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Messages - Dr Justin Saya, MD

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1
This same question was posed directly to me/Defy onExcelMale, so copying response below:

Thread : https://www.excelmale.com/community/threads/dr-saya-ais-estradiol-management.17517/

Any number of reasons that can be gleaned from the clinical experience (and pattern recognition) of our team practitioners treating over 20,000 men in the past 5 years that leads to a valid clinical determination that E2 is going to (or already is) creating issues. This relates to the provider’s intuition (as noted before) about balance (balance/symptoms as noted). This very detail is an extension of the fact that we treat EVERY case individually and do not have a blanket policy for inclusion OR exclusion of an AI based solely on numbers.

I train practitioners to call upon their experience (vast clinical experience as noted above) and evaluate factors such as: baseline E2 levels, E2:T balance, body fat percentage, baseline E2 symptoms (even subtle), baseline psychological symptoms or psychological diagnoses (through experience can be more sensitive to E2 in many cases), alcohol consumption (increases aromatase activity), past clinical history (? history of gynecomastia, history of presumed E2 symptoms), etc, etc. This is partly where the art/intuition of experience meets the objective and subjective findings during consultation.

There are also occasionally practical considerations by the provider and/or patient. If there is valid suspicion or reason to believe an AI is necessary (again we’re talking micro-doses especially if prescribed upon initial consultation...0.125mg commonly...MICRO), a patient (or provider) may express or consider inconvenience and cost of waiting for next labs, paying for next labs, paying for next consultation, etc and may discuss with patient putting an RX on the chart, but advising the patient of the specific symptoms that would trigger the patient to begin taking it. In this sense it would be a “just in case” convenience for the patient and cost/time-saving measure as we always try to remain sensitive to patient costs, budget, etc.

2
Devastating to say the least. I am at a loss for words and still in shock since receiving the sad news.

Dr Crisler was a friend, a colleague, a team member for Defy in the past, and a “patient” under my care for his personal hormone treatment. He was a great man, great physician, and a true visionary. I’ll always cherish the knowledge and wisdom we shared. Such a tragedy.

3
I’ve had private discussions with many of the physicians involved in this debate and suffice to say that there are valid points on both sides, but there is NOT a clear and correct answer based on current knowledge and data.

For what it’s worth, I know from my past discussions with Curt (PeakT) that he did not agree with Rouzier’s views and was rather concerned with possible consequences of high estradiol long term.
Can someone tell me who this "Curt" is?

Certainly! You’re benefiting from his creation right now. Curt Moyer aka “PeakT” the founder of this vast wealth of knowledge known as peaktestosterone.com

One of the finest men one could ever know. Read the first sticky thread for the forum to get better acquainted with his legacy and lasting impact.

4
Yes your estrogen has been crashed (to put it lightly) as is completely expected with an arimidex dosage of 1mg daily. You need to cut it back significantly (or discontinue) and find a new provider.

5
... suffice to say that there are valid points on both sides, but there is NOT a clear and correct answer based on current knowledge and data.
...

Thanks for weighing in, Dr. Saya. Setting aside the issue of long-term safety, what level of confidence do you have in the proposition that higher estradiol does have a detrimental effect on libido and/or sexual function in some men on TRT? There are plenty of anecdotal reports, but these aren't strong evidence for rebutting the laissez-faire approach to estradiol management. And on the flip side, there was one study finding that estradiol over 50 pg/mL was associated with better libido in men on TRT.

With emphasis above being mine, 100% confidence with “some men” being the operative term. It is also true that “some men” do better from a sexual standpoint with somewhat higher estradiol levels. The key is working through the noise to determine which of these applies for any given individual.

6
I’ve had private discussions with many of the physicians involved in this debate and suffice to say that there are valid points on both sides, but there is NOT a clear and correct answer based on current knowledge and data.

For what it’s worth, I know from my past discussions with Curt (PeakT) that he did not agree with Rouzier’s views and was rather concerned with possible consequences of high estradiol long term.

7
this is worth the time to watch

https://www.youtube.com/watch?v=ynHXydSGRR0&t=1137s
Good video.  Thanks for posting it.  It's comforting to know that a HCT > 50  (or whatever the number is) is nothing to worry about.  But if my HCT gets above 50, I'm going in to the red cross to dump some blood. Not taking any chances w/ that.

Did this  video change your opinion?

Im trying it now, I've done a lot which in the second and third order effects I hope will lessen or alleviate this need to donate; HCT. Thru Cyp dose reductions, well controlled Estrogen, I'm hoping I get there or can get to 1-2 donations per year. Im at a point I think my BP has been up but it's also been 5 months since I last donated.

BP (and the resultant stress on the vascular system) is what folks really need to watch (and be concerned with longterm) with high(er) hematocrit levels. Not the misrepresentation of blood clotting, misnomer of polycythemia vera, or countless other distractors that folks (practitioners and lay folks) debate somewhat meaninglessly. Is it pure coincidence that males have (as general comparison to females): almost invariably higher hematocrit levels...higher blood pressure measurements...higher incidence of cardiovascular events...

There’s a lot more to it, but food for thought nonetheless.

8
... But subjectively I felt [DHEA supplementation] may have been beneficial, perhaps reducing anxiety.

As it did for our dearly missed PeakT when I had him begin supplementation.

Because PeakT also had this result I've been emboldened to share the anecdote. I see there is an animal study that's also suggestive: Dehydroepiandrosterone is an anxiolytic in mice on the plus maze.

In the spirit of the Dos Equis guy, we don’t always see subjective results with DHEA supplementation, but when we do it is often less anxiety and better sleep (when taken prior to bedtime) that we see.

9
There are studies showing DHEA supplementation does not affect estradiol in normal—not on TRT—individuals. This leaves open the possibility that something different happens when the HPTA is shut down, but so far I haven't seen any hard evidence in support of this hypothesis.

I started supplementing DHEA just before going on TRT and lack lab tests that would isolate its effects. But subjectively I felt it may have been beneficial, perhaps reducing anxiety.

As it did for our dearly missed PeakT when I had him begin supplementation.

10
Testosterone, Hormones and General Men's Health / Re: lab info
« on: November 05, 2018, 08:18:25 pm »
Primary hypogonadism almost always has LH near or above top-of-range; the body is screaming for more testosterone, but the testicles can't answer.

That's why my doctor doesn't get what's going on and calls what I have primary idiopathic central hypogonadism.  My body is not changing its FSH and LH at all to compensate.  It's like it doesn't give a rat's behind about it so-to-speak.  :(

That can be from the elevated prolactin.

11
... See pasted portion below of one of my old posts to illustrate this point. ...

Here's the original thread: http://www.peaktestosterone.com/forum/index.php?topic=12006.0

There's one correction: the value for 30 nmol/L SHBG is about 285,000 ng/dL. It's a very heavy molecule compared to the hormones.

Thanks Cat. Certainly large in weight comparison as a peptide vs hormones and a good illustration of the difference between molar and weight concentrations.

12
I ran across a link the other day about 10 myths of T replacement for women.

What most people do not understand is that the highest hormone by volume of a woman is testosterone!  It is as much as 3 to 10 TIMES the volume as estrogen!

Granted the level of a womans T is 1/10th that of a man.

However the fact that testosterone is such a hogh level in a woman compared to estrogen should twll you two things!

1) how extremely important testosterone is for a woman
And
2) how extremely powerful estrogen is! 

Almost  every single issue and thing we commonly recognize as “old lady” is the result of the loss of testosterone. Principally osteoporosis and frailty, resulting in falls and broken hips and high mortality associated with pelvis breaks. Flabby tricepts, muscle loss, belly fat.

Osteoporosis is principally a female problem since they have so mich less Testosterone, so when they lose what mittle they have (compared to men) they immediately start losing the ability to build bone.

There are plenty of studies that prove women who are pre-osteo or even in full nlown osteo, once rhey get proper levels of testosterone and hormones rhey build bone. Some after a couple of years have so reversed the situation and built enough bone that they no longer are classified as having, or being at risk for osteo.

Again read the book “The secret Female Hormone” by Dr Kathy Maupin and Brett Newcomb.

All cause mortality is also reduced by women (and men) on hormone replacement. Life expectancy may not be significantly longer, yet the people who receive hormone replacement, have a MUCH healthier quality of mife, are able to love longer independently etc. in large lart due to muscle tone and strength allowing them to be able bodied for much later in life without needing walkers and canes etc.

Very astute observation! See pasted portion below of one of my old posts to illustrate this point. For example, a female with a relatively low testosterone level of 15ng/dL is equivalent to an estradiol of 150 pg/mL. Equally as interesting is how the concentration of DHEA dwarfs most other hormones in the body.

As simple food for thought I'm listing common levels/concentrations for various hormones in the male body. Further, to facilitate direct comparison, I am adjusting the units of measurement to units that we are all familiar in dealing with - ng/dL - the typical units of measurement for total testosterone concentrations. It's interesting to note the relative concentrations (look at DHEA!), but also the biological potency of some of the lower concentration hormones. Eat away and exercise those minds!

Total Testosterone - 1000 ng/dL = 1000 ng/dL

Estradiol, sensitive - 30 pg/mL = 3 ng/dL

DHEA - 350 ug/dL = 350,000 ng/dL

SHBG - 30 nmol/L = 865 ng/dL

Progesterone - 0.3 ng/mL = 30 ng/dL

DHT - 50 ng/dL = 50 ng/dL

Pregnenolone - 60 ng/dL = 60 ng/dL

AM Cortisol (serum) - 15 ug/dL = 15,000 ng/dL

Free T3 - 3.5 pg/mL = 0.35 ng/dL

Free T4 - 1.00 ng/dL = 1 ng/dL

Prolactin - 10ng/mL = 1000ng/dL

13


Some intital data:  Female, age 48 (in January she will be 49), perimenopause. Not physically active and is 5-4 and of 200 lbs.  Total T of 53 (2-45) and serum Free T of 4.3 (0.2-5)



So you wife hasn't quite hit menopause? She probably still has her ovaries and uterus with no surgeries at this point? Reason I ask is my wife had a hysterectomy with ovary removal and her libido tanked after that. She also experienced many of the symptoms your wife did with weight gain, high glucose etc. I think she could really benefit from hormone therapy if for no other reason than to help her lose weight and be healthier.

Exactly.

14
Scar tissue is a total myth in TRT..

It may not be common, but it's not a myth.

Quote
Scar formation. The significance of the necrosis may be negligible when few injections are given, but if multiple injections are given, especially in the same area over a protracted period of time, the areas of necrosis may become quite large and result in large areas of fibrosis of the tissues. This may be manifested by hard nodules felt deep in the tissues and even sunken areas of scar tissue seen on the surface of the skin. Dystrophic calcification of the scar tissue can occur with time resulting in even more painful areas. This is shown in Case 3 of this article. Once this occurs, operative excision of the area is the only therapy. The muscle fibrosis from IM injections is a significant problem for veterinarians as well. The fibrotic scar that occurs in cattle following IM injection of medications may result in meat that is not suitable for the consumer and makes the remainder of the meat tough.[23] The losses to the meat producers runs into the millions of dollars annually.[23] It is apparent that the damage from IM injections is not just suffered by man.
https://www.woundsresearch.com/article/2045

Anecdotal reports: https://www.steroidology.com/forum/anabolic-steroid-forum/650309-scar-tissue-im-injections.html

Most important point above “ if multiple injections are given, especially in the same area over a protracted period of time” —- rotate sites.

15
Quote
Plasma [total estradiol] was measured by a sensitive direct radioimmunoassay (RIA) with an Orion Diagnostica device (Spectria, Espoo, Finland).

It all boils down to the cross-reactivity of this testing method. If they are measuring C-reactive protein along with estradiol then the conclusions are wrong. It's a distinct possibility, as there are other studies based on mass spectrometry testing that do not find problems at higher levels of estradiol.

Very astute observation. High CRP is correlated with higher CV risk and also skews the standard estradiol assay upwards.

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