TRT without the use of Aromatase Inhibitors

[Vince Carter]

You have to know, and remember, that pursuant to all this talk about numbers you delve back to lab ranges. A lab range is a sample of the population that that lab tests. No Dr or any one else has determined that X is high Estrogen in a man. or that X is low Estrogen, for that matter.

And guys under report E sides all the time on this forum, or downplay it. or have the sides that one guy finds tolerable, and the next guy can't stand.

It's all a moot point, really, what E is healthy, and what is not.

Of all the E discussion and problems that permeate this forum, target number one is not allowing your Drs to drive your T to supra physiological levels. Total T is a garbage test of little value. You can look at your trough and say this looks great...and then your peak, where the problems start and lie, is astronomically high...and thus: Estrogen.

 

[ronadams9]

What would be the highest sensitive estradiol reading (on say Labcorps scale pg/mL 8.0 - 35.0) that I should be comfortable with and not try to lower with AIs if I am experiencing no negative side effects and libido and everything else are fine?

 

[user_joe]

Joe, how about libido or sides?

Libido is outstanding. Only side is some body acne. Always have that unless e2 is under 20 which kills everything as far as mood and libido go.

 

[Jeromefrance]

On the topic of things unknown long term, what if the effects are POSITIVE? Why make the assumption very high DHT is going to be negative when stating we don’t know the answer?

What do you think about the lab ranges? They keep showing T levels lower and lower to be “in range.” My father in his 60s routinely rests above range for TT now only bc they lowered the range.

I don’t care to debate you per say, bc I only have my own personal experience to draw from. I can say without a doubt using the tiniest dose of ai possible gives me the best therapeutic effects. Interested in you elaborating on large doses as I currently run 300mg/wk. split into 2 doses that was a trough of 1280. I do daily now. AI has been 1/32mg every 7-10 days the past month. I feel great.

What do you mean by 1/32mg of Ai how much mg do you take per week ?

 

[Blackhawk]

Jerome, some of us take very little AI. I take 1/16mg doses. If your question is how we make doses that small, it is by crushing a 1mg tablet and dissolving it in vodka. For my dose I use 10ml of vodka to dissolve 1-1mg tablet. So 1ml of that solution=0.1mg of anastrozole. 1/16=0.0625, so I draw 0.625 ml on a dosing syringe without needle and take it by mouth.

 

[Jeromefrance]

Jerome, some of us take very little AI. I take 1/16mg doses. If your question is how we make doses that small, it is by crushing a 1mg tablet and dissolving it in vodka. For my dose I use 10ml of vodka to dissolve 1-1mg tablet. So 1ml of that solution=0.1mg of anastrozole. 1/16=0.0625, so I draw 0.625 ml on a dosing syringe without needle and take it by mouth.

Ok that is a really low dose 0.625 per week. Yes less is better. I believe you are not a big converter.

 

[Blackhawk]

Ok that is a really low dose 0.625 per week. Yes less is better. I believe you are not a big converter.

Not .625mg. The .625 is the amount of fluid in ml. Each ml contains 1/10 of that dose in mg

My dose is .0625mg, I take this dose EOD. That is 3.5 doses per week. The total per week is about .22mg This brings my E2 sensitive LC/MS/MS down by about 5-10 points.

 

[Gman86]

On the topic of things unknown long term, what if the effects are POSITIVE? Why make the assumption very high DHT is going to be negative when stating we don’t know the answer?

What do you think about the lab ranges? They keep showing T levels lower and lower to be “in range.” My father in his 60s routinely rests above range for TT now only bc they lowered the range.

I don’t care to debate you per say, bc I only have my own personal experience to draw from. I can say without a doubt using the tiniest dose of ai possible gives me the best therapeutic effects. Interested in you elaborating on large doses as I currently run 300mg/wk. split into 2 doses that was a trough of 1280. I do daily now. AI has been 1/32mg every 7-10 days the past month. I feel great.

It seems crazy that such a small dose of ai, and so infrequently, is doing anything. But tend to believe people first, and then be skeptical 2nd, opposed to most people that do the opposite when guys say stuff like this. What were your symptoms you had that caused u to start taking the ai, jus my curious.

 

[Jeromefrance]

Not .625mg. The .625 is the amount of fluid in ml. Each ml contains 1/10 of that dose in mg

My dose is .0625mg, I take this dose EOD. That is 3.5 doses per week. The total per week is about .22mg This brings my E2 sensitive LC/MS/MS down by about 5-10 points.

Wow ok! I understand. My dose of Ai is near jours. I use 0.30mg per week dosed every Day with drops. I make this like you dissolving in vodka 1mg. Dosing ed looks better for me because the peak is lower.

 

[Dr. John Crisler]

I have edited my posts to change the phrase "Anti-AI Crowd" to simply "those strongly opposed to AI use". My intent was originally just to be descriptive, but I think it sounded a bit pejorative. That is not my intent; rather, to engage in an open presentation of knowledge, thoughts, and clinical experience. We can only do that when we remain men and women of science, and ladies and gentlemen.

I listen carefully to those who maintain opposing views. I want to hear what they have to say, and why they think the way they do. I want my views to be all inclusive, and I always learn something from communicating with my esteemed peers. So it's not just a matter of finding out what they think, I want to know why they think so.

In fact, there are some stark differences in the ways the top thought leaders treat their patients, so the final solutions are probably somewhere in the middle.

But in as much as I must remain evidence-based, so do my peers. Those who are quick to demand a study must also be able to produce them to support their own positions. AND not extrapolate to unwarranted conclusions, rely upon bad laboratory testing, or inappropriate (unrealistic) drug dosing.

We also have to appreciate the inherent fallability in Epidemiology, especially in its application to Endocrinology. And that some studies just simply will never be performed; there, actual clinical experience counts, and even more so, good old fashioned common sense.

I also choose to get along well with folks, and this includes colleagues whose professional opinions differ from my own.

Also, I am sure there are things for which am full of baloney about as well LOL.

 

[JimBob]

If the "those strongly opposed to AI use" crowd base their position on estrogen studies which Dr. Crisler says are "invalid", that should be the area of discussion. If these studies are "invalid", why doesn't the aforementioned "crowd" not recognize this?? Oh, and the HCG/backfilling the pathways issue is yet another contentious point unlikely to be resolved by the men of science. It ends up being a crapshoot for the patient. Flip a coin and pick your doc!

 

[Dr. John Crisler]

If the "those strongly opposed to AI use" crowd base their position on estrogen studies which Dr. Crisler says are "invalid", that should be the area of discussion. If these studies are "invalid", why doesn't the aforementioned "crowd" not recognize this?? Oh, and the HCG/backfilling the pathways issue is yet another contentious point unlikely to be resolved by the men of science. It ends up being a crapshoot for the patient. Flip a coin and pick your doc!

I appreciate your frustration.

Studies which employed laboratory methodology which is now proven to be invalid, or administered drug dosing many times more than anyone would ever use, can not be valid. My only suggestion would be to ask them why they do so. It's important we stick to evidence-based medicine; an important part of that is not just knowing what scientific studies say, but also what they don't say.

Suppressing the endocrine system by administering TRT clearly disrupts downstream metabolites. There is no debating that point. Adding HCG, PREG and DHEA helps counteract this. More so, doing so has improved the lives of countless men on TRT. I hear it every day in clinical practice, and it's repeated all the time on the forums.

It is necessary to understand how the body works. But in every case, precision medicine, customized to each patient, must be administered.

 

[Gman86]

You have to know, and remember, that pursuant to all this talk about numbers you delve back to lab ranges. A lab range is a sample of the population that that lab tests. No Dr or any one else has determined that X is high Estrogen in a man. or that X is low Estrogen, for that matter.

And guys under report E sides all the time on this forum, or downplay it. or have the sides that one guy finds tolerable, and the next guy can't stand.

It's all a moot point, really, what E is healthy, and what is not.

Of all the E discussion and problems that permeate this forum, target number one is not allowing your Drs to drive your T to supra physiological levels. Total T is a garbage test of little value. You can look at your trough and say this looks great...and then your peak, where the problems start and lie, is astronomically high...and thus: Estrogen.

Well said. I think about that all the time about us going by trough total testosterone. I’m not saying it’s wrong, but I think we don’t take into consideration the injection frequency as much as we should. Someone that injects once per week could have a trough of 1100 and we would tell him that his level is perfect. Meanwhile, his peak is probably close to, or over 2000. But if we had another member that injected EOD, and had a pretty steady level at around 1400-1800, we would tell him his level is way too high. Even though we just told the other guy that has a peak around, or over 2000, that his level is perfect. I just think we need to take into consideration the injection frequency more when we are assessing guy’s labs.

Also good points about guys having the same exact high E2 symptoms, and subjectively reporting them very differently, or it effecting them very differently. I think that probably happens quite a bit.

 

[Dr. John Crisler]

You have to know, and remember, that pursuant to all this talk about numbers you delve back to lab ranges. A lab range is a sample of the population that that lab tests. No Dr or any one else has determined that X is high Estrogen in a man. or that X is low Estrogen, for that matter.

And guys under report E sides all the time on this forum, or downplay it. or have the sides that one guy finds tolerable, and the next guy can't stand.

It's all a moot point, really, what E is healthy, and what is not.

Of all the E discussion and problems that permeate this forum, target number one is not allowing your Drs to drive your T to supra physiological levels. Total T is a garbage test of little value. You can look at your trough and say this looks great...and then your peak, where the problems start and lie, is astronomically high...and thus: Estrogen.

We have to remember that we are looking at INDUCED hormone levels. Not baseline levels. That can make things different, from several perspectives.

This concept starts at the differences between association and causation, and extends to the observation induced levels must sometimes be higher for their optimized ranges than baseline ranges.

 

[Dr. John Crisler]

On the topic of things unknown long term, what if the effects are POSITIVE? Why make the assumption very high DHT is going to be negative when stating we don’t know the answer?

What do you think about the lab ranges? They keep showing T levels lower and lower to be “in range.” My father in his 60s routinely rests above range for TT now only bc they lowered the range.

I don’t care to debate you per say, bc I only have my own personal experience to draw from. I can say without a doubt using the tiniest dose of ai possible gives me the best therapeutic effects. Interested in you elaborating on large doses as I currently run 300mg/wk. split into 2 doses that was a trough of 1280. I do daily now. AI has been 1/32mg every 7-10 days the past month. I feel great.

EDIT: I now believe simply waiting it out will allow your elevated E symptoms to calm. Or changing the T dose--up or down.


To be clear, my mind is open.

 

[charile12]

Hey doc. I was doing 90 mg a week cypionate split in 2 subq. My shbg is near 26. I was fine with this and felt good. Kept e2 in low 30s.
I switched to IM just because I thought it was easier to do shallow im which I actually like. So when I started 100 mg a week divided in 2 Injections my e2 went down where my joints click like never before.

Initially it brought my e2 down below 20 now it looks like after 2 months stabilized at around 27. Joints still click.

Now this is contrary to what should have happened. An thinking my e2 is lower on im because my shbg is low normal and with the IM the testosterone gets absorbed quicker. What do you think?
And do you see an issue if I alternate subq and im after each Injection?

FYI Also when I first started trt a year ago and was told I needed an AI I took arimidex and even .1 mg crashed my e2. Everything stabilized after I stopped messing with an AI at the beginning of trt. I have not used one for at least 6 months.

 

[user_joe]

It seems crazy that such a small dose of ai, and so infrequently, is doing anything. But tend to believe people first, and then be skeptical 2nd, opposed to most people that do the opposite when guys say stuff like this. What were your symptoms you had that caused u to start taking the ai, jus my curious.

I’ve done a lot of experimenting. Probably too often honestly. I’ve used an ai for years. The Doctors in the TOT round table were making a while lot of sense based on my own personal experiences. So I tried to use no ai, but I’d end up seeing libido take a bit of a dive or mood change. Each time would be 7-10 days w no ai. I’ve been taking a smaller and smaller ai dose each time. I quit hcg as well once I was able to feel dialed in all the time.

I’ve had good success in the past while taking .25mg here and there as needed. Not near as good as my current protocol.

 

[user_joe]

Because in medicine we have to show a therapy is safe. We can't just assume so. Inducing hormone levels multiple times the top of normal range has never been tested, to my knowledge.

If anyone has seen any examples, please share them. Just because I have not seen something does not mean it does not exist, of course.

...then I think of all the drugs which were granted FDA clearance...and then shown to be dangerous.

Doing medicine for 20 years has taught me bad things can happen if you slam a biological system too hard in one direction. Cross reactivities, untoward suppressions, asynchrony, etc result. My belief it is all about BALANCE.

To be clear, my mind is open. I just want to see some evidence what we are doing is safe. That's impossible to do when these topics have never even been studied.

I was referring to 3-5x over top of whatever range they use now. 1500 would be 1.5x the range on some. It used to just be top of normal.

We do have studies showing doses up to 600mg/wk being safe. Just not long term. They didn’t use an ai either.

You’ve got your logic you are applying, and you have the experience to go with it. Your peers(a few of them) have a different logic they are applying along with experience.

Neither can be definitively proven. We don’t have the studies on a protocol or lab ranges for a trt patient that you consider optimal either.

 

[Dr. John Crisler]

I was referring to 3-5x over top of whatever range they use now. 1500 would be 1.5x the range on some. It used to just be top of normal.

We do have studies showing doses up to 600mg/wk being safe. Just not long term. They didn’t use an ai either.

You’ve got your logic you are applying, and you have the experience to go with it. Your peers(a few of them) have a different logic they are applying along with experience.

Neither can be definitively proven. We don’t have the studies on a protocol or lab ranges for a trt patient that you consider optimal either.

If it's what it takes for a given patient, a Total T of 1500 is not a problem. This would be especially true if he had a high(er) SHBG, for instance. Now add in Endocrine Disrupting Chemicals, Androgen Receptor Resistance, etc.

You make a very good point in that the "normal range" has decreased over time. That directly reflects decreasing androgen levels in the adult male population. Not a good thing, to be sure.

I've seen the study which employed 600mg/week. It really does not show such a dose, long term, is safe.

I think what everyone agrees on is optimization is very much personalized.

 

[Dr. John Crisler]

I’ve done a lot of experimenting. Probably too often honestly. I’ve used an ai for years. The Doctors in the TOT round table were making a while lot of sense based on my own personal experiences. So I tried to use no ai, but I’d end up seeing libido take a bit of a dive or mood change. Each time would be 7-10 days w no ai. I’ve been taking a smaller and smaller ai dose each time. I quit hcg as well once I was able to feel dialed in all the time.

I’ve had good success in the past while taking .25mg here and there as needed. Not near as good as my current protocol.

I'm happy to take any of my patients off their AI if they want to (or not put them on it in the first place). We can also modify their TRT regimen in a number of ways. Smaller, more frequent injections are a great idea...if the gentleman can/will put in the extra time. Not all patients want to fiddle around with it that much.

I'm also happy to either switch them over to, or add in, scrotal testosterone cream. If we find something which works better for them, that is the goal.

I can't ignore the fact there are LH receptors all over the body. They would not be there, expecting to be stimulated, without good reasons. Ignoring this simple fact is what is happening when we stop adding in HCG. So is testicular shrinkage.