Pellets about the size of a grain of rice inserted under the skin (often in the hip area) are a relatively common way to get HRT for both estrogen and testosterone. They most often contain testosterone, estradiol or an estradiol plus testosterone combination and are made by a compounding pharmacy.
More on compounding pharmacies in this article.
As is the case for nearly every medication and certainly for HRT, there are pros and cons. As a practicing functional medicine doc who sees women every day one on one, the cons list outweighs the pros for most women when it comes to pellet therapy in my experience.
Pros: Why Some Women Choose Pellet Therapy
The biggest pro is: convenience. Pellets usually contain estrogen or testosterone and are reinserted every 3 months or so for women (typically 3-5 months depending on how you break them down) making pellets a vey low effort delivery system. Using pellets mean you do not have to think about your HRT daily or even weekly. That’s a win for a busy woman.
That said, if you are using an estrogen pellet and have a uterus you should be on daily or cyclical progesterone (more on cycling your HRT in this article) so this really is not a set it and forget it option in truth.
Proponents of pellets also say that this delivery form gives a more consistent level of hormone into the bloodstream with fewer fluctuations that can happen with creams and patches, though this point is debated among experts.
Pellets are bioidentical hormones and thus they carry less of a risk of blood clots compared to oral estrogen. Other non-oral estrogen forms like patches or creams also carry a lower risk of clots compared to oral estrogen, so this pro isn’t unique to pellets.
Lastly, they work fast. If you’ve been feeling low hormone for a while, getting a pellet inserted will certainly alleviate symptoms such as low energy, low libido or hot flashes quite quickly. Often with other forms of HRT doses are wisely started a bit lower and then you bump up as needed to avoid side effects and more accurately fine tune your best dose.
However, the most common reason women choose pellets over other forms of HRT that I see in my practice is that it was the only option presented by their functional medicine or anti-aging doctor. Because of the large financial incentive with pellet therapy, this is a big red flag. If you were given pellet therapy as one of multiple options that’s another thing, but when it’s presented as the only or even the best option I’d strongly suggest getting more info and a second opinion.
Cons of Estrogen & Testosterone Pellet Therapy
Pellet therapy is a more aggressive way to give a woman HRT where levels rise much faster and much higher increasing the risk of side effects. Levels of hormone often quickly hit supraphysiological, meaning higher than it would normally be if you were making these hormones yourself.
Testosterone levels are often well above male physiological levels on a blood test when given via a pellet and there is simply no reason to have levels be this high and it creates a host of side effects – some of which can be permanent.
Some side effects are minor (though not fun) like water retention, mood swings and breast tenderness while others more worrisome like acne, weight gain, facial hair and loss of hair on the scalp. Once a pellet is inserted, it’s there. So if you have side effects you simply have to tough it out until the pellet fully dissolves.
Side effects like hair loss or breakouts will resolve when hormone levels go back down, others like voice deepening and enlargement of the clitoris from testosterone being too high for too long are permanent and would require surgery to reverse. I wish I could say these are very rare but sadly, I have seen this with many women using testosterone pellets.
For more info on testosterone in women as part of an HRT regimen, see this article.
Because pellets are not readily removed, it is very hard to determine the optimal dose and as well, there isn’t a way to discontinue the therapy if for any reason you want to, such as worrisome side effects. You have to just wait it out and your side effects will slowly resolve.
Also, pellets are expensive. An individual pellet costs on average $300-$350 making it an annual cost of appropriately $1500 and typically this is not covered by insurance. You may spend more or less depending on your individual pellet prescription and how fast you metabolize or breakdown the pellet. Contrast that to many other bioidentical options that depending on insurance coverage range from $20 to $100 per month. Compounded HRT formulations are closer to $50 to $100 with pricing dependent on formulation, i.e. estradiol cream, progesterone capsule, etc.
Infection, itchiness or redness at the incision site is also possible. As is the more rare occurrence of pellet extrusion (when the pellet pokes out of the skin above where it was inserted) which can cause discomfort and infection.
Pellets are not FDA approved, similar to other compounded prescriptions. Critics of pellets cite lack of long term data evidence on safety and efficacy when we have other options available. There is also data to back up dosage inconsistencies in pellets making many providers wary.
And perhaps most concerning is that because pellets are such high doses and we do see increased risk of uterine cancer and pre-cancer. Pellets may not be safe for women with higher risk factors for breast cancer, uterine cancer, heart disease, stroke, clotting disorders, chronic liver disease or migraines.
With the increased risks associated with pellets, the prudent approach is to think about your hormones and health over the long haul vs. the immediate short term fix of a large burst of hormones and that quick alleviation of symptoms. It might feel like more work to fine tune an HRT regimen with lab testing, more visits and more adjustments, it cuts down on risk and allows you to create a safer, more customized approach.
Helping you navigate these nuances and finding a truly individualized HRT regimen is what I do in my practice, so reach out!