Hormone Pellets: The Real Information

By: Alexa Nicole Fiffick, DO, MBS, MSCP • Holly L. Thacker, MD • Posted on January 22, 2024

Currently in the US, there are only a mere 1700 clinicians that are certified by the Menopause Society as Menopause Society Certified Practitioners. With women in the menopausal age range becoming one of the largest demographic groups and projected to include about 90 million women by 2060, it is not difficult to see that there are less menopause clinicians than we need to treat these patients.

It also points to one of the many reasons patients seek out pellets or alternative therapies to treat their menopausal symptoms. However, knowing the risks of pellet therapy is vital to your health and survival, so let’s look at what is known and unknown about hormone pellets.

What are pellets?

Pellets are a type of unregulated hormone therapy that is put into tablets that are injected under the skin, usually in the gluteal buttock region.
They are considered an “implant” due to this nature and are unable to be removed if any side effects or issues arise.
These are supposedly made of estrogen, progesterone, and/or testosterone, and are touted to slowly release over the course of 3-6 months.
Pellets are not covered by insurance and are provided to patients by charging a cash fee. Because they are reported to only last 3-6 months, this cash cost is repeated every 3 or so months when a new implant is recommended.

What are the dangers of pellets?

Pellets have been inadequately studied, at best. At worst, the data that we do have brings some concerning issues to light. Pellets have been found to deliver inconsistent levels of hormones throughout the body. This means that amounts that are too high or too low can be found with administration of hormone therapy through pellets.

Furthermore, if levels are found to be drastically too high or too low, the pellets are unable to be removed, and continue to leach hormones into the body until the dose is depleted. Organizations such as the Menopause Society, the American College of Gynecologists, and more adamantly recommend against the use of pellets due to this.

My friend uses pellets and feels great! Why shouldn’t I use them?

While some patients initially feel improvement in symptoms with pellet use (because they are being exposed to a high level of sex hormones), the risks are not worth the benefits. Often, patients feel well with pellets initially, but then may notice some side effects of inappropriate hormone dose. For example, excess estrogen can cause abnormal uterine bleeding or postmenopausal bleeding, as well as uterine cancer.

When the body has too much testosterone, that excess testosterone is converted by the body into estrogen. Then, if the patient is already receiving estrogen, the levels can become extremely high. This further increases the risk of uterine cancer. Many times the estrogen level is too low and the testosterone level is too high, and having very high levels followed by a dip causes tachyphylaxis and an 'addiction' to the high levels of the sex hormones which affect neurotransmitters and give a sort of artificial 'high.'

Testosterone in Women

The risk of too much testosterone

Excess testosterone has been shown to increase the risk of diabetes and other components of metabolic syndrome in women, among other issues. Excess testosterone in women can contribute to balding, increased unwanted hair growth (called hirsutism), acne, an irreversible increase in the size of the clitoris (that doesn’t improve sexual health), and irreversible deepening of the voice.

Testosterone in women is not FDA approved

Testosterone use in women is currently not FDA approved. It is currently recommended by the Menopause Society, the International Society for the Study of Women’s Sexual Health, and others for the improvement of hypoactive sexual desire disorder (HSDD). However, these guidelines recommend utilizing products designed for males (using 1/10th of a male dose for females), as no commercially available products are FDA approved for use in women.

Topical clitoral testosterone for orgasmic disorders

Compounded topical clitoral testosterone can be used for orgasmic disorders as well as vulvodynia, when applied locally to the clitoris or vulva. However, research on the risks and benefits of systemic treatment with testosterone in women is extremely limited. Thus, there are no guideline recommendations or FDA approvals for use in women for conditions or symptoms outside of those listed above. And to have further information on using systemic testosterone in women safely, more studies need to be done.

What about testosterone patches?

There was a testosterone patch that was going to be brought to market for HSDD that was well studied, but this was squashed by the FDA in the aftermath of the Women's Health Initiative (WHI). There is one old formulation of oral esterified (plant-based) estrogen with oral methyltestosterone HS (half strength standard). EEMTHS was originally under the brand name EstratestHS®, then CovaryxHS®. That is now only generically available and sometimes used when the testosterone is low due to oophorectomy (castration reduces up to 40% of a woman's testosterone/androgens).

Testosterone should only be provided by a healthcare clinician

Some women do need off-label testosterone compounded or an appropriate dose at 1/10th the dose for male replacement, but this must be supervised by someone appropriately trained in menopausal hormone therapy - not a facility that just takes your cash and doesn't give appropriate medical and hormonal follow up. Be wary of facilities that promote 'vaginal rejuvenation' with lasers/MonaLisas and "O shots," which are unproven injections into the anterior vaginal wall.

It also can be used for orgasmic disorders as well as vulvodynia, when applied locally to the clitoris or vulva. However, research on the risks and benefits of systemic treatment with testosterone in women is extremely limited. Thus, there are no guideline recommendations or FDA approvals for use in women for conditions or symptoms outside of those listed above. And to have further information on using systemic testosterone in women safely, more studies need to be done.

Be Strong, Be Healthy, Be in Charge!
-Alexa Fiffick, DO, MBS, MSCP and Holly L. Thacker, MD, FACP

About Alexa Fiffick, DO, MBS, MSCP

Dr. Alexa Fiffick is a Board Certified Family Medicine Physician, a recent graduate of the Specialized Women’s Health Clinical Fellowship at The Cleveland Clinic, a Menopause Society-Certified Menopause Practitioner, and now the Founder and CEO of Concierge Medicine of Westlake, here in Westlake, Ohio, and is a Ms Medicine affiliate. Dr. Thacker was her mentor and leader during her time as a women's health fellow at Cleveland Clinic, guiding her through the Fellowship program.

She graduated from the Doctors Hospital Family Medicine residency program with a Certified Concentration in Women’s Health. During residency she also served as Lead Resident for Ohiohealth’s community outreach program, Wellness-on-Wheels. She is passionate about complex hormonal conditions, Menopause, Perimenopause, POI, PCOS, PMS, PMDD, Menstrual migraine, Breast cancer prevention/early detection, bone health, and preventative medicine. She is a staunch patient advocate, which directly translates into how she cares for patients and works to educate her community. Additionally, she serves as a Menopause Expert for Menopause Mandate US, a 2024 Go Red Woman of Influence, and the Associate Director of Medical Education for Ms. Medicine.

About Holly L. Thacker, MD, FACP

Holly L. Thacker, MD, FACP is nationally known for her leadership in women’s health. She is the founder of the Cleveland Clinic Specialized Women’s Health Fellowship and is currently the Professor and Director of the Center for Specialized Women’s Health at Cleveland Clinic and Lerner College of Medicine at Case Western Reserve University. Her special interests are menopause and related medical problems including osteoporosis, hormone therapy, breast cancer risk assessment, menstrual disorders, female sexual dysfunction and interdisciplinary women’s health. Dr. Thacker is the Executive Director of Speaking of Women’s Health and the author of The Cleveland Clinic Guide to Menopause.

hormone therapy, hormone pellets, estrogen, testosterone, Dr. Alexa Fiffick, Dr. Fiffick, unregulated hormone therapy, menopause, menopause symptoms, progesterone, uterine cancer

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