Frequent Blood Donations Aren’t Enough To Protect The Majority of Steroid Users & Abusers

Testosterone is intimately involved in red blood cell (RBC) production through the process of erythrocytosis. Testosterone is so influential in the production of RBC’s, that many individuals with elevated testosterone levels, whether natural or not, often present with elevated hemoglobin & hematocrit levels that, at times, breaches the ceiling on standard reference ranges. Indeed, polycythemia, a condition defined by abnormally elevated red blood cells (such that hemoglobin >170g/L, and hematocrit >52%), is considered one of the most common adverse effects of testosterone replacement therapy. A retrospective assessment by Hajjar et. al. found that 24% of subjects receiving 200mg Testosterone Enanthate or Cypionate every 2 weeks (100mg/wk) went on to develop polycythemia. A meta-analysis by Calof et. al., meanwhile, found that men receiving replacement doses of testosterone were 3.67-fold more likely to develop polycythemia.

Hajjar et. al.
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Calof et. al.
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Now consider, we’re referring to individuals who generally have their testosterone dosages prescribed by monitoring physicians in efforts to simply re-establish levels within the normal reference ranges as it relates to their ages. Indeed, the study done by Hajjar e. al. involved only a 35ng/dL difference in mean total testosterone levels between the testosterone-treated & control groups, while Calof et. al.’s meta-analysis involved a more expansive, but still relatively unexceptional, 197ng/dL difference between groups, and yet still, polycythemia was consistently significantly more likely to occur in the TRT groups. Expand our scope, then, to the scores & scores of individuals, both young & old, who utilize androgenic/anabolic steroids (AAS) recreationally to get swole, employing dosages often several fold higher than what would be administered during physician-overseen TRT (for example, 500-1000mg Testosterone Enanthate per week in some advanced AAS users, compared to 50-100mg/wk in many individuals undergoing TRT). It’s easy to speculate that a degree of the disease & suffering, and even loss of life, that we’re witnessing amongst fitness influencers and others who have dabbled in the forbidden juices is a consequence of the androgen-induced polycythemia that, for what it’s worth, no one seems to be paying any mind to.

The Dangers Associated w/ Polycythemia

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One prospective study by Braekkan et. al. that examined 26,108 subjects who participated in the Tromso Study of 1994-1995, and amongst who, all first-time life events of venous thromboembolism were documented until 2007, found that men with hematocrit percentages >46% had a 1.5-fold & 2.4-fold increased risk of total & unprovoked venous thromboembolism, respectively, compared to men whose hematocrit were in the lower 40th percentile;

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This suggests that even the 54% ceiling that Canadian guidelines use as a trigger for recommended cessation of TRT may be too high.

Venesection (Blood-Letting) as Perhaps the Only Means of Protecting Against Polycythemia

Many physicians & patients interpret the elevated hemoglobin/hematocrit levels in individuals undergoing TRT to suggest that therapeutic phlebotomy (venesection, or blood-letting) should be carried out;

This, of course, would seem a sensible pathway to managing the problem, because a typical blood donation, as an example, involves a donor parting ways with 460-500mL of blood (roughly 10% of their supply), and with that blood goes scores of red blood cells, given that RBC’s make up ~45% of one’s blood supply. However, unfortunately, according to recent findings in males being dosed with replacement levels of testosterone, even routine blood donations aren’t doing enough to abrogate the risks;

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Chin-Yee et. al. reviewed the hemoglobin & hematocrit levels of all male blood donors at Canadian Blood Services in Southwestern Ontario who were on TRT, only to find that in 25% of the donated samples, hemoglobin & hematocrit levels were higher than the levels at which Canadian guidelines would recommend a cessation of TRT (hemoglobin >180g/L, hematocrit >54%). Even more concerning was that 44% of repeat donors demonstrated persistently elevated hemoglobin/hematocrit levels above this same ceiling, indicating that, even at presumably modest TRT dosages, the risk of polycythemia remained both persistent & prominent. If blood donations, executed on average every 84 days in this study’s population, weren’t enough to stifle the incidence of polycythemia in TRT patients, then what recourse does someone using/abusing AAS have in managing their RBC counts?

Until this question is answered, we’re bound to continue witnessing more young & old lives alike being lost due to the cardiovascular risks associated with recreational AAS use.

References

  1. Braekkan SK, Mathiesen EB, Njølstad I, Wilsgaard T, Hansen JB. Hematocrit and risk of venous thromboembolism in a general population. The Tromso study. Haematologica. 2010 Feb;95(2):270-5. doi: 10.3324/haematol.2009.008417. Epub 2009 Oct 14. PMID: 19833630; PMCID: PMC2817030.
  2. Chin-Yee B, Lazo-Langner A, Butler-Foster T, Hsia C, Chin-Yee I. Blood donation and testosterone replacement therapy. Transfusion. 2017 Mar;57(3):578-581. doi: 10.1111/trf.13970. Epub 2017 Feb 1. PMID: 28150363.
  3. Hajjar RR, Kaiser FE, Morley JE. Outcomes of long-term testosterone replacement in older hypogonadal males: a retrospective analysis. J Clin Endocrinol Metab. 1997 Nov;82(11):3793-6. doi: 10.1210/jcem.82.11.4387. PMID: 9360543.
  4. Calof OM, Singh AB, Lee ML, Kenny AM, Urban RJ, Tenover JL, Bhasin S. Adverse events associated with testosterone replacement in middle-aged and older men: a meta-analysis of randomized, placebo-controlled trials. J Gerontol A Biol Sci Med Sci. 2005 Nov;60(11):1451-7. doi: 10.1093/gerona/60.11.1451. PMID: 16339333.
  5. Ohlander SJ, Varghese B, Pastuszak AW. Erythrocytosis Following Testosterone Therapy. Sex Med Rev. 2018 Jan;6(1):77-85. doi: 10.1016/j.sxmr.2017.04.001. Epub 2017 May 16. PMID: 28526632; PMCID: PMC5690890.