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By Dr. Meyer Schoeman, MD — Precision Sexual Health Clinic, Calgary
There’s a version of Testosterone Replacement Therapy (TRT) that works well on paper — testosterone levels are up, the lab values look good — but the man sitting across from me still doesn’t feel right. Energy is better but mood is flat. Libido improved initially but has plateaued. He’s retaining water. His erections are inconsistent.
In a significant number of those cases, the issue isn’t the testosterone. It’s the estradiol.
Testosterone doesn’t exist in isolation in the male body. A portion of it — typically around 0.3% of total testosterone — is continuously converted to estradiol via the aromatase enzyme, found primarily in adipose tissue, the liver, and the brain. This process, called aromatization, is physiologically normal and necessary.
Estradiol plays important roles in male bone density, cardiovascular health, cognitive function, and libido. The idea that estradiol is purely a “female hormone” that men should drive to zero is both wrong and clinically dangerous. Aromatase is widely expressed in multiple human tissues and is responsible for the local and systemic conversion of testosterone to estradiol, underscoring its essential role in normal male physiology.
The problem arises when estradiol rises disproportionately to testosterone — which is exactly what happens when TRT is managed without attention to this conversion. You introduce more testosterone substrate, aromatase converts more of it, and estradiol climbs. How much it climbs depends on aromatase activity, which is significantly influenced by body fat percentage, insulin resistance, age, alcohol intake, and genetic variation in the CYP19A1 gene.
Men with elevated estradiol on TRT often describe a constellation of symptoms that their prescribing physician may not immediately connect to hormone imbalance. Water retention — particularly around the abdomen and face — is common. So is breast tissue sensitivity or mild gynaecomastia. Mood becomes labile in a way that’s different from the low-testosterone flatness: more emotionally reactive, more anxious, less resilient under stress.
Erectile dysfunction on TRT is frequently an estradiol issue. This surprises men who assumed that more testosterone would straightforwardly mean better erections. The relationship is more nuanced. Both very low and very high estradiol impair erectile function. The optimal range sits in a window that requires actual measurement to find — not guesswork.
The other side of this is equally important. Overly aggressive aromatase inhibition — driving estradiol too low — produces its own problems: joint pain, fatigue, poor sleep, low libido, depression, and accelerated bone loss. I see men who’ve been prescribed anastrozole or exemestane based on a single mildly elevated estradiol reading, without symptoms, and are now symptomatic from suppression that went too far.
Aromatase inhibitors have a legitimate role in TRT management. But they’re a precise tool, not a default add-on. Using them without regular estradiol monitoring is like adjusting a medication dose without measuring what it’s doing.
A responsible TRT protocol measures estradiol at baseline and at each follow-up interval — not as an afterthought, but as a core part of the panel. The relevant test is the sensitive assay for estradiol (LC-MS/MS methodology), not the standard immunoassay, which is less accurate at the levels relevant to men and prone to overestimation.
Beyond estradiol, haematocrit and haemoglobin need regular monitoring because testosterone stimulates erythropoiesis — elevated haematocrit increases thrombotic risk and is one of the more serious manageable risks of TRT. PSA monitoring, lipid panel, and liver enzymes round out a complete picture.
None of this is complicated. It requires a physician who is paying attention to the whole hormonal system rather than just the testosterone number, and who adjusts treatment based on how the patient actually feels — not just what the lab shows.
Before starting TRT anywhere, ask what the follow-up monitoring protocol looks like. Specifically: will estradiol be measured at every follow-up? What’s the threshold for considering aromatase inhibition, and what’s the threshold for backing off? If the answer is vague, or if estradiol isn’t part of the standard panel, that tells you something important about the depth of the protocol.
Testosterone therapy managed well produces men who feel consistently better over time. Managed poorly, it produces a cycle of partial improvement, unexplained symptoms, and frustration. The difference is usually in the details.
Book a consultation with Precision Sexual Health Clinic for Men in Calgary to review whether TRT is right for you. Our approach focuses on comprehensive hormone monitoring, individualized dosing, and careful follow-up to support consistent, long-term results and avoid the common pitfalls of incomplete treatment protocols.
Dr. Meyer Schoeman is the founder of Precision Sexual Health Clinic for Men in Calgary. The clinic offers comprehensive testosterone assessment combining full hormonal panels with detailed clinical history — because a number without context isn’t a diagnosis. Book a consultation at precisioncliniccalgary.ca.