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Author Topic: Starting a guy out on an AI from day 1?  (Read 381 times)

Roguejim

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Starting a guy out on an AI from day 1?
« on: January 22, 2019, 08:18:07 pm »
What is the rationale for starting a guy out on an AI on the first day of TRT?  In other words, in the absence of symptoms?  If it's always about symptom resolution, what symptoms would be manifest before a guy has even begun his TRT?  Numerous patients report being started on an AI right out of the gate.  Now, unless a patient insists on having the AI on hand from the start, is there any other reason why a clinic would start a guy off with an AI, when no symptoms are yet present?

Cataceous

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Re: Starting a guy out on an AI from day 1?
« Reply #1 on: January 22, 2019, 08:55:13 pm »
I view it as borderline malpractice. On day one you have no idea what kind of aromatase activity the guy will have. A lot of guys on TRT end up with estradiol in the 20-30 pg/mL range without an AI. It would be inexcusable to put such men on an AI without testing.

The gray area comes when estradiol is high with no symptoms. Though the current trend is to not treat, I wouldn't condemn a doctor who had concerns about long-term supraphysiological levels of estradiol, as long as he was cautious with the AI dosing, i.e. low and slow.
I am not a medical doctor; any suggestions are meant to be discussed with your doctor.
Age: 57, Ht: 5'10", Wt: 158 lbs
Protocol: 18 mg T enanthate subQ qod, 250 IU hCG subQ qod, 70 mcg anastrozole qod, 6.25 mg DHEA orally bid
7-12/2018 test results: TT: 800 ng/dL, E2: 31 pg/mL LC/MS-MS, DHEA-S: 264 ug/dL (49-344)—SHBG ~30 nmol/L

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Re: Starting a guy out on an AI from day 1?
« Reply #1 on: January 22, 2019, 08:55:13 pm »


Osprey

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Re: Starting a guy out on an AI from day 1?
« Reply #2 on: January 22, 2019, 09:11:19 pm »

I suspect it would be based on the doctor's experience with the typical patient that is using the amount of testosterone prescribed. A highly skilled doctor who has treated thousands of patients will have rules of thumb he/she goes buy to get the best results in the shortest amount of time.

Dr Justin Saya, MD

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Re: Starting a guy out on an AI from day 1?
« Reply #3 on: January 22, 2019, 09:22:39 pm »
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.
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http://www.defymedical.com

NOTE: Comments on this forum are NOT medical advice and are no substitute for individualized patient care. Comments on this forum do not constitute or establish a physician-patient relationship. Please consult your personal physician prior to initiating or changing ANY treatment regimen.

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Re: Starting a guy out on an AI from day 1?
« Reply #3 on: January 22, 2019, 09:22:39 pm »


PakMan

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Re: Starting a guy out on an AI from day 1?
« Reply #4 on: January 22, 2019, 10:28:39 pm »
What is the rationale for starting a guy out on an AI on the first day of TRT?  In other words, in the absence of symptoms?  If it's always about symptom resolution, what symptoms would be manifest before a guy has even begun his TRT?  Numerous patients report being started on an AI right out of the gate.  Now, unless a patient insists on having the AI on hand from the start, is there any other reason why a clinic would start a guy off with an AI, when no symptoms are yet present?

It might be a better idea to just start with low dose AI (without TRT) to raise T. If that worked it would be much better than TRT.
Age: 46, HT: 5' 7'', WT: 75 kg

Jan 16 to Oct 16 - Test Enanthate (35mg 2x/week)
Oct 16 to Feb 17 - HCG (500iu 2x/Week)
Feb 17 - Test Propionate (25mg only 2 injections 4 days apart)
Aug 2017 onwards (Astaxanthin + other oils, supplements)
Dec 2017 Low dose TRT (25 mg twice a week)
Nothing from Jan 1, 2019

21/08/2017 8:10 PM
Total T = 271 ng/dl  (Range 160 - 726)
LH = 5.15 mIU/ml  (Range 0.8 - 7.6)

Cataceous

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Re: Starting a guy out on an AI from day 1?
« Reply #5 on: January 23, 2019, 03:49:48 am »
...
It might be a better idea to just start with low dose AI (without TRT) to raise T. If that worked it would be much better than TRT.

AI monotherapy seems to be exceedingly rare. I can't recall anyone on the forum describing success with this treatment. Arguably this could be because nobody gets the dosing right. But it could also mean it's too difficult to attain the right balance of testosterone and estradiol.
I am not a medical doctor; any suggestions are meant to be discussed with your doctor.
Age: 57, Ht: 5'10", Wt: 158 lbs
Protocol: 18 mg T enanthate subQ qod, 250 IU hCG subQ qod, 70 mcg anastrozole qod, 6.25 mg DHEA orally bid
7-12/2018 test results: TT: 800 ng/dL, E2: 31 pg/mL LC/MS-MS, DHEA-S: 264 ug/dL (49-344)—SHBG ~30 nmol/L

HRT Guru

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Re: Starting a guy out on an AI from day 1?
« Reply #6 on: January 23, 2019, 08:19:32 am »
There are those guys that expect an AI be prescribed as it's included in the what most pill mills could call the trifecta of TRT...Test/HCG/AI. Some will balk at a provider that doesn't, provide, that third leg. If you will. You can see some that do prescribe the AI but in a very low .125mg dose but it's still a basic inclusion even when the guy is told about symptoms and not to take it everyday just because.

DanMac

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Re: Starting a guy out on an AI from day 1?
« Reply #7 on: January 23, 2019, 08:49:43 am »
Okay lets say for arguments sake, the man had very low Estrogen of below 20 say 14 pg/ml before any T.R.T then it would take a good 2-3 months which is about 8-12 weeks for it to finally increase on a twice weekly protocol that is. Only after 12 Weeks proper bloodwork should be evaluated and then given A.I option or not.
New protocol,  75mg twice weekly E5D of Sustanon in Deltoids.  27G sized needle.

30+ year old Male

5 foot 9 1/2 tall. current weight 157  pounds, Heaviest Weight 185 Pounds,  BF % unchecked.

R2D2

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Re: Starting a guy out on an AI from day 1?
« Reply #8 on: January 24, 2019, 07:18:29 pm »
I tried to shortcut to a solution by experimenting with T dose and AI. End result - you won't know if E is low because of the AI or not enough T. Or the extent to which either is contributing.

I've admittedly gone in circles a little. 1 year later - I've started from scratch again. Presently on pure TRT and no AI or HCG. Further, I've reduced the dose of the TRT to a point I'm not experiencing subjective E symptoms. Will be getting labs in a couple of weeks and will then go from there.

So the question is - would you like to guess your way through it (and potentially burn time as I have done) or spend 6 months knowing exactly what effect each component of TRT is having? It's annoying going through the process - especially when you have other things going on which require 'peak productivity/performance', but it really is better in the long run to go 'low and slow'.

 

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Re: Starting a guy out on an AI from day 1?
« Reply #8 on: January 24, 2019, 07:18:29 pm »