Nelson Vergel
Founder, ExcelMale.com
Video Transcript: Estradiol in Men: Friend or Enemy?
Allison Woodworth, Clinical Director of PrimeBody.com:
Estradiol is typically thought of as a hormone that is only present in women, but it is also present in men. Now in men, the body produces testosterone and a portion of that naturally converts to estradiol, so both testosterone and estradiol naturally occur in men's bodies. Testosterone is actually the pro-hormone of estradiol (E2) since it is converted to E2 via the aromatase enzyme present in fat, liver and testicular tissue. Of course, in both genders E2 is present in different ratios. Estradiol is important for gaining and maintaining bone density and men. It also plays a role in sexual drive as well as body composition, so this is a very important hormone to recognize in men and actually test in conjunction with testosterone.
The idea of what the optimal level of estradiol in men is currently a topic of great debate and there was no general consensus among healthcare providers on a specific of range that men need to have. Now a review of the literature does show that on the lower end anything below 20 picograms per milliliter of estradiol is associated with increased risk of osteoporosis, which is thinning or weakened bones and can actually increase a man's risk of fractures later in life. We know that on that lower end less than 20, there can be harmful long-term health outcomes if we suppress a man's estradiol level too low. A study was actually published in 2013 that additionally showed when estradiol levels are low, men have decreased sexual drive and functioning as well as increased fat mass.
This is a very interesting study that showed estrogen is not only associated with gaining and maintaining bone density, but is also an important factor in men's sexual functioning as well as overall body composition. There was one study published in 2009 in the Journal of the American Medical Association which did show that in elderly men with low testosterone and with congestive heart failure a range outside of 20 to 30 picograms per milliliter was associated with increased mortality rates, and that is death rates. This study did focus on a very specific population of man. It was men with congestive heart failure. Can we extrapolate the data from this study in the specific population of men to all men on testosterone replacement therapy, regardless of their age and regardless of their history of congestive heart failure?
That is I would say this issue is still unclear, but that is one study that's important to mention and again the range of 20 to 30 outside that range was noted. Among healthcare providers, there's still significant debate on the ideal level, but it is definitely clear that below 20 pg/mL there are long-term health risks. Now on the other end of the spectrum, what would be too high of an estradiol level? That's a great question that I hear all the time. Some men I think tend to obsess over their estradiol level and say, "Well, you know, it's above 30 or it's above 35. We got to bring that down. Why is that too high?"
Now in my professional opinion and a lot of providers would agree with me, if a man is not symptomatic with symptoms of excess estrogen which would be nipple sensitivity, gynecomastia which is enlargement of breast tissue, possibly moodiness, irritability, water retention, swelling in their feet...If they don't have any of these classic symptoms of elevated estrogen, do you need to suppress your estradiol level? I tell my patients not necessarily. The upper end of what is considered a safe normal range of estradiol in men on testosterone replacement is currently undetermined by literature. There's no general consensus. If you're not symptomatic with these classic symptoms of excess estrogen, it does not necessarily need to be suppressed, because there are greater risk of suppressing your levels too low.
In men, both testosterone and estradiol naturally exist but in different ratios. Now when testosterone is replaced in any form, a portion of that will convert over to estradiol. When we're placing men on testosterone replacement therapy, it's not all about checking their baseline testosterone and bringing that to an upper end of normal range or to an optimal range. We also have to be looking at will how much of that testosterone is converting over to estradiol and manage that level as well. Now this is not true for all men, but in some patients, they will tend to convert excessive amounts of testosterone to estradiol. If this occurs, a man may become symptomatic. Those symptoms would include nipple sensitivity, breast tissue enlargement, moodiness, irritability, water retention, swelling in their feet.
If a man is converting over to estrogen and has this classic symptoms of elevated E2, we can actually control the amount of testosterone that converts over to estradiol. The way that it's done is within aromatase inhibitor. Now the generic name of the one traditionally used or commonly used is anastrozole. This just decreases the conversion of testosterone to estradiol. Now it is dose dependent, meaning the lower the dose of the estrogen blocker, the more testosterone is allowed to convert to estradiol. As we increase the dose less and less will convert to estradiol. It's very important when a provider places a patient on an estrogen blocker or an aromatase inhibitors such as anastrozole to follow up with blood work and retest that estradiol and make sure it's not suppress too low. Doses rarely exceed 1 mg per week.
As I mentioned previously, a level below 20 picograms per milliliter of estradiol is associated with adverse long-term health outcomes, including increased risk of osteoporosis, even cardiovascular disease and men can also experience decreased sexual functioning as well as increased fat mass. It's important to recognize that yes we need to control estradiol if a man is symptomatic but not push them so far to the other end of the spectrum where you're suppressing their levels and putting them at risk for detrimental long-term health outcomes.
The traditional method of testing estradiol levels in men is with the use of an immunoassay test and recent literature has actually shown that this method of estradiol testing can actually overestimate the amount of estradiol present in men. This was found specifically in men with increased inflammatory markers such as high CRP. Our PrimeBody.com's network of providers actually use a more specific test that will give more accurate reading in terms of estradiol in men. This type of test uses liquid chromatography and has been shown to be much more accurate in terms of reflecting the actual amount of estradiol present in men. This is important because when we check blood work, we're actually relying on those results to help us manage our patients.
If we have a I would say outdated test, the immunoassay test and it's telling us the man's estrogen level is really elevated and we treat that to lower than, that could actually cause long-term detrimental health outcomes if we suppress their estrogen levels too low, just because we're using an outdated test that tends to over inflate or overestimate the amount of estradiol present in a man system. That is the reason that we're using this for updated, the liquid chromatography sensitive test for any patient coming to PrimeBody.com .
Allison Woodworth, Clinical Director of PrimeBody.com:
Estradiol is typically thought of as a hormone that is only present in women, but it is also present in men. Now in men, the body produces testosterone and a portion of that naturally converts to estradiol, so both testosterone and estradiol naturally occur in men's bodies. Testosterone is actually the pro-hormone of estradiol (E2) since it is converted to E2 via the aromatase enzyme present in fat, liver and testicular tissue. Of course, in both genders E2 is present in different ratios. Estradiol is important for gaining and maintaining bone density and men. It also plays a role in sexual drive as well as body composition, so this is a very important hormone to recognize in men and actually test in conjunction with testosterone.
The idea of what the optimal level of estradiol in men is currently a topic of great debate and there was no general consensus among healthcare providers on a specific of range that men need to have. Now a review of the literature does show that on the lower end anything below 20 picograms per milliliter of estradiol is associated with increased risk of osteoporosis, which is thinning or weakened bones and can actually increase a man's risk of fractures later in life. We know that on that lower end less than 20, there can be harmful long-term health outcomes if we suppress a man's estradiol level too low. A study was actually published in 2013 that additionally showed when estradiol levels are low, men have decreased sexual drive and functioning as well as increased fat mass.
This is a very interesting study that showed estrogen is not only associated with gaining and maintaining bone density, but is also an important factor in men's sexual functioning as well as overall body composition. There was one study published in 2009 in the Journal of the American Medical Association which did show that in elderly men with low testosterone and with congestive heart failure a range outside of 20 to 30 picograms per milliliter was associated with increased mortality rates, and that is death rates. This study did focus on a very specific population of man. It was men with congestive heart failure. Can we extrapolate the data from this study in the specific population of men to all men on testosterone replacement therapy, regardless of their age and regardless of their history of congestive heart failure?
That is I would say this issue is still unclear, but that is one study that's important to mention and again the range of 20 to 30 outside that range was noted. Among healthcare providers, there's still significant debate on the ideal level, but it is definitely clear that below 20 pg/mL there are long-term health risks. Now on the other end of the spectrum, what would be too high of an estradiol level? That's a great question that I hear all the time. Some men I think tend to obsess over their estradiol level and say, "Well, you know, it's above 30 or it's above 35. We got to bring that down. Why is that too high?"
Now in my professional opinion and a lot of providers would agree with me, if a man is not symptomatic with symptoms of excess estrogen which would be nipple sensitivity, gynecomastia which is enlargement of breast tissue, possibly moodiness, irritability, water retention, swelling in their feet...If they don't have any of these classic symptoms of elevated estrogen, do you need to suppress your estradiol level? I tell my patients not necessarily. The upper end of what is considered a safe normal range of estradiol in men on testosterone replacement is currently undetermined by literature. There's no general consensus. If you're not symptomatic with these classic symptoms of excess estrogen, it does not necessarily need to be suppressed, because there are greater risk of suppressing your levels too low.
In men, both testosterone and estradiol naturally exist but in different ratios. Now when testosterone is replaced in any form, a portion of that will convert over to estradiol. When we're placing men on testosterone replacement therapy, it's not all about checking their baseline testosterone and bringing that to an upper end of normal range or to an optimal range. We also have to be looking at will how much of that testosterone is converting over to estradiol and manage that level as well. Now this is not true for all men, but in some patients, they will tend to convert excessive amounts of testosterone to estradiol. If this occurs, a man may become symptomatic. Those symptoms would include nipple sensitivity, breast tissue enlargement, moodiness, irritability, water retention, swelling in their feet.
If a man is converting over to estrogen and has this classic symptoms of elevated E2, we can actually control the amount of testosterone that converts over to estradiol. The way that it's done is within aromatase inhibitor. Now the generic name of the one traditionally used or commonly used is anastrozole. This just decreases the conversion of testosterone to estradiol. Now it is dose dependent, meaning the lower the dose of the estrogen blocker, the more testosterone is allowed to convert to estradiol. As we increase the dose less and less will convert to estradiol. It's very important when a provider places a patient on an estrogen blocker or an aromatase inhibitors such as anastrozole to follow up with blood work and retest that estradiol and make sure it's not suppress too low. Doses rarely exceed 1 mg per week.
As I mentioned previously, a level below 20 picograms per milliliter of estradiol is associated with adverse long-term health outcomes, including increased risk of osteoporosis, even cardiovascular disease and men can also experience decreased sexual functioning as well as increased fat mass. It's important to recognize that yes we need to control estradiol if a man is symptomatic but not push them so far to the other end of the spectrum where you're suppressing their levels and putting them at risk for detrimental long-term health outcomes.
The traditional method of testing estradiol levels in men is with the use of an immunoassay test and recent literature has actually shown that this method of estradiol testing can actually overestimate the amount of estradiol present in men. This was found specifically in men with increased inflammatory markers such as high CRP. Our PrimeBody.com's network of providers actually use a more specific test that will give more accurate reading in terms of estradiol in men. This type of test uses liquid chromatography and has been shown to be much more accurate in terms of reflecting the actual amount of estradiol present in men. This is important because when we check blood work, we're actually relying on those results to help us manage our patients.
If we have a I would say outdated test, the immunoassay test and it's telling us the man's estrogen level is really elevated and we treat that to lower than, that could actually cause long-term detrimental health outcomes if we suppress their estrogen levels too low, just because we're using an outdated test that tends to over inflate or overestimate the amount of estradiol present in a man system. That is the reason that we're using this for updated, the liquid chromatography sensitive test for any patient coming to PrimeBody.com .
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