Possible estradiol crash, help needed.

[CoastWatcher]

You circle back to the question of "how much" anastrozole you ought to take? The more fundamental question is should you take any? As was pointed out by johndoesmith, you're not sitting in a precarious spot in regard to your estradiol value. You have seen how quickly an AI impacts your serum levels, so I'd wait and see how things develop.

 

[Donovan]

So if I dont take an AI how will I lower my E2 and raise my FT? I can wait like you suggest but for what? E2 was high on my previous tests and FT was also mid range so I don't have a reason to believe that anything will change untill my next bloodwork.

 

[Vince Carter]

I'd go to modifiying your injections schedule based on your SHBG of 20 (pull that again on the next labs you order) but I would *think* that with a 20 you could do better on EOD injections. Curious thing though that you can pull a high Total and a low Free T with SHBG @ 20, you're Free T *should* be much higher, based on the SHBG. I'd concur that you're making far too many subjective changes based upon how you feel from one day to the next, which is how one tends to end up in this kind of quandary your in.

 

[Donovan]

Thanks for the reply. I am trying to find a protocol I can stick with, I know I made a lot of unecessary changes. Could my low FT be attributed to high Estrogen? As far as I can understand high E2 causes that to some people.

 

[Vince Carter]

Im puzzled at your low Free T, myself. The problem with your Anastrozole use has been that's it's too much, sometime an AI is a necessity, it has been for me, but start with a much lower dose, like .25mg twice per week and see how that goes and adjust with testing. .5mg is generally regarded as a major dose.

 

[Donovan]

I spoke with my doctor and he said that the combination of high TT,low FT and high E2 can be seen only if SHGB is high and told me to wait for the rest of the results. I haven't found anybody other case like mine on the internet so I really have no idea on what to do next

 

[johndoesmith]

I spoke with my doctor and he said that the combination of high TT,low FT and high E2 can be seen only if SHGB is high and told me to wait for the rest of the results. I haven't found anybody other case like mine on the internet so I really have no idea on what to do next

Post the full direct results in the form of a picture. It would be helpful to know what type of free testosterone assay they used.

You have an SHBG of 20. So there's no way your free test is low. In fact I calculated it at 33 which I generally use a range of 9-26 for.

Free testosterone assays vary in their reliability. Plus, they're not known for their accuracy. I've never seen a free test assay with that large of a range.

I wouldn't get so hung up on one single test.

 

[Vince Carter]

That's a good point you can calc your Free T here:

http://www.issam.ch/freetesto.htm

Youll need your Albumin test but you can *assume* 4.3 for this purpose.

 

[CoastWatcher]

Free testosterone is a devil of a value to get right.

The literature indicates that there is great dispute in how to measure free test. The direct method there are several, is the preferred, while some calculated methods are particularly criticized.

The essential problem was expressed in Clinical Endocrinology, (2010) 73,382-388.
“Commonly used cFT (Calculated Free Testosterone), and there are several, formulae significantly overestimate FT relative to laboratory measurement by ED (Equilibrium Dialysis) in male serum samples...Such inaccuracy relative to the reference method renders some cFT estimates unreliable for evaluating androgen deficiency as recommended by clinical best practice guidelines.”

The director of the laboratory in the hospital at Queen's University in Kingston, ON questions the widespread testing of free testosterone given the lack of agreed upon lab methods and the lack of consensus as to what these levels mean. The Canadian Journal of Urology, (June 2012) 19(3), 6314-6318. Essentially he threw up his hands and urged doctors and patients to walk away from the entire thing until standards were in place (a pretty silly idea if you think about it, but one that expresses the frustration many feel with this value.

 

[Donovan]

I'll post everything on Friday when I'll have all my tests. I really hope the value is wrong cause this makes no sense.

 

[johndoesmith]

Free testosterone is a devil of a value to get right.

The literature indicates that there is great dispute in how to measure free test. The direct method there are several, is the preferred, while some calculated methods are particularly criticized.

The essential problem was expressed in Clinical Endocrinology, (2010) 73,382-388.
“Commonly used cFT (Calculated Free Testosterone), and there are several, formulae significantly overestimate FT relative to laboratory measurement by ED (Equilibrium Dialysis) in male serum samples...Such inaccuracy relative to the reference method renders some cFT estimates unreliable for evaluating androgen deficiency as recommended by clinical best practice guidelines.”

The director of the laboratory in the hospital at Queen’s University in Kingston, ON questions the widespread testing of free testosterone given the lack of agreed upon lab methods and the lack of consensus as to what these levels mean. The Canadian Journal of Urology, (June 2012) 19(3), 6314-6318. Essentially he threw up his hands and urged doctors and patients to walk away from the entire thing until standards were in place (a pretty silly idea if you think about it, but one that expresses the frustration many feel with this value.

Maybe I'm making this too simple, but if total testosterone and SHBG assays are fairly reliable, and you use the same calculation method, which I do, then it alleviates the inaccuracy of the algorithm. Right?

Free test is a factor of albumin, SHBG, and total testosterone, which in OPs case we know all of them, so it's pretty easy to say his free test is high normal at least.

I've seen lowish shbg tests with high normal total test, but the direct assay says free test is low.

If method A and method B are compared, but disagree with each other, then it's impossible to know which is incorrect. I think the Canadian study misattributed inaccuracy to calculated free test based upon an inaccurate assay method.

Although I'm not an expert in this field, so I'm open to correction, but we all know how alleged "experts" in endocrinology can be with testosterone related controversy.

 

[CoastWatcher]

The authors of the article in Clinical Endocrinology, hold that the standard for measuring free testosterone is the equilibrium dialysis method. Because of the cost and effort associated with that process, however, a number of alternative methods have been developed. Seven different calculations (all presenting with "attractive simplicity") were compared with the standard equilibrium dialysis method. The results "questioned the tacit assumption that that cFT formulae are accurate." Over 2000 blood samples demonstrated that "systematic overestimation" occurs too often in the calculated value when compared to the results obtained by equilibrium dialysis. Doctors are urged to inquire as to how their respective labs derive free testosterone levels and to consider the impact the answer to that inquiry might impact clinical decision making.

Anecdotally, the largest commercial lab in Canada adopted a cFT formula in the summer of 2015. My SHBG and total testosterone didn't change in an appreciable manner but my free testosterone was reported to have jumped by over 30%. I now have that lab test performed at a Toronto hospital that still relies on equilibrium dialysis to reach a result.

 

[CoastWatcher]

Nelson captured another study about the lack of standards in reference values both in free and total testosterone.
https://www.excelmale.com/forum/sho...ference-Values&highlight=laboratory+standards

 

[johndoesmith]

My SHBG and total testosterone didn't change in an appreciable manner but my free testosterone was reported to have jumped by over 30%. I now have that lab test performed at a Toronto hospital that still relies on equilibrium dialysis to reach a result.

Wait, your total and SHBG didn't change much, but calculated free testosterone increased 30%?

I use this: http://www.issam.ch/freetesto.htm

I don't see how putting the same numbers in can give 2 different results.

 

[CoastWatcher]

Wait, your total and SHBG didn't change much, but calculated free testosterone increased 30%?

I use this: http://www.issam.ch/freetesto.htm

I don't see how putting the same numbers in can give 2 different results.

Life-Labs measured free testosterone with the equilibrium dialysis method for years. They adopted a cFT method that indicated my level was significantly higher than it had ever been before, with no change in total testosterone or SHBG. I had a second blood draw performed, two vials, same needle stick. One went back to Life Labs and one went to the Laboratory at the Princess Margaret Hospital in downtown Toronto. Life Labs used a cFT equation and reported very high free test. The hospital ran the more expensive equilibrium dialysis and came back with a number in line with all my previous results. It sustained the study conclusion: in my case results were not reliable using a calculated method. All of the free testosterone draws from my doctor's practice go to the hospital lab.

 

[johndoesmith]

Life-Labs measured free testosterone with the equilibrium dialysis method for years. They adopted a cFT method that indicated my level was significantly higher than it had ever been before, with no change in total testosterone or SHBG. I had a second blood draw performed, two vials, same needle stick. One went back to Life Labs and one went to the Laboratory at the Princess Margaret Hospital in downtown Toronto. Life Labs used a cFT equation and reported very high free test. The hospital ran the more expensive equilibrium dialysis and came back with a number in line with all my previous results. It sustained the study conclusion: in my case results were not reliable using a calculated method. All of the free testosterone draws from my doctor's practice go to the hospital lab.

So you're comparing apples to oranges? Different assay methods do not give results that are directly comparable.

I thought you had 2 calculated free testosterone tests, with different results, but the same total testosterone and shbg level. Is that not the case?

 

[CoastWatcher]

So you're comparing apples to oranges? Different assay methods do not give results that are directly comparable.

I thought you had 2 calculated free testosterone tests, with different results, but the same total testosterone and shbg level. Is that not the case?

Indeed, I did have two cFTs. In February of this year, Dyna-Lab, another commercial lab in Ontario, and Life Labs, aforementioned, received vials of my blood, same needle stick. The reports came back indicating a five point difference. Each lab indicated that results had been obtained via calculation (though we don't know methodology). As my doctor said, "It's TRT, nothing should be assumed." She is always working to have a clearer understanding of the variables that influence decisions in clinical practice. She knows I'm as interested as she is. As a result, I'm part of a small group of her patients who willingly participate in as many hypothesis testing procedures as we can. In these, it was clear that the reliance on cFT values was a dicey procedure.

 

[johndoesmith]

Indeed, I did have two cFTs. In February of this year, Dyna-Lab, another commercial lab in Ontario, and Life Labs, aforementioned, received vials of my blood, same needle stick. The reports came back indicating a five point difference. Each lab indicated that results had been obtained via calculation (though we don't know methodology). As my doctor said, "It's TRT, nothing should be assumed." She is always working to have a clearer understanding of the variables that influence decisions in clinical practice. She knows I'm as interested as she is. As a result, I'm part of a small group of her patients who willingly participate in as many hypothesis testing procedures as we can. In these, it was clear that the reliance on cFT values was a dicey procedure.

Interesting, would you mind sharing the actual values?

 

[CoastWatcher]

Interesting, would you mind sharing the actual values?

Date of Test: 22/02/2016

cFT Value: Life-Lab - 50.8 PMOL/L (15.6-146)

cFT Value: Dyna-Lab - 45.2 PMOL/L (20.0 - 150)

 

[johndoesmith]

Date of Test: 22/02/2016

cFT Value: Life-Lab - 50.8 PMOL/L (15.6-146)

cFT Value: Dyna-Lab - 45.2 PMOL/L (20.0 - 150)

What about the test and SHBG?