• by Bradley Keys
  • March 31, 2024
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Managing hematocrit levels is crucial for those on testosterone replacement therapy (TRT). Elevated hematocrit can increase health risks, making it essential to find effective interventions. Focused on this need, our guide discusses how to lower hematocrit while on TRT, offering practical solutions that blend with your treatment to ensure optimal health outcomes.

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Understanding Hematocrit and Its Importance in TRT

Illustration of red blood cells flowing through blood vessels

Hematocrit refers to the proportion of red blood cells in your blood, a critical indicator of your body’s ability to transport life-giving oxygen to every cell. Think of red blood cells as the vehicles on a highway, with hematocrit measuring the traffic density. Too little and you’re not delivering enough passengers (oxygen); too much, and you risk a standstill—a situation equally dire. Hemoglobin, the iron-based protein within these cells, is the actual carrier of oxygen, and its concentration in your blood aligns with the hematocrit, determining just how much oxygen you can transport throughout your body. While white blood cells play a crucial role in immunity, it’s the red blood cells that are responsible for oxygen transportation.

Adding testosterone replacement therapy TRT to the equation changes the scenario. TRT can act like a traffic controller, influencing the number of red blood cells in circulation. While this can be beneficial for those with low testosterone levels and red blood cell count, it’s a delicate balance to maintain. Typical hematocrit values range from 41% to 50% for adult males and 36% to 44% for adult females, painting a picture of the normal ebb and flow of our circulatory traffic.

For anyone undergoing TRT, grasping this complex equilibrium is vital.

Further examination reveals that testosterone therapy stimulates red blood cell production, much like fertilizer promoting a bloom in our bloodstream. This bloom may lead to a thickening of the blood, a condition with potential cardiovascular risks that we’d rather avoid. Specifically, testosterone stokes the fires of erythropoiesis, the process of creating new red blood cells, which can be more pronounced in the veins of older men. It’s a double-edged sword: the therapy that restores vigor can also lead to erythrocytosis, characterized by elevated hemoglobin and hematocrit levels, and sometimes independent of usual suspects like erythropoietin.

To ease the burden of this burgeoning red cell population, blood donation emerges as a surprisingly simple yet effective solution, helping to decrease the red blood cell count and mitigate the condition. The interplay between TRT, hematocrit, and bone marrow is a delicate dance—one that requires careful choreography to maintain the health and harmony of our circulatory system.

Regular Monitoring: Key to Managing Hematocrit on TRT

Like any well-functioning system, regular monitoring is crucial. For those undergoing testosterone therapy, this means keeping a vigilant eye on hematocrit levels through routine blood tests, ensuring they remain within the boundaries of safety. Such surveillance allows us to promptly catch any upward trends in hematocrit, which in turn enables us to adjust our TRT regimen accordingly, potentially incorporating micro-dosing strategies to manage the issue.

Simple Blood Test Frequency

Before starting treatment, the first step in managing hematocrit on TRT is setting a clear baseline. This initial measure serves as the yardstick against which all future levels will be compared. After the therapy wheels are in motion, hematocrit levels should be checked at three critical intervals: at 3, 6, and 12 months, ensuring any significant changes are caught in their tracks. Beyond the inaugural year, a yearly check-up is the recommended cadence for keeping hematocrit levels under a watchful lens.

While routine, these simple blood tests function similarly to the regular maintenance checks of a high-performance vehicle, ensuring everything runs smoothly and no red flags are waving unnoticed. It’s a non-negotiable aspect of TRT, one that safeguards against the potential risks associated with elevated hematocrit.

Interpreting Hematocrit Value

Once the test results arrive, interpreting your hematocrit value becomes as significant as the test. For adult men, a hematocrit level ranging from 41% to 54% is considered normal, while for adult women, the range is slightly lower, from 36% to 48%. This percentage reflects the volume of red blood cells in your blood, providing clues not only about your body’s ability to transport oxygen but also about your hydration status and hemoglobin levels.

A handy rule of thumb is that hematocrit should be roughly three times the value of hemoglobin; significant deviations from this ratio could suggest either dehydration or over-hydration, both of which can impact your overall health.

Reading between the lines of your hematocrit values can reveal stories of your body’s inner workings, stories that can guide adjustments in your TRT journey and ensure you’re navigating the path with the best possible map at your disposal.

Therapeutic Phlebotomy: A Direct Approach to Lowering Hematocrit

Illustration of therapeutic phlebotomy procedure

Therapeutic phlebotomy emerges as a direct and potent strategy for those with high hematocrit. This procedure, reminiscent of donating blood, targets the removal of red blood cells to alleviate the thickening of the blood. When the hematocrit level crosses the threshold of 54%, phlebotomy is often the go-to strategy to bring the levels down, offering a complementary approach to modifying TRT doses. The process, which typically involves the removal of 450 to 1000 mL of blood, can lower hematocrit by approximately 3% per session, helping to reduce blood viscosity and associated risks.

While the procedure is generally well-tolerated, side effects such as bruising, soreness, or fatigue may occur, akin to the sensations some experience after a blood donation. It’s worth noting that while therapeutic phlebotomy is widely used, it’s not a one-size-fits-all solution; certain conditions like severe heart disease, pre-existing anemia, or blood clots may present contraindications, and alternative treatments like red cell depletion could be explored in such cases.

Lifestyle Adjustments to Manage Hematocrit Levels

Besides clinical approaches to managing hematocrit, a myriad of lifestyle changes can positively impact your hematocrit levels. Staying well-hydrated is a simple yet effective strategy, as sufficient water intake can reduce blood thickness and, by extension, hematocrit levels. It’s a matter of keeping the highways of your circulatory system clear and flowing, preventing the traffic jams that high hematocrit levels can cause.

Coupled with hydration, moderate exercise plays a supportive role in regulating hematocrit. By enhancing circulation and increasing the volume of oxygen-rich blood, exercises such as walking, cycling, or swimming can help maintain hematocrit levels within the desired range. Starting with lower intensity and gradually building up is the key to harnessing the benefits of exercise without overburdening the heart.

Medications and Supplements That Can Help

In the realm of medications and supplements, some can play a pivotal role in managing hematocrit. Here are a few examples:

  • Hydroxyurea: has shown effectiveness in reducing elevated hematocrit levels, especially in conditions like polycythemia vera.
  • Losartan: emerges as another potential aid in the fight against high hematocrit, particularly for those grappling with high blood pressure and looking to treat high blood pressure.
  • Curcumin: a supplement that can bind to iron and reduce its availability for red blood cell production, potentially lowering hemoglobin and hematocrit levels.

While these interventions might seem promising, it’s imperative to navigate them under the guidance of a healthcare professional. Medications like hydroxyurea may be discontinued if the response is inadequate or if tolerance issues arise, and the use of supplements should be approached with the same level of scrutiny and monitoring.

Adjusting the TRT Dose: Balancing Testosterone Levels and Hematocrit

The fine-tuning of the TRT dose becomes crucial as we delve into understanding the balance between testosterone and hematocrit levels. Our body’s response to testosterone therapy is not a static affair; hematocrit levels tend to rise in a linear fashion with the dosage, starting as early as one month into treatment. Older men, in particular, may experience a more pronounced increase, highlighting the need for a tailored approach that takes into account the individual’s age and unique response to testosterone.

If the hematocrit level dips below the 50% mark without secondary causes of erythrocytosis, it may be safe to resume testosterone therapy at a reduced dose, carefully calibrating the amount to maintain a healthy balance. Whether it’s through gels, intramuscular testosterone injections, or oral medications, all forms of testosterone therapy have the potential to increase hematocrit, with the aim being to keep the rise within manageable limits. The median doses for injectables and topicals are set at 83.3 mg/week and 4.2 mg/week, respectively, serving as a starting point for dose adjustments.

The Role of Diet in Controlling Hematocrit

Iron deficiency, a common issue, can significantly impact hematocrit levels. Testosterone therapy can enhance the body’s iron absorption and incorporation into red blood cells, paving the way for increased hemoglobin synthesis and, consequently, elevated hematocrit levels. To counteract this effect, managing iron intake becomes essential, with tactics such as limiting red meat consumption and avoiding unnecessary iron supplements. The introduction of dietary elements like bran, which interfere with iron absorption, offers another avenue to potentially reduce hematocrit levels.

Beyond iron management, the consumption of grapefruit, rich in the flavonoid naringin, may aid in the natural removal of red blood cells, thus lending a hand in lowering hematocrit. Abstaining from alcohol is yet another dietary consideration that can contribute to hematocrit control, weaving together a tapestry of nutritional strategies to maintain optimal blood health.

Donating Blood to Reduce Hematocrit

Illustration of blood donation process

Donating blood, while inherently altruistic, can also be therapeutic for those on TRT, assisting in hematocrit management. By reducing the number of red blood cells, blood donation can prevent complications associated with elevated hematocrit like increased blood viscosity and cardiovascular disease. Regular blood donations also manage iron levels, helping to stave off issues like liver damage due to iron overload. Each pint of blood given can lead to a 3-point drop in hematocrit, offering a substantial benefit to those monitoring their levels. So, if you’re considering to donate blood, remember that it not only helps others but also provides health benefits for the donor.

While frequent donations can be tempting as a quick fix, it’s essential to pace them to avoid symptoms like prolonged fatigue. A schedule of donating every eight weeks, up to six times a year, strikes a balance between therapeutic benefit and personal health, ensuring donations remain a safe and effective tool for managing hematocrit. Consulting with healthcare providers can help tailor a donation schedule that best suits individual circumstances, often falling between every 60 to 90 days for those on TRT with elevated hematocrit levels.

Addressing Underlying Health Conditions

Occasionally, high hematocrit levels stem from underlying health conditions, and addressing these can naturally lower hematocrit. Smoking, for example, diminishes the blood’s oxygen-carrying capacity, prompting the body to produce more red blood cells to compensate—quitting smoking, therefore, can have a direct positive impact on hematocrit levels. Relocating from higher to lower altitudes also contributes to lower hematocrit due to the increased oxygen availability at lower elevations.

Chronic exposure to carbon monoxide and conditions such as sleep apnea, which induce repeated breathing interruptions during sleep, can also lead to elevated hematocrit, underscoring the importance of avoiding harmful exposures and treating underlying sleep disorders. Addressing these underlying conditions not only contributes to overall health but also aids in the management of hematocrit levels during TRT.

When to Seek Medical Advice

Managing hematocrit levels on TRT can be a challenging journey. Symptoms like fatigue, headaches, or chest discomfort could be harbingers of hematological conditions like polycythemia and warrant a conversation with a healthcare professional. The urgency amplifies when signs of more serious concerns such as deep vein thrombosis, heart attack, or stroke rear their heads, marked by pain, swelling, breathlessness, or sudden numbness, where seeking immediate medical attention is paramount.

If there’s a significant deviation from the normal hematocrit values, whether higher or lower, it’s time to seek the expertise of a healthcare provider for further evaluation and treatment. The journey of TRT is unique for each individual, and at times, the guidance of a medical professional is the compass needed to navigate the complex terrain of hematocrit management.


As we reach the end of our journey together, it’s clear that understanding and managing hematocrit levels is a pivotal aspect of testosterone replacement therapy. We’ve explored the physiological interplay between testosterone and red blood cell production, the importance of regular monitoring, and direct interventions like therapeutic phlebotomy. We’ve also discussed how lifestyle choices, dietary adjustments, and certain medications can influence hematocrit levels. Remember, individual responses to TRT will vary, and it’s crucial to maintain open communication with your healthcare provider to ensure a safe and effective treatment plan.  Visit our TRT clinic in Los Angeles today!

Frequently Asked Questions

To treat high hematocrit on TRT, it is recommended to consider regular therapeutic phlebotomy every 8-12 weeks, which can lower hematocrit by around 3%. Additionally, baseline and serial hematocrit values should be monitored, and if the value exceeds 54%, discontinuation of testosterone and phlebotomy may be necessary.

A hematocrit level of 51 is considered high, as normal levels for men range from 41% to 50% and for women from 36% to 48%. Therefore, it is important to consult a healthcare professional for further evaluation and guidance.

Yes, according to recent studies, ingestion of grapefruit has been shown to lower elevated hematocrit levels in human subjects.

Yes, a steady intake of water can lead to an increase in hemoglobin indices and a decrease in MPV, but the impact on hematocrit and hemoglobin levels may not be significant.

The normal hematocrit level for men on TRT typically ranges from 41% to 54%. Regular monitoring is crucial as TRT can elevate these levels, potentially requiring treatment adjustments if they exceed the normal range.

About the Author

Bradley Keys
Bradley Keys

Bradley Keys is an accomplished writer who has covered a wide variety of health, nutrition, and wellness topics including mens health. He graduated with a Bachelor of Science from Florida State University, and has extensively explored a diverse range of subjects within the realms of health, wellness, and nutritional supplementation, showcasing a broad and in-depth understanding of these interconnected fields.

Reviewed By

Majid Sabour, MD
Majid Sabour, MD

Majid Sabour, MD, is the founder and medical director of Gent's Doctor mens clinic in Beverly Hills, California. Dr. Sabour is board-certified in family medicine and provides exceptional anti-aging and wellness services that help patients in Los Angeles look and feel their best. With over 25 years of field experience, Dr. Sabour graduated from Zaporizhzhia State Medical University in Ukraine and completed a family medicine residency program with Columbia University and Cornell at New York-Presbyterian Hospital in Manhattan. He is licensed in both New York and California.