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Hormone Replacement Therapy
Understanding Bio-Identical Hormone Replacement Therapy (BHRT)
Pellet Implants
Introduction
Data supports hormone replacement therapy with pellet implants is the most effective and most bio-identical method to deliver hormones in both men and women. Pellets, placed under the skin, consistently release small, physiologic doses of hormones providing optimal therapy.
What are pellets?
Pellets are made up of either estriol, estradiol, testosterone, finasteride, progesterone. The hormones are pressed or fused into very small solid dosage forms, comparable to a cylinder. These pellets are larger than a grain of rice and smaller than a “tic-tac”. In the United States, most pellets are made by compounding pharmacists and delivered in an appropriate package – either glass vials or unit dose blister packs. There is an FDA approved 75mg testosterone pellet.
Why pellets?
Pellets deliver consistent, healthy levels of hormones for 3-5 months in women and 4-6 months in men. They avoid fluctuations, or ups and downs, of hormone levels seen with every other method of delivery.
In studies, when compared to conventional hormone replacement therapy, pellets have been shown to be superior for relief of menopausal and andropausal (male “menopause”) symptoms, maintenance of bone density, restoration of sleep patterns, and improvement in sex drive, libido, sexual response and performance.Testosterone delivered by a pellet implant, has been used to treat migraine and menstrual headaches. It also helps with vaginal dryness, incontinence, urinary urgency and frequency. In both men and women, testosterone has been shown to increase energy, relieve depression, increase a sense of well-being, relieve anxiety and improve memory and concentration. Testosterone, delivered by pellet implant, increases lean body mass (muscle strength), and decreases fat mass. Men and women need adequate levels of testosterone for optimal mental and physical health and for the prevention of chronic illnesses like Alzheimer’s and Parkinson’s disease and heart attacks, which are associated with low testosterone levels.
Even patients who have failed other types of hormone therapy have a very high success rate with pellets. There is no other “method of hormone delivery” that is as convenient for the patient as the pellets. Pellets have been used in both men and women since the late 1930’s.
How are pellets inserted?
The insertion of pellets is a simple, relatively painless procedure done under local anesthesia. The pellets are usually inserted in the upper buttocks through a small incision. Using a device called a trocar, the pellets are placed in the tissue, and rotated, so that they will not come out. The experience of the healthcare professional matters a great deal, not only in placing the pellets but also in determining the correct dosage of hormones to be used.
Are there any side effects or complications from the insertion of the pellets?
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 very rare. Testosterone may cause a slight increase in facial hair in some women (Super Female can possibly counteract this side effect by adding finasteride to the pellet). 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, also known as polycythemia. If the hemoglobin and hematocrit (blood count) get too high, a unit of blood may be donated. Hematocrit should be checked before starting testosterone therapy as well as during therapy on a regular basis.
After the insertion of the pellet(s), vigorous physical activity should be avoided for 72 hours in women and 5-7 days in men. Early physical activity is a cause of ‘extrusion’, which is a pellet working its way out. Antibiotics may be prescribed if a patient has diabetes or has had a joint replaced. However, this is a ‘clean procedure’ and antibiotics are most often not needed.
Why haven’t I heard about pellets?
You may wonder why you haven’t heard of pellets. The only patented pellet in the United States is a testosterone 75mg strength and has been marketed mainly to urologists. Many anti-aging / functional practitioners commonly use a compounding pharmacy to make their pellets. They come in a variety of strengths and in combination with other pharmaceuticals. Most compounding pharmacies do not advertise directly to the consumer and work closely with the practitioner to serve their needs for individual patients.
Do men need hormone therapy?
Testosterone levels begin to decline in men beginning in their early 30’s and is routinely referred to as “andropause”. 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 as mentioned. Even men in their 30’s can 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.
What if my primary care physician or my gynecologist says that there is ‘no data’ to support the use of pellet implants?
He or she is wrong. There is a big difference between ‘no data’ and the doctor not having read the data. It is much easier for busy practitioners to dismiss the patient, then it is to question their beliefs and do the research. It’s about a patient making an informed choice. After 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, coordination and physical performance. They may see an improvement in skin tone and hair texture. Concentration and memory may improve as well as overall physical and sexual health. These are obvious benefits that the patient experiences. There is also data that supports the “long-term” safety of hormones delivered by pellet implants.
Are there side effects to estrogen delivered by pellet implantation?
When a patient first starts on hormone therapy, there may be mild, temporary breast tenderness, which resolves on its own. Hormone receptors may be very sensitive and take time to adjust. There may be a temporary water weight gain, which will also resolve on its own. Women, especially those who have not had a hysterectomy, may choose a different method of delivery of estrogen, as the risk of bleeding is significant. Also, women that are given too much estrogen in their pellet dosing may experience bleeding again. Balancing the progesterone to estrogen ratio can effectively curtail vaginal bleeding. DIM (Diindolylmethane), which is a supplement, may also help restore healthy estrogen levels.
How long until a patient feels better after pellets are inserted?
Most female patients begin to ‘feel better’ within 48-72 hours while others may take a week or two to notice a difference. Men usually take 2-4 weeks before they start to notice the benefits of the pellets. Diet and lifestyle, along with hormone balance are critical for optimal health. Stress is a major contributor to hormone imbalances and illness.
How long do pellets last?
The pellets usually last between 3-5 months in women and 4-6 months in men. The pellets do not need to be removed. They completely dissolve on their own.
How are hormones monitored during therapy?
Hormone levels will be tested and evaluated before therapy is started. This will include for women: FSH, estradiol, total testosterone, progesterone, and TSH (thyroid stimulating hormone). For the men: PSA, estradiol, total testosterone, and blood count before starting therapy. Levels will be reevaluated during hormone therapy, usually 4-6 weeks after insertion and before insertion of the next set of pellets. After the first year of therapy, hormone levels may be followed less frequently. Men must notify their primary care physician and obtain a digital rectal exam for prostate symptoms. Women are advised to continue their monthly self-breast exam and obtain a mammogram and a pap smear as advised by the gynecologist or primary care physician.
How much does this cost?
The cost for the first insertion may be as low as $600 for men and $350 for women. Men need a much larger dose of testosterone than women, and the cost is higher. When compared to the cost of drugs to treat the individual symptoms of hormone decline, pellets are very cost effective. Pellets also deliver a steady state of the drug and compliance is much better.
Will insurance cover the procedure and pellets?
Most physicians require upfront payment for their services. Patients may want to contact their insurance companies to see if their costs will be reimbursed. At physician offices who take insurance, typically the practitioner can bill for the office visit/procedure, but the pellets are not covered. Patients know that prevention is much more cost effective than a disease.
Summary
Estrogen and testosterone therapy by implementation of pellets is a safe and effective method of hormone therapy for both men and women. Long, continuous administration of hormones by pellets is convenient and economical for the patient. Pellet implantation has consistently proven to be more effective than oral, intramuscular, and topical hormone therapy with regard to bone density, sexual function, mood and cognitive function, urinary and vaginal complaints, lipid profiles, hormone ratios, and metabolites.