Hormone Imbalance in Men: Testosterone, Oestrogen and Aromatase

The phrase "high female hormones" alarms many men. Some see posts in fitness groups and go looking for oestrogen-lowering pills to take on their own. I have seen patients who took so much that their oestrogen became too low, and they came back with joint pain, no sex drive and thinning bones. In this article I want to invite you to see it differently: oestrogen in men is not the villain. What needs looking after is "balance" and "the root cause".

What is the aromatase enzyme?

Aromatase is an enzyme that converts testosterone into oestradiol (E2), the main form of oestrogen. In men, this enzyme is found in fat tissue, the brain, testicles, liver and bone. Most of the oestradiol in men therefore comes from this conversion rather than being made directly.

The more body fat you have, especially belly fat, the more active aromatase becomes. At the same time, obesity suppresses the signals from the brain, lowering testosterone in another way. This creates the cycle of "belly fat, lower male hormones, a higher proportion of oestrogen", which is common in middle-aged men.

1. 1
   More belly fatAromatase in fat becomes more active
2. 2
   Converts to oestrogenTestosterone is turned into estradiol
3. 3
   Male hormones fallObesity also dampens the brain's signals
4. 4
   Fat builds easilyLower hormone leads to more fat

Reducing belly fat is the most effective way to break this cycle.

What do men need oestrogen for?

An important study by Finkelstein and colleagues (NEJM 2013) suppressed hormones in healthy men and then gave back testosterone at different doses, with some groups also having the conversion to oestrogen blocked. The results changed earlier thinking considerably:

• Body fat accumulation depended mainly on oestrogen levels; when oestrogen was low, fat actually increased
• Sexual desire and erections need both testosterone and oestrogen
• Muscle mass and strength depended mainly on testosterone
• Men's bones need oestrogen to maintain density

This means pushing oestrogen as low as possible doesn't make you "more manly"; it may increase fat, worsen your sex life and thin your bones.

Body fat

• Depends mainly on oestrogen
• Too little oestrogen makes fat rise

Desire and erections

• Need both hormones

Muscle

• Depends mainly on testosterone

Bone

• Needs oestrogen to keep density

Finkelstein et al. (NEJM 2013). Pushing oestrogen too low does not make you more manly.

When does high oestrogen become a problem?

The symptom most clearly linked to high oestrogen is male breast enlargement (gynaecomastia): a soft, rubbery lump of breast tissue under the nipple that may be tender, which is different from ordinary chest fat.

Common causes of gynaecomastia:

• Excess weight
• Puberty (usually goes away by itself)
• High-dose testosterone or steroids (read Steroids and PEDs)
• Some medicines, such as spironolactone, some antacids and prostate medicines
• Liver disease, kidney disease, overactive thyroid
• Rarely: hormone-producing tumours of the testicles or adrenal glands

As for symptoms such as mood swings, low mood or sexual insecurity, which an older clinic article linked to high oestrogen, the evidence that they come directly from oestrogen is not clear. These symptoms more often come from obesity, low testosterone, poor sleep or stress. See also Depression or low testosterone.

Oestrogen rises on TRT: what should you do?

When you receive testosterone from outside the body, oestradiol usually rises too, which is normal. Most of the time nothing needs to be done.

• The AUA guideline recommends checking oestradiol before starting TRT in men with breast symptoms or gynaecomastia, not in everyone.
• Routinely using an aromatase inhibitor (such as anastrozole) with TRT is not standard and can push oestrogen too low, thinning the bones.
• If gynaecomastia develops during treatment, the doctor usually starts by reviewing the dose and form of the medicine, for example switching from injections with big peaks and troughs to a steadier form (read Testosterone enanthate vs undecanoate).

Other side effects are covered in TRT side effects.

How to restore hormone balance at the root

1. Lose belly fat. This is the most effective step, because it both reduces aromatase and helps testosterone rise again.
2. Get enough sleep, and get checked for sleep apnoea if you snore.
3. Cut down on alcohol, which affects the liver and hormones.
4. Review every medicine and supplement, including steroids and "test boosters".
5. Combine resistance exercise with aerobic exercise.

Detailed guidance is in Supporting testosterone with sleep, food and exercise.

What should be tested?

• Morning fasting total testosterone, with SHBG to calculate free testosterone (read SHBG)
• LH and FSH to find the cause
• Oestradiol when there is breast enlargement or tenderness
• Depending on symptoms: prolactin, liver, kidney and thyroid function
• Waist measurement and body composition

When to see a doctor, and how the clinic can help

See a doctor if you have breast enlargement or tenderness, lower sex drive together with belly fat, or unusual symptoms while using hormones. At Dr. Kris Clinic I examine you, read your full set of hormone results as a whole picture, and always plan around the root cause first. Any medicine is used as assessed by the doctor, with follow-up. You can consult at the clinic in Surat Thani or online, and consultations in English are available.