Had to stop HRT...

[HEVEW8]

Hi guys, it's been a while since I last posted. Had to stop HRT due to my hematocrit going sky high... I was a pin cushion at the blood bank... The last straw was me getting dizzy and fainted in the donation chair... Scared the crap out of me, so I decided to quit taking test.. What a nightmare emotional roller coaster ride that was! My libido was dead and sex life gone... It has been 3 months now that I've been off cold turkey no pct... I finally got my libido back, I'm where I was before I started HRT. I'm thinking of just cycling. Any thoughts on that, or anyone else have trouble with hematocrit and HRT... Or maybe switching to pro hormones, I had good success with them back in the day... I started taking a test booster to help with LABIDO, but nothing really works as good as the real deal...

Any advise is appreciated
Thanks
Ruben

[100%]

What dose were you on and for how long?

[HEVEW8]

They had me at 200mg a week, split, then after I told them I had a ache in my balls, they dropped it to 100mg split.. Then after my hemacrite got high they dropped it to 50mg split... But by then I was suffering from high symptoms of hematocrit levels... Itchy skin, ringing I'm my ears, high blood presure, over all felling bad, not healthy... I was diagnosed with polycythemia and got a prescription for blood letting... I tried to go through with it, but it was more than I could put up with,.. I have scars on my arms from how many times I have been blood sucked! It looks like I have drug tracks on my arms!!

[junk2222yard]

Hi guys, it's been a while since I last posted. Had to stop HRT due to my hematocrit going sky high... I was a pin cushion at the blood bank... Any thoughts on that, or anyone else have trouble with hematocrit and HRT...

I am afraid I am in the same boat. Haven't decided to pull the plug yet, though.

I am hypothyroid as well as hypogonadal. (Likely the hypothyroid is what caused the hypogonadism.) Like many low thyroid sufferers, my ferritin is low. The exogenous Test boosts my hematocrit, which means I have to donate blood, which wipes out my ferritin, which leaves me feeling worse than pre-HRT.

I am in the process of finding the right balance of keeping hematocrit low enough and ferritin high enough. There is a real possibility that in my case it is not possible.

In short, I feel your pain.

[HRTstudent]

cycling is not the answer to quality of life.

[HEVEW8]

Well, that's fine and dandy to throw that out there... I don't exactly understand how that's a helpfull post as much as it seems a way to tell me how I should live my life according to you....?? I drink alcohol too, is that also not the answer to quality of life,.. I smoke a cigar from time to time also... ?? Hey, but thanks for your input, I will keep it in mind, thanks.

[100%]

They had me at 200mg a week, split, then after I told them I had a ache in my balls, they dropped it to 100mg split.. Then after my hemacrite got high they dropped it to 50mg split... But by then I was suffering from high symptoms of hematocrit levels... Itchy skin, ringing I'm my ears, high blood presure, over all felling bad, not healthy... I was diagnosed with polycythemia and got a prescription for blood letting... I tried to go through with it, but it was more than I could put up with,.. I have scars on my arms from how many times I have been blood sucked! It looks like I have drug tracks on my arms!!

Do you have any of your old bloodwork? With that type of reaction you should stay clear if cycling and try to get to the root of the problem. You will have a happier long term solution.

[HEVEW8]

I have all my blood work posted on here somewhere,.. I think some people are pre-disposed to doing well on HRT and some are not... I have spoken to a few of my friends who are x- body builders, and they have told me plenty of stories when they were coming up through the ranks how some of there buddy's could not handle the use... They had bad reactions.. When others are able to benefit from the use... I'm just a genetic failure....lol. I feel I would do well cycling,.. Everything in moderation...

[100%]

I have all my blood work posted on here somewhere,.. I think some people are pre-disposed to doing well on HRT and some are not... I have spoken to a few of my friends who are x- body builders, and they have told me plenty of stories when they were coming up through the ranks how some of there buddy's could not handle the use... They had bad reactions.. When others are able to benefit from the use... I'm just a genetic failure....lol. I feel I would do well cycling,.. Everything in moderation...

Please read the following
By Nelson Vergel, B.S.Ch.E., M.B.A.

Source: Testosterone Replacement Therapy and Polycythemia in HIV-Infected Patients - TheBodyPRO.com

November 16, 2011




A research letter recently published in the journal AIDS by Vorkas et al determined that testosterone use was associated with polycythemia, and intramuscular administration demonstrated a stronger association than topical (testosterone patch) use. No adverse cardiovascular or thrombotic events were observed. HIV-infected patients taking testosterone should undergo routine hematologic monitoring with adjustment of therapy when appropriate.

Polycythemia is an excessive production of red blood cells. With polycythemia the blood becomes very viscous or "sticky," making it harder for the heart to pump. High blood pressure, strokes and heart attacks can occur.

The association between testosterone replacement therapy and polycythemia has been reported for the past few years as this therapy has become more mainstream. In addition to increasing muscle and sex drive, testosterone can increase the body's production of red blood cells. This hematopoietic (blood-building) effect could be a good thing for those with mild anemia.

Although all testosterone replacement products can increase the amount of red blood cells, the study showed a higher incidence of polycythemia in those using intramuscular testosterone than topical administration (testosterone patch was the main option used -- no gels). Smoking has also been associated with polycythemia and may contribute to the effects of other risk factors.

In the above mentioned study, twenty-five patients met the criteria for polycythemia (21 male; four female). Using the number of unique patients with five clinic visits during the time frame of the study as the denominator, the estimated prevalence of polycythemia was 0.42% (95% CI 0.27-0.61). Mean hemoglobin at the time of diagnosis of polycythemia was 18.9+/-0.42 g/dl in men and 17.0+/-0.83 g/dl in women. Among the four female cases, one was diagnosed with chronic obstructive pulmonary disease (COPD) and severe pulmonary hypertension, while the other three did not have a documented explanation for elevated hemoglobin. Because of the relatively small number of female cases and the fact that the primary hypothesis is related to testosterone use, this case-control study focused on the 21 male patients.

Five of the 21 cases (24%) did not use testosterone, but had other explanations for their polycythemia: pulmonary hypertension, COPD and plasma volume contraction. In two of the 21 cases (10%) there was no documented reason for elevated hemoglobin. No cases met the criteria for polycythemia vera, and no adverse cardiovascular or thrombotic events were noted among the cases or controls.

The letter recommends that all HIV-infected patients taking testosterone should undergo routine hematologic monitoring and adjustment of testosterone dose or cessation of testosterone therapy as appropriate based on hemoglobin values. Unfortunately, no mention is made of therapeutic phlebotomy as a management strategy for this problem. Considering that stopping testosterone replacement would affect patients' quality of life and leave their hypothalamic-pituitary-gonadal axis in a dysfunctional state for weeks, months or permanently, other ways to manage polycythemia besides treatment cessation need to be discussed.

Below is an excerpt from my book, Testosterone: A Man's Guide, further detailing the prevention and management of polycythemia.


Preventing and Managing Polycythemia
It's important to check patients' hemoglobin and hematocrit blood levels while on testosterone replacement therapy. As we all know, hemoglobin is the substance that makes blood red and helps transport oxygen in the blood. Hematocrit reflects the proportion of red cells to total blood volume. A hematocrit of over 52 percent should be evaluated. Decreasing testosterone dose or stopping it are options that may not be the best for assuring patients' best quality of life, however. Switching from injectable to transdermal testosterone may decrease hematocrit, but in many cases not to the degree needed.

The following table shows the different guideline groups that recommend monitoring for testosterone replacement therapy. They all agree about measuring hematocrit at month 3, and then annually, with some also recommending measurements at month 6 after starting testosterone (it is good to remember that there is a ban on gay blood donors in the United States).

Many patients on testosterone replacement who experience polycythemia do not want to stop the therapy due to fears of re-experiencing the depression, fatigue and low sex-drive they had before starting treatment. For those patients, therapeutic phlebotomy may be the answer. Therapeutic phlebotomy is very similar to what happens when donating blood, but this procedure is prescribed by physicians as a way to bring down blood hematocrit and viscosity.

A phlebotomy of one pint of blood will generally lower hematocrit by about 3 percent. I have seen phlebotomy given weekly for several weeks bring hematocrit from 56 percent to a healthy 46 percent. I know physicians who prescribe phlebotomy once every 8-12 weeks because of an unusual response to testosterone replacement therapy. This simple procedure is done in a hospital blood draw or a blood bank facility and can reduce hematocrit, hemoglobin, and blood iron easily and in less than one hour.

Unfortunately, therapeutic phlebotomy can be a difficult option to get reimbursed or covered by insurance companies. The reimbursement codes for therapeutic phlebotomy are CPT 39107, icd9 code 289.0.
Unless a local blood bank is willing to help, some physicians may need to write a letter of medical necessity for phlebotomy if requested by insurance companies. If the patient is healthy and without HIV, hepatitis B, C, or other infections, they could donate blood at a blood bank.

The approximate amount of blood volume that needs to be withdrawn to restore normal values can be calculated by the following formula, courtesy of Dr. Michael Scally, an expert on testosterone side effect management. The use of the formula includes the assumption that whole blood is withdrawn. The duration over which the blood volume is withdrawn is affected by whether concurrent fluid replacement occurs.

Volume of Withdrawn Blood (cc)=
Weight (kg) × ABV×[Hgbi - Hgbf]/[(Hgbi +Hgbf)/2]
Where:
ABV = Average Blood Volume (default = 70)
Hgbi (Hcti) = Hemoglobin initial
Hgbf (Hctf) = Hemoglobin final (desired);
So, for a 70 kg (154 lbs) man (multiply lbs x 0.45359237 to get kilogram) with an initial high hemoglobin of 20 mg/mL who needs to have it brought down to a normal hemoglobin of 14 mg/mL, the calculation would be:
CC of blood volume to be withdrawn = 75 x 70 x [20 - l4]/[(20 + l4)/2] = 75 x 70 x (6/17) = approximately 1850 cc;
One unit of whole blood is around 350 to 450 cc; approximately 4 units of blood need to be withdrawn to decrease this man's hemoglobin from 20 mg/mL to 14 mg/mL.

The frequency of the phlebotomy depends on individual factors, but most men can do one every two to three months to manage their hemoglobin this way. Sometimes red blood cell production normalizes without any specific reason. It is impossible to predict exactly who is more prone to developing polycythemia, but men who use higher doses, men with higher fat percentage, and older men may have a higher incidence.

Some doctors recommend the use of a baby aspirin (81 mg) a day and 2,000 to 4,000 mg a day of omega-3 fatty acids (fish oil capsules) to help lower blood viscosity and prevent heart attacks. These can be an important part of most people's health regimen but they are not alternatives for therapeutic phlebotomy if the patient has polycythemia and does not want to stop testosterone therapy. It is concerning that many people assume that they are completely free of stroke/heart attack risks by taking aspirin and omega-3 supplements when they have a high hematocrit.

Although some people may have more headaches induced by high blood pressure or get extremely red when they exercise, most do not feel any different when they have polycythemia. This does not make it any less dangerous.

[Bliggity]

I agree with 100%'s post in that gels or creams may be an answer due to less chance of developing polycythemia.

Also, have you tried hCG mono-therapy?

[powerlifterty16]

trt is about quality of life not muscle gains. i'm having a hard time with this as well...i dont feel that bad and if i took my test early in the morning ym tt would prob be 400, but im still itching to fill my hcg mono prescription.
my advice is to go back on trt once your symptoms of hc clear up, but only do 100 mg and not 200..200 is a dumb dose to start at, and a mild steroid cycle.

Well, that's fine and dandy to throw that out there... I don't exactly understand how that's a helpfull post as much as it seems a way to tell me how I should live my life according to you....?? I drink alcohol too, is that also not the answer to quality of life,.. I smoke a cigar from time to time also... ?? Hey, but thanks for your input, I will keep it in mind, thanks.

[APIs]

I'd be interested to hear exactly how high your Hematocrit is to have made your Docs pull the plug on TRT? Mine can range from 48 to 51 which I believe is the upper limit on LabCorp? My Doc says he has many patients in this range, but doesnt like to see it pass 51. Just a fact of TRT for some men. When it is elevated, I just doante blood twice and it usually comes back down quite a bit. I try to never miss a donation appointment. Everyone is different though...

[HEVEW8]

I hit 59, and I felt like I had blood poisoning.. I could feel my heart pumping like I had ran up a flight of stairs and I could not catch my breath... Always struggling to catch my breath, just miserable.

[100%]

I hit 59, and I felt like I had blood poisoning.. I could feel my heart pumping like I had ran up a flight of stairs and I could not catch my breath... Always struggling to catch my breath, just miserable.

59 with 200mg of testosterone. What kind of cycle do you plan on running? Even doing a beginner cycle 500 mg could be very dangerous for you. Please explain your logic I just don't see how you think this is better for you.

[HEVEW8]

I don't know,.. I'm just frustrated that my LABIDO is right back to square one again,.. that was the whole reason i went on Hrt... I'll prob start back up again, damn, I really hate my clinic,.. I could be dead right now and they would not give two shits about me... I remember back in the day I would cycle pro hormones and hot damn I was a walking hard on! I never had post cycle symptoms because most of the prohormones did not convert to estrogen... You just took a 6-8week break and start right back up again....
I don't know what I'm going to do... That's why I'm reaching out to the board for ideas.....

[LowT Mike]

I'd be interested to hear exactly how high your Hematocrit is to have made your Docs pull the plug on TRT? Mine can range from 48 to 51 which I believe is the upper limit on LabCorp? My Doc says he has many patients in this range, but doesnt like to see it pass 51. Just a fact of TRT for some men. When it is elevated, I just doante blood twice and it usually comes back down quite a bit. I try to never miss a donation appointment. Everyone is different though...

^^^^ Very good!! It is that easy gentlemen. High hematocrit cutoff for TRT 55% hemoglobin 19. It is recommended if levels go above either of these numbers go give a pint of blood. Thats right! As easy as donating blood or going to Labcorp and doing a Therapeutic Phelbotomy. Usually 1 pint will drop Hematocrit by 15-20%. If you have sleep apnea this condition can be aggravated. You should only have to give blood 2-4 times per year. Titrating dose down is an option of course, but you may be reintroducing LowT symptoms. However, understood if you find yourself one of the lucky guys that have to do this more than 3-4 times per year. It is recommended that maintaining a better balance of hormones with the use of HCG and anastrozole can minimize the use of exogenous T, resulting in controlling hematocrit, while still optimizing T levels. I recommend you find a more qualified doctor. In all my years of practice this is one of the easiest sides to control with the right protocol.

Theres never been a recorded death due to TRT and polycythemia...but no one wants to be the first.

Michael Brookins, Board Certified Anti-Aging and Regenerative Medicine
Chief Clinical Advisor, LowTestosterone.com

[powerlifterty16]

how about platelets? does trt raise platelets? mine have always been right at the bottom of range (120-180) and im not on trt...and hematocrit has always been 48ish and hemoglobin 16.9 ..would these skyrocket on my hcg therapy?.

[HRTstudent]

Well, that's fine and dandy to throw that out there... I don't exactly understand how that's a helpfull post as much as it seems a way to tell me how I should live my life according to you....?? I drink alcohol too, is that also not the answer to quality of life,.. I smoke a cigar from time to time also... ?? Hey, but thanks for your input, I will keep it in mind, thanks.

I'm not telling you how to live your life... I was only telling you that if quality of life (health being a big part of that) is the most important to you, then you would not want to cycle.

[joebailey1271]

Do u eat alot of red meat? I actually had to stop eating alot of it when i started TRT, it made my HCT go up too fast.
I started eating more chicken instead, and although it does go up, just not as fast and dramatic.

[HEVEW8]

@hrtstudent,.. Sorry man, just frustrated, I'm not on the juice anymore and my patience level is shorter than ever... When I was on HRT I felt great and had a better disposition... Lol, go figure.. @ joebaily1271, I actually don't eat a lot of red meet,.. I take my lunch to work which is 4oz chicken breast, 4oz brown rice and 8oz of greens, ( brocolie, or French cut green beans, or 4 spears of asparagus.) I make three of those to go, then I have a small dinner, or protien shake before bed... And about a half gallon of water all day... Every blue moon I will have spigetti with meat sauce, or carne asada burrito, or 100% angus burger from Costco... After I turned 40 I really started watching my diet, and I exercise religiously, weights Monday, wednesday, Friday, cardio, Tuesday Thursday, Saterday... I have a few drinks Friday nights and Saterday nights with friends....over all, I'm pretty balanced out...

[HEVEW8]

@ LowT Mike, finding the right Doctor is the Key your right, I was going between the clinic, ( which are a bunch of duche bags, and My Kaiser Doctor that referred me to a endo which only told me I did not need HRT and that if I continue I will die... The clinic never put me on AI's because my estrogen levels were fine... They never checked my hematocrit levels, they don't have a good test like lab corp... I had to spring for those on my own,.. And after the lab corp test, the clinic doctor looked over them he sent me a email to stop HRT and to go to my doctor immediately, never saying why... ( ****ing asshole!)... So after the clinic left me for dead, kaiser ran a bunch of test and determined my hematocrit was too high, the endo diagnosed me with polycythemia, and wrote me a prescription for phlibodomy's and here I am back to square one... Not to mention the panic attacks I had while my body was re-adjusting, those are the worst! I'm tiered of the whole process... And I'm too scared to try again... I actually feel fine now, just wish I had a little more lead in my pencil...lol

[vere76]

i have the same problem my ferritin is low, which makes me feel like crap. All of my other irons are high. My HCT gets high but after i give blood my ferritin gets lower and i feel worse

[junk2222yard]

i have the same problem my ferritin is low, which makes me feel like crap. All of my other irons are high. My HCT gets high but after i give blood my ferritin gets lower and i feel worse

Yes, as I outlined above, I share this issue. I would love to hear LowT Mike's opinion on this?

A modest hrt program that brings my total t to 900, and free t to the top of the range but not above causes high hematocrit. Donating blood then knocks my low ferritin below the range entirely and I feel like crap.

[joebailey1271]

Yea i wonder why it would lower just the ferritin? It seems like it should lower them all at the same time evenly. How do you know its your ferritin, did u have a blood test? When my hct gets high, i actually get chest pain and dizzy spells like the OP, but i feel alot better after giving blood 1000ml or a pint. I did feel worse though if i gave blood and was dehydrated, i try to drink at least 6 to 8 cups before giving or i feel lethargic from donating.

[junk2222yard]

It lowers all of my irons, but none are low to begin with in me except for ferritin. I get blood work done regularly so know when I need to donate, and know how it impacts me objectively.

[powerlifterty16]

what is low ferritin? i looked at old bw and mine was 55

[joebailey1271]

Ferritin is a protein that stores extra iron until the body needs it. The amount of ferritin in your blood reflects the amount of iron in your body; low ferritin levels indicate that you have low iron

[powerlifterty16]

i was asking if 55 were low

[junk2222yard]

What is the range and units? Using the scale I get here in Canada, 55 would be low but not below range.

After giving blood twice due to high-ish hematocrit, my ferritin was:

12 [24-336 µg/L]

Before starting HRT my ferritin was:

88 [24-336 µg/L]

still quite low for a male who eats meat everyday and red meat 2-3x a week. My hypothyroidism likely makes it hard to absorb iron.

[GotNoBlueMilk]

I'll throw my two cents into the mix by giving my own lesson I learned on this. I started HRT 2 years ago at 50 mg 2x/week. My baseline hemocrit and RBC were not high, but they were up at the high end of normal. My doc told me from the start I would have to donate blood regularly. I did it regularly every 60 days, and my RBC and hemocrit levels were a tad high, always.

I decided to get off TRT for other reasons. I realized my main cause for low T was something I may be able to overcome naturally. Not that I was convinced I didn't need it any longer, I just wanted to make sure. Well, I did the long PCT and after 4 months decided that the T numbers were never going to come up to anything above 400 so I went back on TRT.

But I made big changes when I started TRT again. I started doing EOD injections. This mimics the cream/gel approach more because you are doing more frequent, lower doses. YOu don't have the big spikes, etc. I also dropped to 20 mg EOD, which is the equivalent of 70 mg/week. This did wonderful things for keeping my E2 and RBC/hemocrit levels lower. I no longer need an AI, and I don't have to give blood every 60 days.

I still give blood about once every 60-90 days, but when I go in my numbers are always in the acceptable range. They are still on the high end of in-range, but remember my pre-TRT baseline was too.

The beauty of EOD injections is you don't have nearly as high of spikes and the troughs are a lot less. My doc just smiled when I told him I was doing this. He already knew I was an experimenter but it didn't worry him because I was a conservative experimenter and not one who want to do high doses. In fact, I often suggested I raise my T numbers some. I see no need since I am doing great where I am at. My Total T is 700 and it doesn't fluctuate up or down from that by much because of the EOD dosing.

There is also something about going on TRT and starting low and working up. Those who have done it, or quit and re-started by starting low and working up, seem to experience less gyno symtpoms, and less other problems. It gives your body a chance to adjust to the change more naturally, rather than a sudden hormone shock.

[SEOINAGE]

Dropping your test dose because your balls ache sounds pretty ridiculous. Sure your dose could have been high and that would be a reason to lower it. But nuts aching just makes it sound like your doctor doesn't know what they are talking about. If you get stuff under control you could start back up with your 50 mg dose, and after a period do blood work, and titrate up very slowly and get your test just to mid range on free and total, and see how you feel. Then rather than having to extensive blood letting, just donate fairly regularly.

I don't like how I feel when mine gets too high either, it sucks, sounds like yours is worse than mine got, but I was having a few other problems, that clear up fast from donating for me.

[100%]

I'll throw my two cents into the mix by giving my own lesson I learned on this. I started HRT 2 years ago at 50 mg 2x/week. My baseline hemocrit and RBC were not high, but they were up at the high end of normal. My doc told me from the start I would have to donate blood regularly. I did it regularly every 60 days, and my RBC and hemocrit levels were a tad high, always.

I decided to get off TRT for other reasons. I realized my main cause for low T was something I may be able to overcome naturally. Not that I was convinced I didn't need it any longer, I just wanted to make sure. Well, I did the long PCT and after 4 months decided that the T numbers were never going to come up to anything above 400 so I went back on TRT.

But I made big changes when I started TRT again. I started doing EOD injections. This mimics the cream/gel approach more because you are doing more frequent, lower doses. YOu don't have the big spikes, etc. I also dropped to 20 mg EOD, which is the equivalent of 70 mg/week. This did wonderful things for keeping my E2 and RBC/hemocrit levels lower. I no longer need an AI, and I don't have to give blood every 60 days.

I still give blood about once every 60-90 days, but when I go in my numbers are always in the acceptable range. They are still on the high end of in-range, but remember my pre-TRT baseline was too.

The beauty of EOD injections is you don't have nearly as high of spikes and the troughs are a lot less. My doc just smiled when I told him I was doing this. He already knew I was an experimenter but it didn't worry him because I was a conservative experimenter and not one who want to do high doses. In fact, I often suggested I raise my T numbers some. I see no need since I am doing great where I am at. My Total T is 700 and it doesn't fluctuate up or down from that by much because of the EOD dosing.

There is also something about going on TRT and starting low and working up. Those who have done it, or quit and re-started by starting low and working up, seem to experience less gyno symtpoms, and less other problems. It gives your body a chance to adjust to the change more naturally, rather than a sudden hormone shock.

Great info! I had thought about doing this also. Maybe Ill give it a shot make a lot of sense.

[junk2222yard]

Great info! I had thought about doing this also. Maybe Ill give it a shot make a lot of sense.

I second this. Appreciate you sharing your experience.

[HEVEW8]

Great info from Gotnobluemilk! When I do go back on, I will follow his protocol... Thanks

[Joseph956]

When doing EOD injections, are you doing IM or SQ? I'm wondering if it would make a difference..

[APIs]

I think the OP also mentioned ED or Libido issues too right? If Hematocrit is high, wouldnt this make the blood more viscous/thick? In turn this could raise your BP only contributing to ED? Just a thought...

[PetrX]

I just found out that my HEMATOCRIT was at 53.. Now i'm a type 1 Diabetic and have leukemia as well, but in the past 2 weeks I was feeling very dizzy, light-headed, my gym sessions felt like I was on a cloud of some sort.. So while on my lunch break I decided to take them time and relived a pint of blood and my symptoms disappeared almost immediately thank god. But no libido issues, in fact quite the opposite haha

[HEVEW8]

@Joseph956,.. I started IM and eventually switched to SQ,.. I personally feel IM is more effective....but that's just me.. I tried everything to bring down my high hematocrit,.. Cut out coffee, drinking pedeolite, coconut water, staying away from foods that suck water out of your body, ( asparagus, brocllie).. And had my blood drawn once a month, lowered my test to 50mg per week/split,.. But still my symptoms kept getting worse.... I'm a freak of nature... My body loves to hate test..

[GotNoBlueMilk]

I have always done subq. There was a thread a while back that discussed how this led to less E2 instead of more, as previously thought it would. The limited studies point to no down side to subq and some benefits.