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

[Bnib]

It makes sense to me to break up the dose. I worked with a HRT researcher at the University of Washington who theorized that SHBG would react more aggressively to sudden high doses of injectables or creams. He had me raise my levels very slowly (over the course of 2 months) and it was the first time my free T exceeded 1%. I use this as a general principle now, but am very intrigued by the diabetic needle to the shoulder. Thanks so much for posting!

 

[trt1]

Great post!

2 questions.
What is your test level when you're at an E of 20?
What symptoms do you have when you have low ferritin?

My test has ranged from anywhere from 550 to 1200 ng/dl with my e levels around 10-40 pg/ml. Modulating the amount of AI you take will adjust your E level. I take the smallest amounts now since I'm only taking about 100 mg of cyp a week in 2 doses with about 500 units of HCG in 2 doses.

Low ferritin was frightening. I would feel electric like shocks through my legs around 29 on a scale of 30-300 ng/ml.
Fatigue was very intense, I would get tired from getting up from bed. Recovery from a workout is almost painful, Heart Palpitations, chest pains, restless legs,felt pain in my liver and kidneys for a bit but no signs of issues on a CBC or other standard trt tests. Check out low ferritin symptoms online you will get the picture.

After 2 weeks of supplementing iron at around 20-40 mg a day along with my standard diet my levels have creeped up to 40. Its slow going, considering I hear there is a correlation with supplementing iron and high hematocrit and hemo and rbc's I didn't want to be forced to donate again anytime soon because that would again crash my ferritin so I make sure I get my daily iron RDA but I dont try to go overboard on supplementing. High hematocrit is what led me down the road of trying a lower test dose initially.

I believe they say you want the level around at least 100 for proper thyroid function and overall well being for men.

 

[Bnib]

Is Ferritin something you have to be tested seperate for? I've had those symptoms but none of my labs in the last 3 years reference ferritin or iron.

 

[ERO]

Who do you work with? I've asked about diabetic gauge needles in the past but every dr I've used said it's not available. I hated the shot in the leg. But I'm type 1 diabetic and those shots are really a breeze.

Just get your own insulin syringes and you are good to go. No prescription needed and its $13.50 for a box of 100 here.

 

[rhino5169]

My test has ranged from anywhere from 550 to 1200 ng/dl with my e levels around 10-40 pg/ml. Modulating the amount of AI you take will adjust your E level. I take the smallest amounts now since I'm only taking about 100 mg of cyp a week in 2 doses with about 500 units of HCG in 2 doses.

Low ferritin was frightening. I would feel electric like shocks through my legs around 29 on a scale of 30-300 ng/ml.
Fatigue was very intense, I would get tired from getting up from bed. Recovery from a workout is almost painful, Heart Palpitations, chest pains, restless legs,felt pain in my liver and kidneys for a bit but no signs of issues on a CBC or other standard trt tests. Check out low ferritin symptoms online you will get the picture.

After 2 weeks of supplementing iron at around 20-40 mg a day along with my standard diet my levels have creeped up to 40. Its slow going, considering I hear there is a correlation with supplementing iron and high hematocrit and hemo and rbc's I didn't want to be forced to donate again anytime soon because that would again crash my ferritin so I make sure I get my daily iron RDA but I dont try to go overboard on supplementing. High hematocrit is what led me down the road of trying a lower test dose initially.

I believe they say you want the level around at least 100 for proper thyroid function and overall well being for men.

very interesting. Wondering now how much my low iron and ferritin overlap or contribute to my hypothyroid symptoms.
I'm going to male a point to optimize my levels.
My TIBC and uibc are fine but my iron is low
iron serum is 37, scale of 38-169
Iron saturation is low is 11, scale of 15-55
Ferritin is low at 20, scale of 30-400

I also fear of raising hemoglobin and hematocrit so I'll see what happens.
Thank you for the info.

 

[ratbag]

Also don't forget the moment you have low ferritin you are also hypothyroid. So what you actually feel is both sets of symptoms. My ferritin got to 90 with heavy doses of iron but I was still hypothyroid. So I suspect (haven't got there yet) that I need to get it to at least 120 or perhaps a little more to get rid of the hypothroidism.

 

[rhino5169]

Also don't forget the moment you have low ferritin you are also hypothyroid. So what you actually feel is both sets of symptoms. My ferritin got to 90 with heavy doses of iron but I was still hypothyroid. So I suspect (haven't got there yet) that I need to get it to at least 120 or perhaps a little more to get rid of the hypothroidism.

I wouldnt think though that curing hypothyroidism is just a matter of raising iron and ferritin, its probably a co factor though.

 

[trt1]

very interesting. Wondering now how much my low iron and ferritin overlap or contribute to my hypothyroid symptoms.
I'm going to male a point to optimize my levels.
My TIBC and uibc are fine but my iron is low
iron serum is 37, scale of 38-169
Iron saturation is low is 11, scale of 15-55
Ferritin is low at 20, scale of 30-400

I also fear of raising hemoglobin and hematocrit so I'll see what happens.
Thank you for the info.

Interesting that your iron and ferritin is so low. Do you donate blood often, or are you on a strict diet? If not I would definitely find out what is causing this. Chronic blood loss can be to claim in some way shape or form. Prior to frequent phebotomies via trt my ferritin was always around 170-200. What kind of symptoms are you having with such low levels? Good luck with your health!

 

[ratbag]

I wouldnt think though that curing hypothyroidism is just a matter of raising iron and ferritin, its probably a co factor though.

Well it is and a more common problem than one would think.. go read what symptoms are for low iron

 

[rhino5169]

Interesting that your iron and ferritin is so low. Do you donate blood often, or are you on a strict diet? If not I would definitely find out what is causing this. Chronic blood loss can be to claim in some way shape or form. Prior to frequent phebotomies via trt my ferritin was always around 170-200. What kind of symptoms are you having with such low levels? Good luck with your health!

I have many things going on so the symptoms probably overlap with hypothyroidism, which im taking naturethyroid for as of 7 weeks ago.

I do not donate blood.
I was on a crazy diet for a while maybe 6 months ago but not just average diet consisting of homemade turkey loafs, turkey burgers, bean, feta and chickpea salad, string beans and chicken. I dont eat much red meat.

Symptoms....some of this, which I posted in another ongoing thread:

"1. The most common effect that anemia can have on a guy's manhood is erectile dysfunction. The penis is dependent upon a good supply of oxygen-rich blood to function properly. If that is lacking, it can dampen the degree of tumescence; in severe cases, it can be a significant effect.
2. Beyond the degree of firmness, anemia can also affect stamina. A lack of oxygen not only affects how long the penis will remain in prime condition; it also affects a man's overall energy and ability to engage in sex: the arms get weak, the hips don't thrust with the same vigor, etc.
3. Anemia also just has a deleterious effect on the general health of the penis, aside from its sexual performance. A healthy penis is one that is well oxygenated"

 

[Joey786]

I would not be comfortable with my hormones at such high levels long term as Dr Nichols suggests. I understand that this field is ever changing but I'd rather shoot for high normal range not supraphysiologic.

 

[dek2000]

Dr Nichols,

What are the optimal ranges you like for vitamin D3, DHEA (men and women), and T3 ?

 

[CoastWatcher]

Dr Nichols,

What are the optimal ranges you like for vitamin D3, DHEA (men and women), and T3 ?

Dr. Nichols has not visited the Forum in over a year.

 

[Vince Carter]

Dr. Nichols has not visited the Forum in over a year.

And he won't be back.

 

[tareload]

There are valid points on both sides of this.

Fact: polycythemia vera and erythrocytosis are COMPLETELY different phenomena and should not be confused (though the terms are often erroneously used interchangeably). Polycythemia vera is without a doubt MORE risky, but that doesn't mean erythrocytosis comes without (longterm) risk.

Fact: though the physiology is similar, erythrocytosis from TRT is NOT a physiologic erythrocytosis, but is IATROGENIC. Though physiologically similar, the ethics and medico-legal considerations are certainly much different.

Fact: there is no solid data of increased risk of MI, DVT, etc that is attributable directly to appropriate TRT (I know we all agree on this one).

My take: as I've said before, it is not concern for MI, DVT that presents itself to me with TRT-induced erythrocytosis, but more the LONGTERM vascular consequences. To be clear, I'm generally referring to HCT >53 which is about where I draw the line LONGTERM. Most folks at high altitude DO in fact have higher H/H than their counterparts at sea level, however most are NOT HCT > 53 unless they have multiple exacerbating factors contributing (smoker, high iron levels/intake, OSA - this is a BIG one, COPD, + TRT). We all agree higher HCT = more viscous blood. If we look at simple fluid dynamics and the laws of physics, thicker fluid (blood) inside of a pipe (vessel) = higher pressure (blood pressure). I've seen this countless times in patients requiring blood donation or therapeutic phlebotomy -- BP drops, sometimes dramatically, afterwards and generally remains at the lower levels until (if/when) HCT rises again.

Now of course we also have the other end of the equation with enhanced nitric oxide production - which helps as it dilates the pipe (vessel) - consequently counterbalancing the increase in pressure. The problem is that this vasodilation from nitric oxide is VARIABLE over time, whereas the increased HCT is more constant...meaning that this teeter-totter of "thicker blood" counterbalanced by nitric oxide vasodilation, will certainly present times when the viscosity side of the equation is at a distinct advantage. Thinking of it another way, the body is able to adapt REMARKABLY to many differing situations (one of which noted above with the vasodilation), but nonetheless has it's functional limits. Think of it as an airplane that flies at 60-70% of its functional engine capacity (just estimates as I'm not a pilot!) - this piece of machinery has the capacity to utilize a higher percentage of its capacity, but keeping the "normal operating capacity" of the plain at 60-70% gives that added safety margin. The plain can then "throw it into overdrive" and utilize a higher percentage (temporarily) of its capacity when the situation calls for it. This is a crude analogy, but hopefully will make some sense. For the human side - the human body has a capacity to TOLERATE (probably the best term) HCT levels very high under certain situations as an adaptive mechanism, but the higher the HCT goes you are eating into that safety margin for the max capacity of the cardiovascular system and thus reduce the ability of the cardiovascular to remain plastic and adaptable to other changing conditions or insults. For instance, all may be well when the "teeter-totter" of viscosity/nitric oxide is all balanced, but what about when the patient experiences times of reduced nitric oxide production (or other reasons that the pipe won't dilate...like atherosclerosis as they age)...well then the equation is shifted squarely in favor of the higher viscosity = higher BP --> increased shear forces on arterial walls --> increased risk of macro and microvascular pathology, etc.

We don't have longterm data (and likely will not for a long time to come) for MANY of the interesting and debatable talking points related to TRT and other hormonal treatments. We can just weigh the current data we have, use our own clinical judgment and understanding of the physiology of the human body, and sprinkle in a little common sense from time to time to make the decisions we feel are in the best interest of our patients longterm.

I personally would not feel forthright in telling one of my 30-40-50 year old patients that sustaining an iatrogenic erythrocytosis with HCT >53 for the next two, three, or four decades of their life will not present any longterm risk...but it's a debatable topic and one for which each provider (and patient) must determine where they stand and approach it accordingly.

Note the latest research I posted supports and provides further insight on the careful and prudent advice Dr. Saya provides here. Still marvel at this master class approach to uncertainty. This takes humility and thinking.

Hematocrit drives Blood Viscosity- Does that Matter in Men on TRT? Effect of Altitude?

Reducing dose and increased my hematocrit.

www.excelmale.com

Hematocrit drives Blood Viscosity- Does that Matter in Men on TRT? Effect of Altitude?

Reducing dose and increased my hematocrit.

www.excelmale.com

A nice primer on the constitutive framework for NO production vs Hct given in this paper:

Hematocrit drives Blood Viscosity- Does that Matter in Men on TRT? Effect of Altitude?

Reducing dose and increased my hematocrit.

www.excelmale.com

 

[fifty]

And he won't be back.

Ironic

 

[tareload]

Ironic

What's the story with that?

I can understand how most would rather be entertained than debate mechanisms of NO production and endothelial dysfunction. I am probably trying to push a rope in this case.

 

[fifty]

I understand Vince Carter was banned but I don't know the story of why.

 

[tareload]

From connected thread:


Post in thread 'Royal Men’s Medical destroyed my Estradiol!!! Beware!!' Royal Men’s Medical destroyed my Estradiol!!! Beware!!

Dr. Nichols said: When you were 20-25 your E2 was anywhere form 50-75 or so and you were probably doing great.

......

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.

@RobRoy when you come back also explain this mess about "70". 70 what? How about some units please?

Are These Side Effects from HCG and/or Anastrozole?

Hi, great question. I’ve listened to the lectures and I understand how this comment can be frustrating: It’s going to be extremely difficult for someone not trained in the field to try to make sense of this. This issue is further clouded by the fact that no distinction between RIA and LC/MS...

forums.t-nation.com

Are These Side Effects from HCG and/or Anastrozole?

Yes, I was addressing @mrz123 's question which requires looking at non-TRT population. I couldn’t reconcile the statement when I first heard it made. To your point, you could modify the statement and I would agree that there may be a good percentage of “enhanced” men in their early 20s (a...

forums.t-nation.com

Are These Side Effects from HCG and/or Anastrozole?

@dbossa Thanks for passing on the feedback. Given your platform and network, it would be great if you could clarify on the podcasts that the “average” estradiol (sensitive: my edit) level in a young 20-25 year old man is not 75-100 pg/ml. It would be a good opportunity to teach men about how...

forums.t-nation.com

Embarrassing claims some people make on YouTube and in lectures to medical professionals. I guess I can understand this coming from the pitch guys who are only as smart as the doctors informing them. But what does this say about the MDs where these dudes get their info from?

 

[lowe2sucks]

I think messing with estradiol is huge mistake but thats just me... Im really anti TRT guy now so I don't even know what I am doing here please ban me