Board Certified Regenerative Medicine and Emergency Medicine, Chief Medical Officer of Prestige Regenerative Medicine
If you have had your hormone levels tested and are in need of hormone replacement therapy, your most important decision to make is what method of treatment is best for you. Pellets, creams, or injections? How do you choose?
At Prestige Regenerative Medicine, the most popular choice among our patients is Bioidentical Hormone Replacement Pellet Therapy. But why? Aren’t injections easier for adjusting dosage? Can’t you just get a hormone prescription from your primary care doctor? Doesn’t insurance sometimes cover creams or injections? Why do patients choose hormone pellets instead? Let’s unpack the myths versus the truths about hormone replacement therapy.
Bioidentical Hormone Pellets are compressed doses of the pure, non-synthetic hormone (~99%) compounded with a small amount (~1%) of cholesterol that is used as a binding agent (don’t worry- it won’t raise your cholesterol). Hormone pellets are roughly the size of a grain of rice. They are inserted by a trained practitioner through a tiny incision in an inconspicuous area of the body- usually the lower back/upper buttock. The procedure is done in the office with local anesthesia and is very quick. The only discomfort is usually a little stinging during injection of the anesthesia.
Because of different pellet sizes and doses, men typically require hormone pellet insertion three times per year (every 4 months) and women require it four times per year (every 3 months). The procedure carries a minimal risk of infection (far less than half a percent) or pellet extrusion. In comparison, patients who select injections as their hormone replacement method need to receive injections roughly 2-3 times per week to keep their hormone levels steady.
Unlike the spiking and crashing effect that can happen with pills, creams, or injections, once a hormone pellet is inserted, it begins dissolving and delivers a controlled, consistent, steady daily dose of the hormone into the body, much like how the hormone was secreted by the much younger body. Pellets give the most physiologically correct dosing of hormones and thus are regarded by experts as the safest and most effective way to derive the benefits of bioidentical hormone replacement therapy.
Topical hormone replacement (creams and gels) are the cheapest and best way to get bioidentical hormone replacement.
Although hormone creams and gels may be the least expensive way to replace the hormones lost as we age, and can in some cases work, they are by far the least effective and least convenient method. The skin is a barrier designed to keep things out of the body, and it does an excellent job at that. Creams and gels need to be rubbed in completely — and this is a messy and time-consuming process. When applying topical hormone creams, one needs to put on 5 to 10 times the dose on the skin that is desired in the body, and what is not rubbed in goes somewhere else (like on your spouse, children, grandchildren, pets, or down the drain)! We have even seen cases where hormones are transferred through the shared laundry in a household. Thus, topical HRT is our LEAST favorite method of hormone replacement and we do not recommend it.
Injections are a better way to get hormone replacement therapy because the dosage is more controllable.
While it is true that testosterone dose can be varied with every single injection, there is no advantage to that if you have the option of a practitioner who is skilled in dosing pellet therapy (and in fact, most of the time, standard dosages of injectable hormones are used and rarely varied). There are some other considerations with injections that are worth mentioning…
The natural form of these hormones (testosterone / estradiol) when purified is a powder, and the powder must be dissolved in something to be injected into the body. Most of the time injectable testosterone is mixed with either cottonseed oil or grapeseed oil, so the vast majority of what is being injected is not even the pure hormone — these oils can lead to allergies and intolerances, and potentially other health issues.
The principal issue with injections (other than the frequent painful needle poke) is that the hormones are delivered in a large dose all at once, and then over time, there is less and less available to the body, so the dosing is not all like the consistent steady state achieved with pellets. The half-life of injectable testosterone, depending on the formulation, ranges from 4-8 days. Thus, to have a meaningful testosterone level one week after injection requires injecting about two to four times as much as one needs on the first day — this is even more pronounced when one is getting injections monthly (a terrible idea!) or every 2 weeks. The best way to inject testosterone to keep levels right where they should be, without extremely high levels and extremely low levels, is to inject a small dose daily. Most patients are unwilling or unable to comply with that therapy, so the compromise is to have patients inject testosterone about every 3 days or twice per week. This is inconvenient, uncomfortable, and if one is traveling, requires taking syringes, needles, and associated supplies along. Most of our patients prefer the smooth, continuous, and physiologic dosing achieved with hormone pellets.
My Primary Care Physician (PCP) can manage my hormones.
This may or may not be a myth. It is the rare primary care provider who has received the additional training (not taught in medical school) necessary to provide safe and effective BHRT. Almost most primary care providers (family physicians, internists, even OB-GYNs, and their associated Physician Assistants and Nurse Practitioners) are well trained in conventional medicine, most have little or no training in the science behind bio-identical hormone replacement. All too often, mainstream medicine has ignored the important decline of hormones with aging, and most doctors have learned to either write off the symptoms of hormone deficiencies as “you’re just getting older, accept it” or prescribe pharmaceuticals for many of the symptoms that come with andropause and menopause — difficulty with sleep, mood changes, decreased energy, decreased libido, loss of interest in life, decreased sexual performance, increased body weight, insulin resistance, etc.
One of the most frustrating things we see in our clinics is patients who have gone to their doctor complaining of many of those symptoms and have come away with prescriptions for anti-depressants and anxiety medications! People do not develop anti-depressant deficiencies as they age — they develop hormone deficiencies. We can help!
Synthetic hormones are safe and effective ways to manage the hormonal declines of age.
Although there are some synthetic hormone solutions available for treatment of peri- and post-menopausal symptoms (ie. Premarin and Provera), and they have shown promise in symptom reduction and cardiovascular risk, the largest studies of these (The Women’s Health Initiative Study) have shown they carry an increased risk of both breast and endometrial cancer. Thus, most practitioners will only prescribe these hormones for a limited period and try to make sure a patient is well aware of the potential risks. BHRT is safe, effective, can be used indefinitely without additional risks of cancer or other problems, and has been shown to convey the same protective benefits against cardiovascular disease, osteoporosis, cognitive decline and the ravages of aging. In our clinics, we are huge fans of natural Bioidentical Hormone Replacement Therapy and we won’t even prescribe the synthetic hormones.
Regarding men, there is no substitute for natural bioidentical testosterone. Nothing else works the same or has the same effects. The same is true with women. Women have natural declines in their testosterone levels as they age and in fact, they make their estradiol from testosterone. Thus, in our clinics we focus on bioidentical testosterone replacement therapy as the first line in both men and women. There is no synthetic solution that even compares in terms of safety and efficacy.
I should let my insurance pay for my hormone replacement therapy.
Probably not. Most insurance companies are firmly grounded in the pharmaceutical world and do not cover the use of specially compounded medications. By their very nature, BHRT medications must be compounded (including pellets) and dosed differently for each individual. The safest, most convenient, and most effective method of BHRT is hormone pellet therapy, which is the combination of the compounded pellets (which insurance typically won’t pay for) and the insertion procedure (the practitioner’s time and skill) along with all the follow-up and background medical management involved. Insurance companies regard this as a “life-style” issue (which it is, but it is also a medical issue) and won’t cover the cost.
Most of our patients have been able to use their Health Savings Account (HSA) funds and Flexible Spending Account (FSA) funds to pay for BHRT, and many have been able to get their insurance companies to count it against their annual deductibles.
Injectables or pills are cheaper than pellets.
It depends. First, there is no pill that will do what hormone pellet therapy can do. So, we can rule them out right away. Injectable testosterone might be cheaper, but it depends on how you value your time, discomfort, and convenience.
The vast majority of our patients LOVE pellet therapy because it requires only a few visits a year, it gives them consistent, optimal hormone levels and great results, without the hassle, pain and inconvenience of injecting hormones at home or on vacation, or going to visit a practitioner monthly (a terrible way to dose!) for injections.
Many of our patients tell us that their hormone pellet therapy has allowed them to lead fuller, more productive, more energetic, and happier lives. And what price can we place on that?