How to Manage Polycythemia Caused by TRT

While patients on a Testosterone Replacement Therapy (TRT) protocol typically report symptom relief and improved quality of life, there are also potential side effects.

One is that TRT can sometimes cause a blood-building effect, which means the body produces more red blood cells.

This can be a good thing for those with mild anemia. But for those without anemia, it can cause the blood to become viscous or "sticky," making it harder for the heart to pump. This condition is called polycythemia.

Polycythemia can lead to high blood pressure and, in certain scenarios, an increased risk of stroke and heart attack.

This condition does not affect every TRT patient, but it’s important to be aware of it, and to engage in regular monitoring and preventative care to avoid any complications.

If you’re on a TRT protocol, you doctor should closely monitor your hemoglobin and hematocrit levels via periodic bloodwork to catch any signs of polycythemia.

If your levels indicate this condition, there are ways to manage polycythemia caused by TRT.

Why is Polycythemia a Potential Side Effect of TRT?

As Testosterone Replacement Therapy (TRT) becomes increasingly popular, there has been an increase of reports associating TRT with polycythemia.

But why does TRT potentially lead to polycythemia?

In addition to regulating body composition and sex drive, Testosterone can increase the body's production of red blood cells (RBC). When you raise your Testosterone levels, you may also increase your RBC count.

Although all Testosterone delivery systems can increase the amount of red blood cells, studies show a higher incidence of polycythemia in those using intramuscular Testosterone injections compared to Testosterone patches.

Smoking has also been associated with polycythemia and may contribute to this condition. If you’re a smoker and you’re on TRT, consider a smoking cessation program.

Strategies to Manage Polycythemia

The first step in preventing and addressing polycythemia is to work with a provider who regularly tests your hemoglobin and hematocrit. These two factors are the best indication of increased red blood cell production.

Hemoglobin is a protein on red blood cells that is responsible for transporting oxygen to the tissues and organs throughout the body, and for carrying carbon dioxide back to the lungs. Average hemoglobin ranges are 13.5 to 17.5 grams per deciliter for adult men, and 12 to 15.5 grams per deciliter for adult women.

Hematocrit measures the proportion of red blood cells compared to total blood volume. A hematocrit test is sometimes called a packed-cell volume (PCV) test. You find the percentage of hematocrit by comparing the measurement of the packed red blood cells versus the entire blood column. Ideal hematocrit ranges vary based on factors like gender and race, but the average range for adult men is 41%-50%, while the average range for adult women is 36%-44%.

Any hematocrit result above the recommended range should be evaluated, especially results over 52%.

When to Test for Polycythemia

Typically, you should test your hemoglobin and hematocrit before starting TRT to establish a baseline. Then, you and your provider should test again three months after beginning your TRT protocol.

After that, many established TRT patients move to checking hemoglobin and hematocrit every six months. (Patient protocols may vary based on individual responses, and you should always follow your provider’s guidance).

Should You Stop TRT if You Have a High Red Blood Cell Count?

For many patients, stopping their TRT protocol isn’t the best option.

Patients typically start TRT to address life-derailing symptoms of Testosterone imbalance, including low sex drive, sexual dysfunction, lack of energy and fatigue, fat gain, and more. Without TRT, these unwanted symptoms often return.

You may also wonder if you should switch from injections to topical Testosterone, since the latter seems to have less effect on hematocrit. Many patients don’t like this option, either, because their injection protocol is effective at reducing their hormone imbalance symptoms.

So, what can you do to address polycythemia caused by TRT?

Therapeutic Phlebotomy for Polycythemia

Therapeutic phlebotomy is often an effective option for TRT patients with polycythemia.

Therapeutic phlebotomy is similar donating blood, but this procedure is prescribed by physicians as a way to bring down blood hematocrit and viscosity. Removing one pint of blood generally lowers hematocrit by around 3% (results vary by patient).

Depending on your unique circumstances, your provider may recommend regular therapeutic phlebotomy every 8-12 weeks.

The procedure is simple and performed in the same manner as a blood donation. Successful therapeutic phlebotomy typically decreases hematocrit, hemoglobin, and blood iron in less than one hour.

Is therapeutic phlebotomy covered by insurance?

Unfortunately, it can be difficult to qualify for reimbursement, or to get therapeutic phlebotomy covered by insurance.

Some physicians may write a letter of medical necessity, which the patient can take to their insurance company to justify the procedure. The CPT reimbursement codes for therapeutic phlebotomy are CPT 39107, icd9 code 289.0.

(Note: Defy Medical is a concierge clinic and does not process or accept insurance, or contact insurance companies. Patients can speak with their insurance carrier directly to see if any procedures or therapies are eligible for reimbursement.)

Another Option to Treat Polycythemia: Donating Blood

Healthy patients who are eligible to donate blood can take this route. Since the process is very similar to therapeutic phlebotomy, it typically has the same effect. 

Eligibility requirements for donating blood usually include:

• Being in good health without conditions like common colds, HIV, Hepatitis, and other illnesses or infections.
• Avoiding travel outside of the country to areas with high Malaria risk.
• Having adequate iron levels, without anemia.
• Other requirements depending on the organization collecting blood.

Whole blood donors can typically donate every eight weeks, or up to six times per year.

How Often Should I Donate Blood or Receive Therapeutic Phlebotomy?

The frequency of the phlebotomy depends on individual factors, and your provider should work with you to develop a customized plan.

In general, a blood draw every two to three months is typically recommended for TRT patients experiencing polycythemia. It’s important not to overdraw blood, because doing so can lead to anemia, iron deficiency, and other conditions.

You and your provider should continue measuring your hematocrit and hemoglobin after beginning therapeutic phlebotomy. Your tests results help identify whether the treatment is sufficient.

Regular testing can also let you know if your red blood cell production stabilizes. Sometimes RBC production can normalize without any specific cause.

Who is Most Likely to Experience Polycythemia as a TRT Side Effect?

 It’s impossible to predict exactly who will be prone to developing polycythemia. However, these factors may play a role:

• Higher Testosterone doses in your TRT protocol
• An elevated body fat percentage
• Advanced age
• Behavioral factors like smoking

People with elevated red blood cell production may have symptoms including:

• High blood pressure and an increase in headaches
• Becoming red-faced and flushed during exercise or exertion
• Fatigue, lack of energy, and dizziness
• Shortness of breath when lying down

Just as often, patients with polycythemia show NO symptoms. That’s why careful testing over time is the best way to diagnose and treat this condition.

Are There Other Causes of Polycythemia Besides TRT?

There are different types of polycythemia, which can be caused by different things.

Primary polycythemia occurs because of a genetic mutation inside the bone marrow, which causes it to overproduce red blood cells.

Secondary polycythemia can be caused by:

• Smoking
• Sleep apnea or a breathing obstruction
• Chronic Obstructive Pulmonary Disease (COPD)
• Lung disease
• Heart or cardiovascular disease
• Certain cancers and/or endocrine tumors
• Performance enhancing drugs

Your risk of developing polycythemia may increase if you have any of these conditions and also begin Testosterone Replacement Therapy.

Are There Other Treatments for Polycythemia?

For general heart health and to help prevent heart attacks, some doctors may recommend daily aspirin and/or omega-3 fatty acids (fish oil capsules).

These can be an important part of a heart health regimen, but they are not typically alternatives for therapeutic phlebotomy if you have polycythemia and want to continue TRT.

There are prescription medications that slow the production of red blood cells directly, but patients often prefer trying therapeutic phlebotomy first. The latter has a good safety profile and has been shown to be effective for many patients.  

Expertly Guided TRT with Defy Medical

The key to identifying and managing polycythemia is to work with an experienced provider who monitors your hematocrit and hemoglobin levels and recommends treatment based on the results. This is why individualized care with regular follow-up is so important for a successful TRT protocol.

With Defy Medical, you access telemedicine consultations with Men’s Health experts who can provide on-going guidance. You also access online ordering and doorstep delivery of medications, and a Patient Care team accessible by phone and email who can answer questions and guide you through your protocol.

Want to learn more about polycythemia and TRT, or consult with an expert about how to manage it? Get started today.