TRT and too many red blood cells - what to do?

[reliable]

I started TRT with 200 mg test cyp every two weeks about six months ago, but experimented with shortening the interval to about 10 days and generally felt better. However, in my last round of lab tests my testosterone level came back at 13.84 mg/l (ref 2.80 - 11.00) and hemoglobin at 18.7 g/dl (ref 13.5-17.5), hematocrit 54%. I discussed this with my doctor and we decided that a socially useful way to bring this down would be to donate blood. However, this morning at the blood bank the reading was 20.2 and they refused to accept me as a donor. What to do? One solution seems to be to pause TRT until the hemoglobin level is acceptable and then resume TRT at the two week interval despite my feeling perhaps worse overall as a result. I'm wondering if anyone else had this problem and what they did to solve it. Thanks for any advice!

[pushinweightw]

I started TRT with 200 mg test cyp every two weeks about six months ago, but experimented with shortening the interval to about 10 days and generally felt better. However, in my last round of lab tests my testosterone level came back at 13.84 mg/l (ref 2.80 - 11.00) and hemoglobin at 18.7 g/dl (ref 13.5-17.5), hematocrit 54%. I discussed this with my doctor and we decided that a socially useful way to bring this down would be to donate blood. However, this morning at the blood bank the reading was 20.2 and they refused to accept me as a donor. What to do? One solution seems to be to pause TRT until the hemoglobin level is acceptable and then resume TRT at the two week interval despite my feeling perhaps worse overall as a result. I'm wondering if anyone else had this problem and what they did to solve it. Thanks for any advice!

Ok you need to donate regardless of what the blood bank says so have your doctor order a blood draw. Having hematocrit that high is not healthy and he/she should order a draw.

Something to think about is that with once every two weeks administration your blood levels are going to be all over the place. Try doing .25cc twice a week with a slin pin, this will keep blood levels far more stable.

[reliable]

I appreciate the suggestions! I need to get the hematocrit under control and then follow a dosing interval that helps keep the blood levels more stable. Apparently it is the spiking of testosterone levels that provokes the production of red blood cells in certain usually older males, which must be my case. For anyone interested, I found an article
"How to Manage Polycythemia Caused by Testosterone Replacement Therapy"


by Nelson Vergel that gives a lot of details on this subject, but I'm unable to post the link.

[The Matrix]

Check for dehydration is first or if there is an underlying medical condition potentially causing the dehydration. Increase water consumption before the test. if still not dropping giving 500 cc of blood should work. reducing dosage to 50 Mgs x 2 times a week.may help.

[reliable]

Thank you - I'm thinking of returning to the blood bank well hydrated with water - not coffee, like last time - and see if that works.

[The Matrix]

Thank you - I'm thinking of returning to the blood bank well hydrated with water - not coffee, like last time - and see if that works.

I had a client on TRT and his RBC where higher then yours. The Dr wanted to phleb, I suggested to hold off for a week till I examine his lifestyles. He was drinking 8-10 cups of coffee a day due to the fact he worked in an italian owned company where it was common place to have coffee every time going into meetings. One top of that he drank 2-3 diet cokes a day Coffee they made was incredible strong. When asked how much actually water he drank barely 4 cups. After making the proper correction, accelerating the hydration process with a few recommendations I have used in the past. With in 2 weeks his blood levels where normal. As you can see, through proper evaluation of lifestyles, and dietary evaluations root cause can probably be found in majority of cases. Again lack of proper education in the medical field needs to be reviewed.

[RipdnTxs]

I,m running into this problem again. I switched Docs. and he prescribed me the( IMO ) worthless bio-identical testosterone pellets for under the tongue, my T level dropped back to around 300. He put me on the strongest allowable compounded cream for 3 months and re-ckd. and levels was around 1300 and I felt no different in the any way, so he put me back on Cyp. injections at 75 mg. twice a week and now my face,neck, and hands are red all the time. My latest labs Hemocrit 54, Hemoglobin 17.8, Test was 1008. I have dropped to 60mg twice a week and am going to go and have a double red blood cell draw at the local blood bank, I have done this two other times when on Injectable TRT and it works for a while, but eventually returns. I even had 500 cc drawn twice from a specialist before the new Doc, came on board. The blood Doc. had me stop the Test for three and a half weeks and restested and all bloods came back normal. Not sure where we will go from here, I feel betr and sex drive is great at the moment. Yet some guys do a gram of test a week and not get as red as I do on TRT doses..... Arrrrg

[The Matrix]

I,m running into this problem again. I switched Docs. and he prescribed me the( IMO ) worthless bio-identical testosterone pellets for under the tongue, my T level dropped back to around 300. He put me on the strongest allowable compounded cream for 3 months and re-ckd. and levels was around 1300 and I felt no different in the any way, so he put me back on Cyp. injections at 75 mg. twice a week and now my face,neck, and hands are red all the time. My latest labs Hemocrit 54, Hemoglobin 17.8, Test was 1008. I have dropped to 60mg twice a week and am going to go and have a double red blood cell draw at the local blood bank, I have done this two other times when on Injectable TRT and it works for a while, but eventually returns. I even had 500 cc drawn twice from a specialist before the new Doc, came on board. The blood Doc. had me stop the Test for three and a half weeks and restested and all bloods came back normal. Not sure where we will go from here, I feel betr and sex drive is great at the moment. Yet some guys do a gram of test a week and not get as red as I do on TRT doses..... Arrrrg

look into.dehydration from.consumption of possibly too.much caffeine via coffee

drink 20 oz of water only hour before the blood test

if these do.not work give 500.cc of blood then retest in a week.

under Dr supervision add in aspirin

get checked for sleep apnea

[RipdnTxs]

I dont drink coffee at all and just a glass or two of tea or diet coke a day. I drink between 1/2 to 3/4 of a gallon of water most days. I am actually going to my sleep study this evening for sleep apnea..... Will update findings. Is there a link between sleep apne and the problems I,m having ????

look into.dehydration from.consumption of possibly too.much caffeine via coffee

drink 20 oz of water only hour before the blood test

if these do.not work give 500.cc of blood then retest in a week.

under Dr supervision add in aspirin

get checked for sleep apnea

[The Matrix]

I dont drink coffee at all and just a glass or two of tea or diet coke a day. I drink between 1/2 to 3/4 of a gallon of water most days. I am actually going to my sleep study this evening for sleep apnea..... Will update findings. Is there a link between sleep apne and the problems I,m having ????

where are your ferritin levels and iron serum? Yep just had case of hemochromatosis which.when.undiscovered for 3 years with ferritin.levels of 280 Dr where clueless said it was not a problem. Suggested to go donate some blood 500 cc. A few days later called.me saying first time in 3 years did sleep with machine. Had more energy and cognitive function in a long time. Would not surprise me he t.levels will come up over time as its.one of the side effects of this..Finally went to good hemotologist testing positive for the gene.mutation..

[Gutterpump]

I used to have high hematocrit, just over top of range. I've never given blood once to lower it, but I did lower my TRT dose and it has gone down on it's own to the top 3rd of the range. Is this normal for it to go down without giving blood?

I've been told I'm crazy for not giving regular blood on TRT, or at least a few times a year of bloodletting.

[Whacked]

Subb'd

[Whacked]

How to Manage Polycythemia Caused by Testosterone Replacement Therapy

Testosterone Replacement Therapy and Polycythemia

By Nelson Vergel, B.S.Ch.E., M.B.A.


Source: http://bit.ly/v5nEMu


November 16, 2011

A research letter recently published in the journal AIDS by Vorkas et al determined that testosterone use was associated with polycythemia, and intramuscular administration demonstrated a stronger association than topical (testosterone patch) use. No adverse cardiovascular or thrombotic events were observed. HIV-infected patients taking testosterone should undergo routine hematologic monitoring with adjustment of therapy when appropriate.

Polycythemia is an excessive production of red blood cells. With polycythemia the blood becomes very viscous or "sticky," making it harder for the heart to pump. High blood pressure, strokes and heart attacks can occur.

The association between testosterone replacement therapy and polycythemia has been reported for the past few years as this therapy has become more mainstream. In addition to increasing muscle and sex drive, testosterone can increase the body's production of red blood cells. This hematopoietic (blood-building) effect could be a good thing for those with mild anemia.

Although all testosterone replacement products can increase the amount of red blood cells, the study showed a higher incidence of polycythemia in those using intramuscular testosterone than topical administration (testosterone patch was the main option used -- no gels). Smoking has also been associated with polycythemia and may contribute to the effects of other risk factors.

In the above mentioned study, twenty-five patients met the criteria for polycythemia (21 male; four female). Using the number of unique patients with five clinic visits during the time frame of the study as the denominator, the estimated prevalence of polycythemia was 0.42% (95% CI 0.27-0.61). Mean hemoglobin at the time of diagnosis of polycythemia was 18.9+/-0.42 g/dl in men and 17.0+/-0.83 g/dl in women. Among the four female cases, one was diagnosed with chronic obstructive pulmonary disease (COPD) and severe pulmonary hypertension, while the other three did not have a documented explanation for elevated hemoglobin. Because of the relatively small number of female cases and the fact that the primary hypothesis is related to testosterone use, this case-control study focused on the 21 male patients.

Five of the 21 cases (24%) did not use testosterone, but had other explanations for their polycythemia: pulmonary hypertension, COPD and plasma volume contraction. In two of the 21 cases (10%) there was no documented reason for elevated hemoglobin. No cases met the criteria for polycythemia vera, and no adverse cardiovascular or thrombotic events were noted among the cases or controls.

The letter recommends that all HIV-infected patients taking testosterone should undergo routine hematologic monitoring and adjustment of testosterone dose or cessation of testosterone therapy as appropriate based on hemoglobin values. Unfortunately, no mention is made of therapeutic phlebotomy as a management strategy for this problem. Considering that stopping testosterone replacement would affect patients' quality of life and leave their hypothalamic-pituitary-gonadal axis in a dysfunctional state for weeks, months or permanently, other ways to manage polycythemia besides treatment cessation need to be discussed.

Below is an excerpt from my book, Testosterone: A Man's Guide, further detailing the prevention and management of polycythemia.


Preventing and Managing Polycythemia

It's important to check patients' hemoglobin and hematocrit blood levels while on testosterone replacement therapy. As we all know, hemoglobin is the substance that makes blood red and helps transport oxygen in the blood. Hematocrit reflects the proportion of red cells to total blood volume. A hematocrit of over 52 percent should be evaluated. Decreasing testosterone dose or stopping it are options that may not be the best for assuring patients' best quality of life, however. Switching from injectable to transdermal testosterone may decrease hematocrit, but in many cases not to the degree needed.

The following table shows the different guideline groups that recommend monitoring for testosterone replacement therapy. They all agree about measuring hematocrit at month 3, and then annually, with some also recommending measurements at month 6 after starting testosterone (it is good to remember that there is a ban on gay blood donors in the United States).

Many patients on testosterone replacement who experience polycythemia do not want to stop the therapy due to fears of re-experiencing the depression, fatigue and low sex-drive they had before starting treatment. For those patients, therapeutic phlebotomy may be the answer. Therapeutic phlebotomy is very similar to what happens when donating blood, but this procedure is prescribed by physicians as a way to bring down blood hematocrit and viscosity.

A phlebotomy of one pint of blood will generally lower hematocrit by about 3 percent. I have seen phlebotomy given weekly for several weeks bring hematocrit from 56 percent to a healthy 46 percent. I know physicians who prescribe phlebotomy once every 8-12 weeks because of an unusual response to testosterone replacement therapy. This simple procedure is done in a hospital blood draw or a blood bank facility and can reduce hematocrit, hemoglobin, and blood iron easily and in less than one hour.

Unfortunately, therapeutic phlebotomy can be a difficult option to get reimbursed or covered by insurance companies. The reimbursement codes for therapeutic phlebotomy are CPT 39107, icd9 code 289.0.
Unless a local blood bank is willing to help, some physicians may need to write a letter of medical necessity for phlebotomy if requested by insurance companies. If the patient is healthy and without HIV, hepatitis B, C, or other infections, they could donate blood at a blood bank.

The approximate amount of blood volume that needs to be withdrawn to restore normal values can be calculated by the following formula, courtesy of Dr. Michael Scally, an expert on testosterone side effect management. The use of the formula includes the assumption that whole blood is withdrawn. The duration over which the blood volume is withdrawn is affected by whether concurrent fluid replacement occurs.

Volume of Withdrawn Blood (cc)=
Weight (kg) × ABV×[Hgbi - Hgbf]/[(Hgbi +Hgbf)/2]
Where:
ABV = Average Blood Volume (default = 70)
Hgbi (Hcti) = Hemoglobin initial
Hgbf (Hctf) = Hemoglobin final (desired);
So, for a 70 kg (154 lbs) man (multiply lbs x 0.45359237 to get kilogram) with an initial high hemoglobin of 20 mg/mL who needs to have it brought down to a normal hemoglobin of 14 mg/mL, the calculation would be:
CC of blood volume to be withdrawn = 75 x 70 x [20 - l4]/[(20 + l4)/2] = 75 x 70 x (6/17) = approximately 1850 cc;
One unit of whole blood is around 350 to 450 cc; approximately 4 units of blood need to be withdrawn to decrease this man's hemoglobin from 20 mg/mL to 14 mg/mL.

The frequency of the phlebotomy depends on individual factors, but most men can do one every two to three months to manage their hemoglobin this way. Sometimes red blood cell production normalizes without any specific reason. It is impossible to predict exactly who is more prone to developing polycythemia, but men who use higher doses, men with higher fat percentage, and older men may have a higher incidence.

Some doctors recommend the use of a baby aspirin (81 mg) a day and 2,000 to 4,000 mg a day of omega-3 fatty acids (fish oil capsules) to help lower blood viscosity and prevent heart attacks. These can be an important part of most people's health regimen but they are not alternatives for therapeutic phlebotomy if the patient has polycythemia and does not want to stop testosterone therapy. It is concerning that many people assume that they are completely free of stroke/heart attack risks by taking aspirin and omega-3 supplements when they have a high hematocrit.

Although some people may have more headaches induced by high blood pressure or get extremely red when they exercise, most do not feel any different when they have polycythemia. This does not make it any less dangerous.

For anyone interested, I found an article
"How to Manage Polycythemia Caused by Testosterone Replacement Therapy"
by Nelson Vergel that gives a lot of details on this subject, but I'm unable to post the link.

[Gutterpump]

Great post. Just for reference (for anyone curious), I'm taking a 100mg shot once per week (in the side delt, slin pin), and a bit of test cream later on in the week, on the gonads, to boost DHT. I don't seem to have hematocrit issues with this protocol. Also, I do not use hcg.

I used to use 200mg of test per week (split into two doses), alongside 500iu of HCG. High hematocrit and E2 issues with that protocol. This was from an HRT Rx (typical cookie cutter protocol). I don't suggest following that at all.

[RipdnTxs]

Not sure where my ferritin or iron serum levels are, maybe you could expand on this a little. I had my sleep study done, they came in and woke me up after three hours and said I was stopping breathing more than 15 times an hour and I never got out of stage 1 sleep. They put the c-pap on me and I went back to sleep, I woke up at my usual time and had no headache and actually felt awake and reseted somewhat. They informed me I did get into the deep restful sleep stage while wearing the c-pap and upon waking they took my blood pressure and it was the lowest I can ever remember it being 100/60. So I am waiting to go and see my Doc. and go over the results with him and get started on the machine and maybe start feeling betr. since I wont be suffocating most of the night. The therapist said she had seen people lower or completely come off high BP meds and maybe this will help with overproduction of RBCs. It helps alot just finally knowing why I have felt tired and worn out all the time...

where are your ferritin levels and iron serum? Yep just had case of hemochromatosis which.when.undiscovered for 3 years with ferritin.levels of 280 Dr where clueless said it was not a problem. Suggested to go donate some blood 500 cc. A few days later called.me saying first time in 3 years did sleep with machine. Had more energy and cognitive function in a long time. Would not surprise me he t.levels will come up over time as its.one of the side effects of this..Finally went to good hemotologist testing positive for the gene.mutation..

[reliable]

I had a follow-up doctor visit today to review lab results: hemoglobin 17.9 (13.5 - 17.5 normal); hematocrit 52 (40-50 normal); and testosterone 1159 (280 - 1100 normal). While the values are still above normal, they're closer than they were five weeks ago. I've been trying 100 ml of test cyp every week to minimize spiking and this also spaced the dosages slightly longer compared to before. The doctor recommended a 10-day spacing and to return in two months to repeat the lab tests. If in the meantime I can donate blood, I'll do that. So the issue seems to be getting resolved!

[RipdnTxs]

Looks like ur heading in the right direction, good for you.. I went and had a double red blood cell draw at the local blood bank, my HCT was 56 and I was really red in the face,ears, and neck. I also got my sleep study results, my sleep apnea was rated as severe. I would stop breathing an average of 25 times an hour and my Oxygen levels got down as low as 84% at times. I have used the c-pap the last two nights and both mornings I have woke up with no headache and not feeling like I just want to go right back too sleep. I have also lowered my dosage to 60 every four days, so between controlling the sleep apnea and lowering the dosage I am hoping for my blood levels to stay more in the normal range. Keep us updated on ur progress.....

I had a follow-up doctor visit today to review lab results: hemoglobin 17.9 (13.5 - 17.5 normal); hematocrit 52 (40-50 normal); and testosterone 1159 (280 - 1100 normal). While the values are still above normal, they're closer than they were five weeks ago. I've been trying 100 ml of test cyp every week to minimize spiking and this also spaced the dosages slightly longer compared to before. The doctor recommended a 10-day spacing and to return in two months to repeat the lab tests. If in the meantime I can donate blood, I'll do that. So the issue seems to be getting resolved!

[The Matrix]

Not sure where my ferritin or iron serum levels are, maybe you could expand on this a little. I had my sleep study done, they came in and woke me up after three hours and said I was stopping breathing more than 15 times an hour and I never got out of stage 1 sleep. They put the c-pap on me and I went back to sleep, I woke up at my usual time and had no headache and actually felt awake and reseted somewhat. They informed me I did get into the deep restful sleep stage while wearing the c-pap and upon waking they took my blood pressure and it was the lowest I can ever remember it being 100/60. So I am waiting to go and see my Doc. and go over the results with him and get started on the machine and maybe start feeling betr. since I wont be suffocating most of the night. The therapist said she had seen people lower or completely come off high BP meds and maybe this will help with overproduction of RBCs. It helps alot just finally knowing why I have felt tired and worn out all the time...

Sleep apnea is usual a symptom of.something else usually related to low.thyroid in many cases. Correct the thyroid has resulted in reducing cpap in some cases