How can individuals on testosterone (hormone replacement therapy) therapy undergo therapeutic phlebotomy if they are contraindicated from donating blood?

Therapeutic Phlebotomy Options for Individuals on Testosterone Therapy Who Cannot Donate Blood

For individuals on testosterone therapy who need therapeutic phlebotomy but cannot donate blood, medical facilities can provide prescribed therapeutic phlebotomy services through hospitals, hematology clinics, or transfusion medicine departments where the blood is discarded rather than used for donation. 1

Understanding Erythrocytosis in Testosterone Therapy

Testosterone therapy commonly causes erythrocytosis (elevated hematocrit), which occurs at varying rates depending on the administration method:

• Injectable testosterone: Up to 44% of patients 1
• Transdermal patches: 3-18% of patients 1
• Testosterone gel: 11.3-17.9% of patients (dose-dependent) 1

This occurs because testosterone stimulates erythropoiesis, increasing hemoglobin levels by 15-20% 1. While beneficial for treating anemia, elevated hematocrit above normal range can increase blood viscosity and potentially aggravate vascular disease in coronary, cerebrovascular, or peripheral circulation 1.

Monitoring Requirements

Regular monitoring of hematocrit/hemoglobin is essential for individuals on testosterone therapy:

• Check levels every 3-6 months initially
• Monitor more frequently for those using injectable testosterone
• Watch for hematocrit values exceeding 52-54% 1

Therapeutic Phlebotomy Process

When erythrocytosis develops, appropriate measures include:

1. Prescribed therapeutic phlebotomy: Must be ordered by a healthcare provider 2

   • Specifies frequency (can be more frequent than standard blood donation)
   • Documents medical necessity
   • Establishes communication between referring provider and transfusion medicine physician

2. Medical facility options:

   • Hospital-based transfusion medicine departments
   • Hematology clinics
   • Blood centers that offer therapeutic phlebotomy services

3. Procedure details:

   • Similar to blood donation but blood is discarded rather than used for transfusion
   • Typically removes 450-500 mL of blood per session
   • Can be performed more frequently than standard blood donation (every 8 weeks)

Important Considerations

1. Avoid using voluntary blood donation as a substitute:

   • Research shows that repeat blood donation is often insufficient to maintain hematocrit below 54% 3
   • 44% of repeat donors on testosterone therapy maintained hemoglobin levels ≥180 g/L despite donations 3
   • Some individuals attempt to use blood donation to avoid charges for therapeutic phlebotomy 4

2. Efficacy concerns:

   • Limited evidence supports the efficacy of therapeutic phlebotomy for testosterone-induced erythrocytosis 5
   • Phlebotomy lowers tissue oxygen and depletes iron stores, potentially increasing thrombotic risk 5

3. Alternative approaches:

   • Testosterone dose adjustment may be considered before or alongside phlebotomy 1
   • Temporarily withholding testosterone in severe cases 1

Documentation Requirements

Therapeutic phlebotomy should be properly documented according to College of American Pathologists requirements 2:

• Physician's order specifying frequency and duration
• Indication for phlebotomy
• Target hematocrit/hemoglobin
• Volume to be removed

For Transgender Individuals Specifically

Transgender individuals on testosterone therapy face similar risks of erythrocytosis as cisgender men on testosterone therapy 1. When therapeutic phlebotomy is needed:

1. Ensure proper communication with the blood transfusion service about transgender status (with patient consent) 1
2. Follow local health board policies regarding blood sampling and transfusion in transgender patients 1
3. Be aware that body composition changes after 3-6 months of established hormone therapy may affect clinical parameters 1

By following these guidelines, individuals on testosterone therapy who cannot donate blood can still receive appropriate management of erythrocytosis through medical facility-based therapeutic phlebotomy services.