MHT Including Hormone Pellets

There’s so much information out there about hormone replacement, admittedly it’s hard to keep up even as a menopause specialist! 

When we are considering Menopausal Hormone Therapy (MHT) we have a lot of options. First, we want to establish that the benefit exceeds the risk. Multiple studies have focused on these issues, and I encourage you to read about them here.

MHT aims to replace the hormones that our ovaries stop producing in menopause- and current safety data suggests that both estrogen (specifically estradiol, the primary estrogen that we made in our ovaries) and testosterone should not be given by mouth, since doing so makes it pass through the liver, and seems to be responsible for the risks that have been shown in some studies related to blood clotting, heart disease, and stroke (which makes sense, since the liver makes blood clotting factors). So called “bio-identical” hormones simply describe any form of estradiol, testosterone, or progesterone. This differentiates those hormones that occur naturally in our bodies from Premarin (a combination of estrogens derived from horse urine) or a number of synthetic progesterone look-alikes (progestins).

So, once we have agreed that bio-identical and non-oral MHT is the gold standard based on many good studies, we have some options.  Pellets are one option that provides convenience for many patients. Estradiol patches and gels, or testosterone creams and gels may be good options for other patients. Ultimately the delivery method is personal choice. 

Let’s talk about the pellet option and why it may be the best option for many women (and men).

Hormone pellets are tiny slow-release bio-identical rods made of estradiol or testosterone. They can be dosed differently for each patient, based on her weight, where she is in the menopause spectrum, her symptoms and personal history. The starting dose is determined by a formula based on hundreds of thousands of prior patient experiences and can be modified in the future based on individual response.

The pellets are placed in the soft area of the buttock though a tiny incision, the size of a large needle, after giving local anesthesia to the area. Patients describe the injection of anesthesia as a small sting, and the pellet insert was pain free and took less than 2 minutes. A simple butterfly strip is placed over the insert site, which will heal in a few days to be practically invisible. For women, pellets provide a constant slow release of estrogen and usually testosterone as well, for 12-14 weeks (average 100 days). The benefits of this compared to patches or creams for some women is that it’s not messy, you don’t have to remember anything, and you are getting a relatively even dose which more closely mimics nature, rather than a spike in blood levels every day (or very 3 days with a patch).

After your first pellet insert, we check in with you in 6 weeks to see how you are feeling and measure your blood levels. 

While your personal description of how you are feeling is ultimately more important than what the lab says, we do check your levels 6 weeks after the first pellet insert make sure we reached our target safe goal and that your symptoms have resolved. After that, we draw blood every 6 months to check your general wellbeing, and that’s it. No frequent blood draws!

Most of us know that progesterone is also a really important hormone when we are considering MHT. First, it prevents uterine cancer, so for women with a uterus, it is a MUST do. For women without a uterus, it can still be really helpful for treating insomnia and mood swings in particular, but it’s optional. Progesterone is a much larger molecule than estradiol and testosterone, and is not well absorbed through the skin, and also does not have any adverse effect on the liver. As well as that, since it makes you sleepy, you don’t want to take it during the day. For these reasons we given progesterone by mouth at bedtime, not in the pellet. You can also use a progesterone cream, but it can be messy and the absorption is not as reliable.

So, with pellet therapy, we are using an estradiol/testosterone pellet combo about 3 times a year designed specifically for you (or testosterone only if you are premenopausal or have had breast cancer) and a progesterone capsule or sublingual (under the tongue) application every night.

Why testosterone? Most of us know that estradiol helps almost all of the common symptoms of menopause, like hot flashes, night sweats, vaginal dryness, body aches, and many others. But many emerging studies have shown that testosterone, in small doses, has many more benefits for women than previously thought. Our testosterone levels start to drop in our 30’s, around the same time as we find it harder to build muscle, and easier to build fat. Low testosterone is partly responsible for that, as well as decreasing energy and libido. We are NOT going to make you grow facial hair, get acne or manly muscles as some people fear with testosterone- this happens with high doses of testosterone or the illegal anabolic steroids that some body builders take- but not with the small doses used in pellets. 

Apart from feeling better and keeping a healthy libido, which is an important reason to consider MHT, estradiol and testosterone have been shown in many, many rigorous studies to have numerous very other health benefits. Both hormones prevent osteoporosis which is a severe and debilitating disease of old age. Estradiol also significantly decreases the risk of Alzheimer’s disease and heart disease if started early in menopause, as well as colon cancer. For the great majority of women, we are more likely to live longer with fewer diseases if you take MHT than if you don’t. 

What about men? For men, “Low-T” or low testosterone syndrome is really the “norm” for every man as he ages, but we all know that normal is not always optimal. Many FDA approved T products are available for men, but compounded pellets are available in more doses, last longer,  and may be preferred by some men. Like in women, men’s testosterone decreases rapidly after 35, and is responsible for muscle loss, fat gain, low energy, insomnia, low libido and many cases of erectile dysfunction. Male pellets are testosterone only, and the dose is again based on a formula that takes the individual patient into account. Testosterone levels are measured about 6 weeks after the first pellet, then annually. The goal level is not something super-human, but rather the same levels that younger men have. An important side effect for men in low sperm count so we do not recommend this for men who desire fertility. Lucky for men, they only need pellets two to three times a year. So again, very simple and easy, compared to weekly injections that have large weekly fluctuations. After 7-14 days, most men notice an improvement in sex drive, ability to build more muscle and lose fat with exercise (again fun to see on our body composition machine), stronger erections and more energy. Many also report better sleep. While we don’t treat men as our primary patients, we do treat partners of our patients.

Learn More About Hormone Pellets