TRT without the use of Aromatase Inhibitors

[rafapark]

A very long story how I got there, but most recently, after trying to stick out dosage reduction for E2 to reduce/stabilize I was still going crazy with mood swings and bloating with E2 in the mid 30's.

Now on: 0.0625mg anastrozole, T cyp 24mg, HCG 280 iu, all EOD.

Labs on this kind of regimen: Total T in the 900-1000 range, Free T 18-21, E2 LC/MS/MS 25-30, SHBG 52.

Did you increase your T dosage frequency? I have similar parameters than you. Except for E2 which is now at 39 (sensitive). I felt best when it was in the 25 to 30 range. My E2 increased after I reduced my AI from 0.5 to 0.125 ( after switching from a local clinic to Defy). I want to lower my E2 without increasing my AI (current at 0.125 twice a week). Maybe by increasing my T dosage frequency? I posted the same question to Dr.Crisler. I need to ask that to my Defy doc next time we have an appointment.

 

[Dr. John Crisler]

Hi,
I would like to start TRT in next few weeks
My current TT is 378 and shbg is 50
I do not want to take any medicines apart from multivitamins in future or till my lifetime if at all no need is risen and for sure not in my current age of 40
What should be my starting TRT dosage and frequency as I am already estrogen dominant and do not want to mess up with my estrogen anymore. I just hate AI and do not want to use in my life anymore. I am even happy with a healthier level if not superman level
Thanks

With a Total T that low, and SHBG that high, your Free T is not good.

I'm afraid I cannot create a TRT regimen for you without thoroughly reviewing your case.

 

[Dr. John Crisler]

Dr Crisler, do you recommend more frequent injections regardless of the SHBG? In my case I am injecting

Dr Crisler if I understand correctly you recommend increasing dosing frequency as a way to control elevated estrogen symptoms. Would this apply for guys with high SHBG too? My SHBG is 53 and my E2 sensitive is 39 pg/ml. I would like to start using DHEA as mine is low ( 117.5 ug/dl) but last time I tried dosing 25 mg DHEA daily by Estradiol increased significantly. Would increasing dosing frequency to say 3 times a week help control my E2? Should I go to daily injections then? I really don't mind injecting more often and I prefer that to increasing my AI. Thanks!

Another benefit of smaller, more frequent injecting is it is easier to load the syringe.

I would be quite surprised if only 25mg of DHEA actually elevated your E.

 

[Deleted member 16042]

Did you increase your T dosage frequency? I have similar parameters than you. Except for E2 which is now at 39 (sensitive). I felt best when it was in the 25 to 30 range. My E2 increased after I reduced my AI from 0.5 to 0.125 ( after switching from a local clinic to Defy). I want to lower my E2 without increasing my AI (current at 0.125 twice a week). Maybe by increasing my T dosage frequency? I posted the same question to Dr.Crisler. I need to ask that to my Defy doc next time we have an appointment.

Was previously E3D, switched to EOD at 84mg/week, subjectively felt more stable. I lost the mood/bloat cycle on EOD, but the moodiness and slightly bloated state continued at a more even level before adding the anastrozole.

 

[MidwestNomad]

Dr Crisler, do you think it is wise to start patients on TRT without using an AI until bloods are seen, instead of using it right off the bat and possibly crashing E2? Which method do you believe gets a person dialed in faster?

I am prescribed 80mg Test C 2x per week with 500iu 2x a week of HCG. I have Anastrozole .125mg on hand. Labs are due 90 days from first pin. I plan to get my own labs at 45 days to see where E2 levels at. What are your thoughts?

Thank you.

 

[Dr. John Crisler]

Dr Crisler, do you think it is wise to start patients on TRT without using an AI until bloods are seen, instead of using it right off the bat and possibly crashing E2? Which method do you believe gets a person dialed in faster?

I am prescribed 80mg Test C 2x per week with 500iu 2x a week of HCG. I have Anastrozole .125mg on hand. Labs are due 90 days from first pin. I plan to get my own labs at 45 days to see where E2 levels at. What are your thoughts?

Thank you.

Yes. I usually do not even think to add any dose of AI until follow-up labs are done. The body is going through many changes once TRT is initiated, and things need to even out first.

Then only if the patient is suffering continuing elevated estrogen symptoms.

 

[Dr. John Crisler]

I want everyone to know I am reading all your posts.

 

[Powerdome]

This has the added benefit of retaining more testosterone in the body; rapid accelerations in androgen levels also increase urinary excretion of androgens (but not estrogen, unfortunately). One study concluded 40mg twice per week of test cyp is about the same as 100mg once per week.

I have read this before and it is quite interesting. Obviously, the less urinary excretion the better. How many studies have concluded that 40mg twice per week = 100mg one per week shot?

I only ask as I take 25mg EOD and would like to know what effect this has when compared to a twice weekly shot?

If the effects on 2x weekly shots of 40mg result in being equal to 100mg...what would 4 x 25mg equate too?

Any experts out there!

 

[Dr. John Crisler]

I'm more interested in the fact splitting the dose keeps things more even across the week; plus it produces a better zigzag pattern for serum androgen profile.

It's tough trying to figure out what is going on with a patient who is injecting once per week, especially if he has labs done at the end of the week. This is why I often ask to describe the subjective report as the week goes along.

If a patient says he feels best at the end of his week, that means his dose is too high. Lowering it can do the trick, and often avoid unnecessary estrogen control near shot time.

 

[Dr. John Crisler]

I have read this before and it is quite interesting. Obviously, the less urinary excretion the better. How many studies have concluded that 40mg twice per week = 100mg one per week shot?

I only ask as I take 25mg EOD and would like to know what effect this has when compared to a twice weekly shot?

If the effects on 2x weekly shots of 40mg result in being equal to 100mg...what would 4 x 25mg equate too?

Any experts out there!

It was only one that I have seen. I think Nelsen posted it here.

But reading 24 hour urine panels, with concomitant serum labs all these years has proven to me the body will increase T excretion into the urine when serum androgen levels are rapidly accelerating (as when SHBG is low-er). And that the same thing does not happen with estrogen.

 

[[email protected]]

Testestosterone propionate has reduced estrogen conversion than cypionate, but you need to inject it every 1-2 days, preferably every day.

 

[Deleted member 16042]

Testestosterone propionate has reduced estrogen conversion than cypionate, but you need to inject it every 1-2 days, preferably every day.

Can you provide documentation for that statement?

I am under the impression that aromatase acts on the freed/cleaved form, i.e. the simple testosterone molecule released from the ester, not the ester itself. Isn't that molecule the same regardless of which ester it came from?

 

[[email protected]]

Shorter esters are in your system for less time so less is converted to estrogen.
If you take Aveed (undeconate), estrogen activity will likely be higher than cypionate.
It hasn’t been formally studied. It’s anecdotal experience (usually bodybuilders). In the US cypionate is the most common form due to ease of use.

 

[madman]

Shorter esters are in your system for less time so less is converted to estrogen.
If you take Aveed (undeconate), estrogen activity will likely be higher than cypionate.
It hasn’t been formally studied. It’s anecdotal experience (usually bodybuilders). In the US cypionate is the most common form due to ease of use.

The only difference between esters whether shorter/longer acting is the rate at which the testosterone is released from the oily depot at the injection site.....other factors can also have an impact on the release rate (injection site/volume), blood flow (muscle vs adipose).

Ones injection frequency/SHBG levels will have the biggest impact on how long the T stays in ones system.

If anything shorter acting esters such as propionate would result in higher/faster peaks in T levels compared to longer acting esters.

T is not aromatized until the ester is cleaved off.....ones FT/SHBG levels will dictate to what is available to aromatize.

 

[Deleted member 16042]

Got it, sounds like bad Bro science. Sorry, it doesn't make sense for long term TRT. Such is the problem with anecdote based hypothesis. If I am actually wrong here, I'd like to know why...

If I take 100mg of T cyp weekly in EOD or E3D doses, I am taking in roughly 55mg Testosterone weekly due to the relative weight of the ester. While the T moecules are bound to the ester, they are not aromatized. If I am at steady state taking this dose, 55mg of T are released as available and unbound in my system weekly.

If we adjust for the different concentration of the prop ester, I'd take about 73-74 mg/week, and due to half life, would inject at at least EOD to keep a steady level. Result: I am getting the same 55mg Testosterone released into my body per week. There is the same amount of testosterone molecules released on a weekly basis to be available for armomatization.

Unless there is some kind of fluctuation of aromatase due to the slightly more pulsatile nature of the prop, I still am taking in and utilizing 55mg/week. The same amount will be aromatized.

 

[[email protected]]

Got it, sounds like bad Bro science. Sorry, it doesn't make sense for long term TRT. Such is the problem with anecdote based hypothesis. If I am actually wrong here, I'd like to know why...

If I take 100mg of T cyp weekly in EOD or E3D doses, I am taking in roughly 55mg Testosterone weekly due to the relative weight of the ester. While the T moecules are bound to the ester, they are not aromatized. If I am at steady state taking this dose, 55mg of T are released as available and unbound in my system weekly.

If we adjust for the different concentration of the prop ester, I'd take about 73-74 mg/week, and due to half life, would inject at at least EOD to keep a steady level. Result: I am getting the same 55mg Testosterone released into my body per week. There is the same amount of testosterone molecules released on a weekly basis to be available for armomatization.

Unless there is some kind of fluctuation of aromatase due to the slightly more pulsatile nature of the prop, I still am taking in and utilizing 55mg/week. The same amount will be aromatized.

It’s not bro science, it does cause less estrogen, but it’s definitely not convenient, especially for long term TRT unless you are sensitive. A lot of things when it comes to the body isn’t a straightforward shoot. It may seem counter intuitive, but those who’ve tried it have seen a difference. Would you want to inject daily and not be able to inject once a week if you say had to travel? Probably not. And good luck finding it outside a compounding pharmacy because it’s not convenient, but I’m just providing one solution on reducing estrogen.

 

[Nighthawk]

I just started TRT with Defy and I’m on my third injection. I am due for follow-up labs in 3 months, however, I am not taking my AI yet. I was prescribed .125 of Ameridex to be taken e3.5d or as needed when sides arise. My fear is crashed estrogen.

I am going to wait until 6 weeks to get my own blood panel drawn to see where my E2 levels are at.

I hear mixed opinions on waiting to “feel it”, but I’ve had my E2 levels at 10.0 before and don’t ever want to feel that again.

Do yourself a favor and wait until you get your labs, unless you absolutely know your body and what high e2 feels like for you. I would just take your testosterone before adding hcg and or AI into the mix. Adding in 3 or more elements into your protocol before you even have your first labs is a recipe for chasing your tail and lengthening the time it takes to get dialed in. As you mentioned crashing your e2 is much worse than elevated e2 in my opinion. Eat clean, stay lean and as long as your testosterone dose is reasonable you shouldn't need an AI. I inject test cyp ED @ 20-21mg and only use HCG @ 125-250iu twice during the first week of each month...that's it, simple no AI needed, SHBG in 30's, TT1000, FT 22, E2-24. Good Luck!

 

[Tdizzle]

@Dr. John Crisler

I require an AI even with 16mg/D Cyp. I aromatase at a crazy rate. I eliminated one at a time, Pregnenolone, then DHEA, then HCG, I got to use Cyp only was still very high (88) LC/MS/MS with profound negative symptoms...hot/sweaty in bed, aggressive/volatile/low tolerance for people, body acne was out of control, sexual dysfunction. I too slowly reduced my daily Cyp from 25mg in 2mg increments...never got E and its problems to resolve.
Through it all I had to use .25mg Anastrozole EOD and that still wasn't enough, I was still pushing the lab range on Free E (>0.45).
I've improved with switching to Aromasin, I'm doing the best I've been on TRT with 12.5mg EOD and my LC/MS/MS in the single digits.
At that point my body acne has largely resolved, I no longer have to take 2 showers a day and scrub my body with a brush. A lot of the body heat has come down to a tolerable point, orgasm is greatly improved and I have improved penile sensitivity. Still require PDE5i though which is the only thing I would complain about at this time.

I know you understand my SHBG @ 12 and how the Free E is so very problematic but I think I've figured it out for me...LC/MS/MS needs to be at or below the SHBG value. It was one of your remarks of having low SHBG that could tolerate almost no Estrogen that inspired me to go down this path.

Honestly I have zero negative/low E symptoms using 12.5mg of Aromasin, Daily.

I think you and I have similar situations. My SHBG is in the low teens, most recently it came in 14 while my ultra sensitive estradiol was at 30. I think I may need to lower mine a bit. I’m going to ask my doctor about the free E test as well

 

[bkb33]

@Dr. John Crisler thank you for the incredible service you offer (for free!) by lending your time and expertise to us lay people. I'm posting on this thread because my situation is related to this issue.

I am new to EM, but have been on the some of the other forums for some time, and I've listened to all your appearances on the TOT podcast. I'm a big fan. I wanted to make an account here to specifically ask you about my situation, as I'm baffled.

I am 27, 6'2", 175 pounds, 10% BF, eat clean, and have been healthy my whole life. I sought treatment earlier this year because my libido has been very poor for 1.5 years, which is straining my marriage (heard that one before?). My original bloodwork, in May 2018, was:

Total T: 1148 (Ref 264-916)
Free T: 13.8 (Ref 9.3-26.5)
SHBG: 167.0 (Ref 16.5-55.9)
Estradiol: 43.2 (Ref 7.6-42.6)
IGF-1: 234 (Ref 63-373)

Obviously, SHBG was astronomical. We started treatment with hCG and anastrozole. Two months later, we tested again, seeing these numbers:

Total T: 1828 (Ref 250-1100)
Free T: 174 (Ref 35-155)
SHBG: 112 (Ref 10-50)
Estradiol: 61 (Ref < 29)

The plan and goal, it was clear, was to lower SHBG and E2. Thus, we upped the anastrozole dose. My doc also wanted to add Ibutamoren see if increasing IGF-1 would help. We saw these numbers in October:

Total T: 1989 (Ref 250-1100)
Free T: 193 (Ref 35-155)
SHBG: 110 (Ref 17-56)
Estradiol: 51 (Ref < 29)
IGF-1: 288 (Ref 63-373)

Since then, we have upped the anastrozole dose again (I am now at .5 three times a week) and upped Ibutamoren (now 25 mg/day). However, since then, my libido has somehow gotten even worse. I used to desire sex once every 1-2 weeks; now, I truly never desire it, and it feels like a burden trying to have sex.

Jay and Dr. Nichols would say I should drop the A.I. and saturate my system with testosterone, but I also understand your perspective on the long-term risks of what could be happening in the background. The 'balance' between T and E is rarely black and white. My Total T is already quite high, and I don't know what could happen if I push it to the 2000s or even 3000. I'm guessing my symptoms would improve, but I don't want to risk my long-term health.

My question for you, Dr. John, is: what would you do next? Should I lower my A.I. dosage and try a "low and slow" T dose? I would genuinely appreciate your wisdom, as I've been scratching my head for a while now.

 

[[email protected]]

I bet your prolactin levels are above normal. That can kill libido. The problem with high T is managing estrodial and prolactin.