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.