Can a patient with elevated hemoglobin, hematocrit, and red blood cell (RBC) count, taking testosterone injections, be cleared for surgery?

Management of a Patient with Elevated Hemoglobin on Testosterone Therapy Before Surgery

This patient should not be cleared for surgery until therapeutic phlebotomy is performed to reduce the hematocrit below 50%, as testosterone-induced erythrocytosis increases perioperative thrombotic risk.

Understanding Testosterone-Induced Erythrocytosis

• Testosterone therapy commonly causes erythrocytosis (elevated hemoglobin and hematocrit), particularly with injectable formulations, which are associated with a 43.8% risk of elevated hematocrit values (defined as over 52%) 1
• The mechanism involves testosterone-induced suppression of hepcidin (the master iron regulator), increased erythropoietin production, and enhanced iron incorporation into red blood cells 2
• This patient's hemoglobin of 17.5 g/dL and hematocrit of 50% indicate significant erythrocytosis that requires intervention before surgery 1

Risks of Proceeding with Surgery

• Elevated hematocrit increases blood viscosity, which can aggravate vascular disease in coronary, cerebrovascular, or peripheral circulation, particularly in older patients 1
• Patients with hematocrit >48% while on testosterone therapy have experienced strokes and transient ischemic attacks 3
• The combination of surgical stress and existing erythrocytosis significantly increases the risk of perioperative thromboembolic events 4

Pre-Surgical Management Algorithm

1. Immediate intervention required:

   • Perform therapeutic phlebotomy to reduce hematocrit below 50% before surgery 1
   • Consider temporarily withholding testosterone therapy until after surgical recovery 5

2. Laboratory monitoring:

   • Recheck hemoglobin and hematocrit after phlebotomy and before surgery 5
   • Assess for other cardiovascular risk factors that may compound the risk 1

3. Surgical planning:

   • Once hematocrit is reduced to safe levels (<50%), the patient can be cleared for surgery 1
   • Ensure adequate hydration perioperatively to prevent further hemoconcentration 1

Post-Surgical Considerations

• Resume testosterone therapy only after full recovery and with a modified regimen 1
• Consider switching from injectable to topical testosterone preparations, which have lower rates of erythrocytosis (5.5% for transdermal patches vs. 43.8% for injections) 1
• Implement regular monitoring of hemoglobin/hematocrit every 3-6 months 5

Important Caveats and Pitfalls

• Blood donation alone is insufficient to maintain hematocrit below 54% in patients on testosterone therapy 6
• Do not rely on the absence of symptoms, as thromboembolic events can occur without warning 4
• Be aware that concomitant medications or conditions (such as SGLT2 inhibitors for diabetes) can further increase the risk of erythrocytosis 7
• Avoid the misconception that therapeutic phlebotomy eliminates all risks; dose adjustment of testosterone may still be necessary 4

Special Considerations for Older Patients

• Patients in their mid-50s have higher baseline cardiovascular risk, making testosterone-induced erythrocytosis potentially more dangerous 1
• The American Heart Association recommends phlebotomy for adults with hematocrit >65% before noncardiac surgery, but for patients on testosterone therapy, intervention at lower thresholds (>50%) is warranted 1