Quiz 7: Attention to Estrogen Levels in Males

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Question 1 of 6

1. Question
General considerations concerning estrogens does NOT include:
- Elevated estriol levels are a significant clue to E/T narrowing over time
- Genetic increase in aromatase has been described – younger individuals are affected and demonstrate gynecomastia, sexuality decreases in libido and erectile dysfunction
- Acquired forms of increased E2 are seen in midlife obesity – syndrome X is classic E2 dominance picture
- There is frequently a lack of normal response to T replacement
- There are no optimal ratios of E/T to achieve – clinical response is the bottom line
- Check SHBG – it may elevate from excessive estrogen
- Total estrogens are not always helpful since E1 (weak estrogen) may be the predominant estrogen from adrenal source: test E2
- Low estrogens can be a problem, as can excessive estrogens
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Question 2 of 6

2. Question
Alternative therapies do NOT typically include:
- Zinc 30mg 2-3 X daily for 1-2 months, then decrease to 30 mg daily – it may boost testosterone
- Calcium-D-glucarate 500 mg 1-2 X daily – increases E2 liver metabolism
- A combination of B12, B6, folic acid and vitamin D
- Iodine – Iodoral 12.5mg daily or Lugol’s solution 1-2 drops daily in juice can assist estrogen metabolism
- Topical chrysin 50 mg/gm applied to the scrotal–peri-anal area in small amounts daily
- Trans-resveratrol 250 mg daily and grape seed extract 50 mg – 2-4 daily (is an aromatase an PDE-5 inhibitor)
- Avoid “excess” DHEA and pregnenolone – metabolized to progesterone and estrogens (E1—> E2)
- Avoid treating with progesterone – it can diminish libido
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Question 3 of 6

3. Question
E2:T over lifetime (choose correct answer):
- Increases over a lifetime leading to higher than optimal estrogen effects
- Decreases leading to higher than optimal testosterone effects
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Question 4 of 6

4. Question
What statement concerning aromatase inhibitors is NOT true?
- Aromatase is an enzyme that facilitates the conversion of estrogen to testosterone
- The use of aromatase inhibitors to increase testosterone levels have not been very effective as treatment alone in normal aging men
- Some individuals do well initially then fade over time in benefits – give drug holidays in cycles
- Aromatase inhibitors are most successful in altering excess estrogen during replacement with higher doses of T or in severe obesity cases
- There are three inhibitors in the US: (1) Arimidex 1 mg non-steroidal, compounded in 0.1 or 0.2 mg 2 or 3 times per weak – do have loss of libido so give holiday q 2–3 months; (2) Femara 2.5 mg non-steroidal, potent, use in obese; and (3) Aromasin 25 mg – steroidal
- All these aromatase inhibitors are long-acting, with 3–5 days of action
- They can have the side effect of suppressing thyroid function and lead to significant fatigue, constipation, and more
- Non-steroidals frequently wear off or do have loss of libido so give holiday q 2–3 months
- Aromasin is effective in small doses – 1–5 mg in mini-troches
- Aromasin has androgen receptor activation effects as well as estrogen blocking effects
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Question 5 of 6

5. Question
For obese and genetically high-estrogen men, all are true except:
- Femara is longer acting and higher potency in these cases – start with 1/2 tablet twice weekly and reduce to 1/2 tablet weekly after good clinical response – can be compounded lower if needed
- If lower doses are all that is needed, then Arimidex works very well in small doses 0.1 – 0.2 mg troches 2-3x weekly
- They tend to be hypothyroid and the aromatase inhibitors can interfere further with thyroid function and dosage regulation
- Exemestane can also be used in very small doses – 1–5 mg 2–3x weekly
- Give a drug holiday after 2–3 months – check testosterone and E2 every 3-4 weeks until stable
- Keep E2 >20 pg/ml to avoid bone loss, CVD risk, low libido
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Question 6 of 6

6. Question
With syndrome X and the prescribing of higher doses of testosterone, all are true except:
- Syndrome X is the classic estrogen syndrome where aromatase inhibitors are sometimes useful
- Higher doses of testosterone (1–2x normal) needed to correct the insulin resistance requires aromatase inhibitors to balance out the estrogen increases
- Give aromatase inhibitor on days of injections of T or CG – anti-aromatase coincides with peak estrogen conversion from injection on day 2–3
- Watch estrogen ratio so as to not increase prostate tissue
- Watch thyroid levels and generously replenish T4 + T3 to optimal levels if needed to balance aromatase inhibitors
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