Restoring natural balance with maximum results for men and women
Dr. John Crisler 517-485-4424 PatientCare@AllThingsMale.com
The Power of Estrogen
by Dr. John Crisler, July 2017
Let’s start slow, to build some basics, then ratchet things up.
Even though the sex hormone estrogen is considered “female”, all humans have it; the same way both men and women have the “male sex hormone” testosterone. Actually, estrogen is a group of about 40 known hormones. Testosterone, on the other hand, is a specific molecule. Therefore (for hormone trivia buffs) the opposite of estrogen is not testosterone—it is “androgen”.
We’ll take the opportunity here to share that testosterone causes libido (sex drive) in both sexes, but women have only about 1/10th as much as men. However, it has been shown they get “more bang for the buck” (LOL) per molecule of testosterone than men.
Estrogen is not bad for men. In fact, it is absolutely vital to men’s health. But it can be neither too high nor too low. Additionally, health and happiness is optimized when the proper balance is reached between its various forms. This is where you need a physician who really understands these things.
Sometimes I even use a Rhein Consulting Laboratories 24 hour urine panel (the Gold Standard) to test 7 different estrogens, and check out/manipulate their pathways.
This might be a good time to state there is absolutely no doubt whatsoever we must monitor—and treat, when necessary—estrogen in men. If your doctor disagrees….find another doctor. Also, make sure he/she knows the right test(s) to run. More on that later.
Next we must point out estrogen is made from testosterone. The rate varies; things like stress, alcohol, caffeine, bad diet, and many others increase this conversion. Often we use a medication of the class Aromatase Inhibitor, to inhibit this conversion. Aromatase is the enzyme that converts T into E. There are several. I prefer one called Arimidex (generic: Anastrozole), a pill, as it is a “competitive inhibitor” (AI). Without getting too technical, that basically makes it gentler on the body, particularly for the brain (which needs the right amount of estrogen so much, it makes its own).
Far too many men are being started on large TRT doses (i.e. 200mg per week of testosterone cypionate) and automatically also started on an AI—before it is proven the patient even needs the estrogen control. That is usually because they just want to sell you more drugs, and make more money. And the 200mg per week is about double what the initial dose of testosterone usually should be; everyone has their own sweet spot, and they’ve probably started out by blowing right by yours. With hormones, more is definitely not automatically better. Better to start low, and go slow. A recurring theme: it’s all about balance.
Elevated estrogen can manifest itself as water weight gain, “nipple issues”, excessive moodiness, depression, lack of libido, and feeling bloated. Any combination of these symptoms. But the important thing to note here is I do not treat elevated estrogen—no matter what the labs say—unless the patient complains of any of these symptoms.
That is because there are huge issues with laboratory testing of hormones, and that topic is a large part of my “Quantum Interventional Endocrinology” lecture. Then there are the (varying) effects of Sex Hormone Binding Globulin (SHBG). These subjects are far beyond the scope of this report; but know I am taking it all into consideration, at all times, while evaluating patients.
On the subject of laboratory testing, many years ago I realized the standard assay for Estradiol, known as “E2” (the major player in estrogen evaluation, so it’s the first one we test), by a laboratory technique called immunoassay, is not valid for adult males. That means we can draw NO conclusions from its result whatsoever. NONE. Instead, estrogen in males MUST be tested by the LC/MS technology. Here is a list of the major labs, and the correct E2 test to order:
Quest Diagnostics “Ultrasensitive Estradiol” # 30289
LabCorp “Sensitive Estradiol” #140244
Mayo Clinic “Enhanced Estradiol” #EEST
ARUP “Estradiol TMS” #93247
IF you run the incorrect standard estradiol assay on an adult male patient, each of these labs will include a paragraph straightening you out. For the Quest Diagnostics laboratory, that paragraph appears because of my work with them, many years ago. I had run both standard and LC/MS assays on many patients: their clinical response matched the better testing methodology. I was widely attacked for that position at the time. The science is now well-accepted.
The reason the standard E2 assay (made for women) is not valid for adult males is because the concentration of estrogen is just too low in men for this more crude methodology to be reliable. Also, numerous things like CRP, progesterone, and even a form of AI falsely elevate its result. That means the doctor who relies on it—and treats solely by the numbers on a piece of paper, instead of how the patient actually feels—may mistakenly add in an AI. Since estrogen would then be lowered in a patient whose estrogen was not high to begin with, that tanks the estrogen level. Low estrogen is ALWAYS bad for you: bones are demineralized, the Lipid Profile is blown, joints begin to ache (as they dry out), headaches, and loss of libido. The emotional component of a man’s sexual being comes from estrogen.
Even when estrogen is elevated, we don’t always have to use an AI to lower it. Lowering the dose of testosterone, when possible, always would do that. Often simply using the same amount of testosterone weekly dose, but split into two (or more—for those willing to fiddle around with it more) shots per week. This lowers the testosterone spike from a single weekly injection, and that can lower estrogen on its own. It also decreases urinary excretion of testosterone, so more is kept within the body. That actually works, de facto, to serve as a weekly dosage increase!
Dosing of the Anastrozole can take some strategizing. Sometimes the patient will only suffer elevated estrogen symptoms right after his shot (when T levels are rising, so is conversion to E). A single dose of AI at shot time can take care of this. But what if he experiences estrogen side effects later in the week? Now T is lowering, but the AI only works for a couple days. Do you give more AI, but at a smaller dose? It gets complicated. Here switching to twice per week shots, and taking your AI pill at the same time, can help; both times, as T goes up, the AI is there to inhibit conversion to E.
Those twice per week shots are a lot easier to face now that we are doing them subcutaneously, just below the skin, with a tiny needle. More on that in a future installment. I also have a video out on it, if you want to look it up.
“Usual” dosing of Anastrozole goes from 0.25mg to 0.5mg at a time. IF you are using a T cream instead of shots, you will need the AI at no greater interval than every 2nd or 3rd day, with the steady daily doses of T. I’ve got guys who need to take their AI every day. I’ve seen guys who “hyper-respond” to AI’s (and other substances), so only need a very tiny dose; conversely, I’ve also dealt with 2mg per day of Anastrozole, in very rare cases. We won’t know until we get there.
This is more advanced stuff, but estrogen becomes a problem because (1) too much is being produced, (2) there is not enough testosterone to balance it (when the grass burns over, the weeds take off), (3) the amount is okay, but there are imbalances in the different types of estrogens, (4) it is not being broken down, metabolized and excreted from the body. Then there is (5), the usual situation: a combination of any, or all, of the first four.
To help with (4), you can add an extract from cruciferous vegetables called DIM. Try 200mg per day. Doing so will also lessen the chance of both men and women getting cancer, by the way. It shifts from bad estrogens toward more good estrogens. More below.
This is all shown on the photo attached to this article. There is a constant interplay between E2 and E1. It’s a double-arrowed pathway. You’ve got to shift from E2 more toward E1, as E2 (like 4-OHE, and 16-a-OHE) is genotoxic, mutagenic, and procarcinogenic. Many factors, such as Vitamin D status, influence this enzymatic pathway. Once we get it moved over to more E1, we can break it down, and eliminate it. That is where the DIM comes in.
E2 also makes the prostate grow. We call that Benign Prostatic Hyperplasia (BPH). The answer then is NOT a 5-alpha reductase drug, like Proscar (which can bring SERIOUS, PERMANENT debilitating negative side effects). I’ve been shrinking prostate glands for many years, merely by manipulating estrogen. In fact, I can tell a lot about a man’s estrogenic history simply by feeling his prostate (the Digital Rectal Exam, or DRE).
DIM is an Over-the-Counter (OTC) supplement. So is Calcium d-Glucarate. It helps the body excrete estrogen. I’ve had numerous patients tell me its addition made their libido go through the roof. I take 500mg, twice per day.
As with all hormones, the over-riding concept is that health and happiness are optimized by the balance of hormones. Each one has its own sweet spot. No one who is truly expert is shooting for a particular range—it’s that patient specific—and hormone ratios (often relied on) are merely for describing clinical symptoms, not as treatment goals.
Once you get into the hands of a physician who is truly expert in Interventional Endocrinology, you will find “there REALLY is a difference”!