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While these symptoms may seem mild at first, they can be early signals of much more serious problems ahead. Untreated polycythemia can show up in everyday life with warning signs. But when blood becomes too thick, the opposite can happen. This extra workload can strain the heart, especially in older men or those with heart disease.
Hemoglobin, a protein in red blood cells, is responsible for transporting oxygen throughout the body, while hematocrit measures the proportion of red blood cells in the blood. In both groups, levels of red blood cells increase the most during the first year of treatment. An excess of testosterone can cause your body to make more red blood cells. When red blood cell levels are too high, it can lead to poor circulation and an increased risk of high blood pressure, blood clots, stroke, and heart attack. For this reason, men should never continue testosterone therapy without regular monitoring. A doctor might lower the dose, change the timing, or switch to another type of testosterone delivery that does not raise red blood cells as much. This is why regular blood work is not optional—it is a critical part of safe testosterone therapy.
At Nervana Medical, we understand the complex interplay between testosterone therapy, polycythemia, and iron deficiency. Switching from once-weekly to twice-weekly injections smooths out testosterone peaks and troughs, resulting in less stimulation of red blood cell production (El-Khatib et al., 2022; Okano et al., 2025). At Nervana Medical, we often see this pattern in men on testosterone therapy who undergo repeated phlebotomy and need iron treatment to battle their fatigue despite having optimized their testosterone.
That is why men on testosterone replacement are often advised to have regular blood checks. While this can sometimes improve energy levels and reduce anemia in men with low testosterone, it can also push hematocrit levels too high. When the hematocrit level rises above 52–54% in men, doctors usually consider this polycythemia.
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. 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). Regular testing can also let you know if your red blood cell production stabilizes.
It will explore the causes, identification, and monitoring of polycythemia, alongside discussing practical strategies for managing this condition. These metrics provide critical insights into the body’s response to TRT and the potential development of polycythemia. Excessive RBCs make the blood more viscous or "sticky," posing challenges for the heart in pumping blood efficiently. While an increase in RBCs can be beneficial for those with conditions like mild anemia, it presents risks for individuals without such conditions. However, this therapy is not without its complexities and potential side effects, one of which is polycythemia. Treatment of hypogonadal men with Intranasal T Natesto and testosterone cypionate successfully achieved target serum T level and maintained HCT levels. What is unknown is whether the short-acting vs. long-acting testosterone preparations have different effects on hematocrit.
However, its possibility necessitates careful monitoring and management to prevent potential complications. Not every individual undergoing TRT will experience polycythemia. We evaluated data from two simultaneous ongoing open-label, randomized, two-arm clinical trials to evaluate the impact of TRT on Hematocrit and compared prevalence rates of polycythemia among subcutaneous T pellets (long-acting) and Intranasal Testosterone (Natesto) or Intramuscular Testosterone cypionate (TC) (short-acting). The most commonly reported adverse event among men using TRT is polycythemia. Always consult a physician or qualified health professional on any matters regarding your health or on any opinions expressed within this website. It is not intended to diagnose, treat, cure, or prevent any health problem.
For instance, smoking cessation, maintaining adequate hydration, and engaging in regular exercise can help manage polycythemia. In cases where polycythemia develops, options like therapeutic phlebotomy – a procedure akin to blood donation that helps reduce blood viscosity – can be considered. Abruptly stopping TRT could lead to the return of these distressing symptoms, undoing the therapy’s benefits. Starting with baseline measurements, followed by regular monitoring at appropriate intervals, is key to managing TRT effectively. Testing for polycythemia in TRT patients is a dynamic process that requires careful planning and individualized attention. Continuous monitoring is not just about detecting polycythemia; it’s about managing it proactively.