Depending which menopause rabbit hole you fall down on the internet, you might end up finding a provider who offers you hormone pellets. Pellets are hormone preparations that come in the amounts the provider specifies, and can include estradiol, progesterone, testosterone, or others, alone or in combination, all in a compressed solid. The pellet fits in a needle or inserter, for placement under the skin where it will slowly dissolve. You can probably guess from the image above: my recommendation is that patients interested in hormone therapy avoid pellets. But pellets are available legally and ultimately I'm about patient choice, so here's the information to consider if you're trying to decide.
If a provider offering pellets is ethical and informed, they should be up front about these facts:
No hormone pellets are approved by the FDA
Pellets have received very little research since being introduced in the 1930s. (And, this is why they are not approved by the FDA!) *see note at end
There is no standard formulation - each provider chooses their own combination and dose. They do so without published guidelines from professional societies. So: we don't have much research on it, and everyone makes up their own rules - pretty experimental wouldn't you say?
Once a pellet is placed under the skin, it cannot be removed. Pellets are expected to last 3-6 months but for some people they will dissolve even more slowly. If you don’t like the side effects, or if you develop a medical problem, you’ll have to wait it out.
Use of pellets often results in women having higher blood levels of testosterone or estradiol than the normal ranges of these hormones for women. (To me that makes the lack of research even more stunning!) I have seen this in my own practice. We have to guess at what this means for cancer and stroke risk, among others.
Most providers do mention that you may have a scar, may develop an infection where the pellet is placed, or that the pellet could come out. These are the short term, easily observable risks of pellets, so they are simpler to focus on. A provider who covers only this point and none of the others is not doing enough to gain "ethical and informed" status in my book.
🚩 A provider who is less ethical, less informed, or both, will do some or all of the following:
Say pellets are safer than all FDA approved forms of hormone therapy. The research that would prove this or disprove this has not been done. No one has tried to find out how the risks of pellets compare to risks of other forms of hormone therapy, so the risks of pellets could be more, or different, or less. But acting like we know the risks enough to compare them is a red flag. In one of the few studies to compare them, pellets had more side effects than the FDA approved therapies.
Say the hormone pellets are more natural than other forms of hormone therapy. The hormones in pellets and the hormones in FDA approved therapies all start out as plant extracts and then go through a multi-step chemical conversion process) Pretending some forms of hormone therapy are “more natural” because they “come from plants” should be a big red flag that someone is marketing to you.
Making a big deal about how they are bioidentical. We have many FDA approved hormone therapies that are bioidentical too, so while maybe this was important 20 years ago, today it's nothing to crow about and certainly not a reason that you need to use an experimental medication.
Focus on how their patients feel better on pellet hormone therapy People feel better on heroin too, but I don't recommend it! What problems are pellets solving? What conditions are pellets preventing? Again, we don’t have the research to say for sure.
Require that you do saliva or urine hormone testing before each new dose. Oh, those tests aren’t covered by your health insurance plan and you'll have to pay the provider for them out of pocket? Caution advised - they've practicing "cash cow" menopause care!
Hormone therapy is the source of so much confusing (and sometimes intentionally misleading) information. I hope this gave you some information to help you, or your friends or family. Let me know if it brings up questions for you!
*note:
I went to pubmed and searched for randomized controlled trials with the keywords menopause and pellet, limited to studies with female particpants aged 45+. Only 39 studies came up. All but one was 15 or more years old! Surprising for a therapy that has been around since the 1930s.
I then searched these same filters using keywords associated with other forms of hormone therapy:
menopause and transdermal : 576
menopause and oral estradiol: 630
menopause and micronized progesterone: 104
menopause and conjugated estrogens: 679
As you can see, research on pellets is bizarrely out of date and insufficient. My advice: Go with what we know!