Dr. Saya...AI's, estradiol management...

[Vince Carter]

Dr Saya has given you guys great insight here...note his word "symptoms".

Most of you that are indulging in the TOT roundtable and/or this new fad of letting E go unrestricted (my words), fear of an AI, et al.., are failing to hear or just even infer the part that is being stressed in all of these conversations...without negative symptoms. That's is the part that is being glanced over.

No one should be walking around with body acne, water retention, increased BP, night sweats, and poor erections, or decreased penile sensitivity because of this misguided fad of not acting to reduce Estrogen, when any or all of these are present.

Think too, of low E. We all know that that is bad and constant suppression through overdosing of an AI, keeping E to "0" or keeping it subterranean, is bad.

But, when taken in a trough that is the lowest your E is, that tiny valley in a vacuum if you will. We know that E follows T...as T rises so does E. You're E is not static...another point that most of you are missing out on is that your E is not ~10 day in and day out or thru the day.

Side note, your levels are not more stable in the way you think they are because you shoot daily or EOD. You still have a peak and trough in T and E. You can experience a less pronounced up and down feeling, but peak and trough none the less. Some are so misguided in this way to think that there is no trough with daily or EOD shots!

You would be quite surprised to see how HIGH your E really is in a peak vs a trough.

 

[JimBob]

As a new Defy patient, I would also like to know if their treatment philosophy will change. I started treatment 6 weeks ago and was told to use an AI soon as I started.

Now what exactly is the rationale for starting a guy on an AI right out of the gate? You're not the only Defy patient to have said this, either.

 

[JimBob]

I'm also a Defy patient and am curious about Dr. Saya's opinion on AIs. I've been on TRT for about 2 months now and a couple weeks ago quit taking the prescribed 0.125mg (E3.5D) Anastrazole due to concerns stated on this forum. I wans't experiencing any negative side effects and I haven't noticed anything since stopping the AI, it will be interesting to see what my bloods show in about 1 month (I'm on 70mg test cyp and 500iu HCG E3.5D)

Were you prescribed the AI from day one? If so, did Defy tell you why?

 

[Dr Justin Saya MD]

Now what exactly is the rationale for starting a guy on an AI right out of the gate? You're not the only Defy patient to have said this, either.

Any number of reasons that can be gleaned from the clinical experience (and pattern recognition) of our team practitioners treating over 20,000 men in the past 5 years that leads to a valid clinical determination that E2 is going to (or already is) creating issues. This relates to the provider’s intuition (as noted before) about balance (balance/symptoms as noted). This very detail is an extension of the fact that we treat EVERY case individually and do not have a blanket policy for inclusion OR exclusion of an AI based solely on numbers.

I train practitioners to call upon their experience (vast clinical experience as noted above) and evaluate factors such as: baseline E2 levels, E2:T balance, body fat percentage, baseline E2 symptoms (even subtle), baseline psychological symptoms or psychological diagnoses (through experience can be more sensitive to E2 in many cases), alcohol consumption (increases aromatase activity), past clinical history (? history of gynecomastia, history of presumed E2 symptoms), etc, etc. This is partly where the art/intuition of experience meets the objective and subjective findings during consultation.

There are also occasionally practical considerations by the provider and/or patient. If there is valid suspicion or reason to believe an AI is necessary (again we’re talking micro-doses especially if prescribed upon initial consultation...0.125mg commonly...MICRO), a patient (or provider) may express or consider inconvenience and cost of waiting for next labs, paying for next labs, paying for next consultation, etc and may discuss with patient putting an RX on the chart, but advising the patient of the specific symptoms that would trigger the patient to begin taking it. In this sense it would be a “just in case” convenience for the patient and cost/time-saving measure as we always try to remain sensitive to patient costs, budget, etc.

 

[JimBob]

Thank you. I bet I'm not the only one to learn something here.

 

[lemonflavor]

Now I'm even more excited and hopeful about my first app't with Defy this week. I can't imagine how awful it would be to have symptoms like I'm having and hear a doctor say it's either coincidental, or 'sorry, we can't deal with any [possible high-estrogen] symptoms using an AI'. There was a podcast soon before all of the AI storm came up and they were talking about potential patients (like me) who have significant trouble with anxiety on TRT. They said basically that there's nothing they can do for them.

I'm rather surprised at how willing people are to get on the bandwagon after just hearing a few podcasts. However, I know there are individuals who have done the research themselves and feel strongly against AIs. I fully support and understand their views on this [edit: including Nelson Vergel]. I could someday even become one of those people myself, but not at this point.

I'm glad Defy offers the option, and so glad Dr. Saya replied here. On a recent podcast he was all but named in a pretty much slanderous way. It's great to hear from a different point of view on this for once, even if abbreviated.

 

[S1W]

I'm rather surprised at how willing people are to get on the bandwagon after just hearing a few podcasts. However, I know there are individuals who have done the research themselves and feel strongly against AIs. I fully support and understand their views on this [edit: including Nelson Vergel]. I could someday even become one of those people myself, but not at this point.

^ THIS. I simply cannot believe how much stock people put into a podcast produced by a guy of very questionable credibility whose main aim seems to be nothing other than self-promotion.

I'm glad Defy offers the option, and so glad Dr. Saya replied here. On a recent podcast he was all but named in a pretty much slanderous way. It's great to hear from a different point of view on this for once, even if abbreviated.

I've said this before and I'll say it again - Dr. Saya is a very intelligent guy and extremely good at what he does. When you speak to him and get to know him, you get the sense that you're dealing with a brilliant guy who would have been a success in any career that he may have chosen to pursue. We should count ourselves as lucky that he became a doctor and specializes in this niche field that has such a profound impact on our lives. If I were listening to a podcast that even came remotely close to slandering Dr. Saya - or anyone of his caliber in any context - my b.s. detector would go off and I would simply stop listening to that podcast. If your b.s. detector is NOT going off, then I have a bridge to sell you.

 

[cnc1]

I just had my first appointment this week with Defy, Dr Calkins. He explained everything to me, why he wanted to prescribe my test protocol, hcg and AI. He answered all my questions fully and explained his answers. I feel confident in Defy. I am new to TRT and I am catching the wave of anti-AI movement which I understand their reasoning. But I understand the reasoning behind prescribing an AI. I prefer to initially be prescribed the AI. If I don't need great, less drugs the better. But no one knows how my body will react to trt. I see the AI as a just in case. I rather have all the tools to start with and dial it in from there.

 

[Gman86]

Ya I just can’t get behind any doctors that think one hormone works outside of the laws of balance. It just doesn’t make sense that everything in the human body needs to be balanced, yet estrogen somehow not only doesn’t need to be, but has very beneficial properties when raised to levels never seen in nature. Even if let’s say certain hormones did have beneficial properties when elevated to levels never seen in nature. Would it be healthy to ramp them up to those levels for the rest of you me life? Would there be a negative consequence to making ur body run at full steam all day, for years on end?

The other reason that my bullsht meter is going off is the fact that they are majorly generalizing. They say “99.9% of men will not need to regulate E2”. There’s two things you want in a quality doctor. Well there’s more than two things, but two boxes that always have to be checked off when finding a good doctor is that they understand the concept of balance, and also that they know that every guy is different, and needs to be treated as an individual, and all variables with that person need to be considered.

 

[Sean Mosher]

Well said by Dr. Saya.
There is a reason he is well respected around here and one of the many reasons is how he has always professionally presented himself (and yes technically I'm with the opposition LOL, but we all want the same for every guy in need of treatment).

What he said below in quotes is the question that I think many of us would like to hear answered by the anti-AI crowd (I personally am not on an AI myself either):

"We know that there is risk with too low and too high of levels for any hormone in a biological entity (is E2 the only exception in the human body?). Where is that line of too high?"

 

[Tednacious73]

Were you prescribed the AI from day one? If so, did Defy tell you why?

I was prescribed the 0.125mg dosage of Anastrazole from day 1, I don't really recall if Dr Calkins said why, I believe he just said that they wanted my E2 to eventually fall into the 30-45 range (my pre TRT labs showed my E2 to be around 20)

 

[cnc1]

Were you prescribed the AI from day one? If so, did Defy tell you why?

Dr Calkins told me as my testosterone is elevates my estrogen will climb higher leading to side effects from too high estrogen. I understand the pros and cons of high/low estrogen. I am the ultimate judge on whether I take it or not. I rather have it and not need it then need it and not have it.

 

[Dansk]

Dr Calkins told me as my testosterone is elevates my estrogen will climb higher leading to side effects from too high estrogen. I understand the pros and cons of high/low estrogen. I am the ultimate judge on whether I take it or not. I rather have it and not need it then need it and not have it.

This is still all new to me, but if E follows T, why not just control T to where E would be in the desired range? I'm pretty sure lots of folks here are doing that?? something about a conversion rate of T to E?? Seems simple but maybe not....IDK.

 

[Cataceous]

This is still all new to me, but if E follows T, why not just control T to where E would be in the desired range? I'm pretty sure lots of folks here are doing that?? something about a conversion rate of T to E?? Seems simple but maybe not....IDK.

The glib answer is that management this way results in inadequate testosterone for some guys. But the "why" is pretty complicated. The anti-AI argument is that the natural aromatization level is almost always optimal or even suboptimal. But TRT is somewhat unnatural, even (or especially?) when we add hCG. So can we really expect estradiol to end up in the "right" place?

 

[charile12]

I was prescribed the 0.125mg dosage of Anastrazole from day 1, I don't really recall if Dr Calkins said why, I believe he just said that they wanted my E2 to eventually fall into the 30-45 range (my pre TRT labs showed my E2 to be around 20)

I read this often. They prescribe it and say take it just in case.
A newbie on trt will most likely take it. One of the biggest problem is when you start trt you need to give it at least 6 weeks for hormones to stabilize on THEIR OWN.
And starting a guy on 150 MG or higher a week the guy may experience some very temporary nipple itching. So instead of waiting it out they take AI.

As your hormones go up from being low you will get symptoms. You need to wait it out. My mistake was I saw my e2 in low 30s. Blamed everything in it cause thought I was suppose to be lower. Took ai. As low as.1 MG. All it did was crash me and put me on a roller coaster. Once I stopped ai. I stabilized nicely.
BTW ai mess your lipids too.

Best to control e2 if still high on a decent protocol, by lowering dose, losing weight, try to see if liver is the issue.

 

[christee]

I think doctors are always calling the shots when prescribing. But they all have a range that it's up to your discretion how you want to treat, and they take input within that range. Doctors have a legal and ethical responsibility not to facilitate the patient in harming themselves.

So, no matter how knowledgeable I am, if I say I feel best at a Total T of 3000 at trough, I don’t think you will find any legitimate doctors willing to prescribe enough testosterone to get you that high.

The patient is always calling the negative shots. I can always refuse any recommended treatment.

A knowledgeable patient knows that they can ask for and what is out of a doctor’s ethical bounds to prescribe. The confusion is that each professional office has their own standards of practice that can be quite different. So, one doctor may regard a total T of 300 as not needing TRT, while another doctor will treat a total T of 400. No doctor is going to say a total T of 700 (with normal range SHBG) needs TRT / extra testosterone. And it's not always up to the doctor's personal opinion, they all operate within a legal and office framework.

I don’t know Defy policy in regards to estrogen, but I am thinking if you are at 50 pg/ml, I doubt they will allow you to order an estrogen product to get your estrogen up to 100 pg/ml even if you think that is heart protective. (I could be wrong about that, but it’s my guess).

Beautifully stated Dr. Saya,

Thank you so much for bringing light to this discussion. So many patients have been discussing this in the recent weeks. I always tell our patients "WE TREAT PATIENTS (PEOPLE) NOT NUMBERS." I really appreciate hearing your thoughts directly. Some of Dr. John's patients have been reaching out to me on social media and they are asking me some of these same questions, along with my thoughts on Test Cream applied topically to scrotum, how we support our patients during the discontinuation of AI use, and if we have experience with these techniques.

I think that as a provider I aim to support patients and align to their personal TRT goals. I am not here to tell any individual what should or should not feel good to them. Hormone BALANCING is a very personal experience, especially depending on the reasons (symptoms) that prompted patients to seek therapy in the first place, and what symptoms continue to linger or come up along the way. I think that this is an excellent time to reach into our "tool bag" and potentially support our patients with topical Tamoxifen cream that Empower recently released. I realize this product might not be a one-size-fits-all solution, but it is promising for patients who tend to have no other "high E2 complaints," aside from an occasional nipple twinge, or bump. I find myself educating patients on dose control for E2 regulation several times everyday, "don't automatically reach for the AI bottle, think about decreasing T shot next dose a couple of notches and see if that does the trick."

Thank you for sending this message to myself and the rest of the Defy providers. I can only speak for myself, but I am privileged to have you as my mentor and Medical Director, you are one of the best doctors I have known, but better than that you are a wonderful person. Dr. John's Legacy will live through you and the other pioneer's of TRT. I am honored to have this opportunity to learn from you and work with you.
Christee

 

[Jesse-Defy]

I'm a patient of Dr. Saya as well, initially my E2 was rather low as well as my Testosterone. Personally, I've never needed an AI and subsequently was never offered one. Patients will often ask what our protocol is, and quite frankly, there isn't one. This can make determining future costs to be difficult, but patients do understand when I explain that each protocol is custom made for them as an individual, based upon their circumstances. I simply give an estimate of what it'd be.

As the first point of contact for patients, I feel it's my obligation to be informed regarding how our providers treat patients, and I can honestly say that I only recommend to patients what I'd do myself.

Defy has helped me to transform my life by balancing my hormones, that I had to join the team and help others, like me.