Estrogen and Aromatase Inhibitors – an introduction to their clinical use in TRT

Part of an optimal testosterone regimen is making sure your Estrogen levels are dialed in–not too high, and not too low.

Testosterone is converted into estrogen in our bodies by Aromatase. This happens to a greater extent in fat cells, so overweight people often make more estrogen, especially when supplementing with exogenous testosterone.

Excess estrogen can leave to some uncomfortable symtpoms such as: Gynecomastia (breast enlargement), Reduced sex drive, infertility, erectile dysfunction, or poor mood/depression.

In some patients with excess estrogen, certain medications can be given to prevent the conversation of testosterone to estrogen.

Unfortunately, LOW estrogen also gives many of the same symptoms as HIGH estrogen. This leads to a risky situation wherein a person may think the their symptoms are from high estrogen rather than low estrogen, causing them to increase the dose of their estrogen-destroying medications rather than decreasing it, and thereby making the problem worse by crashing their estrogen level into the ground.

Fortunately, this problem is fixable. Your observant and attentive doctor (you have one, right?) should be able to tell from plummeting estrogen levels that your problem is not one of estrogen excess but of deficiency. After stopping the AI you should see an expected increase any your estrogen. After this fiasco you should work with your doctor to precisely adjust your AI so that your estrogen is in balance.

While adjusting your aromatase levels can help with this, simply changing the dose or the dosing schedule can often resolve these kindds of problems. Spacing your injections more frequently reduces the peaks and trough associated with infrequent dosing–and the peaks are when aromatase activity is highest, causing higher estrogen. Reducing testosterone dose will also reduce conversion to estrogen. While this should be done judiciously, a small decrease in dose may eliminate the need for an aromatase inhibit. Finally, losing some weight can help eliminate the need of an aromatase inhibitor altogether.

If you are on testosterone replacement therapy and you don’t know whether your estrogen levels are optimized, or if you are having trouble controlling your estrogen, I can help!