Should We Be Managing Estradiol and Hematocrit in Men on Testosterone Replacement?

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Let's try to clear up some confusion here. No need to debate what the E2 level in a young male going through puberty would be but yes it can run >70. This is not the point. The point is that a level of 70 is not harmful to men. The harm to men is with blocking estrogen. After 50 years of administering IM T to men which significantly raises E2 levels , there is not a study which showed the harm of raising E2. Also, what study has showed benefit to lowering E2 levels? None.

The harm is when E2 is blocked. NEJM 2013 Sep 12:369(11): 1011-1022 "Gonadal steroids and body composition, strength, and sexual function in men". There are 2 ways to lower estrogen

1. Aromatase inhibitors

2. Androgen deprivation therapy (ADT)

I could fill several pages on the negative effects of ADT which totally wipes out both T and E2 (google it). It is used in the treatment of prostate cancer. These men then develop osteoporosis, sexual dysfunction, obesity, insulin resistance, diabetes, metabolic syndrome, cognitive dysfunction, dyslipidemia, and a significantly increased risk of cardiovascular mortality. If they don't die of prostate cancer we kill them in another way and believe me these men want to die because their quality of life is zero.

When these men are treated with E2 it dramatically improves their quality of life. They don't become osteoporotic, their lipid profiles remain good, the have improved cognition, and they maintain the cardioprotective effects of estradiol. Also, E2 is apoptotic and anti angiogenic to prostate cancer cells. E2 has just as many important functions in men as it does women...we just don't need as much.

Next issue, method of delivery. I have no problems with the differing methods of delivery. I have used pellets, injections, gels, and compounded creams in myself and my patients. There are some studies that show no effect and some that show a negative effect on HDLS with injections: Clinical journal of sports medicine 1996 jul; Vol 6 "Changes in lipoprotein-lipid levels in normal men following administration of increasing doses of testosterone cypionate".

I am not anti injections but just like with so many other treatments there is sometimes a better way. I treat numerous men each week who are on injections. They are all skeptical at first but most are referred in from their male friends. Once they make a switch to our method of delivery I have not had a single patient go back to injections. Let be say again I am not anti injectable T. I will give it if they want. I use a 200mg/gm compounded cream in a HRT base (or lipoderm) and it is applied BID to the testicles (yes I said testicles as there is 4-5x greater absorption).

I treat symptoms and adjust dose until symptom improvement. I aim for optimal...not normal. Normal is basically the average for a population of sick people that a pathologist at a lab randomly assigns. Do you think with these lab values they go out and test only the most healthy in shape people? All of my male patients have a free T from 30-50 some even higher depending on their optimal. This usually correlates with a total of 1500-2000 .

I use LabCorp but not too long ago they changed their reagent where you could not get a accurate free T level. We specifically order a T free/total equilibrium ultra filtration test so I get a actual number. Labcorp's normal range" is basically 5-21. Everyone gets caught up in a number and I am treating patients and optimizing their T levels.

Not one single patient has had to take a AI. Their levels are consistent day to day and the only way that could be reproduced with injections is with daily low dose injections.

So get T the way you can, but also be open to alternative methods. Find a MD that is not caught up in a number on a piece of paper but instead is focused on your symptoms and optimizing your levels to what works best for you. I'll ask anyone on this board would you rather be normal or optimal?

There is another subject that I will address in the near future and that is the issue of polycythemia. T DOES NOT cause polycythemia. It causes a physiologic erythrocytosis just like what occurs at high altitude. That is why our Olympic training center is at high take advantage of the erythrocytosis.

Polycythemia Vera is a blood disorder where there is a increase in all blood components...most importantly is the increase in platelets which clot. TRT does not cause a increase in platelets. There is absolutely no need to donate blood due to your erythrocytosis.

It is not PV. Measure anyone's blood that lives at high altitude and they will have a high H/H. Patients with COPD have high H/H and we are not bleeding them. This is just another one of the falsehoods that gets propagated like blocking estradiol.
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