High Estrogen and Low Testosterone: How to Manage levels on TRT

While men’s testosterone naturally decreases with age, estrogen levels can increase leading to uncomfortable issues if the imbalance is not brought down to normal levels. High levels of estrogen are associated with diabetes and cancers so it’s important to control imbalances through diet, exercise, and medications. This is especially important for men on testosterone replacement therapy (TRT) since the addition of testosterone into your system can affect your body’s estrogen production as well.

What is Estrogen?

Estrogen is typically called the “female” hormone and testosterone is called the “male” hormone but both genders use both hormones to function properly. Without normal levels of testosterone and estrogen, men (and women) will feel irritable and begin to see excess weight showing up around the mid-section and chest.

There are three types of estrogen estradiol (E2), estrone (E1), and estriol (E3, produced by women during pregnancy).

For men, the dominate estrogen – estradiol – is crucial to sexual function, fertility and erection health. Estrone comes into play during the metabolization estradiol and helps the body regulate fat stores.

• Low estrogen in men can cause excess belly fat, weak bones, and low sexual desire.
• High estrogen in men can lead to enlarged breasts (gynecomastia), poor erections, depression and infertility.

For men that have a beer gut and have had the belly popping for years can develop imbalances in testosterone to estrogen ratios. Many studies show that diabetes and heavier set people have much higher estrogen and lower testosterone. These high levels of estrogen can still show up in skinny individuals, but with estradiol and estrone hanging around in fat storage, imbalances are clearly more prevalent.

Testosterone is the most significant hormone that helps develop and maintain physical, mental and sexual function, but estradiol must stay in balance with testosterone to help with mental clarity and perhaps more importantly control sex drive, the ability to have an erection, and the production of sperm.

• Close to 20% of circulating estrogens is created directly from testicular production by the conversion of cholesterol being “processed” through the Leydig Cells.
• The remaining 80% generates from conversation of testosterone into estrogen called aromatization. This chemical reaction occurs throughout a man’s life acting as a regulator keeping the testosterone to estrogen ratio in order; however, with age the entire endocrine system begins to malfunction causing a decrease in testosterone production.

During testosterone replacement therapy, the reintroduction testosterone into the circulation will naturally kick-start aromatase leading to the creation of estrogen. Aromatase is also known as the estrogen synthesizer enzyme for the body.

Reference, Reference

Estrogen and the brain

Within the central nervous systems and hypothalamus (/hīpəˈTHaləməs/) part of the brain, estradiol plays key roles in controlling appetite, resting energy usage, mood and motivation and body weight. The aromatase enzyme should be producing just enough estrogen to maintain healthy sexual performance and mental clarity, which go hand-in-hand with the goals for most men on low testosterone therapy.

The body’s fat storage (Adipose tissue) is rich in estrogens, testosterone, and other hormones. Like testosterone, estrogen helps the liver break down fat cells through lipolysis.

Estradiol help regulate fat metabolism primarily in the creation and burn off process but also help regulate how the fatty acids respond and interact to other bodily functions.

In the immune system and skeletal muscles, the body uses estrogen to break down fat cells through lipolysis then triggers then oxidation or burn away process. The hormone also helps regulate glucose levels to keep energy cells moving through the liver at a normal rate. All of these processes are driven by the liver.

What causes the testosterone and estrogen imbalance?

The most common cause for estrogen imbalance is aging. As men get older, they produce less testosterone and estrogen levels increase. Some studies have found that both testosterone and estrogen decrease in parallel or show no change at all.

But the fact of the matter is, if your testosterone levels are low at age 45 and you choose to normalize your T levels, there could be an indirect impact on estradiol production. Most men on TRT do not experience an increase in estrogen as the body is able to regulate the aromatization of testosterone to estrogen on its own. Most of the time, dosage adjustments by the provider can help aid in reducing any fluctuations.

Obesity

In men with increasing weight there is a natural increase in aromatase activity, which “eats” away testosterone converting the hormone into estradiol resulting in an imbalance.

Higher levels of estradiol plays a role in hypogonadism and obesity since the increase in estrogens within the fat tissue stops luteinizing hormone (LH) production from the pituitary gland, which in turns reduces testosterone secretion from the testicles. More fat mass negatively impact hormone production.

Certain foods and materials have foreign or xeno estrogen substances that connect to estrogen receptors causing estrogen imbalance. Most commonly ingested through food containing xenoestrogen compounds, like soy or flax, there are chemicals found in plastics and pesticides that carry xenoestrogen, like BPA (bisphenol A) is used to manufacture plastics.

Most manufacturers have stopped uses BPA in the process so risk factors have drastically reduced. It’s important to reduce or remove such chemicals and substances to avoid ingesting too many harmful xenoestrogen. It is rare for foods to cause the estrogen imbalances but it is worth highlighting. Reference

How does alcohol impact estrogen and testosterone levels?

According to researchers, “The effects of alcohol on endocrine function are multiple and complex. Several variables, including the type, length, and pattern of alcohol exposure; level of intoxication; and coexisting medical problems, such as malnutrition and liver dysfunction, must be considered when assessing the impact of alcohol on hormonal status…”

Let’s breakdown how brewski, vino, and fireball impact what’s called the hypothalamic-pituitary-adrenal axis. This axis is center point for testosterone, estrogen, and cortisol production. The axis communication between the brain and testicles where the brain asks the pituitary gland to produce testosterone.

It’s ground control while the hormones are major Tom.

Alcohol intoxication activates the axis and results in increased glucocorticoid levels to help fight off cortisol, which is naturally released when toxins enter the bloodstream. Elevated levels of stress hormones may contribute to alcohol’s “pleasurable effects.”

Throwing off this axis with chronic alcohol consumption can speed up the aging process due to the fact that the body is constantly releasing anti-cortisol hormones rather than normal amounts of testosterone and estrogen.

While moderate drinking 1 or 2 days per day may cause a slight decrease in testosterone and elevation in estradiol, researchers do not believe this to be a concern as the body can detox the lighter workload. However, five or more drinks in a two-hour period regardless if occasional or on the regular, has an impact on hormone levels due to the amount of ethanol consumed and how much work the body do in order to detox.

Ethanol, the main chemical component in alcohol, is considered toxic to men’s hormone levels.

Drinking a lot of alcohol for extended periods can reduce testosterone leading to sexual dysfunction, reduced sperm count, and infertility.

Beer hops and barley have two chemicals that can increase estrogen levels (phytoestrogen and prolactin). Some wines and bourbons may contain phytoestrogen, which is naturally produced in plants and can increase estrogen levels. Most beverages have extremely low amounts of these compounds so it should not be a factor.  While socially drinking, day drinking or a night caps seems unavoidable, practicing moderation and allowing enough days to detox between drinks is the best tool to keep estrogen levels in check. Reference, Reference

What happens if a man has too much estrogen?

Too much estrogen in men can lead to erectile dysfunction, weight gain, decrease in libido, enlargement of the breast tissue, depression, loss of energy and decrease in muscle mass. Reference

Normal Estrogen (estradiol and estrone) levels in men should be 10 and 40 pg/ml. For men over 35 years old, it is important to keep these pg/ml lower end but not below 10.

High Estrogen Symptoms in Men

• Erectile dysfunction
• Infertility (Spermatogenesis)
• Lowered sex drive
• Weight gain
• Gynecomastia

Erectile Function

An erection is a delicate dance of nerves, vessels, and actions in the hypothalamic-pituitary-adrenal axis that work together to coordinate blood flow directly to the penis. If there is a mismatch between estrogen to testosterone, at least one of these triggers will misfire causing dysfunction.

If estrogen spikes and testosterone then drops, then it is more likely to experience erectile dysfunction. High estrogen and low testosterone is associated weaker and less frequent erections.

With higher estrogen levels, physiologic steps within the smooth muscle and endothelium will impact cell-to-cell communication leading to ED.

The smooth muscle and endothelium help nitric oxide (NO) get into the penis allowing muscles to relax and blood flow continuously into the penis. NO is synthesized from the amino acid L-arginine. Reference

Production of Sperm (Spermatogenesis)

Estrogen plays a role in the production, concentration, movement, and formation of sperm. Too much estrogen in the testes can impact fertility. As we’ve learned earlier in this article, estrogen receptors and aromatase are found in the brain, testes, and penis. Estrogen regulates the cells that line protect the lining of the testicles, however it can also negatively impact the quantity and quality of sperm if the cells are overloaded with estrogen.

Many studies have shown that a normal testosterone to estrogen ratio keeps sperm healthy.

Researchers found that men with elevated estradiol showed improvements in sperm production and health once decreasing estradiol directly and normalizing the testosterone to estradiol ratios with aromatase inhibitor medication or indirectly blocking estradiol with Clomid (clomiphene citrate). Reference

Sex Drive

Normal estrogen levels affect men’s sexual arousal and drive from a psychological perspective.

The conversion of testosterone to estrogen during aromatization is partially responsible for sex drive. This chemical reaction induces specific sexual effects starting in the nervous system, including changes in mood and sexual arousal. This is another delicate dance of ratios and the effects of estradiol on sexual desire is linked to balance of testosterone levels.

Elevated estrogen in men naturally causes a decrease in testosterone, which throws off the axis causing lower libido.

In others situations, high estrogen and ratio imbalance may cause men to develop depression, along with fatigue and other negative mood changes. Estrogen helps create serotonin and beta-endorphins sometimes called the “feel good” neurotransmitters, and it plays a part in maintaining one’s verbal and spatial (3D) memory in men.

As it relates to sex drive, the happy chemical, serotonin, dances close to estrogen receptors within the brain causing a dip in desire. If you are on medications for depression, adding Low T, TRT, or ED medication is a common strategy to start feeling better in the bed room.

Weight Gain

Fat stores throughout the body are rich with estrogen and testosterone. Simply put if testosterone naturally begins to decrease with age, then men are more vulnerability to estrogen dominance or increases while on low testosterone and TRT treatment due to aromatization. High estrogen levels impact liver function as well. Normalizing testosterone to estrogen ratios will determine how the liver processes these fatty acids. This is why men with diabetes or weight problems commonly have low testosterone and elevated estrogen.

In the hypothalamic-pituitary-adrenal axis, estradiol controls appetite and energy regulation influencing mood and motivation in men. If there are high estrogen levels present, these mental imbalances could produce changes in appetite and willpower that influence overall energy balance and, consequently, body weight. High estrogen can cause negative mood swings and depression impacting a man’s desire to stay fit and healthy; therefore, stimulating weight gain and obesity.

In some cases, high estrogen may also increase your chances of thyroid dysfunction like hypothyroidism.

According to the American Cancer Society, high estrogen levels puts men at risk prostate cancer. Higher estrogen levels can cause toxic compounding damage to prostate cancer cells further mutation. Reference, Reference

Low estrogen

Now let’s look at how the body reacts to low estrogen and low testosterone.

There are several warning signs for high estradiol as well as an imbalance in testosterone to estrogen ratio.

Low estrogen due to low testosterone has a wide range of causes.

Causes of Low Estrogen in Men

• Obesity
• Malnourishment or not getting enough basic nutrients and vitamins
• Rapid weight loss
• Kidney or liver conditions
• Autoimmune conditions like Addison’s disease
• Genetic disorders like Turner syndrome or Klinefelter syndrome
• Infections of the sexual organs like syphilis and gonorrhea
• High levels of iron in the bloodstream (hemochromatosis)
• Exposure to radiation
• Having surgery on your penis or testicles
• HIV (Human immunodeficiency virus)
• Conditions that affect the pituitary gland
  • Sarcoidosis
  • Tuberculosis
  • Histiocytosis
  • Brain surgery
• Cancer growth near the pituitary gland

There are several signs of low or imbalanced estrogen as well.

• Night sweats or hot flushing (flushing around the ears or on the face) (from estradiol lowering, causing loss of water retention). Men that experience hot flashes or night sweats are no different than the sweats that women feel, it’s just a matter of why.

A hot flash is intense sensation of heat affecting the face, neck, and back. Sometimes described as a cold, clammy sweat, which leads to discomfort.

Hot flashes can occur 6 to 10 times a day and last for up to an hour. One study showed that 75% of men with prostate cancer who had surgery to remove the testes experienced hot flashes. In high risk cancer patients on androgen suppression therapy (Androgen deprivation therapy (ADT)) is used to reduce the growth of cancer cells. Androgen (testosterone) is removed from the body because prostate cancers may grow larger when exposed to androgen. Naturally, no testosterone and imbalanced estrogen levels will cause hot flashes.

• Muscle aches and pains are common in men with high and imbalanced estrogen. With the hypothalamic-pituitary-adrenal axis regulating estrogen and cortisol levels, when your cortisol levels rise, estrogen and testosterone levels decreases which can impact how men’s bodies respond to health and pain.

High levels of cortisol can then cause your muscles to tense up and become painful, IE – stress. Increased levels of cortisol also make the body more sensitive to pain leading to muscle aches and pains.

Similar to high estrogen levels and low or imbalances in the normal flow of the hypothalamic-pituitary-adrenal axis causes issues for men. Men may feel anxious, racing heart rate, irritability, and nausea.

Symptoms of Low Estrogen in Men

• Sexual performance may decrease due to a testosterone-to-estrogen imbalances causing a soft erection or inability to maintain one.
• Water retention is a common complaint for men experiencing testosterone to estrogen imbalance leading to excessive sweating, abnormal blood pressure spikes. Water retention can also lead to bloating or puffiness.
• General sleep issues like issues falling asleep and constant fatigue.
• Testicles shrinkage or testicular atrophy can occur due to low testosterone and estrogen due to both Primary and Secondary Hypogonadism where the link from the brain to the testicular in the hypothalamic-pituitary-adrenal axis is no longer working. In primary, the testicles simply fail to produce testosterone and sperm. While on TRT, our provider might prescribe Human Chorionic Gonadotropin or HCG to prevent the testicles from shrinking during treatment. HCG is used to treatment secondary hypogonadism where the pituitary gland is not telling the testicles to produce testosterone. HCG is a common low testosterone treatment for younger men that want to remain fertility. Reference

What are treatment options for high estrogen?

To manage high estrogen or estrogen imbalance, our providers might prescribe medications or help you adjust your diet if necessary.

If diet is not enough to manage high estrogen while on testosterone replacement therapy, our provider may adjust your dose or prescribe an aromatase inhibitor. The most common prescription is anastrozole (Arimidex), which stops the enzyme aromatase from converting testosterone into estrogen.

It’s common practice to prescribe anastrozole with TRT at 0.1mg per week if estradiol is too high. Anastrozole is an aromatase-inhibiting oral pill medication.

Slight adjustments to men’s diets could make an normalize estrogen aromatization. Kick starting the metabolize estrogen levels with natural phytochemical herbs from vegetable extracts.

Diindolylmethane found in leafy greens and vegetables is the best place to start. Veggies like broccoli, cauliflower, kale, and brussel sprouts are considered to be the most active cruciferous substance for promoting beneficial estrogen metabolism. Diindolylmethane (DIM) helps increase the ratio of good “bind friendly” estrogen, which connects to sex hormone binding globulin (SHBG), leaving more room for free testosterone to float around. Diindolylmethane also flushes out bad or weak estrogen (Estrone).

These plants contain phytochemicals that aids in blocking estrogen production.

• Red grapes contain trace amounts of natural estrogen blockers called resveratrol and proanthocyanidin. Shout out winos, drink responsibly.
• Pomegranates are high in estrogen-blocking phytochemicals.
• Micronutrient called polyphenol help reduce estrogen levels. Seeds and grains like Sesame seeds flaxseed, as well as whole grains like oats, corn, and rice. Green tea is another good source of polyphenol
• Indole-3-carbinol (I3C) is another compound found in DIM vegetables that has proven to be beneficial in the metabolism of estrogens. I3C is commonly concentrated extract capsule form.

While the first line of defense for high estrogen levels could be anastrozole (Arimidex), a diet rich with leafy greens and supplements that may help manage estrogen spikes well. If you chose to proactively manage estrogen levels without medication, supplements can be pricey but a dieting could be your best bet. Dieting can reduce some of the risk factors that lead to estradiol imbalance by reducing inflammation and burning away unwanted fat where estrogen lives.

Medically peer reviewed by Dr. Kenneth Lecroy, MD. Written by Our Editorial Team.

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