There’s so much information out there about hormone replacement, admitedly it’s hard to keep up even as a menopause specialist! Recently I completed an intensive training course about hormone pellets, and was surprised that I actually learned a whole lot of new information that I am excited to share with you here.

If you want to read about hormone replacement in general, I have a couple of other posts about exactly that, including my blogs “I Think I Need Hormones, But Aren’t They Dangerous? and “What Is The Deal With Bio-Identical Hormones?”, but today I want to talk specifically about pellets.

From my other posts, we already know that many studies have shown what I consider to be the two most important things when considering hormone replacement therapy (HRT). First, we should be putting hormones into our system that are biologically identical to those that our body makes (not some chemical or animal look-alike.) These “bio-identical” hormones come in many forms, and pellets are one of them. Second, estradiol (bio-identical estrogen) 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 (makes sense, since the liver makes blood clotting factors).

So, once we have agreed that bio-identical and non-oral HRT is the gold standard based on many, many good studies, we have some options. 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 bio-identical testosterone. They can be dosed differently for each patient, based on her age, where she is in the menopause spectrum, her symptoms and personal history. In other words, the tiny rods come in many doses and can be added together to achieve a higher dose for patients who need that. For example, some men need might receive 8 testosterone pellets in one application, and some women might receive an estrogen and a testosterone pellet. 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. When I got my first pellet, the injection of anesthesia was a small sting, then 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 couple of weeks to be practically invisible (or for me, totally invisible amongst other freckles, stretch marks and scars!). For women, pellets provide a constant slow release of estrogen and usually testosterone as well, for about 4 months. The benefit of this compared to patches, shots or creams is obvious- first it’s just easy, it’s not messy, you don’t have to remember anything, and secondly you are getting an even dose which more closely mimics nature, rather than a spike in blood levels ever day (or very 3 days with a patch).

After your first pellet insert, we check in with you in 4-6 weeks to see how you are feeling. The rule “treat the patient, not the lab” is really important. If you are still having low estrogen symptoms like hot flashes, you may need a small “boost.” Though very unlikely, if you are having high estrogen symptoms like breast tenderness or water retention, we know we have to go down on the dose next time. You can see why it’s really important to have a very highly trained expert calculate your starting dose, since you can’t take pellets out. While the aim is to get it spot-on the first time, it’s better to be on the low side than the high side- you can always get more, but waiting for it to wear off if it’s too high is no fun!

While your personal description of how you are feeling is way more important than what the lab says, we do check your levels 4-6 weeks after the first pellet insert only, to see where we are. For example, if you feel great, I want to know what levels make you feel great so we can refer to that in the future. If you are still symptomatic, we want to see if the labs are showing that your levels are low, or if something else is going on. So, labs do have a place, but that place if secondary to what you are actually feeling. For example, if you feel great and the lab says your estradiol is still on the low side, or your testosterone is on the high side, I am not going to change it. We will just know that you feel good at a special level, and that’s important for YOU to know in case you see another doctor. We each need to know what dose works for us, and we are all similar but different. After that, we draw blood annually 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 HRT. 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 probably 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 “cures” 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 bio-identical testosterone- this happens with high doses of non bio-identical male hormones or the illegal anabolic steroids that some body builders take- but not with the small doses used in pellets. About 10 days after my first testosterone containing pellet, I definitely started to notice an increase in energy, improved sleep, and have started to see my muscle mass increase in the body-composition scanner (we can do this for you in the office, it’s really fun to see those changes!). My libido was already pretty good, but it certainly gave it a boost.

Apart from feeling better and keeping a healthy libido, which honestly is the MOST important reason to consider HRT in my opinion, estradiol and testosterone have been shown in many, many rigorous studies to have numerous very other health benefits. Both hormones reduce bone loss, and prevent osteoporosis which is a severe and debilitating disease of old age. Estradiol also significantly decreases the risk of Alzheimer’s disease, heart disease and colon cancer. It is a proven fact that you are more likely to live longer, and with less likelihood of dementia and physical pain and restricted mobility if you take bio-identical HRT than if you don’t. For any science nerds out there like me, I can provide you with TONS of very reputable studies to back up that statement. Personally, I am not wanting to spend the last 10 years of my life in a physically and mentally debilitated state being unable to care for myself. If I can do something natural (these are not drugs, they are naturally occurring hormones) proven to safely and significantly reduce hip fracture, heart disease and Alzheimer’s, sign me up!

And here is something that totally turns what we used to be taught upside down: NON-ORAL ESTRADIOL DOES NOT INCREASE THE RISK OF BREAST CANCER, HEART DISEASE OR STROKE. Wow!! This is a hard one to swallow since for the past 18 years, ever since the large Women’s Health Initiative study came out in 2002, we have been taught that this was not true. The problem is, that study used non-bioidentical hormones that were given by mouth (the exact same two things we DON’T do any more). Even the authors of that study published a follow-up in the prestigious journal JAMA in 2017 stating that estrogen alone showed no increase in any of these diseases (and that was even with oral horse estrogen!).

After 18 years of re-analyzing that data, the problems in that study were not related to the estrogen compound called Premarin (from pregnant mare’s urine- yuck) but to the compound called Provera, which is a progesterone look-alike that we no longer use. But we all know that good news doesn’t travel as fast as bad news, and most doctors are still stuck in their old belief system, which was very, very ingrained. Now, it IS true that if you have breast cancer, estradiol will cause it to grow faster and possibly spread faster. So it’s important to have a mammogram before your first pellet and annually thereafter. Until you have been completely cured from your breast cancer and are 5 years out from the original diagnosis, it’s generally wise to avoid estradiol. But testosterone can still be a great choice to improve your quality of life.

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. 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 6-8 weeks after the first pellet, then annually. The goal level is not something super-human, but rather the same levels that younger men in their mid 20’s have. An important side effect for men in low sperm count, but this is reversed once pellets are stopped. Lucky for men, they only need pellets twice 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 WILL treat partners of our patients, since it takes two to tango!

More questions about pellets? I am loving mine! Contact me at and let’s chat.

If you want to hear more from Dr. Susan please click here to listen to her being sexually woke interview with BA50 publisher Felice Shapiro.

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