Page 2 - High Hematocrit

Testosterone replacement therapy can be a great way to improve your health and vitality, but certain risks areassociated with it. One of the most important things you need to monitor when taking testosterone is your hematocrit levels. High hematocrit is one potential side effect of testosterone treatment that should not be ignored or overlooked, as it can lead to serious health complications if left untreated. In this blog post, we'll go over what high hematocrit is, how testosterone replacement therapy raises hematocrit levels, and how to reduce high hematocrit due to testosterone treatment so that you can benefit from all the advantages of hormone optimization safely and effectively. Table of Contents: What is Hematocrit? Definition of Hematocrit: How Does Testosterone Replacement Therapy Increase Hematocrit? a. Effects of Testosterone on Red Blood Cells: How to Lower High Hematocrit Caused by Testosterone Treatment? Monitoring and Managing High Hematocrit Levels with Testosterone Replacement Therapy Regular Blood Tests to Monitor Hematocrit Levels: Conclusion FAQs in Relation to High Hematocrit Should I worry if my hematocrit is high? What can cause high hematocrit? What are symptoms of high hematocrit? How do you treat high hematocrit levels? Conclusion What is Hematocrit? Hematocrit measures the percentage of red blood cells in your body. It’s an important indicator of overall health and can help diagnose various conditions, such as anemia or dehydration. Definition of Hematocrit: Hematocrit is a measure that reflects the ratio between the volume of red blood cells (RBC) and the total volume of whole blood in your body. The hematocrit value is expressed as a percentage, with normal values ranging from 40 to 54 percent for men and 36 to 48 percent for women. How is Hematocrit Measured? A hematocrit test measures how much space red blood cells take up in your bloodstream by spinning down a blood sample in a centrifuge machine. This separates different components within the sample, including RBCs, white blood cells (WBCs), platelets, and plasma. The amount of packed RBCs compared to other components gives you your hematocrit value. Normal ranges vary slightly depending on age and gender but generally range from 40–54% for men and 36-48% for women. Low levels could be a sign of anemia or bleeding disorders, whereas high levels might be the result of dehydration or specific cancer treatments like chemotherapy or radiation therapy. Hematocrit is an important measure of health and can be increased through testosterone replacement therapy. However, it is important to understand the potential risks associated with high hematocrit levels before beginning treatment. How Does Testosterone Replacement Therapy Increase Hematocrit? TRT has been found to have numerous health benefits, including improved energy levels, increased muscle mass and strength, and improved sexual function. One of the most important effects of TRT is an increase in hematocrit, which is the percentage of red blood cells in your bloodstream. a. Effects of Testosterone on Red Blood Cells: Testosterone helps stimulate the production of red blood cells by increasing the number of stem cells that produce them. It also increases their lifespan so they can circulate longer throughout your body before being broken down and replaced by new ones. This leads to an overall increase in hematocrit levels as more red blood cells are present in your bloodstream at any time. An increased hematocrit level can provide many benefits, such as better oxygen delivery throughout the body, improved stamina during physical activity, and reduced risk for certain diseases like heart disease or stroke due to higher amounts of oxygen-carrying red blood cells circulating through your system at all times. Additionally, some studies suggest that higher hematocrit may even improve cognitive performance since it provides more oxygen to the brain for mental processes like memory formation or problem-solving skills Testosterone replacement therapy can increase hematocrit levels, but it is important to know the potential risks associated with high hematocrit. We'll talk about lowering a high hematocrit that results from testosterone therapy in the following section. In a study done by Dr. Ramasamy and his team at the University of Miami Medical School, a total of 5,842 men who received TRT and developed polycythemia were matched and compared to 5,842 men who did not develop polycythemia. Heart problems or venous thromboembolism - VTE were more likely to happen to men with polycythemia (301 cases, or 5.15% of all cases) while they were on TRT than to men with a normal hematocrit (226 cases, or 3.87%) (OR 1.35, 95% CI 1.13–1.61, p <0.001). The same team later found out that greater changes in hematocrit predicted greater cardiovascular risks in men on testosterone therapy.   Key Takeaway: Testosterone replacement therapy (TRT) increases hematocrit levels, providing numerous benefits such as improved oxygen delivery throughout the body, increased stamina during physical activity, and better cognitive performance. How to Lower High Hematocrit Caused by Testosterone Treatment? High hematocrit levels caused by testosterone treatment can be a serious health concern. It is important to understand the causes and treatments available for this condition. Some physicians and TRT guidelines believe that stopping TRT is the best way to lower hematocrit.  But stopping TRT can have negative consequences for the quality of life, as men who do so tend to stay hypogonadal for months, and most do not return to “normal levels.”  Fortunately, there are several ways to decrease high hematocrit and potentially prevent it. How Can High Hematocrit Be Reduced Due to Testosterone Therapy? A severe health hazard might result from high hematocrit levels brought on by testosterone therapy. Understanding the underlying causes and available therapies for this illness is crucial. TRT guidelines and several doctors concur that the best strategy to reduce hematocrit is to cease TRT. However, discontinuing TRT can harm a man's quality of life because most men who discontinue TRT do not revert to "normal levels" and instead tend to stay hypogonadal for months. Fortunately, there are a number of strategies to lower high hematocrit and avoid it. Donate blood. Men on testosterone therapy can lower their hemoglobin levels with this tried-and-true method. And while you're doing it, you're helping someone else! Every donated unit of blood can reduce hematocrit by three points. Be careful not to donate more frequently than every 2.5 months, as the Red Cross advises, to prevent losing too much iron and ferritin, which can cause fatigue in men taking testosterone therapy. This iron blood test allows you to determine your iron and ferritin levels. It is advised that you donate when your hematocrit is between 51 and 52 percent. If you want to donate blood, you should avoid having a hematocrit above 53% because some organizations (like the Red Cross) would reject blood at that level. Men whose high hematocrit disqualifies them from blood donations may still donate blood if their doctors request therapeutic phlebotomy at the nearby blood center. Reduce the TRT dose. Your doctor could tell you to lower your dose if you have high hemoglobin or hematocrit levels as a result of testosterone therapy. This is not always a negative thing because some men take more testosterone than they need, which can have both long-term and short-term side effects. Make sure you drink water. It's critical to keep in mind that hematocrit is highly dependent on the amount of water you drink. This might have made things worse if you were already dehydrated when you had your blood drawn. Talk to your doctor about a repeat test if you believe you were dehydrated. Address thyroid problems. Your RBC counts can decrease with hypothyroidism (low thyroid function) and increase with hyperthyroidism (high thyroid function). Doing this could be a good idea if you have yet to examine your thyroid function. And if you can afford it, have a complete thyroid panel, including thyroid antibodies. [10] Think about testosterone applied topically to the skin. According to a research summary, intramuscular testosterone injections are the only form of testosterone that significantly raises hematocrit above normal levels. Topical testosterone creams or gels often do not have this effect. However, it does so strongly, changing up to 6% from the starting point. The testosterone gel comes in second place, with a 2.5% average increase over baseline levels. [7]. Therefore, switching to topicals may help if you are receiving intramuscular injections and experiencing high hematocrit or hemoglobin. Discuss this with your doctor. COMPOUND TESTOSTERONE CREAM AND GEL IS A CHEAP ALTERNATIVE Change from intramuscular to lower dose testosterone subcutaneous injections. 236 men participated in a study that the University of California conducted. All men's baseline values in each of the four measurement locations were noted, as well as those between 6 and 12 weeks after therapy. According to the findings, males who received subcutaneous testosterone injections (SubQ) exhibited an increase in total testosterone levels that was 14% greater than that of patients who had intramuscular testosterone injections (IM). Additionally, post-therapy, hematocrit was 41% lower in SubQ patients than in IM patients, and estradiol levels were 26.5% lower. No PSA readings were abnormally high in any group of men.  Steer clear of or consume less red meat. It's fascinating because one of the arguments used by meat eaters against vegetarians is that plant meals include a lot of "anti-nutrients" that might inhibit the absorption of or bind to minerals like iron. For instance, groups like Weston Price criticize vegetarians for consuming phytic acid. Plant foods contain phytic acid, which binds to calcium, magnesium, phosphorus, and iron. Mineral deficits may result from overuse. Dr. Bernard notes that because certain minerals, like zinc and iron, are neurotoxic at even very modest levels of tissue accumulation, they are often likely to be highly health protective for most people. Additionally, studies have demonstrated a connection between colon cancer, too much iron, and heart problems. If no other preventive measures are taken, avoiding red meats, which are heavy in iron, stands a decent chance of decreasing your hemoglobin levels and preserving your long-term health (such as by giving blood). The validity of this claim requires dietary research. Females had significantly lower hemoglobin levels, according to a study that compared vegetarians and non-vegetarians. Although it could not have been statistically significant, males had lower amounts. It was found in a more solid study that vegetarians had much lower levels of white blood cells, neutrophils, serum ferritin, and serum vitamin B12 compared to control patients. Vegetarians also had much lower levels of hematocrit and mean corpuscular hemoglobin. By the way, ferritin is a crucial indicator since it shows that tissue iron levels are lower, which suggests that there will likely be less long-term harm. It should be emphasized that this study did reveal that some vegans were iron deficient. Correct sleep apnea. Depleted oxygen saturation levels brought on by sleep apnea may encourage the body to create more red blood cells and hemoglobin in an effort to make up for the low oxygen levels in the blood during sleep. Indeed, there is research that backs this up as well.  Consider having a sleep apnea test done if your hematocrit, hemoglobin, or RBC levels are high. "One possible explanation is that repeated episodes of nocturnal hypoxia (low oxygen status) lead to a hypercoagulable state that predisposes individuals to thrombotic (blood clotting) events," a recent study stated. Research backs up a number of changes in the blood that affect hemostasis. These include higher hematocrit, blood viscosity, platelet activation, clotting factors, and lower fibrinolytic activity. Minimize inflammationInflammation can further reduce hepcidin, the hormone that controls iron absorption. It could be helpful to check for infections, CRP levels, etc., before treating the underlying reason. [13] Think about Curcumin (Turmeric).More research is being done on turmeric, or curcumin, as an anti-inflammatory and anti-cancer substance. It produces iron shortage in mice by binding to ferric iron in the stomach. According to a case study, a person consuming turmeric may have had iron deficiency anemia. Stop smoking. Smoking lowers the blood's oxygen saturation, which causes the body to create more red blood cells and hemoglobin to make up for it. [14] Talk to your doctor about Losartan, which is used to treat high blood pressure. You should think about taking Losartan if you have high blood pressure. [15] In patients with COPD and erythrocytosis, losartan can be administered safely and efficiently to normalize hematocrit, which may eliminate the requirement for therapeutic phlebotomy. Eat grapefruit. Grapefruit extract (narigin) may lower the hematocrit [16]. Although there was no discernible difference between eating half or a whole grapefruit each day, the effect of grapefruit consumption on hematocrit was statistically significant at the p 0.01 level. However, bring up with your doctor the possibility that grapefruit may elevate drug levels in the blood. Monitoring and Managing High Hematocrit Levels with Testosterone Replacement Therapy It is essential to monitor hematocrit levels while on testosterone replacement therapy (TRT). TRT can have an impact on hematocrit, which measures the quantity of red blood cells in the body. Regular blood tests should ensure that hematocrit levels remain within normal range. If high hematocrit levels are detected, some steps canbe taken to manage them. Regular Blood Tests to Monitor Hematocrit Level: It is recommended that men on TRT have their hematocrit tested every 3–6 months or more frequently if needed. This will help identify any potential issues with high hematocrit early on so they can be addressed quickly and effectively. High hematocrit may indicate an underlying medical condition such as polycythemia vera, which requires further evaluation and treatment from a healthcare provider. Adjusting Dosage or Frequency of Testosterone Injections as Needed: If high hematocrit levels are found during regular testing, adjusting the dosage or frequency of testosterone injections may help lower them back into the normal range. For example, reducing the dose or spacing out injections over longer periods of time could reduce the risk for complications associated with elevated hemoglobin and/or red cell counts due to TRT use. Additionally, lifestyle changes such as increasing physical activity level and making dietary modifications may also help lower high hematocritevels caused by TRT use. By closely monitoring hematocrit levels and adjusting testosterone dosage or frequency as needed, men can successfully manage high hematocrit levels while undergoing testosterone replacement therapy. Next, we'll discuss the key points to remember when managing this condition.   Key Takeaway: Regular blood tests should be done to monitor hematocrit levels while on TRT. If high hematocrit is detected, adjusting the dosage or frequency of testosterone injections and making lifestyle changes may help lower them back into normal range.   FAQs in Relation to High Hematocrit Should I worry if my hematocrit is high? Yes, you should be concerned if your hematocrit is high. Hematocrit is a measure of the number of red blood cells in your body and can indicate an underlying health issue. High levels may mean that there are too many red blood cells in circulation, which can lead to thickening of the blood and other serious complications such as stroke or heart attack. It's important to speak with your doctor about any concerns regarding your hematocrit level so they can determine the best course of action for managing it. What can cause high hematocrit? Dehydration, testosterone therapy, smoking, polycythemia vera (an overproduction of red blood cells), and specific medications are just a few of the things that can cause high hematocrit levels. Dehydration occurs when the body does not have enough fluids to function properly. Smoking increases the production of red blood cells in the bone marrow. Polycythemia vera is an uncommon disorder that causes too many red blood cells to be produced in the bone marrow. Certain medications, such as erythropoietin or testosterone, may also cause high hematocrit levels due to the increased production of red blood cells in response to these drugs. What are the symptoms of high hematocrit? High hematocrit is a condition where the percentage of red blood cells in the bloodstream is higher than normal. Symptoms can include fatigue, shortness of breath, dizziness, headaches, and pale skin. In more severe cases, it can lead to chest pain or heart palpitations due to an increased risk of clotting. It is important to seek medical attention if any symptoms are present, as high hematocrit levels can be indicative of underlying health conditions such as anemia or dehydration. How do you treat high hematocrit levels? High hematocrit levels can be treated by making lifestyle changes, such as reducing alcohol consumption and increasing physical activity. Additionally, medications may be prescribed to reduce the production of red blood cells or increase their breakdown. Other treatments include phlebotomy (the removal of excess red blood cells) and iron chelation therapy (the removal of excess iron). It is important to speak with a doctor about the best treatment plan for high hematocrit levels, as it will depend on the individual's medical history and current health status. Conclusion In conclusion, high hematocrit is a common side effect of testosterone replacement therapy and should be monitored closely. It's crucial to comprehend what hematocrit is, how testosterone replacement therapy raises it, and how to lower a high hematocrit that results from testosterone treatment. With proper monitoring and management of your levels with the help of your doctor or healthcare provider, you can reduce the risk of any health complications associated with elevated levels of hematocrit due to testosterone replacement therapy. Are you suffering from high hematocrit? ExcelMale is here to help. Our online men's health forum provides a wealth of knowledge and resources on testosterone replacement therapy, general health, and sexual dysfunction. Join our community today to get the support you need for managing your condition and improving your overall wellbeing. Register for this TRT forum .   REFERENCES   Secondary Polycythemia in Men Receiving Testosterone Therapy Increases Risk of Major Adverse Cardiovascular Events and Venous Thromboembolism in the First Year of Therapy GREATER CHANGES IN HEMATOCRIT PREDICT MORE FREQUENT MAJOR ADVERSE CARDIAC EVENTS IN MEN INITIATED ON TESTOSTERONE THERAPY - A LARGE CLAIMS DATABASE ANALYSIS The Journal of Clinical Endocrinology & Metabolism, Volume 95, Issue 10, 1 October 2010, Pages 4743–4747 TRANSFUSION 2008; 48: 2197-2204

Introduction Testosterone Replacement Therapy (TRT) is a commonly administered treatment for men grappling with hypogonadism or low testosterone levels. TRT has been shown to help ease the symptoms of low testosterone, but it also has a noticeable side effect: it raises hematocrit levels, which can cause a medical condition called erythrocytosis or polycythemia. Elevated hematocrit levels cause the blood to thicken, bringing about potential cardiovascular risks like strokes, heart attacks, and clotting events. This comprehensive guide seeks to elucidate various strategies to manage high hematocrit levels induced by TRT, fostering a well-rounded understanding for both patients and healthcare providers. Table of Contents Introduction Understanding Hematocrit and Its Normal Ranges Factors Contributing to High Hematocrit Levels in TRT When to Act on Rising Hematocrit Levels Testosterone Treatment and Blood Cell Production Managing High Hematocrit Levels Monitoring Adjusting TRT Dosage Lifestyle Modifications Sleep Apnea Management Medication and Supplements Comparative Effects of Different Testosterone Therapy Forms Therapeutic Phlebotomy Treating High Red Blood Cell Counts with Phlebotomy No Set Guidelines for Phlebotomy in Testosterone Therapy Yet Phlebotomy: A Temporary Solution? Conclusion References Footnotes Understanding Hematocrit and Its Normal Ranges Hematocrit gauges the volume of red blood cells in the blood, expressed as a percentage, illustrating the proportion of blood comprised of red blood cells. Normal hematocrit levels for men range from 41% to 50%, and for women, they range from 36% to 48%. Factors Contributing to High Hematocrit Levels in TRT Testosterone Replacement Therapy can trigger erythrocytosis, where an overproduction of red blood cells occurs. It is known that testosterone lowers hepcidin levels. Hepcidin is a hormone that is made in the liver and is closely connected to iron absorption pathways. This lowers hepcidin levels leads to erythrocytosis and raises hemoglobin and hematocrit levels. When to Act on Rising Hematocrit Levels If you're using testosterone therapy (TT) and your hematocrit—the percentage of red blood cells in your blood—reaches 54% or more, experts from the European Association of Urology (EAU) and the American Urological Association (AUA) recommend taking action. The EAU advises checking for other possible causes that might be increasing your hematocrit, which could include factors mentioned in their risk section [8]. Testosterone Treatment and Blood Cell Production Typically, the body produces more red blood cells in the first six months of testosterone treatment before this process levels off. If you stop TT, your hematocrit and hemoglobin (the protein in red blood cells that carries oxygen) usually return to normal within 3 to 12 months. Adjusting your TT dose or how it's administered might help prevent high red blood cell counts by mimicking the body's natural hormone levels more closely. Managing High Hematocrit Levels Monitoring Regular monitoring of hemoglobin and hematocrit levels is pivotal for patients undergoing TRT. It is recommended to get baseline hematocrit values before starting treatment and then to do regular measurements at 3, 6, and 12 months after starting treatment. Adjusting TRT Dosage In instances where hematocrit levels soar beyond 54%, healthcare providers might consider decreasing the TRT dosage or temporarily halting the therapy until hematocrit levels normalize. Additionally, switching to subcutaneous injections could also be contemplated as a strategy to modulate hematocrit levels. Lifestyle Modifications Adopting certain lifestyle alterations can significantly impact hematocrit levels. Hydration: Ensuring ample fluid intake to maintain high blood volume. Exercise: Engaging in regular physical activity to reduce blood thickness. Smoking Cessation: Avoiding smoking can decrease hematocrit levels Sleep Apnea Management TRT has the potential to make sleep apnea, a condition marked by intermittent breathing interruptions while sleeping, worse. Continuous Positive Airway Pressure (CPAP) devices or other medically approved treatments that help people with sleep apnea can also help people with high hematocrit levels improve their health. Medication and Supplements Medications like Losartan and supplements like Naringin have shown promise in helping manage high hematocrit levels. However, it's crucial to consult with a healthcare provider before embarking on any new medication or supplement regimen. Comparative Effects of Different Testosterone Therapy Forms While all forms of testosterone therapy, such as gels, pills, patches, and injections, are linked to increased hematocrit levels, injectable forms were once thought to have the most significant impact. Recent studies have shown that although injections like testosterone enanthate can significantly raise hematocrit compared to patches, usually no form of therapy increases hematocrit by more than 4.3%. This suggests that careful patient selection and monitoring could mitigate the risk of excessive red blood cell production. The risk does not seem to correlate with the duration of testosterone therapy but is more pronounced during the initial phase due to the abrupt hormonal shift. Typically, hemoglobin and hematocrit levels rise within the first six months of therapy and tend to normalize within a year of discontinuation. However, dosage is a critical factor, and selecting an appropriate dose requires considering individual patient factors. Therapeutic Phlebotomy Therapeutic Phlebotomy (TP) is a widely adopted procedure to manage testosterone-induced polycythemia, involving the removal of a pint of blood to diminish hematocrit levels. The frequency of  blood donations should not exceed once every 12 weeks to prevent iron loss due to frequent donations, contingent on individual responses to TRT. Treating High Red Blood Cell Counts with Phlebotomy Phlebotomy—the process of drawing blood—is a common treatment for polycythemia vera (PV) and high hematocrit caused by testosterone therapy, a condition with too many red blood cells, and there's no reason it can't be used for people with high red blood cell counts from TT [13]. A study by Marchioli and colleagues found that keeping hematocrit levels below 45% significantly reduced blood clots and other serious issues compared to allowing levels to be between 45 and 50%. While phlebotomy has been helpful in PV, its effectiveness for TT-related high red blood cell counts needs more high-quality research. An observational study by Hazegh et al. showed that men on testosterone who donated blood saw their average hemoglobin levels decrease over a year. The frequency of their donations varied widely, indicating that blood donation could be a useful strategy. There are No Set Guidelines for Plebotomy in Testosterone Therapy Yet Currently, there are no specific guidelines on how often or how much blood should be drawn if you're on TT and experiencing high red blood cell counts. Phlebotomy: A Temporary Solution? While phlebotomy can lower hematocrit levels, it may not be a permanent fix. Chin-Yee et al. evaluated patients who donated blood and found that many had high hematocrit levels even after donating. This suggests that while phlebotomy can help, it might not completely control red blood cell counts related to TT. In summary, phlebotomy can safely reduce hematocrit levels temporarily, but it should be used alongside other methods, like adjusting TT doses, to manage red blood cell counts effectively. More research is needed to define the role of phlebotomy in managing TT-related high red blood cell counts. Conclusion The meticulous management of high hematocrit levels in patients on TRT is pivotal to averting potential cardiovascular risks. A multifaceted approach can be used to effectively manage hematocrit levels. This includes monitoring, changing TRT dosages, making changes to the patient's lifestyle, managing sleep apnea, therapeutic phlebotomy, and medication or supplementation. It's incumbent upon healthcare providers and patients to collaborate and ascertain the most conducive management strategy, ensuring the efficacy of TRT while safeguarding the patient's health. References Footnotes Excel Male TRT Forum. (n.d.). How to Manage High Hematocrit Caused by Testosterone Replacement Therapy. Retrieved from Excel Male TRT Forum ↩ ↩2 Discounted Labs. (n.d.). High Hematocrit Caused by TRT: How to Lower and Manage it. Retrieved from Discounted Labs ↩ ↩2 ↩3 PubMed Central (PMC). (n.d.). Testosterone use causing erythrocytosis. Retrieved from PMC ↩ PubMed. (n.d.). Management of Erythrocytosis in Men Receiving Testosterone Therapy. Retrieved from PubMed ↩ Iron Mountain Men's Health. (n.d.). How to Lower Hematocrit While on TRT. Retrieved from Iron Mountain Men's Health ↩ American Journal of Clinical Pathology, Oxford Academic. (n.d.). Therapeutic Phlebotomy for Testosterone-Induced Polycythemia. Retrieved from Oxford Academic ↩ American Journal of Clinical Pathology, Oxford Academic. (n.d.). Therapeutic Phlebotomy for Testosterone-Induced Polycythemia. Retrieved from Oxford Academic ↩

Table of Contents Sleep Apnea and Testosterone Sleep Apnea and Cortisol Health Consequences of Sleep Apnea Sleep Apnea Solutions REFERENCES: Do you snore? Do you feel fatigued every day? Do you wake up frequently throughout the night? It may be that the shallow breathing or breaks in breathing caused by sleep apnea are the reason. There are different types of sleep apnea, one of which is obstructed sleep apnea (or OSA), which is when breathing is interrupted by a physical block to airflow. With OSA, snoring is common. Sleep Apnea and Testosterone What does apnea have to do with testosterone?  Everything!  Your precious shuteye is responsible for a host of all-important physiological functions, including rebuilding your testosterone and neurotransmitters, optimizing stress hormones, and mapping memory. Therefore, any condition, such as apnea that lowers the quality or quantity of sleep, is a physical and hormonal train wreck waiting to happen. Apnea is one of the nastiest sleep disorders because it is so disruptive.  After all, what could interfere with sleep more than having your airways and oxygen blocked off? Unfortunately, one study after another has rolled out showing how complex apnea is on the body, and hormones are no exception. One early study looked at just how severe the damage can be and found that apnea sufferers went from an average low testosterone test of 391ng/dL to a much closer-to-normal 487ng/dL after corrective surgery. [1] That's a jump of 25% in testosterone after their apnea was corrected!  However, a later study of guys in their 40's, showed an astonishing 68% difference between controls and males with apnea. [2] Regardless of the exact number, you get the idea:  apnea is devastating to your most precious hormone, testosterone. However, there is actually a logical explanation for the difference in the two numbers above:  the first number comes from a comparison after apnea correction and the second before correction.  Researchers have found that guys who have had apnea for a significant amount of time are often overweight, even obese. [3]    In other words, if you've built up a big spare tire during your sufferings with apnea, CPAP or other therapy cannot get you back to where you were before because your own body is fighting against itself. The researchers found that apnea subjects appeared more like aged subjects where LH (Luteinizing Hormone) cycles at night were increased, yet without a corresponding increase in testosterone as is experienced by younger males.  Young guys get a pulse of luteinizing hormone followed by one of testosterone and so on.  This cycle is dampened increasingly in males as they age, and apnea appears to accelerate this process. In other words, once you get your apnea corrected, you must take care to also lose any excess weight in order to re-optimize your testosterone as much as possible.  The good news is that just getting treated for apnea will give you a nice jump in testosterone, and then as you lose weight and control cortisol, you should increase it even further.  Studies have even verified this in obese men with a BMI of 32, which isn't what would even called obese, by the way.  When they lost weight, they regained their testosterone. [4] Sleep Apnea and Cortisol Similarly, apnea also leads to elevated cortisol level.  One study found that subjects had 50% percent higher cortisol before CPAP when compared to after. [6] This is truly nasty:  cortisol is not something you want to be elevated by even the smallest amount.  Higher cortisol elevations, especially in the middle age and beyond years, can lead to memory damage, lowered testosterone, increased fat mass, lower immunity, poor sleep and a host of other ills.   In the last ten years, researchers have uncovered the fact that most apnea is actually lifestyle-related and not simple genetics or aging. Health Consequences of Sleep Apnea Sleep apnea has been shown to increase the incidence of these health problems: Heart Disease. Blood Glucose Control and Diabetes. If you have diabetes, sleep apnea can make it more difficult to manage your diabetes. Increased blood viscosity due to high hematocrit: As you starve your body of oxygen at night with sleep apnea, the body compensates by producing more oxygen-carrying hemoglobin and red blood cells, which increases hematocrit and blood viscosity. This can cause heart disease, high blood pressure and require frequent blood donations if you are on testosterone replacement therapy (TRT). Note: TRT can worsen sleep apnea in some men [10] Memory Loss and Dementia Risks.  Heavy snoring and sleep apnoea may be linked to memory and thinking decline at an earlier age, according to a study published in the April 15, 2015, online issue of the journal Neurology. The research also suggests that treating the disorders with a breathing machine may delay the decline. “Abnormal breathing patterns during sleep such as heavy snoring and sleep apnea are common in the elderly, affecting about 52% of men and 26% of women,” said Ricardo Osorio, MD, at the NYU Langone Medical Center. Fatigue and daytime sleepiness. Depression. Irritability.   Sleep Apnea Solutions One interesting aspect of apnea research is that researchers are finding that there are many natural solutions that can often help apnea sufferers and sometimes even cure their apnea.  This is important for several reasons.  First of all, in some cases, it shows that there is a root cause of apnea, i.e., there is not some inherent genetic weakness causing this debilitating condition but rather some lifestyle change that can help significantly.  Secondly, the medical solutions for apnea are rather invasive:  surgery (somnoplasty and snoreplasties) and/or a cumbersome CPAP machine worn through the night.  Many of those with apnea would like to avoid such solutions and find something more natural. However, it should be noted that there is one other medical procedure, the Pillar procedure, that is significantly less invasive. This is performed by a dentist and involves tiny polyester implants in the soft palate of an apnea (or snoring) sufferer.  It is actually the vibration of the soft palate that can lead to snoring and often apnea, so this can be an easy fix in some cases since it is done with minimal anesthetics. WARNING:  It is critical to get your apnea treated.  One study looked at 380 participants with moderate or severe sleep apnea over a 14-year period and found that one-third of the patients died! [9] That's in comparison to 8 percent without apnea.  Those suffering from apnea or other sleep disorders should definitely consider green tea, as they get their condition under control. The oxidative stress from apnea typically affects memory and the ability to learn. Researchers have found that green tea, at least in animals, protects the brain from oxygen-deprived states that occur in apnea and related disorders. Green tea for the rats in this study actually protected their brains and memory from the ravages of apnea sleep loss. [4] Below is a summary of additional natural solutions that researchers have found for apnea:   Weight Loss. Research shows that mild apnea can often be significantly helped or even cured simply by losing those extra pounds.  One recent study found that almost two-thirds of study participants who dropped 23 pounds through diet and exercise were actually completely cured of their apnea. [2] Therefore, assuming your apnea isn't too severe, you may want to try simple weight loss first as a solution and, as a side benefit, you may have your testosterone significantly restored as well. In other words, dropping those pounds has the potential to boost your testosterone and cure your apnea at the same time.   If your apnea is severe, however, simple weight loss will not do the trick, and you will likely end up with a CPAP (Continuous Positive Airway Pressure) These masks can be testosterone and life and saver, literally.  There are also dental mouthpieces and surgery of the throat as options as well, but these are considered less effective in most cases. Your doctor can order a sleep study for you to get tested at a sleep lab or using a home-based system. There are also telemedicine services for sleep apnea. A study done in Portugal and published in 2017 found that after people used CPAP machines for six months, their red blood cell count, hemoglobin, hematocrit, and platelet count showed a significant decrease [11]   Treat Hypothyroidism. Apnea can result from hypothyroidism, an underactive thyroid that will be unresponsive to standard treatments.  It is estimated that 2-3% of apnea sufferers fall into this category. [3]   Improve Sleep Position. Some practitioners have noticed that sleeping on the side can significantly help with apnea. Another solution is to sleep in a partial sitting position.  One study showed that half of all apnea sufferers could actually cure their condition by sleeping in this position! [5]   Avoid Alcohol at Night. If I got woken up a couple of hundred times during the night from lack of oxygen, I might want a few drinks, but researchers have found that this decidedly exacerbates apnea. [6]    Stop Smoking. Smoking makes apnea significantly worse because it inflames airway tissues and is associated with an increased incidence of this condition. [7]   Avoid Sitting for Long Periods. Sitting a lot during the day pools water and blood in the legs, and this aggregation of liquids then migrates to your neck region when you go to Sleep leading to apnea in many cases.  Keep moving throughout the day. [8] Download a step counter App to your phone, carry your phone in your pocket, and measure the total steps you take daily. If you’re sedentary, add 2,000 more daily steps so that you average at least 4,400 daily steps. While 2,000 steps equals one mile, it’s not necessary to walk it all at once. Instead, try to take extra steps over the course of each waking hour.   Monitor Your Oxygen Saturation. Use an oximeter connected to a Bluetooth enabled App to see how many times your blood oxygen level drops during your sleep cycle. Bluetooth Oximeter syncs the measurement readings to the free ViHealth app via Bluetooth automatically and securely. The app can store unlimited history data, which gives you a quick overview and helps you monitor your health.   As you can see, reversing sleep apnea can not only extend your life span but also its quality.  Giving your body the oxygen it needs will change your life!   REFERENCES:   1) Journal of Sexual Medicine, 6(11):3147-3157, Published Online: 29 Jun 2009, "Sleep Apnea is an Independent Correlate of Erectile and Sexual Dysfunction" 2) Consumer Reports on Health, Jul 2009, p. 10. 3) Am. J. Respir. Crit. Care Med., Aug 1999, 160(2):732-735, "Screening for Hypothyroidism in Sleep Apnea" 4) Amer J of Respiratory and Critical Care Med, May 15 2008, Goza 5) Am Rev Respir Dis, 1986 Apr, 133(4):662-6, "The effects of posture on obstructive sleep apnea" 6) Amer J of Medicine, Aug 1981, 71(2):240-245, "Alcohol increases sleep apnea and oxygen desaturation in asymptomatic men" 7) SLEEP AND BREATHING, 5(4):167-172, "Higher Prevalence of Smoking in Patients Diagnosed as Having Obstructive Sleep Apnea" 8) Men's Health, May 2009, p. 33. 9) Sleep, 2008 Aug , ;31(8):1079-85, "Sleep apnea as an independent risk factor for all-cause mortality: the Busselton Health Study" 10) The Journal of Clinical Endocrinology & Metabolism, Volume 88, Issue 8, 1 August 2003, Pages 3605–3613. “The Short-Term Effects of High-Dose Testosterone on Sleep, Breathing, and Function in Older Men” 11)  Revista Portuguesa de Pneumologia (English Edition) Volume 23, Issue 2, March–April 2017, Pages 71-78. "Hematological evaluation in males with obstructive sleep apnea before and after positive airway pressure"  

Testosterone Replacement Therapy (TRT) has changed the lives of many men around the world.  Like any therapy, it can have great benefits if properly managed but negative side effects if not monitored.  This article will briefly and simply review the different TRT tests that most physicians use to monitor your progress while minimizing potential side effects.   Table of Contents How to Know if You Need TRT Follow Up Lab Tests After Starting TRT Avoiding or Lowering High Hematocrit on TRT Avoiding Low Ferritin and Iron Monitoring the PSA Test on Testosterone Monitoring Estradiol Test on Testosterone Avoiding High Blood Pressure and Water Retention on TRT Monitoring Kidney Function Avoiding High Liver Enzymes Monitoring Thyroid Tests Maintaining Good HDL Levels on TRT Prolactin in Men with Low Testosterone: The Forgotten Hormone Where to Buy Your Own TRT Tests: How to Know if You Need TRT The first thing doctors actually measure before you get on testosterone replacement is your total and free testosterone blood levels to find out if you have low testosterone. They will also ask you a few questions to see if you have low testosterone or hypogonadal symptoms. They include low sex drive, erectile dysfunction, fatigue, low mood, and issues with cognitive capacity and function. So, testosterone replacement therapy includes anything to increase testosterone levels with either injections or creams, gels, pellets, oral, nasal, and other TRT options. Follow Up Lab Tests After Starting TRT Once you get on testosterone replacement, your doctor will have you come back either at week six or eight to run another blood test to see if your dosage needs to be adjusted and/or you may require other medications to monitor or to modulate or change levels like estradiol, hematocrit, etc. The first one obviously is testosterone total and free. You come back at week six or eight, and your total testosterone is not over 500 nanograms per deciliter, your doctor will probably choose to increase your dosage or your frequency of injections in the case of injections. Free testosterone is usually around 2% of total or higher. If you have lower than 2%, your doctor will probably focus on any issues related to high sex hormone binding globulin (SHBG), which is a protein that binds to testosterone and does not free it up for action. Avoiding or Lowering High Hematocrit on TRT Hematocrit is the proportion of red blood cells in the blood. Testosterone tends to increase red blood cells.  Some men don't have that issue, but most men at least have a two to a three-point increase in hematocrit after starting TRT. Hematocrit increases a lot more in men on TRT who have sleep apnea and in smokers since these two can cause oxygen starvation.  High hematocrit can increase the viscosity of the blood and may cause cardiovascular issues. So, the magic number to go for is a hematocrit of 53 or below. When you're getting close to 53, you have to basically donate blood or go for what we call a therapeutic phlebotomy to bring down the red blood cell amount in the blood. And that's very important because as hematocrit goes up, your blood becomes more and more viscous, and your cardiovascular system gets compromised.  It's also very important not to let it go too high because above 52, most blood centers would not accept you as a donor, so you would have to require a special prescription for a therapeutic phlebotomy from your doctor for the blood centers to take your blood and dispose of it later. Keep in mind that donating more frequently than every three months may decrease your ferritin and iron stores considerably, which can cause fatigue and other issues. Here are some hematocrit lab panels, or you can buy them as part of the CBC panel. Avoiding Low Ferritin and Iron When your hematocrit is over 53, and you donate blood frequently than every three months, you can deplete your iron stores which makes you tired, depressed, and with no libido. Blood donations should not be happening that frequently because you'll lose iron. Some doctors will test your iron and your ferritin, and if you have low levels, they will put you on an iron supplement. Discounted Labs sells a blood donation panel that is designed to inform you if you can safely donate blood. Monitoring the PSA Test on Testosterone High PSA, prostate-specific antigen, is the only contraindication for testosterone replacement therapy if it is 4 or above. Obviously, physicians get very concerned that a man with higher PSA may have prostatic cancer, although it could be caused by an infection of your prostate (prostatitis) that could be easily treatable with an antibiotic. So, all high PSA tests do not mean you have cancer, but it could mean that you could have a treatable prostatic infection.  Your doctor may prescribe antibiotics and retest your PSA after your antibiotic cycle is finished.  He or she may need to refer you to a urologist if your high PSA test does not come down.  But if you do have a PSA of four or higher, you are not going to be allowed to use testosterone replacement unless your doctor can actually prove that it's an infection that will eventually be treated so that your PSA can come down. Monitoring Estradiol Test on Testosterone Estradiol (E2) is a very important hormone for men. We need it because estradiol is actually linked to bone health, cognitive functioning, cardiovascular health, even sex drive, and decreased fat mass. Having very low estradiol of under 20 pg/mL is actually not good for you since it can decrease bone density and cause other issues. Having very high estradiol in relation to your testosterone blood level may also have some consequences.  Several studies have different opinions and conclusions on what high estradiol means. About 0.3 to 0.4% of testosterone gets converted into estradiol by the aromatase enzyme. So obviously, the body increases the amount of estradiol as your testosterone goes up. There's nothing wrong with that. Estradiol balances testosterone to keep a better lipid (cholesterol) profile and to keep healthy sperm counts, just to name a few benefits. But what level of estradiol in men is too high? For example, if you have a testosterone level after you start TRT of 700 nanograms per deciliter, obviously, your estradiol is going to be higher than when before you started TRT. Is that cause for concern? Most men on testosterone replacement therapy do not need to take medications to lower estradiol. Estrogen blocker medications like anastrozole (Arimidex) are being overprescribed by many TRT clinics.  Men with a history of gynecomastia or breast enlargement may have issues with gynecomastia again if your estradiol's over 50 pg/ml, but in most studies where men with gynecomastia were followed, a lot of those men had low testosterone while they had high estradiol. A large study in adolescent boys showed that most of the ones with gynecomastia also had high IGF-1.  Some studies have shown that the ratio of testosterone to estradiol is really the important factor to monitor, with ratios over 12 being needed for healthy sperm production in men. But the management of estradiol in men is a very controversial topic as there is not a lot of agreement in the field.  Some doctors insist on keeping an E2 level of 20 to 40 picograms per milliliter no matter how high testosterone levels reach. We have learned in the past three years that the old immunoassay-based estradiol test tends to overestimate estradiol in men. Two studies have shown that the real estradiol value is better tested with a liquid chromatography-mass spectrometry sensitive estradiol assay. So, make sure that if your doctor is going to check your estradiol, you're using the right LC/MS E2 test. Discounted Labs offers several lab panels that contain sensitive estradiol.  Another concern of high estradiol is that some men feel that water retention is an issue, although that has not been proven by any studies. Most men with TRT-related water retention assume that their estradiol is high but fail to get it tested. Avoiding High Blood Pressure and Water Retention on TRT Some men on testosterone replacement therapy tend to have increased blood pressure related to water retention. There are some central nervous system effects that increase blood pressure and heart rate. These men can gain considerable weight during the first weeks of TRT.  Most lose most of that weight after a few weeks of therapy.  Some studies have shown that testosterone may decrease sodium excretion by the kidneys, which makes the body retain water to keep that sodium diluted. Ways to improve blood pressure are to lose weight, take a blood pressure medication, exercise, and decrease excessive sodium intake. Many men assume that their estradiol is high when they experience water retention. That assumption has not proven to be correct. Monitoring Kidney Function The estimated glomerular filtration rate, or eGFR, is a way to measure your kidney function. It's part of what we call a CMP blood test panel, and we are aiming at an eGFR over 60. Anything below that is indicative of a slowdown in the way your kidneys are filtrating toxins from your body. TRT does not really cause a decrease in eGFR. However, a lot of men taking creatine, exercising heavily, or eating very high protein intake tend to probably have artificial increases in creatine that decrease eGFR. You can Google eGFR formula and see how that's calculated. Avoiding High Liver Enzymes Current testosterone replacement therapy options have not been shown to increase liver enzymes; only the old oral forms of TRT used to cause that problem. However, doctors obviously follow it up. A very important distinction to make is that men that are exercising heavily with weights at the gym may artificially  increase in AST and ALT that has nothing to do with toxicity to the liver. Monitoring Thyroid Tests TSH, thyroid stimulating hormone, is also something else that most doctors follow up, although some actually do not. Low thyroid function (hypothyroidism or high TSH) may have the same symptoms as low testosterone. TRT medical guidelines groups around the world recommend different schedules for monitoring men on TRT, and a few of them agree with each other. Rarely do any guidelines mention thyroid function monitoring in men on TRT. TSH levels above 2.5 may indicate that you have hypothyroidism. If you have high TSH, doctors usually tend to use a comprehensive thyroid panel that includes free T3 and free T4, along with antibodies, to see if you have an autoimmune disease like Hashimoto's that may be inducing hypothyroidism. Maintaining Good HDL Levels on TRT High-density lipoprotein or HDL is another one of the variables most affected by testosterone replacement, especially at higher doses. When I say higher doses, anybody using 200 milligrams of testosterone replacement per week — cypionate or enanthate — tend to have a lowering of HDL. Low HDL has been shown to cause cardiovascular issues, so your doctor will always follow your lipids. Testosterone replacement has not really been shown to increase LDL, and there are some studies that show that TRT improves triglyceride blood levels because testosterone tends to improve the way the body metabolizes carbohydrates. There's very little we can do to increase HDL besides aerobic exercise, losing weight, decreasing TRT dose, and taking a supplement. Niacin supplementation is one of the ways to increase HDL, but some people get flushing of the skin and face. Last but not least, the use of anastrozole, an estradiol blocker, can also decrease HDL since estradiol is known to protect HDL levels. Prolactin in Men with Low Testosterone: The Forgotten Hormone Prolactin is not a hormone that is usually measured at TRT baseline or even at follow-up unless you have severe erectile dysfunction, even with good levels of testosterone. Men that have low testosterone at baseline, and I mean low testosterone, very low — under 150 nanograms per deciliter — are probably the best candidates to get a prolactin test. It is a hormone that women and men produce – obviously, women that are lactating produce it at higher concentrations in their bodies because it helps lactation. It also has some other benefits; otherwise, men would not have it. Prolactin has some immune-enhancing benefits and some cardiovascular benefits that are starting to show up in studies. So, prolactin is not an evil hormone, but it can, at higher concentrations, cause erectile dysfunction. The reason for high prolactin could be a benign tumor called pituitary adenoma (diagnosed by MRI), which can be producing a lot of pituitary output for prolactin, and that could actually impair your testosterone replacement therapy benefits. So, it's a hormone that is hardly looked at unless you are a man that has very low testosterone blood levels at baseline or do not respond well (unresponsive erectile dysfunction) after eight weeks or ten weeks of testosterone replacement therapy and/or you are having high prolactin symptoms, like lactation. That's actually a very rare symptom that actually occurs in men with pituitary adenomas. Where to Buy Your Own TRT Tests: DiscountedLabs.com provides very low-cost blood testing in most US states. You don't need to see a doctor because the company has in-house physicians that provide a prescription. After ordering your lab test online, you receive an email with the lab request form that you take to the closest lab near you. Once you go to a lab and get your blood drawn, you receive an email with your results within five to seven business days, depending on the blood test. For more information, visit DiscountedLabs.com   Visit ExcelMale.com to download Nelson's latest book: Beyond Testosterone   Click here for TRT Resources

Here are Some Important Things That Your Doctor May Fail to Tell You Before You Start Testosterone Replacement Therapy (TRT):       1- TRT decreases your sperm count.     Some doctor prescribe Clomiphene alone or hCG with TRT to preserve your fertility     2- TRT may increase your blood viscosity due to increased hematocrit, the amount of red blood cells in the blood.     Some doctors may want to stop your TRT when this happens, but this side effect can be managed easily with blood donations or therapeutic phlebotomy.   Just be careful: frequent blood donations can deplete iron and cause fatigue.     3- TRT shuts down your own testosterone production.     It may take up to 6 months for your testosterone to return to baseline after you stop.     4- TRT works to improve your sex drive, muscle mass, and burn fat.     But it does not work for everyone and dose/frequency are important along with other factors like side effect management.   TRT is not a magic bullet.     5- Testosterone can be injected under the skin (Most doctors think you should inject deeply into muscle)     6- Testosterone gels and creams are effective but some doctors do not adjust the dose based on your blood level and symptoms.     7- Many doctors still prescribe testosterone injections at 200 mg every two weeks.     Many are moving towards recommending 100 mg/week or 50 mg twice per week with an insulin syringe.     8- TRT can worsen sleep apnea.     Apnea can improve with weight loss and can be treated with a CPAP machine.     9- TRT improves erectile function in some men but not all.     It improves libido in most men regardless of age, though.     10- You can monitor your own blood tests via companies that sell discounted labs without a doctor visit.     11- You can access a testosterone doctor via telemedicine if you don’t have one close by.     However, most of them do not take insurance.     12- TRT does not cause prostate cancer or heart attacks.     Cardiovascular outcomes depend on proper monitoring of hematocrit, HDL, and blood pressure.     13- Many men do not know that they ask questions to TRT-experienced men by visiting the ExcelMale forum.     14- In follow up visits, some doctors only measure blood levels of total testosterone but forget to include free testosterone, DHT (metabolite), and thyroid function tests.     15- Most insurance companies only pay for certain TRT products but not others.     And most refuse to pay if your testosterone is over 350 ng/dL.     16- You can buy affordable TRT options with a prescription at compounding pharmacies like Empower Pharmacy.     17- Urologists are quickly becoming the most knowledgeable doctors of TRT management.     18- Some men fail to achieve benefits from TRT. Comorbidities and other issues can be to blame.     GO TO: DiscountedLabs.com/Resources for   Free Testosterone Book Doctor's Referrals Forums & More

Table of Contents Does Testosterone Increase Risks of Heart Disease? What is the Effect of Testosterone Therapy in Older Men? What Can You Do to Prevent Heart Disease While on Testosterone Replacement Therapy? BUY A TESTOSTERONE BLOOD TEST PANEL Reference:  Does Testosterone Increase Risks of Heart Disease? There is widespread misinformation that testosterone supplementation increases the risk of heart disease. There is no evidence to support this belief in men younger than 65 years of age. Testosterone administration to middle-aged men is associated with decreased visceral fat, triglycerides, lower blood sugar concentrations, and increased insulin sensitivity. Several studies have shown that low total and free testosterone concentrations are linked to increased intra-abdominal fat mass, the risk of coronary artery disease, and type 2 diabetes mellitus. Testosterone has also been shown to increase coronary blood flow. Similarly, testosterone replacement retards the build-up of plaque in experimental models of atherosclerosis. In 1994, Phillips and colleagues studied 55 men with angina. They found a strong correlation between very low levels of testosterone and increased severity of coronary artery disease as measured by arteriograms, suggesting that testosterone may have a protective effect. This is consistent with the observation that the risk for atherosclerosis increases with age in men, while testosterone levels decrease. Two other smaller studies found that the administration of testosterone decreased risk factors for coronary artery disease. The prospective European investigation into cancer in Norfolk (EPIC- Norfolk) Prospective Population Study examined the prospective relationship between the body’s own (endogenous) testosterone concentrations and mortality due to all causes, cardiovascular disease, and cancer in a nested case-control study based on 11,606 men aged 40 to 79 years surveyed in 1993 to 1997 and followed up to 2003. Among those without prevalent cancer or cardiovascular disease, 825 men who subsequently died were compared with a control group of 1489 men still alive, matched for age and date of baseline visit. Lower endogenous testosterone (the body’s own) concentrations at baseline were linked to mortality due to all causes (825 deaths), cardiovascular disease (369 deaths), and cancer (304 deaths). So this study found that in men, endogenous testosterone concentrations are inversely related to mortality due to cardiovascular disease and all causes and that low testosterone may be a predictive marker for those at high risk of cardiovascular disease.   What is the Effect of Testosterone Therapy in Older Men? But there are some emerging contradicting data from a much smaller study that showed that older men who have higher endogenous testosterone (without taking testosterone) might have a higher incidence of heart disease. A large U.S. multicenter study showed that older men with higher testosterone levels are more likely to have a heart attack or other cardiovascular disease in the future. The results were presented at The Endocrine Society’s 92nd Annual Meeting in San Diego in June 2010. Study participants were age 65 or older and included 697 community-dwelling men who were participating in the National Institutes of Health-funded study, called the Osteoporotic Fractures in Men (MrOS). None of these men were receiving testosterone therapy, according to the study abstract. All subjects had blood tests to determine their testosterone levels. The investigators then divided the men into quartiles, or four groups, of testosterone range to observe trends in rates of coronary heart disease events. This type of heart disease results from plaque-clogged or narrowed coronary arteries, also called atherosclerosis. A coronary heart disease event included a heart attack; unstable angina, which is chest pain usually due to atherosclerosis and which doctors consider a prelude to a heart attack; or angioplasty or bypass surgery to clear blocked arteries. During an average follow-up of nearly four years, 100 men, or about 14 percent, had a coronary disease event, in particular, heart attacks. After the researchers adjusted for other potential contributing risk factors for heart disease, such as elevated cholesterol, they found that higher total testosterone level relates to an increased risk of coronary disease. Men whose total testosterone was in the highest quartile (greater than or equal to 495 nanograms per deciliter, or ng/dL) had more than twofold the risk of coronary disease compared with men in the lowest quartile (below 308 ng/dL). So, this is contradictory data that may be concerning, but does it say anything about the cardiovascular risks of supplementing testosterone to men with testosterone deficiency? A report published in the New England Journal of Medicine in June 2010 about a study researching the use of testosterone gel in older men showed that such study was stopped early due to a higher incidence of side effects in men treated with the gel. Participants in this trial called the Testosterone in Older Men with Mobility Limitations, or TOM, were non-institutionalized men aged 65 and older who had difficulty walking two blocks or climbing ten steps and whose serum testosterone was 100 to 350 ng/dl (very low levels). So, these were frail older men. The goal was to recruit 252 men, but only 209 subjects had been enrolled by the time the trial, which started in 2005, was stopped on December 2010. Testosterone use had the desired effect of improving the men’s muscle strength and mobility. But they also experienced a high rate of adverse effects — not just cardiovascular problems but respiratory and skin problems. Unfortunately, they did not report hematocrit, estradiol, and bioavailable testosterone. I dream of the day when a study will be done the right way to include all of those variables. Only then we can draw the right conclusions about who is more prone to side effects. Managing high hematocrit with blood donation/phlebotomy and high estradiol with anastrozole can probably eliminate some of the reported side effects in older men, but there is only one way to find out: To have proper studies using those management strategies. To date, no study listed in clinicaltrials.gov is following men who are taking testosterone and who have access to phlebotomy or estrogen blockers to manage the two main side effects that may affect cardiovascular health in older men: high hematocrit and estradiol. Previous studies have shown that in general, older men have more side effects when using testosterone (polycythemia, gynecomastia, high blood pressure, prostatic hyperplasia) and more comorbid conditions. High hematocrit and estradiol increase clotting and viscosity, so it is not surprising to me that older men who use testosterone would have more cardiovascular risks if monitored poorly by their physicians. It amazes me how many older men using TRT are walking around with hematocrit over 54 and estradiol levels above 100 pg/dl without being offered phlebotomy or estrogen blockers. This is one of the main reasons I felt compelled to write this book. Older men also require more testosterone to reach normal levels since they have more sex hormone binding globulin that attaches to testosterone and renders it useless. So, physicians should carefully monitor these patients if they decide to provide testosterone replacement. The age cut off when the risk-to-benefit ratio of testosterone changes is not known yet. There are several studies that are currently being performed to provide more answers. A U.S.-based study showed that testosterone therapy does not increase men's risk for heart attack. The study, conducted by researchers at the University of Texas Medical Branch at Galveston, examined 25,420 Medicare beneficiaries 66 years or older treated with testosterone for up to eight years. It appeared in the July 2, 2012 issue of the Annals of Pharmacotherapy. So, the jury is still out. But if no complicating factors like high cholesterol, blood pressure or strong family history of heart disease are present, many doctors opt for prescribing testosterone to older men who need it to have a better quality of life. And most doctors keep an eye on hematocrit but few on estradiol. Hopefully, this will change as more doctors wake up to the risks associated with poor monitoring and management of TRT. It is the excessively high doses of testosterone used by athletes and recreational bodybuilders that are linked to significant decreases in the plasma concentration of HDL (high-density lipoprotein - the good cholesterol) and increases in LDL (low-density lipoprotein – the bad cholesterol). Replacement doses of testosterone have been shown to have only a modest or no effect on plasma HDL in placebo-controlled trials. Testosterone supplementation has been shown to decrease triglycerides, a dissolved fat that can lead to cholesterol increases and metabolic syndrome. In spite of these studies, some physicians continue to think that testosterone replacement can dramatically increase cholesterol levels.   What Can You Do to Prevent Heart Disease While on Testosterone Replacement Therapy? Given the state of the modern diet, all of us should have our doctor check our fasting cholesterol and triglycerides (another lipid-linked with heart disease risk). If you think that you have low testosterone, you may already have a problem with your lipids. The recommendations of exercise and diet (low in sugars and animal fats) apply for everybody but are especially important for men who have high LDL and high triglycerides at the time of starting testosterone replacement. Testosterone therapy can be an important part of your health regimen but don’t start it thinking that it will cure high cholesterol. Sometimes high lipids are related to poor diet, sedentary lifestyle, medication side effects, and bad genes. Your treatment for high cholesterol and triglycerides can also include statin and fibrates drugs prescribed to you by your doctor. I would try to modify your diet and to exercise before you jump on taking these medications since they may have muscle related side effects and do not correct the root cause of the problem, which is a metabolic abnormality that could be addressed with good adherence to lifestyle modifications. The key word is “adherence,” which seems elusive is many people who rather take a pill than watch their diet and exercise. For more on diet and exercise, refer to the chapter “ Miscellaneous Health Tips to Support Healthy Testosterone.” NOTE: I think you’re getting why I’m telling you that you need doctor’s supervision when on testosterone. So far you’ve read about the potential impact on hemoglobin and hematocrit, blood pressure, and estradiol, all of which can negatively affect your cardiovascular health. Imagine the even greater risk of those using testosterone at higher than replacement doses that usually buy it from underground sources and do not have a doctor who monitors them. No wonder testosterone and anabolic steroids get such a bad reputation. I tell bodybuilders that do not have a doctor to follow them to at least decrease their risks by getting a bodybuilder panel on DiscountedLabs.com that do not require a prescription. There are many around the United States, and you can find them by visiting DiscountedLabs.com . Of course, this is not the best solution and in no way a replacement for the supervision of a doctor. Irresponsible bodybuilders do more self-inflicted damage when their mistakes fuel the hysteria surrounding hormones in the United States. This hysteria has made it difficult for many men who need TRT to get it. Over-the-counter “testosterone boosters” may present problems with lipids, so do not think that because you are buying something at a health food store, that makes that product safe. Let your doctor know if you are taking any of those. Most do not work and those that did where banned by the FDA and taken off the market.   BUY A TESTOSTERONE BLOOD TEST PANEL   Reference:  From the book “Testosterone: A Man’s Guide” by Nelson Vergel (available on Amazon.com)

Table of Contents High hematocrit: the main side effect of Testosterone Replacement Therapy (TRT) What are the symptoms of high hematocrit? What are factors that increase the risks of TRT polycythemia ? How to Lower Hematocrit? How to Manage Increased Hematocrit Caused by Testosterone Replacement Therapy High hematocrit: the main side effect of Testosterone Replacement Therapy (TRT) Testosterone replacement therapy (TRT) is one of the most effective ways to combat low testosterone levels, but it's vital that you understand the risks associated with the treatment. As with any form of hormone replacement therapy, there are a few downsides to receiving regular injections of testosterone. But do these risks outweigh the benefits? That's a decision you'll have to make for yourself! Note: Remember the purpose of TRT: to restore testosterone to NORMAL, healthy levels in the body. Ideally, testosterone levels should be normal after TRT. Even at normal levels, there is a risk of side effects. One of the primary risks of testosterone that is you need to be aware of is called polycythemia. This is a condition where your body produces too many red blood cells, also known as high hematocrit level. Hematocrit refers to the red blood cell content in your blood. If your hematocrit levels rise, your blood will become too thick or viscous. This can, in turn, make it more likely that you will develop strokes, heart attacks, and clotting events. Polycythemia is serious and potentially life-threatening if untreated.   What are the symptoms of high hematocrit? In recent years, there has been an increased association between TRT and polycythemia. With TRT becoming a more mainstream treatment, more people are experiencing the symptoms of polycythemia, which include: Weakness Fatigue Headache Itching redness of the skin bruising joint pain dizziness abdominal pain shortness of breath breathing difficulty when you lie down numbness, tingling, or burning in the hands, feet, arms or legs Turning very red or "flushing" after workout When polycythemia occurs, the blood becomes very thick. But instead of being able to carry MORE oxygen, the increase of red blood cells can be dangerous. The risk of clotting increases as a result of the red blood cell count increase. Note: While there is a risk of hematocrit increase, there is no proof that TRT increases the risk of clotting events. It's vital to be aware of the potential risk, so doctors need to be careful when prescribing TRT to men with high hematocrit levels, red blood cell disorders, and obstructive pulmonary disease. All of these things increase the risk of clotting events as a result of the hematocrit increase caused by TRT.   What are factors that increase the risks of TRT polycythemia ? There are a number of factors that can increase your risk of developing this problem. According to Dr. Michael Scally, polycythemia "occurs quite frequently in people who are on replacement testosterone." Age also plays a role in your polycythemia risk. Young men are far less likely to experience this problem than older men. The mode of delivery and the dose of testosterone affect the increase in your hematocrit levels. Men who receive formulations of pharmacokinetically steady-state delivery hormones are far less likely to develop the problem than men who receive intramuscular injections of testosterone. Topical preparations only cause the problem in up to 20% of cases. 5 to 15% of those who use testosterone patches develop polycythemia, while 10 to 20% of those using the testosterone gel develop the problem. Of course, the amount of testosterone delivered per day (50 to 100 milligrams) also affects the risk of developing polycythemia. Testosterone injections may increase hematocrit more than gels, patches, pellets, nasal or oral testosterone formulations.  Smaller injection doses given more frequently may increase hematocrit less rapidly than larger dose injections, but data are lacking to prove that fact. Men with sleep apnea or those who smoke are at the highest risk of high hematocrit since their bodies are trying to compensate for the decreased oxygen level by producing more red blood cells.  TRT enhances that red blood cell production.   How to Lower Hematocrit? So what can you do about the problem? Is there any way to manage it? Those undergoing TRT must be aware that polycythemia is a real risk, as do their doctors. They must keep a close eye on their hemoglobin and hematocrit levels. If hematocrit rises above 52%, further examinations may be necessary. Some doctors counsel reducing or stopping testosterone treatment. However, for those who are undergoing TRT as a means of restoring healthy hormone levels, this may not be an option. Some means of managing and reducing the risk of high hematocrit levels include: Scaling back on the amount of testosterone gel delivered per day (50mg or less) or injection dose. Changing the method of administration (using more frequent injections with smaller doses, or using a testosterone gel or cream) Making sure that you are hydrated when you get your blood drawn for lab tests Stopping smoking Getting sleep apnea diagnosed and treated with a CPAP machine to enhance oxygen saturation levels when sleeping. If these options do not work, a therapeutic phlebotomy (blood donation) may be the answer. Removing just one unit of blood can help to lower hematocrit by as much as 3%. For those with very high hematocrit levels, the therapy may continue for months, gradually reducing hematocrit to safe levels over time. Some physicians even prescribe regular phlebotomies (no more frequently that every 56 days is the safe frequency to avoid iron loss) as a means of preventing overly high hematocrit levels. While phlebotomies are not covered by your insurance, they can be performed at any blood bank. Even if your insurance company won't cover the cost, you can solve the problem by donating blood (provided you are free of hepatitis, HIV, and other blood-borne infections). Experts agree that donating every 2.5 to 3 months is safe, and it's a good way to keep your hematocrit levels under control. It is important to note that hematocrit can stabilize in men on longer term TRT, so many men do not have to donate blood after a few months on TRT. Warning: Donating more than 1 unit of blood more frequently than every 2.5 months can lower your iron and ferritin levels. This can cause fatigue. Make sure to replace the lost iron with a supplement in order to prevent anemia. You can check your iron and ferritin with this iron blood test. It's recommended that you donate when you are in the 51-52% hematocrit range. However, some organizations (like the Red Cross) will reject blood with a hematocrit higher than 53%, so it is good to avoid that hematocrit high level if you want to donate blood. Hematocrit is included in the CBC and other panels: Get Your Hematocrit Test Now Testosterone, Hematocrit, Ultrasensitive Estradiol and Prolactin Panel Hematocrit + Total and Free Testosterone   To find out more information, click  How to Manage Increased Hematocrit Caused by Testosterone Replacement Therapy