Bone loss, joint discomfort, pain, inflammation
Sarcopenia, muscle loss, aches, decreased strength
Changes in cognition, mental focus, and memory
Insomnia, sleep disturbance
Urinary incontinence, vaginal dryness, prostate issues
Diminished sense of well-being
Dysphoric mood (sadness, depression, anxiety, irritability)
Persistent, unexplained fatigue
Sexual – decreased performance, libido, receptivity and pleasure
Vasomotor instability (hot flashes), heart discomfort (A-Fib)

The insertion of pellets is a simple, relatively painless procedure done under local anesthesia. The pellets are usually inserted in the lower abdominal wall or upper buttocks through a small incision, which is then closed with a skin tape (steri-strip). The experience of the health care professional matters a great deal, not only in placing the pellets, but also in determining the correct dosage of hormones to be used.

Complications from the insertion of pellets include minor bleeding or bruising, discoloration of the skin, infection, and the possible extrusion of the pellet. Other than slight bruising, or discoloration of the skin, these complications are rare.
Testosterone may cause a slight increase in facial hair in some women. Testosterone stimulates the bone marrow and increases the production of red blood cells. A low testosterone level in older men is a cause of anemia. Testosterone, delivered by implants or other methods, can cause an elevation in the red blood cells. If the hemoglobin and hematocrit (blood count) get too high, a unit of blood may be donated.
After the insertion of the implants, vigorous physical activity is avoided for 48 hours in women and up to 5 to 7 days in men. Early physical activity is a cause of ‘extrusion', which is a pellet working it's way out. Antibiotics may be prescribed if a patient is diabetic or has had a joint replaced. However, this is a ‘clean procedure' and antibiotics may not be needed.

You may wonder why you haven't heard of pellets. Pellets are not patented and have not been marketed in the United States. They are frequently used in Europe and Australia where pharmaceutical companies produce pellets. Most of the research on pellets is out of Europe and Australia. Pellets were frequently used in the United States from about 1940 through the late 70's when oral patented estrogens were marketed to the public. In fact, some of the most exciting data on hormone implants in breast cancer patients is out of the United States. Even in United States, there are clinics that specialize in the use of pellet implants for hormone therapy.

Testosterone levels begin to decline in men beginning in their early 30's. Most men maintain adequate levels of testosterone into their mid 40's to mid 50's, some into their late 70's to early 80's. Men should be tested when they begin to show signs of testosterone deficiency. Even men in their 30's can be testosterone deficient and show signs of bone loss, fatigue, depression, erectile dysfunction, difficulty sleeping and mental decline. Most men need to be tested around 50 years of age. It is never too late to benefit from hormone therapy. In addition, as men age and their testosterone level declines, estrogen levels may increase. Elevated estrogen may prevent optimal results from testosterone therapy and cause problems like weight gain, fluid retention and anxiety, as well as have an adverse effect on the prostate gland. It is important to have both testosterone and estradiol levels measured.

He or she is wrong. There is a big difference between ‘no data' and not having read the data. It is much easier for busy practitioners to dismiss the patient, than it is to question their beliefs and do the research. It's about a patient making an informed choice. After testosterone pellets are inserted, patients may notice that they have more energy, sleep better and feel happier. Muscle mass and bone density will increase while fatty tissue decreases. Patients may notice increased strength, co-ordination and physical performance. They may see an improvement in skin tone and hair texture. Concentration and memory may improve as will overall physical and sexual health. There is also data to support the ‘long term' safety of testosterone delivered by pellet implants.

Testosterone, delivered by pellet implantation, has been shown to decrease breast proliferation and lower the risk of breast cancer, even in patients on conventional hormone replacement therapy. Clinical studies show that testosterone balances estrogen and is breast protective. In the past, testosterone implants have been used to treat patients with advanced breast cancer. In 1940, it was theorized that treating patients with testosterone implants earlier, at the time of diagnosis, would have an even greater benefit, preventing recurrent disease. Androgens have also been shown to enhance the effect of Tamoxifen® therapy in breast cancer patients. References supporting these statements can be found in the data section of the website in the ‘Breast Cancer Folder'.

In contrast to testosterone, Estradiol, whether delivered by pellet implant*, applied topically to the skin or taken orally has been shown to increase the risk of breast cancer. This is not surprising, as continuous Estradiol, a strong estrogen, has been shown to stimulate breast tissue.

*Million Women’s Study

Testosterone prevents the growth of hormone receptor positive breast cancer and has been used to treat breast cancer for over 80 years. However, testosterone can be aromatized to estradiol, which can stimulate a breast cancer. The testosterone must be combined with an aromatase inhibitor like anastrozole or letrozole, which prevents the conversion of testosterone to estrogen. The combination implants safely relieve symptoms in breast cancer survivors, decrease recurrence and increase survival. Breast cancer tumors also respond to therapy.

Bio-identical progesterone (including FDA approved Prometrium®) has not been shown to increase the risk of breast cancer like the synthetic progestins. In addition, progesterone, used vaginally, does not negate the beneficial effects of estrogen on the heart like the synthetic progestins.

Estriol is a bio-identical estrogen widely used in Europe that does not bind strongly to estrogen receptor and does not stimulate breast tissue. We have shown that pre-menopausal women diagnosed with breast cancer had lower levels of estriol than controls, i.e. women without breast cancer. Numerous studies have shown that vaginal estriol does not increase the risk of breast cancer (RR 0.7). It has safely been used in breast cancer survivors. ‘High dose’ (>25 mcg) vaginal estrogens like Estrace® (estradiol) and vaginal Premarin® provide systemic levels of strong estrogens that may stimulate breast tissue. However, Vagifem®, which delivers smaller doses of estrogen (10 mcg) is considered ‘local’ therapy and may be a safe option for vaginal hormone therapy in breast cancer patients. If you are a breast cancer survivor, it is important that your physician understands this concept.

We have shown that symptoms, including hot flashes, are relieved with continuous testosterone alone. Testosterone delivered by pellet implant is extremely effective therapy. In addition, it does not have the unwanted side effects of estrogen therapy. Over half of women treated with estrogen (especially the pellet implant) will experience uterine bleeding. If a menopausal patient has bleeding, she must notify her physician and have an evaluation, which may include a vaginal ultrasound and endometrial biopsy. Estrogen also stimulates the breast tissue can cause breast pain and cysts. It also increases the risk of breast cancer. Higher levels of estrogen (in the second half of the menstrual cycle) are needed for pregnancy. Most women feel better with lower levels of estrogen.

Almost all symptoms, including hot flashes, are relieved with testosterone pellets alone. A study by Sherwin in 1985 looked at testosterone, testosterone with estradiol, estradiol alone and placebo. The group of women who responded best (somatic, psychological and total score)…testosterone alone! The groups that did the worst…estrogen alone and placebo. Higher levels of testosterone were associated with a better response. These results are expected. Testosterone is the major ‘substrate’ for estrogen production in the brain, bones, vascular system, breast and adipose tissue. Some physicians do not understand this and may insist that estrogen therapy is needed.

Excess estrogen can cause anxiety, weight gain, belly fat, tender breasts, emotional lability, symptoms of PMS, and mood swings. Long-term exposure to stronger estrogens like estradiol and Premarin can increase the risk of breast cancer. In addition, there is exposure to many estrogen-like chemicals.

Some women (and men) ‘aromatize’ or convert too much testosterone to estradiol, which can interfere with the beneficial effects of testosterone. An ‘aromatase inhibitor’ (i.e. anastrozole) may be prescribed to prevent this. Patients, including breast cancer survivors and men with elevated estrogens, may be treated with the combination testosterone-anastrozole implants.

Hormone deficiency is a common cause of hair loss and treatment with testosterone implants can help to regrow hair. Hair becomes thicker and less dry with pellet therapy. Click here for more information ‘Hair Health and Hormone Balance'

Although there are abundant claims of ‘voice deepening’ with testosterone therapy we have not seen this in clinical practice. Therapeutic levels of testosterone, delivered by subcutaneous implant, had no adverse effect on the female voice including lowering or deepening of the voice.

No, subcutaneous testosterone pellets do not increase the risk of blood clots. Non-oral testosterone ‘bypasses the liver’ and does not increase clotting factors. However, estrogen levels should be monitored: increased estrogen can affect blood clotting.

Some patients begin to ‘feel better' within 24-48 hours while others may take a week or two to notice a difference. Diet and lifestyle, along with hormone balance are critical for optimal health. Stress is a major contributor to hormone imbalance and illness. Side effects and adverse drug events from prescription medications can interfere with the beneficial effects of the testosterone implant.

The pellets usually last between 3-4 months in women and 4-5 months in men. The pellets do not need to be removed. They completely dissolve on their own.

No. Women who are treated with testosterone implants alone (no estrogen therapy) do not require progestin therapy.

However, if estradiol, or other estrogen therapy is prescribed, progestins are also needed. The main indication for the use of synthetic progestins, like Provera® or progesterone, is to prevent the proliferation (stimulation) of the uterine lining caused by estrogen. Progestin therapy is NOT required if estrogen therapy is not prescribed. However, there may be other health benefits from the hormone, progesterone. It may help with anxiety or insomnia. Interestingly, progesterone implants have been used since the 1940’s.

Hormone levels may be drawn and evaluated before therapy is started. This may include an FSH, estradiol, and testosterone (free and total) for women. Men need a PSA (prostate specific antigen), sensitive estradiol, testosterone, LH, liver profile and blood count prior to starting therapy. Thyroid hormone levels (TSH) may also be evaluated.

In men, follow up levels, including a PSA, blood count and estradiol, may be obtained prior to subsequent testosterone implantation. Men must notify their primary care physician and obtain a digital rectal exam each year. Women are advised to continue their monthly self-breast exam and obtain a mammogram and/or pap smear as advised by their gynecologist or primary care physician.

The cost for the insertion of pellets is between $260 and $560 depending on the dose of the hormone and the number of pellets needed. Men need a much larger dose of testosterone than women and the cost is higher. Pellets need to be inserted 2 to 4 times a year depending on how rapidly a patient metabolizes hormones. There is also an initial consultation fee.
When compared to the cost of drugs to treat the individual symptoms of hormone decline, pellets are very cost effective.

Some insurance companies cover the cost of pellets, especially in men. Others do not. Most physicians require payment for their services. Patients may want to contact their insurance companies to see if their costs will be reimbursed. Prevention is much more cost effective than disease.
Patients are able to ‘appeal' a denied claim.

Testosterone pellets may be used in pre-menopausal females (women who have not stopped menstruating). Testosterone has been shown to relieve migraine or menstrual headaches, help with symptoms of PMS (premenstrual syndrome), relieve anxiety and depression, increase energy, help with sleep and improve sex drive and libido. If a pre-menopausal female has a testosterone pellet inserted, she must use birth control. There is a theoretical risk of ‘masculinizing’ a female fetus (giving male traits to a female fetus).

Very rarely, a patient will develop local zone of redness (3-8 cm) and itching at the site of the testosterone implant. There is minimal or no tenderness and no other sign of infection. Pellets are made of up testosterone, stearic acid and PVP (povidone). Patients may react to the PVP. Implants can be compounded or made without PVP. Many patients who develop a local reaction to the implant have low cortisol levels and upon further questioning, have symptoms of adrenal insufficiency. Cortisol testing may be recommended. If needed, 25-50 mg of Benadryl works well for the itching. See handout ‘Local allergic reaction’ for further recommendations.