Your Estradiol During HRT (for Men)

Estradiol monitoring and management is a hot topic in HRT (testosterone therapy) right now and a few recent studies have highlighted that estradiol is just as important to male brain and sexual function as testosterone itself. Unfortunately, the research is still in the early stages and there are multiple areas of controversing, including the fact that there are

a) several different kinds of estradiol lab tests with varying degrees of accuracy,

b) potential (but poorly understood) clotting issues even with low dose Arimidex,

c) AI-sensitivity in some men and

d) considerable variability in individual estradiol needs.

These issues and the general lack of studies have led to tremendous confusion. Most doctors are still completely ignorant about the subject and still other doctors think that it is okay for men on HRT to have high estradiol.  However, our guest author today is going to present the opposite view and the evidence that he has seen for it, i.e. that estradiol not only must be tested for regularly but must be controlled and kept in a tight range. 

And there is considerable precedent for his view:  HRT and anti-aging clinics have been managing estradiol with considerable success with their men on testosterone therapy.  The general consensus, according to this school of thought, is that "men feel better in the 20-30 pg/ml range."  I haver found this to be case as have many men on the Peak Testosterone Forum.  Ultimately, though, you have to do your own research and work with your doctor.

GUEST AUTHOR: Kierkegaard

Symptoms of E2 and Why You Need to Spot Estradiol Problems Yourself:

In my experience, both personally and with the countless talks I�ve had with fellow TRT-ers, the single biggest reason why TRT doesn�t �work� is because of estradiol (E2) management. In my case, every single instance of me feeling bad on TRT has been related to estradiol being out of balance. This makes sense for two reasons, one hormonal and the other institutional. Hormonally, testosterone always, each and every time, metabolizes to dihydrotestosterone and estradiol. Both can cause problems in different ways, with DHT causing oily skin and estradiol with a serious list of potential symptoms depending on whether it�s too high or too low (we�ll get to these in a moment).

Institutionally, Nelson Vergel points out that none of the medical guidelines recommend even testing estradiol when administering TRT, so it�s clear that most doctors know not only nothing about this hormone in relation to guys, but many doctors scoff at the idea of treating estradiol, especially by an aromatase inhibitor, which prevents much of the conversion from testosterone to estradiol. As one whose name I�ve forgotten put it, his doctor said, �there�s no way I�m putting you on a medication for breast cancer.�

So what this means is that if you�re doing TRT, you need to know about estradiol by studying up on it yourself. Thankfully, you can do this by just reading this to the end. There are studies on the importance of testing estradiol, and even a study I�ve found on anastrozole monotherapy for the treatment of hypogonadism. The data are out there, and it�s always helpful to check them out and bring them to your doctor. See the references below for a wealth of information on how estradiol affects functioning in multiple ways.

Why E2 (Estradiol) Is So Important

So why is estradiol so important? It has profound implications for general health and has the potential to cause very unpleasant symptoms if unbalanced. One single study drives this point home (slightly edited for readability):

Among 501 men with chronic [heart failure], 171 deaths (34%) occurred during the 3-year follow-up. Compared with quintile 3, men in the lowest and highest estradiol quintiles had increased mortality� For increasing estradiol quintiles, 3-year survival rates adjusted for clinical variables and androgens were 44.6%, 65.8%, 82.4%, 79.0%, and 63.6%; respectively (P < .001). [1]

Notice the most important phrase: Compared with quintile 3. What is a quintile? Any of five equal groups. Quintile 3 is smack dab in the middle. It turns out that moderation is the game with sex hormones as well. Notice further the five percentages listed in the final paragraph: 44.6%, 65.8%, 82.4%, 79.0%, and 63.6%. Which one is the third quintile? The one with the 82.4% survival rate. Notice how it starts small, at 44.6%, then goes up to 65.8% (looking better), then maxes at 82.4% (looking best), and then what happens? It starts declining! Higher is definitely not always better with estradiol. What does this middle quintile come to in raw data terms? Between 21.8 and 30.11 pg/ml. Interestingly, the TRT and steroid community has typically held between 20 and 30 pg/ml to be the best in terms of managing unbalanced estradiol symptoms.

What�s interesting about this number? Well, not only does it correlate very tightly (hence the multivariate regression analysis study) with not dying of heart failure and other related problems, it also happens to be the Goldilocks zone for feeling best on TRT in terms of estradiol level. Shocking! That�s how wise your body is: when you�re feeling best, you�re usually healthiest.

So what happens when people go too low or too high? This is a subject that has virtually no research behind it, so we�re left with the anecdotal experiences of countless TRT patients. As a general point, erectile strength appears to be the best barometer for determining if estradiol is within the range mentioned above. If your erections start getting soft, this usually means high estradiol or considerably low estradiol, but for some guys their estradiol levels can be slightly low and still experience strong erections. However! They tend to experience weak erections. The following is a list of the most common symptoms of high and low estradiol. Note that these generally assume that your testosterone level is at least decent.

High and Low Estradiol Symptoms

Low Estradiol: fatigue along the lines of sleepiness; hypersomnia (sleeping too much and too often); strong erections but limited sensitivity; loss of erections; osteoporosis and osteopenia; joint pain, clicking or popping joints; eye fatigue (eyes seem more tired despite adequate sleep, dark circles); loss of libido (interest in sex); difficulty retaining water (constant urination); anxiety, depression, irritability. Exclusive to low estradiol (usually): sleepiness fatigue; hypersomnia; limited penile sensitivity; osteoporosis/osteopenia, joint clicking/popping, pain; difficulty retaining water (urination); anxiety/depression.

High Estradiol: soft erections, inability to maintain an erection; water retention (less frequent urination), leading to excessive sweating, including more than 2-3 pounds of weight loss after an intense cardio workout; blood pressure spikes or high blood pressure (from the water retention); insomnia; hot flushing (flushing around the ears or on the face); night sweats (from estradiol lowering, causing loss of water retention); bloating; brain fog (like your head is in a bubble); testicles seem smaller than usual (not accounted for by testicular atrophy via TRT). Exclusive to high estradiol (usually): soft erections, inability to maintain; water retention; excessive sweating; blood pressure spikes or high blood pressure; brain fog; night sweats; bloating.

An important tip: if you have only one or two symptoms, you might not actually be suffering from high or low estradiol. The more you have, the more likely you have high or low estradiol. Pay extra attention to the ones underlined.

Another tip: what�s the biggest lesson here? Learn to listen to your body. Pay attention to what it�s doing, and even create an Excel file charting changes day by day. I�m at the point now where I rarely need bloodwork to know if my estradiol is too high or too low.

The following are tests I�ve thought up for determining if you have high or low estradiol. Know that this overlaps with the symptoms mentioned above.

Tests to determine estradiol:

1. The ring finger test. If you wear a ring and it's tighter than usual, this can mean water retention, which means high estradiol. If it�s too loose, this can mean low estradiol. (Remember that sometimes drinking enough water actually makes your body lose water retention.)

2. Weight. If you weigh more than usual, especially in the morning before a meal, this can also mean water retention.

3. My favorite: the jogging pretest-posttest. I weigh myself before I go on a good run. The more I sweat and the lower my weight posttest will tell me how much I'm aromatizing. Note that you'll always lose normal water weight when you sweat a good deal. E.g., going from 181 to 176 indicates moderate-high water retention, and going from 175 to 173 indicates low water retention.

4. Fatigue and eye tiredness. The more tired my eyes look earlier in the day, the more I'm usually at the higher end of estradiol. I've always had allergic shiner-like half dark circles, but when I get slight full circles, then I know something's up. Note that this could indicate bad sleep related to alcohol or sleep apnea. The better I look and the less the dark circles, the know I�m closer to being reeled in correctly.

CAUTION:  Don't rely exclusively on self-tests.  Work with your doctor and get a regular estradiol test done.  My former HRT clinic pulled estradiol every 3 months and one month after any protocol alterations.  If your doctor will not pull your estradiol numbers due to ignorance, you can pull them yourself (in most states).  See my page on Reasonably Priced HRT Labs.

How to control for estradiol:

The following are methods people use to control estradiol. Know this information is covered in more detail on Peak�s main page.

How to Raise Estradiol (for men on testosterone therapy):

  • Take HCG concurrent with or independent of testosterone.
  • Cut down on supplements and any aromatase inhibitor, and pay attention to diet: even green tea consumption and sugar reduction can bring estradiol down in some people. Know that the half life of anastrozole (the usually prescribed AI for TRT users) is around 50 hours, which means it will take about a week before it�s mostly out of your system. According to Dr. Crisler, it takes about a month for estradiol levels to stabilize, and this is also relative to SHBG, which binds up bioavailable estrogen. The higher the SHBG, the slower it takes to raise, so be patient.
  • Increase your testosterone dose, provided it�s still within normal range (or you risk polycythemia).
  • If doing subcutaneous injections, you can try �intermittent� intramuscular injections at a very small dose on top of your usual subq injection as a way of giving you a �bump� for a few days before your next injection as your levels gradually rise.
  • How to Lower Estradiol (for men on testosterone therapy):

  • Do Subcutaneous Injections. Easily the biggest solution to high estradiol levels, slashing my levels in half from IM injections. Know that going from IM to subq will likely involve a good drop in estradiol as your body builds up the T level via this slower method. And slowness is why estradiol is lower, as well as lower peaks and higher troughs, reflected in the research literature (see references 8-10 below).
  • CAUTION:  You have to be extremely careful in lowering your estradiol.  If you go too low for too long, you can end up with osteoporosis.  In addition, setting an estradiol target is more difficult now, because the big labs are no longer using the old assays but rather a more accurate technology called LC-MS/MS.  However, this test lowered the range and so more research needs to be done to correlate the old versus the new values.
  • Take DIM, Zinc, or Other Supplements. Zinc is probably the most potent, but be sure to balance this with copper levels if going above the daily value. DIM is a bit controversial, because for many guys it has resulted in clear changes in feelings, but many guys can�t find these differences reflected in bloodwork, which might be explained by how DIM works, by speeding up the metabolism of estrogen rather than preventing it from converting as much from T (as an AI does).
  • Get on an Aromatase Inhibitor. Arimidex (anastrozole) is the most popular, but there are others out there. Beware how strong this stuff is; you don�t want to swing the other way by going too low with your estradiol.  CAUTION:  Even low dose Arimidex could potentially negative impact the clotting cascade.  Discuss with your physician.
  • Lower Your Testosterone Dose. Lower T means less converted to estradiol, as well as DHT. And you get a bonus of not risking polycythemia, which is always good. Just make sure your free T doesn�t get too low.

    1. Jankowska, E.A., Rozentryt, P., and Ponikowska, B. (2009). Circulating estradiol and mortality in men with systolic chronic heart failure. Journal of the American Medical Association. 2009 May 13;301(18):1892-901.

    2. Leder BZ, Rohrer JL, Rubin SD, Gallo J, Longcope C. Effects of aromatase inhibition in elderly men with low or borderline-low serum testosterone levels. J Clin Endocrinol Metab. 2004Mar;89(3):1174-80

    3. Zumoff B, Miller LK, Strain GW. Reversal of the hypogonadotropic hypogonadism of obese men by administration of the aromatase inhibitor testolactone. Metabolism. 2003 Sep;52(9):1126-8.

    4. Raman JD, Schlegel PN. Aromatase inhibitors for male infertility. J Urol. 2002 Feb;167(2 Pt 1):624-9

    5. Chearskul S, Charoenlarp K, Thongtang V, Nitiyanant W. Study of plasma hormones and lipids in healthy elderly Thais compared to patients with chronic diseases: diabetes mellitus, essential hypertension andco ronary heart disease. J Med Assoc Thai. 2000 Mar;83(3):266-77

    6. Cengiz K, Alvur M, Dindar U. Serum creatine phosphokinase, lactic dehydrogenase, estradiol, progesterone and testosterone levels in male patients with acute myocardial infarction and unstable angina pectoris. Mater Med Pol. 1991 Jul-Sep;23(3):195-8

    7. 386. Carlsen CG, Soerensen TH, Eriksen EF. Prevalence of low serum estradiol levels in male osteoporosis. Osteoporos Int. 2000;11(8):697-701