high hematocrit/hemoglobin - what to do

[locutus]

my general doc panicked, told me to immediately stop TRT (not my hormonal clinic)
wants to refer me somewhere. stopping not an option.
I had 2 readings, 1 before blood donation, 1 after:
before donation:
RBC - 6.40
Hemoglobin - 18.8
hematocrit - 55.8

after donation:
RBC - 6.06
Hemoglobin - 18.0
Hematocrit - 53.3

general doc says still too high. I have no symptoms. but I can't donate for 2 months or so.
i'm on 150mg TRT 3x week. would daily dosing help? or maybe reduce a bit. again, I feel ok

 

[Systemlord]

My hematocrit runs 57% on my current protocol (Jatenzo 237mg 2x daily) and hemoglobin 19.2 and get therapeutic phlebotomy every 6 to 8 weeks.

I have no symptoms either at these levels and don't feel any different after the phlebotomy. I didn't feel too well on the 198mg dosage, so I'm forced to get phlebotomies.

The simple solution is to reduce your dosage.

 

[Vince]

It would be nice to see your total testosterone labs. I would cut your t dose way down. Maybe even in half or 10 mg daily.

 

[locutus]

during my last reading:
Total T: 953
Free T: 33.5
Estradiol: 48.7

everything else pretty good. my TSH and IGF/1 improved massively during last 6 months.
I started doing daily injections. I think I feel better on them. libido higher for sure. roughly 20mg T daily. HCG 2x week

 

[Nelson Vergel]

Here is a good article to review:

High Hematocrit Caused by TRT: How to Lower and Manage it

Testosterone replacement therapy (TRT) is one of the most effective ways to combat low testosterone levels, but it's vital that you understand the risks associated with the treatment. As with any form

www.discountedlabs.com

 

[Gman86]

during my last reading:
Total T: 953
Free T: 33.5
Estradiol: 48.7

everything else pretty good. my TSH and IGF/1 improved massively during last 6 months.
I started doing daily injections. I think I feel better on them. libido higher for sure. roughly 20mg T daily. HCG 2x week

How many iu’s of HCG u taking per week total?

 

[Vince]

during my last reading:
Total T: 953
Free T: 33.5
Estradiol: 48.7

everything else pretty good. my TSH and IGF/1 improved massively during last 6 months.
I started doing daily injections. I think I feel better on them. libido higher for sure. roughly 20mg T daily. HCG 2x week

Even though your levels look good. You going to have to lower your dose to improve your HCT levels.

 

[TorontoTRT]

Even though your levels look good. You going to have to lower your dose to improve your HCT levels.

That doesn’t always work. My hematocrit went up to an average of 56 regardless of dosage or shot frequency. As low as 80 mg a week to 240 mg a week, hematocrit went up the same way.

 

[Vince]

That doesn’t always work. My hematocrit went up to an average of 56 regardless of dosage or shot frequency. As low as 80 mg a week to 240 mg a week, hematocrit went up the same way.

When you adjusted your testosterone levels, how long did you wait before you did labs?

 

[TorontoTRT]

3-6 months.

 

[Jurek Kletsy]

I don‘t understand the fear about slightly elevated hematocrit levels on TRT. Testosterone induces erythocytosis and not polycythemia. It is only the latter that inceases the risk of blood clots.

Can anybody show me a study that concludes that slightly elevated hematocrits below (<60) alone, so in the measured absence of other variables such as hypertension, polycythemia, insuline resistance, etc, leads to cardiovascular disease or other serious health issues?

The key point is that the health reasons why your RBC content is higher matter. Is it causes by something sinister like sleep apnea or polycythemia, or is it instead caused by testosterone or living at higher altitudes? You can’t just look at a blood marker without context and make a general assumption, but this is exactly what researchers, doctors and as a result the general public are doing more and more.

if you ‘feel better’ giving blood and you don’t have low iron, go ahead…but I would not let my RBC levels determine the course of my TRT treatment.

 

[Gman86]

I don‘t understand the fear about slightly elevated hematocrit levels on TRT. Testosterone induces erythocytosis and not polycythemia. It is only the latter that inceases the risk of blood clots.

Can anybody show me a study that concludes that slightly elevated hematocrits below (<60) alone, so in the measured absence of other variables such as hypertension, polycythemia, insuline resistance, etc, leads to cardiovascular disease or other serious health issues?

The key point is that the health reasons why your RBC content is higher matter. Is it causes by something sinister like sleep apnea or polycythemia, or is it instead caused by testosterone or living at higher altitudes? You can’t just look at a blood marker without context and make a general assumption, but this is exactly what researchers, doctors and as a result the general public are doing more and more.

if you ‘feel better’ giving blood and you don’t have low iron, go ahead…but I would not let my RBC levels determine the course of my TRT treatment.

Well said!

 

[tareload]

@Jurek Kletsy

I don‘t understand the fear about slightly elevated hematocrit levels on TRT. Testosterone induces erythocytosis and not polycythemia. It is only the latter that inceases the risk of blood clots.


Can anybody show me a study that concludes that slightly elevated hematocrits below (<60) alone, so in the measured absence of other variables such as hypertension, polycythemia, insuline resistance, etc, leads to cardiovascular disease or other serious health issues?

The Effect of Route of Testosterone on Changes in Hematocrit

Study Need and Importance: Secondary erythrocytosis, defined as hematocrit (HCt) ≥51% in males, is a well-known consequence of testosterone therapy. Testosterone formulation and route of administration can significantly influence changes in HCt, but the degree of HCt increases has not been...

www.excelmale.com

Hematocrit drives Blood Viscosity- Does that Matter in Men on TRT? Effect of Altitude?

Hi ExcelMale folks, I wanted to start off by expressing my gratitude for this site, all of the amazing work that has been put in to make this place such a great source of information. I would expect no less from a chemical engineer :). I've been following this "debate" about how to properly...

www.excelmale.com

Maybe these links will help, maybe not. Gory detail about what elevated Hct means (as you correctly point out - erythrocytosis, Not PV). Higher Hct means higher blood viscosity which means more work for your heart. Integrate (math term for area under the curve) that extra work over 20 years and it may or may not be a problem for you as an individual. There are many papers looking at the optimal Hct for various animals which try to balance the extra oxygen carrying capacity vs the extra blood viscosity - hence tradeoff analysis.

The study you are looking for does not exist. What's the objective function? Live as long as possible; have fun for 10 years then drop dead? Hard to really define.

But that doesn't stop the astute researcher or hobbyist from being cautious especially if they have other issues like inflammation, elevated cRP--->increased plasma viscosity.

Does High Hematocrit Lead to Complications for Men on TRT?

I plan on using this thread to capture comments/discussion on secondary erythrocytosis from TRT (Hct/viscosity) and cardiovascular risk. Alot of my previous comments/question/posts have been spread over a number of other’s threads. In particular, I’ve seen a number of comments (even interviews...

forums.t-nation.com

From this link:

The primary concern with elevated blood viscosity is hypertension, increased shear stress to the lumen (I’m sure you are familiar with what that does), and risk of ischemia and reduced perfusion for compromised patients / older patients. Also, what’s the concern with young person running high blood viscosity for years? Ask AAS abusers what the long term implications of elevated Hct are? Integrate out over 20 years the cost of making your heart do extra, measurably more work. Combine that with a patient who has limited vasodilation ability.


So according to this logic, no worries with elevating serum viscosity, just let it ride? For a patient with plenty of mileage on the heart, pre-CHF or CHF, no worries with cranking up the blood viscosity? Harmless?

This response is lazy and avoids having to discuss the fact the heart is a pump and a pump is designed to operate on a pump curve (just to keep it simple). Depending on the viscosity of the fluid the pump is pumping, you will land on a point on that curve. Surely you understand the long term implications of running a pump too high on the gpm vs hp curve? Any concerns for long term issues if you want that pump in service for a while? We aint talking about a pump in a manufacturing facility that can be replaced rather easily. We are talking about a heart.



For folks who talk about optimization, you seem to not understand or ignore the penalty function associated with performance vs longevity. For readers, I’ve shared what I think is important for you to consider. Take care of your cardiovascular system. That means use reasonable caution. Running your Hct above 50, or even 55 is not that. But given the TT levels you guys are recommending, I can see how this little inconvenience causes an issue. Elevated Hct has to be harmless in your practice otherwise you have to have your patients doing an oil drain on a regular, painful basis.

Does High Hematocrit Lead to Complications for Men on TRT?

I posted some similar information over at another forum. Here’s was a response: None of this matters. Testosterone INCREASES NO production and dilates blood vessels to account for any blood thickening essentially cancelling out any negative side effects. Hence no one on TRT us dropping dead...

forums.t-nation.com

Does High Hematocrit Lead to Complications for Men on TRT?

Further thoughts in response to above copied hear to stimulate discussion/review/thoughts/feedback: @_____, help me understand how TRT would fundamentally shift the qualitative shape of the curves attached below? In order for testosterone to counteract any and all increase in blood viscosity...

forums.t-nation.com

...the same Hct in two persons doesn't always equate to the same whole blood viscosity.


Personally, I haven't found a free lunch. There are many times consequences for pushing your physiology outside where it's designed/equilibrated to operate. Not a good everyday long term strategy IMO. If you are going to fiddle, you better be smarter than your body or be very cautious.

 

[locutus]

I am also somewhat skeptical about those blood readings. look at lipids; I am fairly convinced that cholesterol is mostly not an issue, and was designed to sell people statins. even my last general doc told me that statin research is outdated and nobody should be taking them anymore. there are some things which definitely matter, like glucose, liver levels etc. I suppose I will donate blood (a good thing anyways), start daily dosing (seems improves my mood a bit), and go purely by symptoms from now on.

 

[Vince]

I am also somewhat skeptical about those blood readings. look at lipids; I am fairly convinced that cholesterol is mostly not an issue, and was designed to sell people statins. even my last general doc told me that statin research is outdated and nobody should be taking them anymore. there are some things which definitely matter, like glucose, liver levels etc. I suppose I will donate blood (a good thing anyways), start daily dosing (seems improves my mood a bit), and go purely by symptoms from now on.

Statins are for people with plaque in their arteries. You need a heart scan to know.

It takes one year for soft plaque to calcify and become stable plaque. Plaque is made up of 20% calcium, that's what the scan sees. The calcium.

But this thread is about HCT, not statins.

 

[tareload]

but I would not let my RBC levels determine the course of my TRT treatment.

I'm hope you are just taking that risk for yourself and not applying it to your patients. If you had charge of other's health care treatment and understand the ramifications of what I posted above, you might be more sympathetic to the plight of physicians. Unless of course you are Keith Nichols, Rouzier or one of their disciples who can just wave their magic wand and declare elevated Hct as completely harmless in the context of secondary erythrocytosis due to androgen replacement therapy. Must be nice for them as providers but maybe not so nice for their patients.

 

[Jurek Kletsy]

@readalot
There is no evidence that testosterone-based secondary erythrocytosis increases CVD. The studies that you posted do not dispute this. They apply to a different context and/or contain conflating variables. They also can’t account for a possible protective effect of testosterone. In research evidence is strictly dictated by context, else it is just an assumption.

You are presenting your opinion, but it it not absolute truth. Because we do not know it. And I am presenting my opinion for which the same applies:
In absence of well-merited research on TRT-patients, one should not rob himself of the evidence-based health benefits of testosterone therapy by quitting or drastically reducing dose just because hematocrits are slightly out of range while other contributing risk factors are kept in-check.

 

[tareload]

You are presenting your opinion, but it it not absolute truth.

Best wishes on your journey. Be careful with what I posted above. You are correct that some of it is speculation; however, some of it is not.

• Elevating Hct increases whole blood viscosity [Fact].
• What does that mean to you in the specific context of your plasma viscosity and inflammation status [I don't know].
• Elevating Hct increases your individual cardiac risk over 1, 5, 10, 20 years [I don't know].
• I recommend being cautious as everyone always thinks they have it figured out until they don't [My Opinion].

They also can’t account for a possible protective effect of testosterone. In research evidence is strictly dictated by context, else it is just an assumption.

As you state, the pluses and minuses of primary, secondary, tertiary, .... effects of testosterone therapy for each individual are not known a priori. However, I hope one takes away from the information I posted above there is no theoretical or experimental data showing Testosterone's positive effect on NO can counteract any and all negative impacts of elevated Hct on the endothelium. There is a limit and neither you or I know what that cutoff is for each individual. Setting 60 as the ceiling is reckless as a general rule of thumb based on review of all available evidence [My opinion].

If you are comfortable labeling Hct < 60 slightly elevated and if that works for you, have at it.

 

[tareload]

There is no evidence that testosterone-based secondary erythrocytosis increases CVD.

And I'm sure you are well aware of this article and many others like it:

Statistics notes: Absence of evidence is not evidence of absence

The non-equivalence of statistical significance and clinical importance has long been recognised, but this error of interpretation remains common. Although a significant result in a large study may sometimes not be clinically important, a far greater problem arises from misinterpretation of...

www.bmj.com

When we are told that “there is no evidence that A causes B” we should first ask whether absence of evidence means simply that there is no information at all. If there are data we should look for quantification of the association rather than just a P value. Where risks are small P values may well mislead: confidence intervals are likely to be wide, indicating considerable uncertainty. While we can never prove the absence of a relation, when necessary we should seek evidence against the link between A and B—for example, from case-control studies. The importance of carrying out such studies will relate to the seriousness of the postulated effect and how widespread is the exposure in the population.


TRT/TOT/blah blah blah is a large uncontrolled experiment. Caution is in order when the probability is high that you'll learn your individual response before you get RCT evidence to point at.

Thanks for your thoughts.

EDIT: By the way this guy with the comment on the article at the bottom is an absolute stud.

 

[locutus]

I am wondering who established the baseline HCT blood range. was it done based on general population? if max HCT per labcorp is 51 and mine is 53.3 which is a 4.5% increase from the max. in the example of cholesterol, those ranges are adjusted to maximize statin sales, which makes me somewhat skeptical of this. where is the evidence that slightly 'elevated'(if you can define elevated) HCT can cause any issues?