TRT without the use of Aromatase Inhibitors

[bkb33]

Just watched the video with Dr Rouzier. I'm not going to be disrespectful but i cannot take any merit from what he has said. He seems to think that the more estradiol, the better. Absolutely bizarre. No mention of the importance of shbg either. I still hold DR john crisler as the most credible trt physician.

I watched it as well. I also wish he had touched on SHBG, and I agree that it's a bizarre take. That said, I think he made a pretty convincing argument that we should, at the very least, rethink estradiol. His anti-prostate-cancer arguments were interesting. He's clearly a very bright, well-read man. I just wish he would address the counterarguments raised in this thread.

 

[Gman86]

TRT is an evolving science. We will have difference of opinions for a long time. You have to choose a doctor you trust and stick with him. My doctor is Dr Saya and I trust him 100%.

Same. He’s my doctor, and couldn’t be happier. Wish he had time, and a platform to do something like the TOT round table. But I understand he’s a very busy guy.

 

[Gman86]

I watched it as well. I also wish he had touched on SHBG, and I agree that it's a bizarre take. That said, I think he made a pretty convincing argument that we should, at the very least, rethink estradiol. His anti-prostate-cancer arguments were interesting. He's clearly a very bright, well-read man. I just wish he would address the counterarguments raised in this thread.

My thoughts exactly. Clearly a very smart guy, and I love they way he looks and analyzes things. Just wish we could hear his counter arguments.

 

[Vince Carter]

I guess what would be of utmost important in this whole discussion would be what was brought up earlier............if all those studies that Rouzier and Jay are referencing were done using the ImmunoAssay / the wrong testing method, then how could we possibly draw accurate conclusions from them?
It would be interesting to ask Dr. Rouzier if he even tests estradiol using liquid chromatography and if he does, why reference studies using a test he no longer employs?
I'm all for this discussion as long as it stays civil, which in this thread thankfully it has.
Always interested in learning more!

More to that point Sean is we've had the same discussion about the mythical 21-30 E2 range. Now that was given in the ImmunoAssay period, and does that even correlate to the LC/MS/MS method?

 

[Vince Carter]

I watched it as well. I also wish he had touched on SHBG, and I agree that it's a bizarre take. That said, I think he made a pretty convincing argument that we should, at the very least, rethink estradiol. His anti-prostate-cancer arguments were interesting. He's clearly a very bright, well-read man. I just wish he would address the counterarguments raised in this thread.

SHBG and E2 are largely IMVHO were a lot of answers lie for guys; Free Hormones.
To that extent is testing LC/MS/MS akin to ONLY using Total Test and not even testing for Free T?

I don't think that we can ignore Free Estrogen any longer.

 

[Dr. John Crisler]

Of course, this just begs the question as to why Dr. Rouzier refers to such "invalid testing in the first place". Has anyone ever asked him directly about this?

Is the immunoassay consistent at all by how much it overestimates actual serum concentration? In other words, does it overestimate by a fairly consistent percent whereby one could factor this in to arrive at a more accurate serum concentration?

Thanks for posting here, Dr. Crisler.

That's a great question.

How much the immunoassay overestimates actual serum concentration is not consistent. There are too many other constituents of the blood, with their own varying level, to do so.

Compared to when the correct assay was run at the same time, I have seen it over, way over, and under.

C Reactive Protein (and its factor) mimics E on that test. So it could be why those with high immunoassay E2 are sick: they are inflamed.

 

[Dr. John Crisler]

Are they actually business partners? Where'd you see that?

GUYS: Can we please keep this discussion about ideas, rather than about people?

 

[Dr. John Crisler]

I’m far more interested to hear your take on Jay and Dr Rouzier’s latest podcast where Dr Rouzier essential debunks the theory that lowering E2 has any health benefits and in fact can only lead to poorer health.
I was especially interested when he brought up the study that I hear about on this site every time there is a conversation about having high E2. The study goes something like this, people at the lowest and highest levels of E2 have the highest rates of mortality. What is never mentioned on this site is that the people with the highest E2 already had metabolic conditions and that was the reason for the high E2. His claim seems pretty logical that the reason they had a higher mortality was the metabolic condition and not the E2. He went through study after study pointing out the same flaws in the E2 argument.

Excellent point. That is the difference between association and causation.

For instance, visceral fat produces lots of estrogen. It's also extremely inflammatory. So we see the high E and the illness, and blame it on the E; it was the inflammation all along.

 

[Dr. John Crisler]

Of course, this just begs the question as to why Dr. Rouzier refers to such "invalid testing in the first place". Has anyone ever asked him directly about this?

Is the immunoassay consistent at all by how much it overestimates actual serum concentration? In other words, does it overestimate by a fairly consistent percent whereby one could factor this in to arrive at a more accurate serum concentration?

Thanks for posting here, Dr. Crisler.

Every Lab Director in the country knows immunoassay is invalid for adult males. If you run the wrong run, it will tell you so on the printout when you get the results back.

 

[Gman86]

Dr. Crisler, can you briefly give your opinion on why Dr. Rouzier stated that young men usually have an E2 around 75-90?

Also, what is your opinion on his views of E2? He seems like such an intelligent guy. It’s hard to believe he doesn’t know what he’s talking about. I just don’t get how he can have thousands of patients, over the years, not managing E2, and having great results, yet we know for a fact that some guys on this forum report feeling substantially better when E2 is managed. Is it all in these guys’ heads? Why do you think there’s such drastic differences between his patients, and guys in the real world that report on here about receiving great benefit from using a small dose of ai? And what about your patients? Do you ever have patients that report a benefit from managing E2? Thanks.

 

[Dr. John Crisler]

More to that point Sean is we've had the same discussion about the mythical 21-30 E2 range. Now that was given in the ImmunoAssay period, and does that even correlate to the LC/MS/MS method?

Yes, let's talk about "Sweet Spot".

To my mind, there is no such thing as correctly tightening E2 within some mythical ideal range. Given differences in genetics, metabolism, receptor density, EDC exposure etc etc the difference across the population is far too great for such a thing to even be possible.

And I have many patients with LC/MS E2 at, for instance, 70, who are very happy. I leave them be.

 

[Gman86]

Yes, let's talk about "Sweet Spot".

To my mind, there is no such thing as correctly tightening E2 within some mythical ideal range. Given differences in genetics, metabolism, receptor density, EDC exposure etc etc the difference across the population is far too great for such a thing to even be possible.

And I have many patients with LC/MS E2 at, for instance, 70, who are very happy. I leave them be.

...but every time, I wonder whether there may be something untoward going on in the background. After all, such a level has NEVER been properly studied. Why would anyone just make an assumption?

There’s never going to be a general sweetspot with total E2. There probably won’t ever even be a sweetspot with free E2. Although, if there is ever going to be a “sweetspot”, whether it be tight, or more broad, it’s going to be with free E2. So I’m not sure why we even pretend that total E2 matters that much.

Free E2 is all that matters. For example, you say you have patients with an E2 of 70. But those patients could all have high SHBG levels, and have free E2 levels arounds the same as men with a total E2 of 30, who have very low SHBG. So saying you have guys with an E2 of 70 means very little. What’s their free E2? If their free E2 is way over the top of the range and they are without any negative symptoms, now that plays into this whole discussion for sure. Until we focus on free E2, we’re just spinning our wheels, which I would think we would be way past by now. No offense obviously. I know testing for free E2 comes down to money, and it might not be cheap enough yet, or not offered to everyone, but this just seems as ridiculous as only testing for total testosterone and then having full blown debates about it, while people from the future laugh at us. That’s how I view having discussions about total E2. Am I wrong?

Again, with that example of the guys with E2’s of 70. The reason it means almost nothing, is because say you had 2 patients. Both with a total E2 of 70. One has a very low SHBG, and his free E2 is way over the top of the range. Then, the other guy has a very high SHBG, and his free E2 is mid range, even though his total E2 is 70. So both men have a total E2 of 70, but as you can see, have extremely different free E2 numbers, which is what matters. So that’s why it means very little to say you have a patient with a total E2 of 70. Again, no offense obviously. Just trying to prove a point about how total E2 is a joke. Is it better than nothing? Yes, of course. With SHBG and albumin levels, you can still make protocol changes based off of it, but is it optimal? Absolutely not. Why do things sub optimally, doesn’t make much sense.

 

[Gman86]

I have been wondering the same things.

And, yes, I have made literally hundreds of guys better by dropping E down a bit. But it still ended up higher than it was before TRT. Low E is always bad. Higher E then is always good. But how about really high? The simple truth is we will not know until it is properly studied.

Thank you for your reply. I really appreciate it.

 

[JimBob]

There’s never going to be a general sweetspot with total E2. There probably won’t ever even be a sweetspot with free E2. Although, if there is ever going to be a “sweetspot”, whether it be tight, or more broad, it’s going to be with free E2. So I’m not sure why we even pretend that total E2 matters that much.

Free E2 is all that matters. For example, you say you have patients with an E2 of 70. But those patients could all have high SHBG levels, and have free E2 levels arounds the same as men with a total E2 of 30, who have very low SHBG. So saying you have guys with an E2 of 70 means very little. What’s their free E2? If their free E2 is way over the top of the range and they are without any negative symptoms, now that plays into this whole discussion for sure. Until we focus on free E2, we’re just spinning our wheels, which I would think we would be way past by now. No offense obviously. I know testing for free E2 comes down to money, and it might not be cheap enough yet, or not offered to everyone, but this just seems as ridiculous as only testing for total testosterone and then having full blown debates about it, while people from the future laugh at us. That’s how I view having discussions about total E2. Am I wrong?

Again, with that example of the guys with E2’s of 70. The reason it means almost nothing, is because say you had 2 patients. Both with a total E2 of 70. One has a very low SHBG, and his free E2 is way over the top of the range. Then, the other guy has a very high SHBG, and his free E2 is mid range, even though his total E2 is 70. So both men have a total E2 of 70, but as you can see, have extremely different free E2 numbers, which is what matters. So that’s why it means very little to say you have a patient with a total E2 of 70. Again, no offense obviously. Just trying to prove a point about how total E2 is a joke. Is it better than nothing? Yes, of course. With SHBG and albumin levels, you can still make protocol changes based off of it, but is it optimal? Absolutely not. Why do things sub optimally, doesn’t make much sense.

If what you're saying is correct, and free E2 is what absolutely matters, akin to free T, then yes, most of the past discussions here over estradiol levels have been largely moot.
So, how much does that free E2 lab run?

 

[fifty]

It’s $100

 

[bkb33]

GUYS: Can we please keep this discussion about ideas, rather than about people?

I understand this may seem like gossip, but that's not my intention. I think it's important to know about business relationships when we're interpreting information on the podcast.

 

[Nashtide]

I’ll be testing free E2 next time.

 

[Vince Carter]

The downside on Free E is that is pricey and I nearly always have to add that caveat that if be affordable for the guy...huge detractor when youre paying retail/out-of-pocket. But, when you're in that space of not having found the problem or problems persist when conforming to the TRT "norm" then it could offer you a better picture.

 

[Vince Carter]

Remember too when considering what's too low for E...you have to remember that E follows T and that the low number you see in a trough is not static, or constant. It's going to go up again with your injection schedule. That's opposed to constant suppression which is making E constantly low day-after-day is not what I'm saying, we know that that is generally not good.

But too saying we know that low is Bad, makes high(er) E good, saying it that as a rule or in a definitive sense that way is very flawed.

 

[Chopsuey]

Guys if you listen to the whole thing Dr. Rouziers rntire point, from my understanding, is more estrogen the better.

The method of testing is really moot at this point when he says things like most are several times over reference range, with 2 dozen doctors themselves in the 200 to 300 range for E2, regardless of the method of testing the E2 is going to be high with numbers like this...

So the real question is this high E2 good or not and is there an adjustment period to feel good with high estrogen?