WARNING: Do not believe Internet "gurus" proclaiming no need to manage hematocrit on TRT

[Nelson Vergel]

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Debunking the Myth About High Hematocrit in Men on TRT​

I know many of you want to feel reassured that managing hematocrit isn’t necessary. However, misinformation is spreading, with some "bro science" videos and even a few so-called expert doctors claiming that men on TRT don’t need to worry about elevated hematocrit because people living at high altitudes have high hematocrit without increased mortality.


Let’s set the record straight—again.


High hematocrit in men on TRT is NOT the same as high hematocrit in people living at high altitudes. These are two completely different physiological conditions. Here’s why:

1. TRT Increases Both Hematocrit and Blood Volume
   • Testosterone stimulates red blood cell production, raising hematocrit.
   • It also increases blood volume due to sodium retention and other factors.
   • This combination can contribute to increased blood viscosity, which raises cardiovascular risk.
2. People at High Altitudes Experience Different Physiological Adaptations
   • At high altitudes, lower oxygen availability triggers an increase in red blood cell production to compensate.
   • However, these individuals do not experience the same increase in blood volume that men on TRT do.
   • Additionally, hypoxia (low oxygen levels) promotes blood vessel dilation, helping maintain proper circulation despite increased hematocrit.

A key paper on altitude physiology states:
"To compensate for the low partial pressure of oxygen at altitude, the body undergoes physiological changes, including increased circulating hemoglobin. However, there is also a fall in plasma volume, increasing hemoglobin concentration in the early stages of hypoxic exposure."


The crucial difference? Men on TRT experience increased blood viscosity due to both higher hematocrit AND increased blood volume, while high-altitude dwellers do not.

The Data on TRT, High Hematocrit, and Cardiovascular Risk​

Real-world evidence is already showing that elevated hematocrit in men on TRT is linked to a higher risk of cardiovascular events. For example:


Rises in Hematocrit Are Associated With an Increased Risk of Major Adverse Cardiovascular Events in Men Starting Testosterone Therapy: A Retrospective Cohort Claims Database Analysis.


This study found a significant correlation between increased hematocrit and cardiovascular risks in men undergoing TRT.

Conclusion​

The claim that men on TRT with high hematocrit face no additional health risks because high-altitude residents have high hematocrit is scientifically flawed. These are two different conditions with fundamentally different effects on blood circulation and cardiovascular health.


If you are on TRT and your hematocrit is rising significantly, it is not something to ignore. Proper monitoring and management are essential for long-term health.



People living at high altitudes who have high hematocrit are NOT the same as men on TRT with high hematocrit who live at "normal" altitudes. Why?

TRT increases red blood cells/hematocrit AND blood volume (due to sodium retention and other factors) AND blood pressure (depending on the patient). People at high altitudes (and not on TRT) are exposed to lower atmospheric partial pressures, which increases dilation of blood vessels. These people also do not experience increased blood volume even with higher red blood cells/hematocrit.
"In order to compensate for the low partial pressure of oxygen at altitude, the human body undergoes a number of physiological changes. A vital component in this process is the increase in the concentration of circulating hemoglobin. The role of HIF-1alpha, erythropoietin and red blood cells in this acclimatization process is described, together with the fall in plasma volume that increases the concentration of hemoglobin in the early stages of hypoxic exposure."

Difference between these people and men on TRT: We have increased blood volume and hemoglobin/hematocrit.

Full paper: Heights and haematology: the story of haemoglobin at altitude


We already are gathering data on higher mortality in men on TRT who have high hematocrit:

Rises in Hematocrit Are Associated With an Increased Risk of Major Adverse Cardiovascular Events in Men Starting Testosterone Therapy: A Retrospective Cohort Claims Database Analysis

 

[Seagal]

@madman or @Nelson Vergel can you access the full article and maybe share some details?

I cannot believe the statements in the abstract, e.g. I would think that any man would see an increase of hematocrit with TRT.

 

[excelnelg]

It's clear to me that one should be 99.9% skeptical of anyone proclaiming anything in a podcast or YouTube video when the primary motivation is money and not truth.

 

[Nelson Vergel]

This is a very detailed explanation of the mechanism of action involved in testosterone- induced high hematocrit:

Thread 'TESTOSTERONE THERAPY–INDUCED ERYTHROCYTOSIS: CAN PHLEBOTOMY BE JUSTIFIED?'

Sep 1, 2024

Testosterone therapy-induced erythrocytosis: can phlebotomy be justified?

Erythrocytosis, or elevated hematocrit, is a common side effect of testosterone therapy (TTh) in male hypogonadism. Testosterone stimulates erythropoiesis through an initial rise in erythropoietin (EPO), establishment of a new EPO/hemoglobin ‘set point’, and a parallel decrease in the master...

ec.bioscientifica.com

ABSTRACT

Erythrocytosis, or elevated hematocrit, is a common side effect of testosterone therapy (TTh) in male hypogonadism. Testosterone stimulates erythropoiesis through an initial rise in erythropoietin (EPO), establishment of a new EPO/hemoglobin ‘set point’, and a parallel decrease in the master iron regulator protein hepcidin, as well as several other potential mechanisms. Evidence shows an increased thrombotic risk associated with TTh–induced erythrocytosis. Several guidelines...

• madman
• androgens erythrocytosis polycythemia testosterone
• Replies: 8
• Forum: Testosterone Side Effect Management

• 

 

[Seagal]

How to manage hematocrit

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[Nelson Vergel]

T

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

Mar 22, 2019

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 manage TRT users and hematocrit levels and am really shocked. I'm not going to link to the videos or podcasts that have surfaced recently in this post directly but the debates corresponding to this concept have been covered here at ExcelMale.

> High T and High red blood count Q​

​

...

• tareload
• heart hematocrit longevity testosterone viscosity
• Replies: 168
• Forum: Testosterone Side Effect Management

• 

 

[Nelson Vergel]

My summary

How to Lower High Hematocrit on TRT

Discover effective strategies on how to lower high hematocrit and red blood cell count while on testosterone. Explore tips and techniques on our blog to manage high hematocrit levels.

www.discountedlabs.com

 

[NeverSayNeverAgain]

Is there a hard number on what's considered high are your sticking with 54%? I see so many guys above 55 all the time now, and not to debunk this stuff but has anyone notice how many guys don't clean up diets and only eat worst food once they are hitting the gym a lot more on T? I definitely would like to see Lipid profiles from the case study could just be the guys I know and not a realistic baseline but just wanted to throw that in.

@FDV70

Thoughts?

 

[FDV70]

The signal to noise ratio pollutes the whole discussion. I see SO MANY people comparing TRT to living at elevation. Except people at elevation STOP going up, because the mechanism of their erythrocytosis if activation of HIF1 and HIF2 which increase EPO but in TRT, Testosterone has a direct stimulation effect on EPO so in many guys HCT just keeps going up and won't stabilize. That's just one 'for instance'. It is SUCH A LENGTHY TOPIC to address and guys and even docs on YT just blithely ignore the biology.
That example I gave above? Exactly ZERO docs mention that. Becuase they probably don't know what HIF1 and HIF2 are. SHBG, we have known since 2005, is a transport protein that carries Test into cells (it doesn't deactivate Test like you still read in posts in other forums). SHBG transports Test into cells expressing megalin. Guess where most cells expressing megalin in the human body are -- if you guessed the kidneys, you're right! And that's another reason why TRT increases EPO so much! And exactly ZERO docs on YT mention that, either!

It's a long discussion. I want to see the bloodflow (especially cerebral) as well as transient pulmonary hypertension mentioned, but no doc ever does. I want it mentioned that all of these studies of TRT not being associated with clots did NOT control for men who gave blood. (Read that again.) These studies were run... in men who got phlebotomies. Guys on YT mentioning this: zero again.

Complex topic given too little exploration. I personally wouldn't go over 54. The problems aren't linear. It's not like 55 is not so bad because it's "just one number higher than 54." I mean, it isn't exponential, but it is not trivial.

 

[GreenMachineX]

Is there a hard number on what's considered high are your sticking with 54%? I see so many guys above 55 all the time now, and not to debunk this stuff but has anyone notice how many guys don't clean up diets and only eat worst food once they are hitting the gym a lot more on T? I definitely would like to see Lipid profiles from the case study could just be the guys I know and not a realistic baseline but just wanted to throw that in.

@FDV70

Thoughts?

Where are you seeing these guys above 55?

I recently tested again at 54.3, but didn’t get the results for 2 weeks after so I could be even higher now. So frustrating, and this is from 8mg test cyp shallow IM daily.

 

[FDV70]

Where are you seeing these guys above 55?

I recently tested again at 54.3, but didn’t get the results for 2 weeks after so I could be even higher now. So frustrating, and this is from 8mg test cyp shallow IM daily.

In ******** groups. TRT Community and Nelson's TRT FB group, Testosterone Replacement Therapy Discussion. Guys at 56 all the time, guys at 60 a few a month freaking out.