Stop Iron Supplements Immediately
You should discontinue iron supplementation immediately given your adequate iron stores (ferritin 158 ng/mL) and address the elevated hematocrit (53%) through TRT dose adjustment or therapeutic phlebotomy. 1, 2
Critical Issue: Elevated Hematocrit on TRT
Your hematocrit of 53% is approaching the concerning threshold of 54% where Canadian guidelines recommend discontinuing or reducing TRT due to increased risk of adverse vascular events 2. The FDA label for testosterone cypionate specifically warns that hemoglobin and hematocrit levels should be checked periodically to detect polycythemia 1.
Why Iron Supplementation is Contraindicated
- Your iron stores are adequate: With a ferritin of 158 ng/mL, you are well above the threshold for iron deficiency (ferritin <30 µg/L for healthy adults) 3
- Testosterone suppresses hepcidin: TRT independently increases iron incorporation into red blood cells by downregulating hepcidin, which increases iron availability for erythropoiesis 4, 5
- Adding iron worsens polycythemia: Supplementing iron when stores are adequate will further drive red blood cell production, exacerbating your already elevated hematocrit 4
- No benefit, potential harm: Long-term iron supplementation with normal or high ferritin values is not recommended and potentially harmful 3
Immediate Management Steps
1. Discontinue Iron Supplements
Stop all iron supplementation immediately given your ferritin of 158 ng/mL indicates adequate stores 3.
2. Address the Elevated Hematocrit
Option A - Reduce TRT Dose: Consider reducing your testosterone cypionate from 150 mg/week to 100-125 mg/week split across the same injection schedule 1, 2
Option B - Therapeutic Phlebotomy: Research shows that repeat blood donation is often insufficient to maintain hematocrit below 54% in men on TRT, with 44% of repeat donors having persistently elevated hemoglobin despite regular donation 2. However, phlebotomy can be attempted while adjusting TRT dose.
3. Monitor Closely
- Recheck hemoglobin and hematocrit in 4-6 weeks after intervention 1
- If hematocrit reaches or exceeds 54%, TRT must be discontinued or dose significantly reduced per FDA guidance 1
- Monitor iron parameters (ferritin, iron, transferrin saturation) every 3-6 months 3
Important Caveats
The hemoglobin value of 13 g/dL seems inconsistent with a hematocrit of 53% (which typically corresponds to hemoglobin ~17-18 g/dL). Verify this value with your healthcare provider, as it may represent a laboratory error or different units. The hematocrit is the more concerning value here 1, 2.
Testosterone-induced erythrocytosis is dose-dependent and occurs through multiple mechanisms including hepcidin suppression and increased erythropoietin production 4, 5. This effect is independent of conversion to DHT 5.