The Fallacy of Testosterone Precipitated Erythrocytosis

Neal Rouzier, M.D.

Director, The Preventive Medicine Clinics of the Desert, Palm Springs, CA

There are long term studies and literature support for testosterone improving longevity and decreasing the diseases of aging. However, testosterone has also been implicated in significant side effects, the most common of which is termed polycythemia. Therefore, it has become customary to phlebotomize men on testosterone therapy that experience an elevated hemoglobin/hematocrit, which is the most common side effect of testosterone therapy. The Endocrine Guidelines require regular monitoring of therapy for this elevated hematocrit, commonly referred to as polycythemia. However, despite what most believe, testosterone does not cause polycythemia vera (PCV) nor does it cause an increase in arterial or venous thrombosis as commonly seen with PCV. Nevertheless, the erythrocytosis that is prevalent with testosterone administration is commonly extrapolated to be just as harmful as polycythemia vera, which is a blood disorder that increases the risk of blood clots, both arterial and venous. This is both an incorrect and inappropriate extrapolation due to misunderstanding of the terms. Although the widespread use of phlebotomy as the treatment of erythrocytosis is common, erythrocytosis is not polycythemia vera nor should the harm of PCV be extrapolated to be the same for physiologic erythrocytosis. The literature supports no harm of physiologic erythrocytosis caused by either testosterone or living at altitude, and this elevation of red blood cells does not require treatment even though it has been the typical standard operating procedure for decades. Erythrocytosis does not result in the same harm as true PCV and assuming that it does is both incorrect and leads to inappropriate treatment. We should not extrapolate or misconstrue the two entities, although most hematologists and cardiologists will disagree. The purpose of this lecture is to present the literature support of lack of harm of testosterone-induced erythrocytosis or the need to phlebotomize men with erythrocytosis, even though multiple medical society guidelines recommend regular monitoring and phlebotomy. The safety of erythrocytosis and the difference between erythrocytosis and thrombo-producing PCV will be reviewed. The importance of following evidence-based standards, and not public opinion, will be explained and demonstrated. Reality is not consensus of opinion, yet this seems to be the case when it comes to testosterone-induced erythrocytosis or altitude-induced erythrocytosis. However, it has become customary to phlebotomize men with an elevated.