I suppose the first question is, do you need to ‘control’ oestrogen on TRT?
The answer? Not normally, but you do need to be aware of the symptoms of oestrogen excess as your TRT protocol will need adjustment.
Symptoms of oestrogen excess include:-
- Loss of libido / erectile dysfunction
- Breast tissue swelling / nipple tenderness
- Water retention / weight gain
- Fatigue / ‘brain fog’
- Anxiousness / low mood
- Poor sleep
You control oestrogen by titrating your TRT protocol according to your symptoms and quantitive levels. These are often pre-determined by your genetics and physiology, but can be influenced by your lifestyle, nutrition, exercise and medications. The focus of this blog is your TRT protocol.
Here at The Men’s Health Clinic, our gold standard TRT protocol is Testosterone Enanthate and Human Chorionic Gonadotrophin (HCG). Less than 5% of my guys are on an aromatase inhibitor. Why? Because 95% of them don’t need or want one. Are they happy? Have a read of the testimonials page on our website.
Why would you add an artificial chemical into your body when you don’t need one? Why would you take something that has no long-term efficacy or safety data supporting its use(1)? Why potentially crash your oestrogen because of poor prescribing and Broscience? Why not simply amend your protocol to have the correct levels for your genetics and physiology?
It’s important to understand the importance of ratios in determining whether you need to adjust your oestrogen level. An oestradiol test is essentially useless without a testosterone level alongside it. I would argue that for a complete picture, you need to test your sex-hormone binding globulin (SHBG) and prolactin also.
Typically, there is a linear increase in testosterone and oestradiol with an increase in dose of a single-acting ester such as Testosterone Enanthate(2). That means, if you increase your dose, your resultant levels will predictably increase as well. Therefore, simple dose adjustment will often rectify any symptoms of oestrogen excess.
It’s also important to recognise that the body likes stability. Stable levels are achieved after approximately 50 days, since the half-life of testosterone enanthate is approximately 10 days and it takes 5 half-lives to achieve relative stability. To appreciate the qualitative changes of TRT, you must be aware that there is an adjustment period. The body seems to tolerate consistent high and low levels far better than erratic peaks and troughs. We’ve found some guys with anxiety are very sensitive to the peaks and troughs that are inevitable on initiation of TRT, only to enjoy the relative stability a few weeks later.
The body has an incredible ability to adapt, but if you artificially manipulate your level’s, there are limited compensatory mechanisms to allow for this. In guys with diagnosed hypogonadism, even a moderate dose of 62.5mg testosterone enanthate every 3.5 days can be a shock to the system. There can be a psychological and/or physiological reaction to the spike from the exogenous testosterone. Normally, there is no cause for concern and with the proper counselling and follow-up, this can easily be managed. There’s a definite rationale for more frequent doses to minimise any spikes, yet there is the need to weigh up the pros of improved stability compared to the cons of more frequent injections.
People often have a knee-jerk reaction to oestrogenic symptoms.
“The fear of ‘bitch tits’ is strong in those unfamiliar in the ways of the TRT doctor” – Yoda (TRT Wars).
A low sex-hormone binding globulin (SHGB) level essentially means that the exogenous testosterone you administer is quickly metabolised. Your SHBG level should always be taken into consideration on deciding your starting TRT protocol. To achieve stable levels in-between injections, guys would need to inject more frequently than a standard starting protocol. If you measure your trough level and the injection interval is too long, your testosterone level will seem lower than expected and your oestrogen disproportionately higher. People are mistakenly prescribed aromatase inhibitors to combat the high oestrogen levels. However, what they really need is to increase their injection frequency to improve stability and reduce the unrecognised spike that is causing elevated oestrogen.
Prolactin is another hormone that should be taken into consideration when addressing oestrogenic side effects and reviewing oestradiol levels in the blood. There is a correlation between high oestrogen and high prolactin. The symptoms of high prolactin can mimic some oestrogenic symptoms without an elevated oestrogen(3)(4). The beauty of a short-acting ester is that you don’t need to overreact to abnormal levels. Our healthcare system is focused on curative rather than preventative medicine. Think logically and problem solve, don’t unnecessarily add another variable into the equation, such as an aromatase inhibitor, without exploring causation.
Human Chorionic Gonadotrophin (HCG) is an essential part of any TRT protocol. For more information, have a read of ‘The Benefits of using HCG with TRT’. It causes an increase in intratesticular production of testosterone and a subsequent rise in oestradiol. In my experience, this is the most common cause of elevated oestrogen. The beauty of HCG is that it has a very short half-life (approx 2 days), meaning manipulation of either dose and/or injection frequency can quickly have a positive outcome on both symptoms and quantitive levels.
It’s true some guys are prone to high oestrogen levels, some have a genetic predisposition to aromatisation. I’m sure there is a link to obesity(7), high alcohol consumption(6) and liver dysfunction(8). The use of an aromatase inhibitor is sometimes necessary. However, In my opinion, it is often prescribed to justify supraphysiological levels by the Broscience / ‘I really should go back to medical school’ / ‘I should actually go to medical school before offering medical advice’ brigade. It’s pure laziness and bad science to offer ‘oestrogen-control’ as part of your gold standard.
You should never make any amendments to your protocol without discussing your concerns with your prescribing TRT doctor and reviewing your blood work. A good clinician will take all of the above factors into consideration before deciding on a management plan, a great clinician will have already taken these factors into consideration before commencing you on your protocol in the first place. Why shut the gate after the horse has bolted?
As already mentioned, our gold standard treatment is testosterone enanthate and HCG. We have a standard starting protocol that we work from, which can then be adjusted according to a number of parameters. It would be remiss of me to say that it’s perfect, although I would say it’s as close as dammit to the perfect starting protocol. It provides a stable foundation that we can safely adjust in order to find you that perfect protocol. Your genetics, physiology and lifestyle all play an important part in determining how you will react to TRT, there is no one-size-fits-all. Much like we share many similarities, our differences are just as important.
The gold standard oestradiol test is done via liquid chromatography–mass spectrometry (LC-MS)(5), it is often referred to as the ‘sensitive oestradiol’ or ‘sensitive E2′ test. The issue is that it’s not readily available in the UK, or so we thought! I put Detective Hughes on the case and I am delighted to announce that our patients all now have access to the sensitive E2 test. The issue with the standard oestradiol test done by most laboratories is that the test cannot differentiate between oestradiol and CRP, which means it can over read. Does that actually matter if you are aware of the problem? If you are using the standard test, it is important to take symptoms into consideration when assessing your oestradiol level, it’s important to look at all of the other parameters discussed above. I cannot overemphasise the importance of a healthy doctor-patient relationship and the need for a holistic approach.
“Do you want to know why I insist on a face-to-face New Patient TRT Consultation? Skype is too impersonal. You can’t savour all the… little emotions. In… you see, in these moments, people show you who they really are.” – Said in the Joker voice
Here at The Men’s Health Clinic we pride ourselves in offering a personalised medical service. My patients are exactly that, MY patients. We haven’t needed to use to sensitive E2 test as of yet because we have an effective way of managing oestrogen. Keep it simple, keep it safe.
Dr Robert Stevens MBChB MRCGP Dip.FIPT