a study out there that was used to come up with the math.

I want to stay on the same protocal Im currently on without having to fly back to CA yearly, just not sure what Im going to run in to out here.

(Yes, I could go to Defy, but right now its an insurance issue.( i know someone will suggest that. Lol)

 

[ERO]

At least some doctors will let you stay on your current protocol, I would think. Especially since you have been on a while and everything works. Just let them know that you are "dialed in" already and just want to stay on the same protocol.

 

[CoastWatcher]

There are no standard references for estradiol levels recognized by the various professional societies (endocrine, urological). As Nelson has written, it is one of the last frontiers of TRT research. The concept of the testoterone estradiol ratio is one that physicians with years of experience have begun to recognize. Nelson's research, studying the levels of both hormones in various populations, adolescent boys in puberty, healthy, young men, middle-aged men, healthy and those dealing with androgen deficiency, has lead him to conclude that there is a great deal of truth in this concept. Once again, we are ahead of the research.

 

[Vince Carter]

Its the one theory that has worked for me, I'm quite happy off Anastrozole. I haven't been tested lately but I'm following the T:E ratio and have no complaints. I treat Dr, until I switched to Defy, and even now, I follow what is best for me. Contrary to some times the prescribed things, as long as I'm not abusing it, it's like any other medication, people rarely take it exactly as prescribed. In fact when I had my consult with Dr Saya, I was emphatic about not making any changes and he's was totally cool with it.

 

[Nelson Vergel]

Vince

I will try to find the paper that looked at ratios for fertility purposes. It is not a ratio that is well researched but more and more clinicians are talking about.

Very little data on T/E2 ratios (that actually use LC/MS for both parameters).​

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My hypothesis is that, like all hormones, there is an inverted U-shaped curve (for benefits vs T/E2 ratio). Some studies hint at T/E2 above 14, but we have no data on the upper range since very high T/E2 may be indicative of low estradiol.​

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Post #12: Is Testosterone to Estradiol Ratio Important in Men?​

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Since 0.3-0.4 percent of TT is normally aromatized into E2 in healthy men, then it makes sense that​

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1/0.03= 33 should be used as a benchmark​

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Estradiol tends to plateau as T dose increases (probably also due to increased DHT that acts as an estradiol blocker). Aromatization was shown to be higher for older men here:​

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Effect of Testosterone Injections on Estradiol and DHT in Young and Older Men - ExcelMale​

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I think 0.25 mg per week of anastrozole makes sense for men whose conversion is above 0.3 percent (I think we should monitor estradiol like we do free T. Free T percent should be 2% of TT or above). DHT should be 10% of TT or above.​

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I have been trying to get a hold of this doctor since he did not mention what T/E2 ratios were best:​

AUA 2017: Calculated Free T and T:E Ratio but not Total Testosterone and Estradiol Predict Low Libido

Boston, MA (UroToday.com) Libido is thought to be influenced by hormonal milieu, particularly testosterone. The knowledge about the role of estradiol in male sexual function has been found to be more important than originally thought. The estradiol cut-off point of 5 ng/dL in hypogonadal men is thought to directly affect libido. Dr. Gupta presented a study assessing the impact of sex hormones on libido specifically in a cardiac patient population.

The study focused on 200 men in a cardiology practice who completed the IIEF-15, ADAM, and previous ED treatment questionnaires. Additionally all patients had serum total testosterone (T), estradiol (E), and sex hormone binding globulin (SHBG) levels measured via morning lab draws. Their free testosterone (CFT) was calculated using an online ISSM calculator. Patients that were diagnosed for hypogonadism in the past or who were currently on medications possibly affecting T levels were excluded. Hormonal levels were correlated to responses to the IIEF questions 11 and 12 (IIEF11, IIEF12), focusing on libido.

Results demonstrated the mean total T level to be 310 ng/dL with CFT of 5.4 ng/dL. Mean E levels were 4.4 ng/dL and mean T:E ratio was 8.2. Importantly, 55% of patients had T levels less than 300 ng/dL and 74% of patients had a CFT < 6.5 ng/dL. Negative correlation was found between estradiol and IIEF11 and IIEF12, but was not statistically significant. However, a positive correlation was found between IIEF11 and IIEF12 and CFT and T:E ratio (p=0.007, p=0.009, respectively). At a cutoff of E=5ng/dL, no difference was found for either hypogonadal or eugonadal men on the IIEF11 or IIEF12.

In summary, CFT and T:E ratio were predictive of positive libido response on IIEF11 & 12 questions in the IIEF questionnaire. Estradiol, even at a cutoff of 5 ng/dL, was not independently associated with improved libido. Surprisingly, no correlation was found between total testosterone and IIEF11 (desire frequency). The effect of testosterone and estradiol on libido requires further research with prospective studies.

Presented By: Nikhil Gupta, Springfield, IL

Written By: Hanan Goldberg, MD, Urologic Oncology Fellow (SUO), University of Toronto, Princess Margaret Cancer Centre

at the 2017 AUA Annual Meeting - May 12 - 16, 2017; Boston, Massachusetts, USA

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[bigfred32]

I wasnt sure if I was putting the cart before the horse so to speak regarding my treatment. Ive called several dr out here and most of them do pellets or androgel and wont do injectables or what im using now, a compound cream. Im not even going to waste my time with an appt with them. I have found two within my network that sound promising and will see them later this month. Im just doing my homework because I have found that being an "educated" patient is sometimes intimidating to doctors and the ones that embrace persons like ourselves here is the kind im looking for in my new area.
The only thing I was unclear on was the T/E ratio concept scientifically, except to know that I subscribe to it and feel FANTASTIC!

 

[CoastWatcher]

I wasnt sure if I was putting the cart before the horse so to speak regarding my treatment. Ive called several dr out here and most of them do pellets or androgel and wont do injectables or what im using now, a compound cream. Im not even going to waste my time with an appt with them. I have found two within my network that sound promising and will see them later this month. Im just doing my homework because I have found that being an "educated" patient is sometimes intimidating to doctors and the ones that embrace persons like ourselves here is the kind im looking for in my new area.
The only thing I was unclear on was the T/E ratio concept scientifically, except to know that I subscribe to it and feel FANTASTIC!

It's impressive, isn't it? I've found that my system permits me a bit more flexibility - I can tolerate a slightly higher ratio. Which isn't surprising, this whole ride is so unique to each person.

 

[Someguy]

Interesting. This could explain why I felt better with a TT of around 600-800 and E2 around 20 than I did with a TT of 1200-1500 and E2 of around 20. I wasn't considering the ratio at all, just that the absolute e2 number was fine before so should be fine now.

I'm guessing there's still an upper e2 number that you don't want to exceed even if your T is high enough to keep the ratio correct, right? You'd need an E2 of 60 to offset a TT of 1200 and keep the ratio at 20. Probably not a good idea, right?

 

[Vince Carter]

There is no established high E2 number. It's based on nipple issues, primarily. Absent those or any other high estrogen symptom, there's no treatment advised, minding the ratio.

 

[Someguy]

Is it the ratio or the absolute e2 number that causes gyno? For example, if a guy has gyno symptoms at an e2 level of 50 at 600 TT, would he also have gyno symptoms at an e2 level of 50 with a TT of 1200?

 

[ERO]

it is the ratio. An absolute E2 number is only meaningful in its relation to the total T number.

Not a perfect analogy, but helpful if you think of it as being similar to the horsepower to weight ratio in a race car. A 200 hp engine in a car that weighs 1500 lbs is gonna be a hell of a lot faster than an engine making 350 hp in a car weighing 4000 lbs. You have 7.5 lbs per horsepower in the first car and 11.42 lbs per horsepower in the second car.

 

[Nelson Vergel]

CLINICAL UROLOGY: Original Articles

EVIDENCE OF A TREATABLE ENDOCRINOPATHY IN INFERTILE MEN
The Journal of Urology
Volume 165, Issue 3, March 2001, Pages 837–841

Purpose
We establish whether a subset of infertile men have decreased serum testosterone-to-estradiol ratios and whether this condition can be corrected with an oral aromatase inhibitor.

Materials and Methods

The serum testosterone-to-estradiol ratios of 63 men with severe male factor infertility or hypergonadotropic hypogonadism (mean follicle-stimulating hormone 21.2 ± 1.8) were compared with those of an age matched, fertile, control reference group. Of the 63 men 43 were azoospermic with biopsy proved severe male infertility and 20 were oligospermic. The men with the lowest ratios (less than 20th percentile) were treated with 50 to 100 mg. of the aromatase inhibitor testolactone orally twice daily. Testosterone-to-estradiol ratios and semen analyses were evaluated during testolactone therapy.

Results
Men with severe male infertility had significantly lower testosterone (328 versus 543 ng./dl., p <0.01) and higher estradiol (58.4 versus 43.5 ng./l., p = 0.01) than fertile control reference subjects, resulting in a decreased testosterone-to-estradiol ratio (×10[SUP]−1[/SUP] = 6.9 ± 0.6 versus 14.5 ± 1.2, respectively, p <0.01). Of the 45 men treated with testolactone a correction of these abnormalities was seen and ratios (×10[SUP]−1[/SUP]) increased into the normal range (5.0 ± 0.3 to 12.7 ± 1.2, p <0.01). Semen analyses were considered evaluable only in men with sperm in the ejaculate before aromatase inhibitor treatment. Semen analyses before and during testolactone treatment revealed significant increases in sperm concentration (16.1 to 28.9 million sperm per ml., p = 0.03) and motility (27.1% to 45.3%, p <0.01) in 12 oligospermic men.
[h=4]Conclusions[/b]We identified an endocrinopathy in men with severe male factor infertility that is characterized by a decreased serum testosterone-to-estradiol ratio. This ratio can be corrected by aromatase inhibition, resulting in a significant improvement in semen parameters in oligospermic patients.

T/E2 Ratios:

 

[bigfred32]

My current doctor is very open minded and progressive when it comes to TRT. We actually discuss treatment and things I learn from this site, books and others. She listens to the T/E ratio whether or not she fully understands it, because I dont. I just know it makes sense and I feel balanced. She works with me msnaging E2 and I stay within the parameters that Ive learned here.
I wanted to sound alittle more educated and squared away when discusding this therory with a new doctor so I dont sound like Im making stuff up. Hahahahaha

 

[Nelson Vergel]

At this point, there are not enough data to know what the minimum T/E2 ratio is. Studies hint at 10.

Most doctors in antiaging treat estradiol with anastrozole when it gets over 35 pg/mL. They usually overdose the patient with doses above 0.5 mg per week. They also use the old (less accurate) estradiol test that is based on ECLIA technolocgy (immunoassay).

In my opinion, a dose of 0.25 twice per week of anastrozole may do the job. Estradiol testing via sensitive assay (LC/MS) should be performed before starting anastrozole and 4-6 weeks after starting it.

There are no guidelines written for estradiol management in men.

 

[DHM]

I think these are good general guidelines Nelson, however Ive been going through an opposite scenario.

For over a year Ive been on a Clomid titration from 25mg EOD to now 12.5 twice a week.

TT has been in the range of 900-1100 with high estradiol numbers, Always felt shitty for a long time.

Once I got to the low doses (~12.5 mg clomid x3/wk+ 1mg Anastrazole 3x/wk). I started feeling really good, with little need for any nootropics. Numbers matched preceived feeling 1k TT and 52 E2s= ~21 T/E2 ratio.

Im up for a panel soon as Ive dropped the Clomid dose down again and took out DHEA supplementation (too edgy).

The question I have about the labs are how/if clomid is interferring with the e2 assay.

I think the boat is sailing straight and it feels good.

Thanks!

 

[croaker24]

Interesting. This could explain why I felt better with a TT of around 600-800 and E2 around 20 than I did with a TT of 1200-1500 and E2 of around 20. I wasn't considering the ratio at all, just that the absolute e2 number was fine before so should be fine now.

I'm guessing there's still an upper e2 number that you don't want to exceed even if your T is high enough to keep the ratio correct, right? You'd need an E2 of 60 to offset a TT of 1200 and keep the ratio at 20. Probably not a good idea, right?

This is the question I had and I see that Vince provided an answer. I switched to Defy and asked the same question and they indicated symptoms as the clues to it being too high - nipple sensitivity / water retention. Even if the ratio is fine, and one is not having any symptoms, could a high e2 still result in other problems, cardiovascular, etc?

 

[ERO]

No, you are way over complicating this. If your ratio is fine and you have NO symptoms - you are fine.

A number - any number - is only meaningful in context, which in this case is the ratio of T to E.

Say for example you weigh 200 lbs. Are you overweight or underweight? Impossible to answer unless we know your height and body fat percentage. See what I mean? The number in this example - 200 lbs - means absolutely nothing by itself.

 

[Vince Carter]

I agree with ERO, there is NO number that is high. You WILL find a number that is high, for YOU. Frequent self testing and being in tune with your body, over time, will guide you.

 

[jfullam]

This thread is of interest to me. Just about to start my new protocol with Defy next week:
1.) 60mg Test Cyp (200 mg/ml) 2x per week (I will inject subq on Sun and Wed mornings).
2.) 100iu HCG Daily every morning (also subq).
3.) Anastrozole 0.5mg/DIM 200mg By mouth 2x per week on Test injection day.
I would prefer not to take the AI if it is not completely needed.
My most recent BW was:
Total T: 263
Free T: 5.9
Estradiol Sensitive: 16.9
LH (Luteinizing Hormone): 2.5
Assuming my E2 will rise along with my Total T, if I monitor my E2 levels monthly (initially), what things can I do to ensure I keep those levels in check without resorting to an AI? I know some guys on here do without an AI. Does it come down to diet and exercise? I do exercise 4-5x per week (intensely), but I currently still have some belly fat that has been difficult for me to eliminate. My goal would be to execute on the above protocol without relying on an AI, if possible.

 

[Vince]

I've never used an AI, the three things I know that may help. Get rid of belly fat, use zinc supplement and Cialis also helps to keep E2 in check.