Labs Tomorrow & I'm Concerned

[Starplex]

So I really like my GP and now worried that TRT with him might not work out. Started on TRT in July based off Low T results. (He did test TSH so Thyroid was ok, as well as PSA). Discussed the benefits of TRT and he seemed to be very knowledgeable. Asked me about HCG or if I was planning on any more children. Discussed Gyno as a possible side effect, but not likely, etc. He has been taking TRT himself going on 4+ years. I seem to recall him saying something about being a part of some Hormone Group or something like that.
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Prescribed 250mg Test Cyp from local Compounding Pharm. (I now know this is a high dose). He even mentioned he prefers to see higher numbers. Injecting 0.5mL twice/week.
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So after doing all this research I have come to understand that I need to be watching E2 as well as other tests, SHBG, DHEA-S, etc. Need to also find the sweet spot.
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I know I went through the sweet spot (I had it for about a week in week 7 or 8). Morning Wood, Crazy Energy that wouldn't stop, Libido like a Dog in Heat, etc. I suspect I have high E2 now, but not huge symptoms. I can say I'm certainly not in the sweet spot, not as much MW, still have Libido but not as sensitive during sex. (I've lasted longer then ever, new record, ha ha). I have high hopes that I'm controlling to some degree with Grapeseed extract 400mg day, ZMA at night, 18%BF, Exercise & diet.-
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So now for your help. I was quite certain that I would get all these tested on my upcoming lab work, but I called just to be sure, and said I just want to make sure that my Lab order for next week includes the E2 Ultra Sensitive Test and not the IA method. To my surprise they weren't even going to test E2, nor the SHBG, nor DHEA. Basically just PSA, CBC, Total Test, & Free Test.
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I told them no I at least needed and wanted to add the E2 test & I would pay for it. Nurse would not add it, said it had to come from the Dr. So after me explaining that there must be some mistake and that this is part of TRT protocol the Dr. has agreed to meet with me prior to my blood work. I've printed out several items to bring that includes the TRT Follow up Panel, Article by MD Miguel Gonzalez on why E2 Monitoring is crucial for TRT, Nelsons Monitoring Targets, Another article by Gene Devine on E2.
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Anything else I should be prepared with. I was hoping to be able to control E2 with a very small dose of Adex & I know he is familiar with it as he mentioned it during the gyno discussion. But if he wasn't going to test E2 to begin with, this might be a struggle. Hopefully this is all just a paperwork mistake, but I'm afraid it might not be.
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Sorry for the long first post.

 

[Helboi]

You can always use Discounted Labs to get your E2 (sensitive) test done and skip him entirely on that. Then you can take it back to show him later and hopefully get better care from him going forward.

 

[Starplex]

You can always use Discounted Labs to get your E2 (sensitive) test done and skip him entirely on that. Then you can take it back to show him later and hopefully get better care from him going forward.

I will definitely do that if he doesn't agree to pull the test tomorrow.

 

[johndoesmith]

Hey man, it sounds more like a communication or paperwork error. The nurse is right, she cannot add tests without the doctors approval. Did you ask the nurse if she can ask the doctor to add it on at your request?

Hopefully that's all this is.

 

[bruin]

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So now for your help. I was quite certain that I would get all these tested on my upcoming lab work, but I called just to be sure, and said I just want to make sure that my Lab order for next week includes the E2 Ultra Sensitive Test and not the IA method. To my surprise they weren't even going to test E2, nor the SHBG, nor DHEA. Basically just PSA, CBC, Total Test, & Free Test.
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I will definitly be following your outcome, I probably mirror 95% of your scenario. I m returning this week to the original Provider where I started HRT and starting a new slate with a new Dr., my concern is to get the full panel of test required and you are correct in your position.

 

[Starplex]

Well it was an interesting visit. To my surprise he was extremely familiar with the protocol that is mainly used as described in many of the forums (balancing T and E). Was very aware of Life Extension and many of the other Male Aging Clinics and their protocols. However, his stance is different then many of these Aging Clinics. He takes a stance similar to what Nelson has quoted in some of the Stickies around High E2 and High T. Basically that the high E2 really doesn't matter and that there are newer studies that actually show that High E2 lowers the risk of Heart Disease, etc. Similar to when Females have high E2 there risk of Heart Disease is low, but after Menopause and E2 gets low their risk increases.
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He stated that he has hundreds of guys on TRT and has yet to see a case of Gyno either. (Assuming they aren't abusing the system).
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However, since I had done so much research and discussed the topic with him in detail, and that I am taking 400mg of GSE along with ZMA to try and combat Aromatase he agreed to test the E2 just to see where it is at. Although if high I'm sure there will be No AI prescription. He stated his E2 was well over 100 & has been for a long time.
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He also agreed to test DHEA-S, and said we can supplement if needed, but has seen some aggression in some people (including himself) when supplementing DHEA. He said testing SHBG is a waste and not required. (once again the old school of thought.) He did write a script for Cialis though and said that it has many more benefits then just in the downstairs area. Increase in Nitric Oxide will also help with the Sensitivity issue and circulatory system.
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We will see where the blood work values land and go from there. It will be a little over a week before my follow up. Maybe it is just me, but I am still shocked at how knowledgeable he was in every single area where I asked a question. It wasn't like he was grasping or didn't know. He backed up his comments with studies from various areas as well. Appears he has been doing TRT for along time. Otherwise I would have been skeptical and wanted to run, but it almost felt like he knew more up to date technical details about this stuff that just hasn't caught on yet in the general TRT area.

 

[johndoesmith]

Well it was an interesting visit. To my surprise he was extremely familiar with the protocol that is mainly used as described in many of the forums (balancing T and E). Was very aware of Life Extension and many of the other Male Aging Clinics and their protocols. However, his stance is different then many of these Aging Clinics. He takes a stance similar to what Nelson has quoted in some of the Stickies around High E2 and High T. Basically that the high E2 really doesn't matter and that there are newer studies that actually show that High E2 lowers the risk of Heart Disease, etc. Similar to when Females have high E2 there risk of Heart Disease is low, but after Menopause and E2 gets low their risk increases.
-
He stated that he has hundreds of guys on TRT and has yet to see a case of Gyno either. (Assuming they aren't abusing the system).
-
However, since I had done so much research and discussed the topic with him in detail, and that I am taking 400mg of GSE along with ZMA to try and combat Aromatase he agreed to test the E2 just to see where it is at. Although if high I'm sure there will be No AI prescription. He stated his E2 was well over 100 & has been for a long time.
-
He also agreed to test DHEA-S, and said we can supplement if needed, but has seen some aggression in some people (including himself) when supplementing DHEA. He said testing SHBG is a waste and not required. (once again the old school of thought.) He did write a script for Cialis though and said that it has many more benefits then just in the downstairs area. Increase in Nitric Oxide will also help with the Sensitivity issue and circulatory system.
-
We will see where the blood work values land and go from there. It will be a little over a week before my follow up. Maybe it is just me, but I am still shocked at how knowledgeable he was in every single area where I asked a question. It wasn't like he was grasping or didn't know. He backed up his comments with studies from various areas as well. Appears he has been doing TRT for along time. Otherwise I would have been skeptical and wanted to run, but it almost felt like he knew more up to date technical details about this stuff that just hasn't caught on yet in the general TRT area.

Having an E2 of over 100 and being knowledgeable is a contradiction. Yes he is right that low E2 is unhealthy, but so is high E2. Comparing men's E2 levels to women's "higher" E2 levels doesn't make sense.

There's a study showing being high or low E2 is bad for mortality, although it was done in older male patients with chronic heart failure, so it might not apply to young men without heart failure. http://www.discountedlabs.com/blog/management-of-estradiol-in-men-what-do-studies-show/

A TRT doctor that doesn't think E2(especially the sensitive test) doesn't need to be tested isn't doing you any good. All good TRT doctors test E2 with testosterone. If I told my doctor I didn't want to pay for an E2 test, I'd probably be educated why it's so important and if I still didn't want it, be discharged after a restart. I can't imagine not checking E2.

 

[CoastWatcher]

Well it was an interesting visit. To my surprise he was extremely familiar with the protocol that is mainly used as described in many of the forums (balancing T and E). Was very aware of Life Extension and many of the other Male Aging Clinics and their protocols. However, his stance is different then many of these Aging Clinics. He takes a stance similar to what Nelson has quoted in some of the Stickies around High E2 and High T. Basically that the high E2 really doesn't matter and that there are newer studies that actually show that High E2 lowers the risk of Heart Disease, etc. Similar to when Females have high E2 there risk of Heart Disease is low, but after Menopause and E2 gets low their risk increases.
-
He stated that he has hundreds of guys on TRT and has yet to see a case of Gyno either. (Assuming they aren't abusing the system).
-
However, since I had done so much research and discussed the topic with him in detail, and that I am taking 400mg of GSE along with ZMA to try and combat Aromatase he agreed to test the E2 just to see where it is at. Although if high I'm sure there will be No AI prescription. He stated his E2 was well over 100 & has been for a long time.
-
He also agreed to test DHEA-S, and said we can supplement if needed, but has seen some aggression in some people (including himself) when supplementing DHEA. He said testing SHBG is a waste and not required. (once again the old school of thought.) He did write a script for Cialis though and said that it has many more benefits then just in the downstairs area. Increase in Nitric Oxide will also help with the Sensitivity issue and circulatory system.
-
We will see where the blood work values land and go from there. It will be a little over a week before my follow up. Maybe it is just me, but I am still shocked at how knowledgeable he was in every single area where I asked a question. It wasn't like he was grasping or didn't know. He backed up his comments with studies from various areas as well. Appears he has been doing TRT for along time. Otherwise I would have been skeptical and wanted to run, but it almost felt like he knew more up to date technical details about this stuff that just hasn't caught on yet in the general TRT area.

Nelson has NEVER written that high "e2 doesn't matter." He HAS written estradiol in many cases is over-treated in men on TRT. He argues that there is no magic number that all men on TRT need to fear; he suggests that the absolute value of total testosterone, the testosterone:estradiol ratio, and how the patient feels all need to be weighed prior to the introduction of an AI.

 

[Nelson Vergel]

Around .2 to .3 % of testosterone converts to estradiol in healthy men. The more T, the more E2. The increase seems to flatten at higher doses. One study that capped estradiol at 35 pg/mL did so after reviewing data in older men with an average of 320 ng/dL of total testosterone who had history of cardiovascular disease.
Testosterone, DHT and Estradiol and Mortality in Older Men


Not one study has looked at the effect of estradiol on cardiovascular, edema, erectile function, gynecomastia incidence and mood in men on TRT with TT levels above 500 ng/ml. NOT ONE. I am not saying high estradiol is not a problem. What I am saying is that men with higher TT can accommodate more estradiol than men with low TT. Using the same upper limit for both populations makes no sense at all unless proven by a study. The Life Extension article that started this craze plus our preconceived judgement of a "female" hormone have not served us well in this field.

It is my belief that over 50 % of men on TRT should not have been prescribed anastrozole at baseline but at week 6 or 8 of follow up and using the correct LC/MS testing assay for estradiol.

Nipple sensitivity, like penis sensitivity, increases with estradiol. The former has nothing to do with gynecomastia. Also, the majority of cases of edema have nothing to do with high estradiol levels. These two considerations are over used and abused i the clinical world.

Like DHT, estradiol is downstream of testosterone not to diminish its effect but to enhance it.

Men with history of gynecomastia (mostly those with high IGF-1 and a genetic predisposition) may be more sensitive to higher levels of estradiol than others. But most men not on anastrozole do not ever get gynecomastia.

I consider Dr Mongentaler the smartest TRT doctor in the world. He hardly mentions estradiol in his talks and had done a review of studies that left him with the same questions I have.

We have broken through the myths of TRT causing prostate cancer and heart attacks. The next myth to be broken will be the estradiol one. We just need more data from physicians groups willing to follow men with TT over 500 ng/dL and hopefully stratify them up to 1500 ng/dL.

You can download the paper attached to this post (registered members only).

 

[Starplex]

Sorry for not getting back with an update sooner. Had to travel out of the country on business and just now getting around for the update. I got my labs back and had an interesting follow up with the Doc. And as mentioned before, no AI, but was willing to give this a shot.

Estradoil from Quest Ultra Sensitive = 88 Recommended < or = 29
Testosterone Total = 1788 Recommended 250 - 1100 ng/dl
Free Test = 421 Recommended 35 - 155 pg/mL
DHEA-S = 131 Recommended 70-495 mcg/dL

I complained to him about my lack of sensitivity in the manhood area during sex and that libido wasn't what I was hoping for, referring to the previous sweet spot that I blasted through.
He thought my DHEA was low and prescribed a Compounded formula 50mg/day to bring the value higher.
He prescribed Cialis 5mg/day (a generic from local Compounding pharmacy, cheaper then name brand).

I've been on that protocol continuing with Test Cyp injections twice/week for about a week now. Wow, what a difference. I have morning wood again and night time wood, and feel like a dog in heat again. Orgasms are much better too!! I just now got back into the gym due to jet lag, but man I had energy going through the roof. Hitting the Heavy bag between Deadlift sets. I'm hoping this stays the course. Maybe it is the T:E ratio added with the Cilias /DHEA-S. So thus far the E2 at 88 doesn't seem to be an issue.

 

[Vince Carter]

In the ratio concept you're in the 14-20 range with an 88. It might be good for you.

If you're not having any negative symptoms, there's no reason to treat a number. Me I get warm/hot at night in bed and can be rather bitchy and PMSish, I'm going through it now having my E so high, 88 at last test so in that way, it's a problem but I still have good libido and drive but with some ED that needs 25mg of Viagra. I seem to have a better experience with Viagra than Cialis.

 

[johndoesmith]

Sorry for not getting back with an update sooner. Had to travel out of the country on business and just now getting around for the update. I got my labs back and had an interesting follow up with the Doc. And as mentioned before, no AI, but was willing to give this a shot.

Estradoil from Quest Ultra Sensitive = 88 Recommended < or = 29
Testosterone Total = 1788 Recommended 250 - 1100 ng/dl
Free Test = 421 Recommended 35 - 155 pg/mL
DHEA-S = 131 Recommended 70-495 mcg/dL

I complained to him about my lack of sensitivity in the manhood area during sex and that libido wasn't what I was hoping for, referring to the previous sweet spot that I blasted through.
He thought my DHEA was low and prescribed a Compounded formula 50mg/day to bring the value higher.
He prescribed Cialis 5mg/day (a generic from local Compounding pharmacy, cheaper then name brand).

I've been on that protocol continuing with Test Cyp injections twice/week for about a week now. Wow, what a difference. I have morning wood again and night time wood, and feel like a dog in heat again. Orgasms are much better too!! I just now got back into the gym due to jet lag, but man I had energy going through the roof. Hitting the Heavy bag between Deadlift sets. I'm hoping this stays the course. Maybe it is the T:E ratio added with the Cilias /DHEA-S. So thus far the E2 at 88 doesn't seem to be an issue.

When was that test taken relative to injection?

There's no way that you can sustain that long term. That is a mild blast you're on there. Hematocrit will absolutely be an issue. Not to mention negative health consequences from being so high in E2. Even tho T/E2 ratio isn't bad, but that is only a theory, there is a point with E2 where too high is too high. I'd highly recommend lowering your dose. 1788 is WAY too high lol.

 

[CoastWatcher]

When was that test taken relative to injection?

There's no way that you can sustain that long term. That is a mild blast you're on there. Hematocrit will absolutely be an issue. Not to mention negative health consequences from being so high in E2. Even tho T/E2 ratio isn't bad, but that is only a theory, there is a point with E2 where too high is too high. I'd highly recommend lowering your dose. 1788 is WAY too high lol.

I have to agree with these comments. What did your last CBC look like?

 

[Starplex]

Thanks for the comments guys. The labs were taken on the day before my 3.5 day injection. Labs on Tuesday morning, injection Wednesday night & Sunday morning.
Not sure what all you are interested in within the CBC, but here are a few.
Platelet Count 167
Hemoglobin 16.1
Red Blood Cell 5.55
Hemocrit 49.7, Already given blood.
Cholesterol Total 154
HDL 49
Triglycerides 72
LDL 91
All my cholesterol numbers moved to the better slightly.
All areas on CBC are in the green and in range.
I agree on lowering the dose. I might try instead of 1/2 a mL I will move it down to 0.4 and see what happens.

 

[johndoesmith]

Thanks for the comments guys. The labs were taken on the day before my 3.5 day injection. Labs on Tuesday morning, injection Wednesday night & Sunday morning.
Not sure what all you are interested in within the CBC, but here are a few.
Platelet Count 167
Hemoglobin 16.1
Red Blood Cell 5.55
Hemocrit 49.7, Already given blood.
Cholesterol Total 154
HDL 49
Triglycerides 72
LDL 91
All my cholesterol numbers moved to the better slightly.
All areas on CBC are in the green and in range.
I agree on lowering the dose. I might try instead of 1/2 a mL I will move it down to 0.4 and see what happens.

Why are you testing day before injection? In your case wednesday morning would be as close as you can get, 12 hours won't matter much.

Even with another 36 hours to trough, 1788 is really high. I am simply amazed that your CBC looks like that. How long have you been on this protocol?

200mg per week will probably still have you supraphysiological honestly, it's hard to say exactly.

 

[Vince Carter]

Well he did just donate blood as he indicated and his HCT is only 3/10ths below the lab high range of 50.0 so he's not THAT great in that regard. By the time another donation period opens (59 days) he'll be way high on HCT, probably 53 or 54.
But i concur your labs could look better on paper if you're testing on Wed right before your injection, not on Tues the day before.

 

[johndoesmith]

Well he did just donate blood as he indicated and his HCT is only 3/10ths below the lab high range of 50.0 so he's not THAT great in that regard. By the time another donation period opens (59 days) he'll be way high on HCT, probably 53 or 54.
But i concur your labs could look better on paper if you're testing on Wed right before your injection, not on Tues the day before.

I took it as "already given blood" meaning in response to his labs, he donated blood, not that he donated BEFORE getting labs done. Now I am not so sure on what he meant by that lol.

 

[Starplex]

I donated after getting labs and seeing that the Hemocrit was high. I started the protocol 2nd week in July. So a little over 4 months in now. Labs were taken end of September so roughly 12 weeks of protocol.