The Downside to Pellets for HRT

Dr. Gina Tobalina

I've been prescribing customized bioidentical HRT for a decade now. That's a lot of experience in a complex field. I've seen fads and trends come and go, and we never dabble or experiment on our patients. I use tried and true methods with safety as my #1 priority. Hormones are such a strong and deeply controlling part of our physiology, they are not to be played with!

With that said, I never jumped on the pellet bandwagon. For sure, pellets have a lot of upsides like convenience and simplicity. I'm very handy with needles and could easily place the pellets for my patients. Plus I think it pays pretty well for the managing doctor. With all that upside, why haven't I ever prescribed or injected pellet HRT? One simple reason. If the dose isn't correct, you're stuck.

Let me share a little story about my lovely patient who saw me last week. Let's call her Jane, which is not her real name. She is my regular clinic patient and I manage her overall health. She sees an outside hormone doctor for pellet HRT, she told me she was unaware that I do hormones until recently. (It's true, I never push HRT on my regular medical patients, but if they ask me then it's fair game to discuss!) Jane has been on estrogen and testosterone pellets for about a year and felt a dramatic improvement in her health and vitality, but recently she noted something is off. After her last pellet placement, her outside HRT doctor decided to have her draw labs. Her testosterone level was over 400! Now for context a healthy woman's testosterone should be 40-70. Her T was over 10 times what it should be. Even more shocking is that a T level of 400 is normal for a man! She reported facial hair growth, she said she felt thick and has been lifting heavy weights at the gym, she said she felt like an Amazon woman and aggressive. I chuckled to myself, thinking she could probably beat up a man with those T levels.

Jane asked me what she could do. I told her that the reason I don't do pellets is for this exact reason. Her testosterone is dangerously high (like levels to become transgender, honestly) and there is nothing to do to fix it. Sure, her HRT doctor could try to surgically remove the pellets- but Jane is a very pretty lady and the scarring would be unacceptable. So she's left with waiting it out, and trying to manage her facial hair growth and muscle mass. I advised her to take spironolactone to help protect her skin from the hair growth, and to change from lifting weights to doing pilates and yoga to avoid putting on more bulky muscle. And of course to talk with her HRT doctor about changing her doses. She can also, of course, change her HRT management to me where we monitor closely and treat for optimal but safe doses.

I use a combination of topicals and oral hormones in lower doses and then gradually raise the dose until symptoms are controlled. The oral and topical formulations are easily titratable, meaning I can lower the dose in one day if we find the dose is too high. Pellets can take 3-6 months to wear out of your body. If you are on pellet therapy, ask your provider to check your serum levels to be sure the dose isn't too high. Everyone's body metabolizes these hormones at a different rate, and the doses should never be one-size-fits-all. Hormone balancing, when done well, gives you a custom dose that fits you perfectly.