What do we know about estrogen in men? We know a lot. More than just tanking men’s testosterone levels, estrogen excess is related to other health problems. And is not just estrogen excess, but recent science[1] has shown us that estradiol has both inhibitory and stimulatory influences on male sexual function in an intricate and dose-dependent fashion. In this article let’s look at symptoms of estrogen excess in men, why it develops, and its associated health risks.

Symptoms of estrogen excess in men

Andropause is a common condition in men in which natural testosterone levels drop too fast as we age, starting in our 30s. Andropause is not optimal health.

Because testosterone can be converted enzymatically to estradiol by the activity of the enzyme aromatase, estradiol excess can be the very cause of low testosterone levels in men. The most common signs and symptoms of estrogen excess in men include:

• Sexual dysfunction (low libido, decreased morning erections, decreased erectile function)

• Enlarged breasts

• Increased abdominal fat

• Loss of lean muscleMoodiness such as sadness, worry, despair

• Easy fatigue

• Urinary tract symptoms associated due to an enlarged prostate

• Type 2 diabetes
   

Why estrogen builds up in men

First off, cholesterol is the parent molecule in sex hormone metabolism. After several metabolic changes, cholesterol eventually becomes testosterone. I don’t know of any man who naturally has too much testosterone (and who complains about it), I know many patients with low testosterone.

In addition to genetic predisposition, there are a few reasons why testosterone conversion to estradiol is increased:

• Advancing age increases aromatase activity. It I not uncommon for older men have higher estrogen levels than age-matched postmenopausal women.

• Fat tissue contains aromatase and also nicely stores estradiol. Men create testosterone in their testes, but then it circulates and become converted to estrogen predominately in body fat. Therefore, increasing body fat (due to inactivity and poor diet) increases aromatase activity and helps store estradiol.

• Testosterone therapy (injections, creams, troches, pellets) can trigger increased conversion to estradiol, especially if dosed too high in overweight men.

• Hormone feedback in the brain can also function poorly. Elevated estradiol levels can trigger even lower testosterone production, thus worsening the estrogen dominant condition and symptoms.
   

Any health risks to estrogen excess in men?

Because of the relationship between estrogen excess in men and low testosterone, consider the health risks of testosterone deficiency in men:

• Increased risk of cardiovascular disease.[2] [3] [4] [5] [6] [7]

• Increased risk of all-cause mortality.[8] [9] [10] [11] [12] [13] [14] Researchers conclude that a decrease of 2.1 standard deviations from normal total serum testosterone level predicts a 25% increase in death rate.

• Low testosterone is found in as high as 40% of patients with type 2 diabetes.[15] The Endocrine society[16] recommends routinely screening for low testosterone in men who have type 2 diabetes, metabolic syndrome (now nearly 1 in 3 American adults have this), chronic lung disease, osteoporosis, HIV infection, alcohol abuse, and those who have prolonged treatment with steroids, opiate pain relievers, or anticonvulsants.

• Consider the other health conditions that improve with testosterone replacement: low skeletal muscle mass and strength, pain and death resulting from sarcopenia (degenerative loss of skeletal muscle mass), osteoporosis (loss of bone density), [17] declining cognitive function, memory,[18] and verbal fluency,[19] elevated total cholesterol,[20] libido, sexual appetite, frequency and firmness of erections, energy and feeling of well-being, anxiety/fear/depression, loss of self-confidence, anemia, heart and blood vessel strength, blood pressure, and even blood clots.
   

In addition to experiencing the most common signs and symptoms listed above, a recent study[21] was presented suggesting that age-related estrogen excess in men may be the main trigger behind inguinal hernias. This condition is common in elderly men and is a leading cause for surgery in men. To date, there is no identifiable root cause for the inguinal hernia.

This study in mice showed that abdominal wall scar tissue weakened and hernias developed significantly with increased estrogen levels in just the male mice. By eliminating estrogen it prevented hernia formation. The researchers concluded that it might make sense to treat estrogen excess in at-risk aging men.

I’ll address treatment for male estrogen excess in my succeeding article on the subject.

To long-term health and feeling good,

Michael Cutler, M.D.

[1] Schulster M, Bernie AM, Ramasamy R. The role of estradiol in male reproductive function. Asian J Androl. 2016;18(3):435-40. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4854098/

The Abstract reads, “Estrogen receptors, as well as aromatase, the enzyme that converts testosterone to estrogen, are abundant in brain, penis, and testis, organs important for sexual function. Low testosterone and elevated estrogen increase the incidence of erectile dysfunction independently of one another. Regulation of testicular cells by estradiol shows both an inhibitory and a stimulatory influence, indicating an intricate symphony of dose-dependent and temporally sensitive modulation.

[2] Muller M, et al. Endogenous sex hormones and progression of carotid atherosclerosis in elderly men. Circulation 2004. May 4;109(17):2074-9.

[3] English KM, et al. Low-dose transdermal therapy improves angina threshold in men with chronic stable angina. Circulation 2000 Oct 17;102(16):1906-11.

[4] Khaw K-T, Dowsett M, Folkerd E, et al. Endogenous testosterone and mortality due to all causes, cardiovascular disease, and cancer in men: European prospective investigation into cancer in Norfolk (EPIC-Norfolk) prospective population study. Circulation 2007; 116(23):2694–2701. [PubMed]

[5] Vikan T, Schirmer H, Njølstad I, Svartberg J. Endogenous sex hormones and the prospective association with cardiovascular disease and mortality in men: the Tromsø study. European Journal of Endocrinology. 2009;161(3):435–442. [PubMed]

[6] Hyde Z, Norman PE, Flicker L, et al. Low free testosterone predicts mortality from cardiovascular disease but not other causes: the health in men study. Journal of Clinical Endocrinology & Metabolism.2012;97(1):179–189. [PubMed]

[7] Yeap BB, Hyde Z, Almeida OP, et al. Lower testosterone levels predict incident stroke and transient ischemic attack in older men. Journal of Clinical Endocrinology & Metabolism. 2009;94(7):2353–2359. [PubMed]

[8] Shores MM, Matsumoto AM, Sloan KL, Kivlahan DR. Low serum testosterone and mortality in male veterans. Archives of Internal Medicine. 2006;166(15):1660–1665. [PubMed]

[9] Hackett G, Kirby M, Sinclair AJ. Testosterone deficiency, cardiac health, and older men. Int J Endocrinol. 2014;2014:143763.

[10] Laughlin GA, et al. “Androgen Deficiency and All-cause Mortality in Older Men: The Rancho Bernardo Study.” Abstract 55-2 presented June 5, 2007. Endocrine Society Annual Meeting.

[11] Tivesten Å, Vandenput L, Labrie F, et al. Low serum testosterone and estradiol predict mortality in elderly men. Journal of Clinical Endocrinology & Metabolism 2009; 94(7):2482–2488. [PubMed]

[12] Maggio M, Lauretani F, Ceda GP, et al. Relationship between low levels of anabolic hormones and 6-year mortality in older men: the aging in the chianti area (InCHIANTI) study. Archives of Internal Medicine. 2007;167(20):2249–2254 [PubMed]

[13] Araujo AB, Dixon JM, Suarez EA, Murad MH, Guey LT, Wittert GA. Endogenous testosterone and mortality in men: a systematic review and meta-analysis. Journal of Clinical Endocrinology & Metabolism. 2011;96(10):3007–3019. [PubMed]

[14] Haring R, Völzke HV, Steveling A, et al. Association of low testosterone levels with all-cause mortality by different cut-offs from recent studies. European Heart Journal 2010; 31:1494–1501.[PubMed]

[15] Oh J-Y, Barrett-Connor E, Wedick NM, Wingard DL. Endogenous sex hormones and the development of type 2 diabetes in older men and women: the Rancho Bernardo study. Diabetes Care.2002;25(1):55–60. [PubMed]

[16] Bhasin S, Cunningham GR, Hayes FJ, et al. Testosterone therapy in adult men with androgen deficiency syndromes: an endocrine society clinical practice guideline. Journal of Clinical Endocrinology & Metabolism. 2006;91(6):1995–2010.

[17] Harman SM, et al. Baltimore Longitudinal Study of Aging. Longitudinal effects of aging on serum total and free testosterone levels in healthy men. Clin Endocrinol Metab. 2001;86:724-731.

[18] Moffat SD, Resnick SM. Long-term measures of free testosterone predict regional cerebral blood flow patterns in elderly men. Neurobiol Aging. 2007 Jun;28(6):914-20.

[19] Bassil N, Alkaade S, Morley JE. The benefits and risks of testosterone replacement therapy: a review. Ther Clin Risk Manag. 2009 Jun;5(3):427-48

[20] Malkin CJ, et al. The effect of testosterone replacement on on endogenous inflammatory cytokines and lipid profiles in hypogonadal men. J Clin Endocrinol Metab. 2004 Jul;89(7):3313-8.

[21] https://news.feinberg.northwestern.edu/2018/10/rising-estrogen-levels-may-cause-common-mens-hernias/