How to Lower Hematocrit on TRT: Treating Side Effects

Testosterone Replacement Therapy (TRT) is a widely used treatment for men with hypogonadism, helping restore energy, muscle mass, libido, mood, and overall quality of life. 

However, a frequent side effect is an increase in hematocrit, the percentage of red blood cells in your total blood volume. 

In the following sections, we’ll discuss Hematocrit, its downsides, and how to lower it.  

What are Normal Hematocrit Levels? 

Normal hematocrit for adult men typically ranges from about 41% to 50%, but TRT can push it higher by stimulating erythropoietin production in the kidneys, which signals the bone marrow to make more red blood cells. This leads to secondary erythrocytosis (or polycythemia), where blood becomes thicker, potentially raising risks like high blood pressure, blood clots, stroke, or heart issues, if unmanaged.

Not everyone on TRT experiences significant rises in rates. They are somewhat dependent on dose, formulation, age, and other factors. Injectable forms (like testosterone cypionate or enanthate) often cause more pronounced spikes due to peak-and-trough levels, while other routes of administration tend to produce steadier, lower elevations.

What Is Hematocrit and Why Does It Rise on TRT?

Hematocrit measures the proportion of blood occupied by red blood cells, reflecting oxygen-carrying capacity. On TRT, testosterone directly boosts erythropoiesis (red blood cell production) via increased erythropoietin and possibly androgen receptor effects on bone marrow. 

This can improve anemia in some men but overshoots in others, especially with higher doses or injectable routes. Additional contributors include smoking (causing hypoxia), untreated sleep apnea, high altitude living, older age, and higher BMI. Recent studies even suggest moderate increases (up to ~52%) may correlate with lower mortality in hypogonadal men due to better oxygen delivery, but levels beyond that may warrant attention.

Understanding High Hematocrit Levels: When Is It a Problem?

High hematocrit becomes concerning when it thickens blood (increased viscosity), straining the heart and raising risks. Symptoms may include headaches, dizziness, fatigue, facial flushing, ruddy complexion, or tingling, though many remain asymptomatic.

Current guidelines vary slightly. The Endocrine Society and many experts recommend intervention at >54%, with temporary TRT hold, dose reduction, or phlebotomy. Some U.S. sources note contraindication above 50% at baseline, but 54% is a common action threshold. Levels up to 52% may even offer benefits in controlled studies, provided blood pressure is managed and no symptoms appear. Always confirm elevations with repeat tests when well-hydrated, as dehydration can falsely inflate readings by 10-15%.

Primary Medical Interventions to Lower Hematocrit on TRT

The most direct and effective methods are medical:

• Therapeutic phlebotomy - Removing ~250 mL to 500 mL of blood (one unit) drops hematocrit by ~3% on average. Performed in a clinic as needed, it's safe, quick, and often covered by insurance with a doctor's note. Many report symptom relief.

• Blood donation - Similar effect. Eligible men can donate blood every 8 weeks (up to 6 times/year). Check with blood banks, as some restrict TRT users.

These are first-line for levels ≥54% or symptomatic cases. In many instances, if a patient drinks 1-2 liters of water, hematocrit will decrease 1-2 points between level checks.

Generally, some clinics have different thresholds for hematocrit levels. At Lucidity Health, our reference ranges do not tag an elevated hematocrit unless it is > 56%. At that point, it is monitored and if it increases to > 58%, therapeutic phlebotomy is recommended. Critical levels of hematocrit are > 62.5% and anything at 60% or greater therapeutic phlebotomy is required.

Adjusting Your TRT Protocol to Reduce Hematocrit

Modifying therapy often resolves elevations without stopping benefits:

• Lower the dose - Reducing testosterone while keeping levels therapeutic minimizes erythropoietin stimulation.

• Increase injection frequency - Switching from weekly to every 3-4 days (or more) smooths peaks, reducing spikes.

• Change formulation - Move from injectables to transdermal routes offer a steadier release and lower erythrocytosis risk.

• Temporary pause - Hold TRT briefly until normalization, then restart lower.

Recent innovations in formulations (e.g., newer gels or orals) show promise for fewer hematocrit issues.

Lifestyle and Natural Strategies to Help Manage Hematocrit

Supportive habits can prevent or mitigate rises:

• Stay hydrated - Drink 3-4 liters of water daily; dehydration concentrates blood, falsely elevating readings.

• Exercise moderately - Aim for 150 minutes/week of aerobic activity (walking, cycling, swimming) to improve circulation and reduce viscosity. Avoid excessive high-intensity workouts that dehydrate.

• Quit smoking - Cessation normalizes levels over time by reducing hypoxia.

• Treat sleep apnea - CPAP therapy can drop hematocrit by addressing nighttime oxygen dips.

• Moderate alcohol/caffeine - Limit diuretics that dehydrate.

• Diet tweaks - Reduce excess iron-rich foods if ferritin is high; some evidence supports daily grapefruit (half to one) for its naringin content, which may help clear older red cells.

These strategies enhance TRT safety and efficacy.

Supplements and Additional Tips (With Caution)

Evidence for supplements is limited and anecdotal. Always consult your doctor:

• Naringin/grapefruit extract - Studies show daily grapefruit or naringin (500-1000mg) may lower elevated hematocrit by promoting red cell removal, but watch for drug interactions.

• Other mentions - Curcumin (turmeric) or nattokinase appear in forums for potential iron-binding or blood-thinning effects, but lack strong TRT-specific data.

Avoid iron supplements unless deficient. Low-dose aspirin may help prevent clots in high-risk cases, but only under medical guidance.

Monitoring Hematocrit on TRT: Best Practices

Prevention starts with vigilance:

• Baseline - Check hematocrit/hemoglobin before starting.

• Early phase - Retest at 3-6 months (some suggest 1-2 months for topicals), then every 3-6 months in year one.

• Stable phase - Annually if levels hold, or more often for high-risk patients (e.g., smokers, OSA).

Test well-hydrated, alongside testosterone, estradiol, PSA, and lipids. Track trends. Early detection allows simple fixes.

The Bottom Line: Safe Management Keeps You on TRT

Elevated hematocrit is a manageable TRT side effect, not a reason to quit therapy. Most men control it through monitoring, lifestyle changes, protocol tweaks, or occasional phlebotomy/donation, allowing continued benefits without compromising health. 

At Lucidity Clinic, we strongly recommend that you work closely with an experienced provider for personalized plans, as thresholds and risks vary. With proactive care, TRT remains safe and transformative for long-term well-being.

Feel free to reach out to us for more information, for affordable and easy-to-do lab testing, or to learn more about our affordable and effective TRT subscription options.