Why is estradiol so important? It has profound implications for general health and has the potential to cause some very unpleasant symptoms if its levels are unbalanced. As testosterone levels decrease and estradiol levels increase, the ratio of free testosterone to estradiol reaches a critical point where high estrogenic side effects are more noticeable: Sexual dysfunction such as poor erectile strength, lack of libido or arousal, poor sleep and reduced insulin sensitivity are some of them.
When Doesn’t Testosterone Optimization Therapy Work?
In our experience, both personally and in consulting with many men who are on Testosterone Optimization Therapy, the biggest reason why TOT doesn’t “work” is because of poor estrogen (E2) management. Often, it’s out of balance due to a lack of physician observation and supervision. Unfortunately, a man can have side effects when suffering from both low and high levels of estrogen. Believe it or not, the single most significant determinant of whether estradiol (E2) is out of balance or not is based on erectile strength. When a man is unable to maintain a firm erection, this is usually the sign of excess E2 (estrogen) production. On the other hand, when E2 levels are too low which is usually due to overdosing of an aromatase inhibitor (AI) medication, it causes sexual dysfunction or lack of interest and an inability to get an erection.
There is nothing more psychologically damaging to a man than being unable to perform sexually when the opportunity arises. Another evident and noticeable side effect of high E2 levels is water retention. Some men genetically overproduce aromatase (the enzyme necessary for the conversion of testosterone to estrogen), leading to increased estrogen production and its potentially adverse side effects. 
Why It’s Imperative to Work with an Experienced TOT Physician
It is imperative to work with an experienced physician to dial in your estradiol levels as you begin TOT. Typically, a good doctor will take initial blood estradiol (E2) panel to establish a baseline, and then take future readings after starting TOT to figure out what level of estradiol is best for you. There is a narrow therapeutic estrogen (E2) range in which a patient feels good when balancing estrogen and testosterone while initiating and adhering to lifelong optimization at the same time. Therefore, it is CRITICALLY essential for you and your doctor to understand the optimal range of estradiol for your body. It is crucial that a TOT physician orders a ‘sensitive’ or ‘enhanced’ estradiol assay (lab work) before and after a patient initiates TOT.
It is important because the standard estradiol test is designed for women and tends to overestimate a patient’s actual estrogen levels significantly. It is critical for both the patient and the doctor to establish accurate baseline levels of estrogen (E2) before starting TOT AND during TOT. It is also why it’s important for your physician to initiate therapy with testosterone in isolation to understand how your body responds to it by itself. Doing so will help establish a legitimate baseline between testosterone and estrogen. To find out much more about Testosterone and its role in helping us achieve optimal mental health and physical performance, purchase The TOT Bible. 
