Managing Hematocrit (HCT) & Polycythemia: A Therapeutic Phlebotomy Guide for Test Users

The Number One Cardiovascular Risk

While the media often focuses on emotional side effects, the single most significant, quantifiable, and life-threatening risk of exogenous testosterone use is the resultant increase in red blood cells (RBC), a condition known as secondary Polycythemia or Erythrocytosis.

Testosterone acts as a stimulus for Erythropoiesis (the production of RBCs). As the number of RBCs increases, the blood becomes thicker (more viscous). This state is measured by Hematocrit (HCT), which is the percentage of your total blood volume occupied by RBCs.

• Risk: Elevated blood viscosity significantly increases the chance of Venous Thromboembolism (VTE), including Deep Vein Thrombosis (DVT), Pulmonary Embolism (PE), heart attack, and stroke.
• Mandate: Monitoring HCT is not optional; it is the most crucial blood safety marker you must track to minimize severe cardiovascular events.

Learn more about testosterone with our ultimate Canadian TRT guide

Phase 1: Establishing the Hematocrit Danger Zone

Clinical guidelines are extremely clear on the threshold for intervention. Your personal QC must strictly adhere to these limits.

Hematocrit Limits and Action Thresholds 

The Danger of Supraphysiological Peaks

Concentration variability, common with grey-market products, is a major factor. If your Test C is dosed infrequently (e.g., every 10–14 days), the high peak concentration causes a massive, temporary spike in RBC production. The recommended shift to minimum twice-weekly dosing minimizes these peaks and is the first line of defense against HCT creep.

Phase 2: Management Protocol – Non-Invasive Methods

Before resorting to blood removal, the first steps involve dosage and lifestyle adjustments to allow the body to naturally manage the red blood cell (RBC) count.

1. Increase Dosing Frequency 

If you are injecting less than twice weekly, switch to a smaller, more frequent injection schedule (e.g., 50mg three times per week, instead of 150mg once per week). By keeping the serum levels more stable and flattening the hormonal peak, you reduce the strong stimulus on the bone marrow to produce RBCs.

2. Optimize Hydration 

Dehydration can artificially elevate your HCT reading, as the blood plasma volume decreases. Ensure high water intake, especially in the 24 hours before a blood draw, to ensure the reading is accurate. High-intensity exercise can also temporarily skew the number upwards due to fluid loss.

3. Dosage Reduction 

If your HCT rises above 50% and remains there despite improved dosing frequency, you must reduce your overall weekly dosage. Prioritize long-term safety over maximizing the immediate concentration.

Phase 3: The Clinical Intervention – Therapeutic Phlebotomy

When HCT remains at or above 52%, Therapeutic Phlebotomy (blood donation/removal) becomes a mandatory procedure. This physically removes the excess red blood cells, instantly lowering viscosity and reducing clot risk.

What is Therapeutic Phlebotomy?

This is a medical procedure where approximately 450ml to 500ml of blood is safely drawn from a vein, identical to the process of standard blood donation.

How to Access Phlebotomy in Canada

1. Doctor Referral: The official, prescription-based route requires a doctor’s referral to a hematologist or a specialized phlebotomy clinic. This is the safest and clinically monitored route.
2. Blood Donation (Canadian Blood Services): If you meet the general donor health requirements, a blood donation will perform the function of phlebotomy. However, you must be honest about your T usage with the attending staff, as the risk profile changes. Furthermore, they are a donation service, not a medical treatment facility, and cannot provide prescriptive medical guidance.

Phlebotomy Frequency and Risk

• Protocol: Phlebotomy is usually performed every 6 to 12 weeks, based on repeat blood work.
• The Risk of Iron Deficiency: Frequent phlebotomy can lead to iron deficiency anemia. You must monitor your Ferritin (iron storage) levels alongside your HCT. If Ferritin drops too low, the body struggles to produce new, healthy RBCs, and phlebotomy must be temporarily suspended.

Key Takeaway: The HCT Control Cycle

Self-monitoring Polycythemia requires a dedicated QC cycle:

1. Test: Get HCT measured every 8 to 12 weeks.
2. Action: If HCT > 52%, immediately stop T and/or get phlebotomy.
3. Adjust: Lower your dosage and/or increase injection frequency.
4. Re-Test: Re-test HCT and Ferritin (iron) 4 weeks after intervention to confirm safety.