TRT without the use of Aromatase Inhibitors

[Jiu Jitsu Dude]

Hi Dr. John, (or another expert)

Coming off trt now. Was on 50mg E3.5D for 5 months with .125 AI E3.5 Days. I'm 10 days from last 50mg T-cyp shot. Very sensitive to any E2 over 20. Using 10mg tamoxifen per day for 6 weeks. Was advised to keep taking .125 Anastrozole every 3.5 days for this 6 week restart. I'm ok doing this but could it crash my E2? I have a dropper that I could dissolve it daily for smaller (but equal) consistent values then run a sensitive E2 test? Or is it unlikely I would crash E2? And as you know it's a week to get labwork back on E2 so by then I might be (you know the word @#$%ed).

 

[Gman86]

With respect to estrogen levels and AI use, the real question is whether it is safe to induce estrogen levels which are very high. The simple fact is no one knows.

But is estrogen at the top of normal range, or even higher better for you than low(er) levels? To me, the evidence clearly shows it is. But conflating that to an automatic "the higher the better" is not good science, or good medicine.

...and no one should be arguing for taking E very low. That is what EVERY single scientific study has done. That always turns our badly. Those opposed to any AI use keep showing those studies, as if we can extrapolate conclusions where, on average, 7 times even a higher amount of weekly AI dose hurt men, to rational use. To my mind, that is like saying we should never have a glass of wine because drinking a fifth of liquor a day will kill you.

I wish I could tattoo the word BALANCE on everyone’s forehead, I really do lol. And yes, I don’t think anyone can argue, at this point, that for overall health, it is beneficial to keep free E2 levels close to the top of the range. As far as subjective benefits/ symptoms, some men are going to need their free E2 a little lower, there’s no way around it. Everyone is different. I would say those men are probably in the minority though, and the majority of men will do well objectively, as well as subjectively, with their free E2 on the higher end of the range.

To say it will be beneficial for all men to have a TOTAL E2 in the upper range, is just too broad of a statement. A person with a very low SHBG level could have a lowish, or mid range total E2, and still have a free E2 at the top of the range. If that same person let their total E2 get to the top of the range, their free E2 might be way too high, which could possibly not only cause negative subjective symptoms, but could also cause negative objective symptoms, and possibly be detrimental to their overall health. So I agree, but only when we’re talking about being in the upper range for free E2, not total serum E2.

Ohhh, I misread ur statement a little. U weren’t saying that having E2 in the upper range, or higher, was always ideal. You were saying that having E2 in the upper range, or higher, was always better than having LOW E2. Which is obviously 100% correct, when we’re talking about free E2, at least. Sorry, I thought you were saying that it is always beneficial for every man to have their E2 levels in the upper range, or a little over. I still stand behind my overall statement, but again, sorry, I missed a few details in your original reply.

 

[Nashtide]

I also wonder what you mean by “symptoms” of high estrogen? When mine gets high, I have a little less libido, a little less energy in the gym and I don’t sleep as well. So nothing earth shattering, but enough to feel less dialed in. This is why I take a tiny dose of anastrazole. Just keeping my E2 in the mid to upper 30’s improves my quality of life.

 

[HealthMan]

Estrogen Balance and Aging Men - page 1 | Life Extension

“A study published in the Journal of the American Medical Association (JAMA) measured blood estradiol (a dominant estrogen) in 501 men with chronic heart failure. Compared to men in the balanced estrogen quintile, men in the lowest estradiol quintile were 317% more likely to die during a 3-year follow-up, while men in the highest estradiol quintile were 133% more likely to die.24

The men in the balanced quintile—with the fewest deaths—had serum estradiol levels between 21.80 and 30.11 pg/mL. This is virtually the ideal range that Life Extension® has long recommended male members strive for.

The men in the highest quintile who suffered 133% increased death rates had serum estradiol levels of 37.40 pg/mL or above. The lowest estradiol group that suffered a 317% increased death rate had serum estradiol levels under 12.90 pg/mL.

The dramatic increase in mortality in men with unbalanced estrogen (i.e., estradiol levels either too high or too low) is nothing short of astounding. It uncovers a gaping hole in conventional cardiology practice that is easily correctable.”

 

[HealthMan]

Not sure if they used the correct test for measuring estradiol - and course - free estradiol wasn’t checked. But the message is clear.
My opinion hasn’t changed. Most men on TRT aim for very high testosterone levels because most think that more is better and a lot of them care more about gains at the gym than anything else. For most cases when you start to have too many side effects this is a sign you should lower your dosage. I am a good example. When my dosage was “high” i had HCT issues, high estradiol, high iron levels, etc. Once i adjusted my dosage lower these all went away. No more side effects.

In my experience estradiol levels make or break a TRT protocol. Specially when it comes to libido and erectile function. And when it comes to health benefits that also seems to be the case.

I actually feel much better on a lower dosage than a higher one. Most people would be surprised if they tried. I wonder how different things would be if patients didn’t have access to their bloodwork. I am inclined to say a lot of them would feel better on a more moderate dosage.

Side effects for the most part are a sign something is out of balance. In most cases too much testosterone. The most logical approach would be to lower the dosage and not adding another drug. However there are cases where true optimization is not possible without drugs like anastrozole. So its use is legitimate for a lot of folks.
However guys aiming high levels of TT / FT should understand that side effects like high HCT and estradiol will probably occur.

 

[Nashtide]

The notion that there should be a ratio between T and E2 intrigued me. Just makes sense that men with higher T levels would have and need higher E2 levels. If this is valid, then the study that just looks at absolute E2 numbers wouldn’t be helpful.

 

[Gman86]

I also wonder what you mean by “symptoms” of high estrogen? When mine gets high, I have a little less libido, a little less energy in the gym and I don’t sleep as well. So nothing earth shattering, but enough to feel less dialed in. This is why I take a tiny dose of anastrazole. Just keeping my E2 in the mid to upper 30’s improves my quality of life.

This is definitely another factor that complicates things and leads to guys debating. The fact that two people can experience the exact same high E2 symptoms, but one views them as insignificant, and the other might view them as having a high negative impact on their lives. Different people can view things very differently, and have very different subjective opinions on how they feel.

 

[HealthMan]

TRT objective should be to optimize how we feel and to optimize our health. It should not be about only optimizing numbers. Numbers are an important part of the equation but are not everything. Most men think: the more testosterone the better. And they end up creating a lot of issues that would never exist if they were not chasing numbers in the first place.
And another fact is that for a lot men that go under TRT their main objective is to improve body composition. So they are chasing high numbers and end up fighting against side effects that usually snowball. Example: HCT goes too high. Patient donates blood too often to control it. Ferritin tanks. This affects how patient feels.
Same happens with estradiol. Too much testosterone ends up jacking up estradiol levels too high. An AI is added but patient never finds a protocol that he feels good.
All this could be prevented - in a lot of cases - by using lower testosterone dosages. Again, not saying AI is not appropriate in any case. It is appropriate when no further dosage reduction is possible (it starts to negatively affect how the patient feel subjectively and his health).
However if someone objective is to use TRT to get bigger and leaner. Then understand that side effects will happen more often and just deal with it

 

[DragonBits]

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.

When was 1500 ng/dl TT EVER the top of the testosterone range, neanderthal / prehistoric times?

I have tests back to 1996, the top of the range was 270-1070.

If you have a link, I am interested in the subject of the historical decline in TT levels, but they didn't have test for TT back very far in history, so hard to know what levels were even 100 years ago. And as far as I know, this decline is speculated to have started in the 1980s.

 

[Nashtide]

I know I sound like a broken record, but there are zero scientific studies showing that very small dose of anastrazole are harmful. Zero. Having very low E2 is bad, that is not the fault of anastrazole, that is almost always a dosage problem. You’d have side effects if you quadrupled your high blood pressure meds or your insulin. That doesn’t make those medications bad, it makes the dosage bad.

 

[Gman86]

I know I sound like a broken record, but there are zero scientific studies showing that very small dose of anastrazole are harmful. Zero. Having very low E2 is bad, that is not the fault of anastrazole, that is almost always a dosage problem. You’d have side effects if you quadrupled your high blood pressure meds or your insulin. That doesn’t make those medications bad, it makes the dosage bad.

Repetition is the number one way to learn. It’s how I got through nursing school. Just going over the same info over and over until it was burned into my brain. Don’t ever feel bad about repeating yourself. Serves two purposes. 1st, there’s always new members joining the forum, and this might be the first time they are seeing this info. And 2nd, sometimes it takes repeating the same info over and over again for some people to understand/ remember certain concepts.

 

[HealthMan]

I know I sound like a broken record, but there are zero scientific studies showing that very small dose of anastrazole are harmful. Zero. Having very low E2 is bad, that is not the fault of anastrazole, that is almost always a dosage problem. You’d have side effects if you quadrupled your high blood pressure meds or your insulin. That doesn’t make those medications bad, it makes the dosage bad.

True. And for most men an AI would not be needed if their testosterone dosage was more moderate and their testosterone levels were not way above range (and here the discussion about peak and trough comes back to place. A bunch of guys here are over range on trough imagine their lvls at peak).
Anastrozole is a fantastic drug that definitely has its place on TRT (without it TRT would not be possible for many men). However in my opinion many men on TRT should try to lower their testosterone dosage first before thinking about adding an AI if their testosterone levels are “out of range”.
Presence and severity of side effects should be used as a guidance to determine if dosage of a medicine is appropriate. With any kind of medication people would reduce its dosage in the presence of side effects. Why not for testosterone? Apart from the reason someone would not feel good with lower dosages there is no reason not to try to lower someone’s dosage to avoid/diminish side effects

 

[Nashtide]

True. And for most men an AI would not be needed if their testosterone dosage was more moderate and their testosterone levels were not way above range (and here the discussion about peak and trough comes back to place. A bunch of guys here are over range on trough imagine their lvls at peak).
Anastrozole is a fantastic drug that definitely has its place on TRT (without it TRT would not be possible for many men). However in my opinion many men on TRT should try to lower their testosterone dosage first before thinking about adding an AI if their testosterone levels are “out of range”.
Presence and severity of side effects should be used as a guidance to determine if dosage of a medicine is appropriate. In any kind of medication people would reduce its dosage in the presence of side effects. Why not for testosterone? Apart from the reason someone would not feel good with lower dosages there is no reason not to try to lower someone’s dosage to avoid/diminish side effects

You make valid points. However, when I began this journey I just wanted to feel better. I wanted the fog to lift, I wanted more energy, I wanted to sleep better and I wanted to lose weight. All of these things happened and more. The more that I didn’t expect was the changes in my body composition and the fantastic feeling that gives me. Now, I take a moderate dose of T cyp at 100mg/week. I probably could drop my dose to 70mg and obviate the need for anastrazole, but that lowered dose might reduce the positive benefits of TRT. I can maintain all of these positive benefits by adding 0.1mg of anastrazole twice weekly. I fail to see a really compelling reason to change my dosage schedule. Just my opinion.

 

[JimBob]

Per Dr. Crisler's request, I shared his comments with some other folks. Here's what I got back in return:
"LOL.

There is no such thing as “Top of Normal Range”.

John doesn't understand this stuff anymore.

We have moved into a diff era now.

Move into the Big Boy space is my best advice to you.

This week EVERYTHING WILL CHANGE!"


To Your Ultimate Health,

Jay Campbell

 

[HealthMan]

You make valid points. However, when I began this journey I just wanted to feel better. I wanted the fog to lift, I wanted more energy, I wanted to sleep better and I wanted to lose weight. All of these things happened and more. The more that I didn’t expect was the changes in my body composition and the fantastic feeling that gives me. Now, I take a moderate dose of T cyp at 100mg/week. I probably could drop my dose to 70mg and obviate the need for anastrazole, but that lowered dose might reduce the positive benefits of TRT. I can maintain all of these positive benefits by adding 0.1mg of anastrazole twice weekly. I fail to see a really compelling reason to change my dosage schedule. Just my opinion.

You should not lower your dosage in this case in detriment to how you feel just to avoid an AI. Completely agree. I use a tiny AI dosage as well. Going below 100mg a week doesn’t work for me. My e2 is in range without an AI but i always get gyno when it gets close to 30s

 

[HealthMan]

Happy new year everyone!

 

[Gman86]

You should not lower your dosage in this case in detriment to how you feel just to avoid an AI. Completely agree. I use a tiny AI dosage as well. Going below 100mg a week doesn’t work for me. My e2 is in range without an AI but i always get gyno when it gets close to 30s

What’s your SHBG at? Must be pretty low to get signs of gyno when E2 is close to 30. I believe you obviously, just wondering how low your SHBG actually is. With a range please lol. And happy new year to you too!

 

[Gman86]

Per Dr. Crisler's request, I shared his comments with some other folks. Here's what I got back in return:
"LOL.

There is no such thing as “Top of Normal Range”.

John doesn't understand this stuff anymore.

We have moved into a diff era now.

Move into the Big Boy space is my best advice to you.

This week EVERYTHING WILL CHANGE!"


To Your Ultimate Health,

Jay Campbell

Jay has literally lost his mind. Dr. Crisler doesn’t understand this stuff anymore?? Not only is jay out of his tree, but so disrespectful. He talks about enlightenment and becoming a better person, yet he might be one of the worst examples of a human being that I’ve seen in a while. How he has so much success while being a complete idiot is literally beyond me.

 

[HealthMan]

What’s your SHBG at? Must be pretty low to get signs of gyno when E2 is close to 30. I believe you obviously, just wondering how low your SHBG actually is. With a range please lol. And happy new year to you too!

20-25. Got gyno like 4-5 times. Terrible!

 

[user_joe]

When was 1500 ng/dl TT EVER the top of the testosterone range, neanderthal / prehistoric times?

I have tests back to 1996, the top of the range was 270-1070.

If you have a link, I am interested in the subject of the historical decline in TT levels, but they didn't have test for TT back very far in history, so hard to know what levels were even 100 years ago. And as far as I know, this decline is speculated to have started in the 1980s.

Depends on the lab. I’ve got tests from a couple years ago ranging 350-1197 iirc.

The 1500 number cam from a couple of the TOT round table discussion. All dr’s seemed in agreement. My own father was out of range at 1100 recently. He’s in his 60s and not on TRT. I bet an inexperienced doctor would think there was a problem. Apple fell hard from the tree. Lol