Hormone Replacement Therapy

© 2020 by Larry A. Richardson, MD, MFOMA

As more and more patients are enjoying our Weight Loss and Bio-identical Hormone Therapy, one of the most popular questions I hear is "Why don't you offer pellet therapy?"

Here is why I don’t recommend pellets:

While there are some practitioners of bio-identical hormone replacement therapy (BHRT) that promote the use of pellet therapy in their clients, I have chosen to take a different therapeutic course for my patients in the interest of giving them the best options in terms of convenience, comfort, cost and long-term considerations.

In my years as a physician, I have found that when doctors try to replace hormones and modify cycles and rhythms in the human body, it is generally best to attempt to emulate the body’s own natural patterns and levels as closely as possible.

A brief study of human physiology will reveal that most of our body’s major processes, including hormonal secretions, follow a diurnal (daily) pattern, often with peaks and valleys of the levels and activity of the process under consideration. One such example would be a normal cortisol level that typically peaks around 8 am and falls to its lowest level around midnight. Another hormonal example is testosterone, which is often highest about 8 am and lowest around 9 pm.

One of the main reasons I disagree with the use of pellets for BHRT is as follows.

When pellets are inserted, the hormones begin a steady rise and reach a peak around 30 days (1 month) later. On average, they then begin a steady decline and reach their lowest levels between 4 to 6 months after insertion. Why take such care to make hormones that our bodies recognize as being ‘natural’ and identical to our own hormones, yet then deliver them by pellet therapy in such an ‘unnatural’ dosing pattern? Even though the hormones released are considered ‘bio-identical’, such an abnormal delivery pattern (ie, not diurnal) of the hormone itself does not sound very ‘physiological’ to me!

Other considerations regarding pellet therapy are as follows:

• Pellets are sometimes promoted to last ‘about 6 months’, though actual efficacy (relief of symptoms) is often much less than that (eg. 2 to 4 months).
• If the pellet dosing is wrong (particularly if too high and/or causing problematic side-effects), they cannot be removed. If the dose is excessive, it cannot be readjusted. Symptoms must be dealt with until the pellets dissolve and the levels drop. It is quite rare that doctors get hormone dosing optimized on the first attempt. Adjusting hormone dosing is a regular part of treating patients with hormone imbalances and it can take months to get everything just right.
• If the pellets are placed improperly or if the body rejects them for whatever reason, they may cause visible bumps or nodules (often uncomfortable) within the skin as the body extrudes the pellet.
• Insertion of pellets requires an office visit and a small surgical procedure each time (every 3, 4, 5 months?). This procedure always carries a small risk of infection and is certainly more costly to the patient than alternative prescribing methods of hormonal delivery. At the very least, there are always some ‘post-op restrictions’ after each implantation.
• In theory, pellets are no more effective than a gel, cream or injections.
• Pellet implantation invariably causes scar tissue. It is not often revealed that in some patients, after about 2 years of pellet insertions, some may have so much scar tissue build-up that they are no longer pellet candidates.