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Welcome to The Modern Midlife Collective—where midlife isn’t a crisis, it’s a rebirth. Hosted by Dr. Ade Akindipe, DNP, and Dr. Jillian Woodruff, MD, this is the podcast for women ready to unapologetically own their power, thrive through the ups and downs of hormones, weight, and self-care, and show the world that thriving at 40 and beyond isn’t just possible—it’s your birthright.
Biweekly, we bring you science-backed insights on hormones, menopause, longevity, and sexual health—real tools to empower women in midlife and beyond. With a fearless blend of functional medicine, real-life wisdom, and no-nonsense empowerment, we’re here to challenge the norms, break through the barriers, and help you step into a life of vitality, confidence, and unstoppable strength.
Ready to rise? Let’s do this.
speaker-0 (00:00)
Have you ever been told that hormone pellets are the only way to replace hormones naturally? Or maybe you've heard the opposite, right? They're dangerous, they're impossible to reverse, they're a scam. And I think this is why today is so important for us because we need to separate fact from fiction when it comes to hormone pellets and specifically bio-identical hormone pellets.
speaker-1 (00:25)
Yeah, I think we really need to put the truth out there because we both prescribe pellets and we both have patients who absolutely love them. They're thriving on them. But we also know that we there is no one size fits all. people have done better in creams, patches, gels. I mean, there's different forms. so it's not just about choosing one or just being prescribed one thing. It's about choosing what's going to be
you know, what's gonna work right for you. So it's about choosing the right treatment for the right woman.
speaker-0 (01:47)
Exactly, exactly. Okay, so I think we should start with the basics. And actually, before we even talk about pros and cons, let's explain what we are talking about when we're talking about bioidentical hormone pellets. Bioidentical for one, and we've said this before, but bioidentical simply means that the hormone molecule is chemically identical to a hormone our bodies naturally produce.
So it doesn't mean that it's automatically safer or better, or well, could it mean more natural? You know, perhaps, right? All these hormones are found in nature, and then there is some type of synthesis to make them into a form that our bodies can use. But people probably don't know that when they're taking synthetic hormones, the molecular structure of it is a little bit off. So it's made to
function similarly to our natural hormones, but it's not exact because the the nature is a little bit off to make it more stable, lasts longer, less expensive to create and can be created in mass, right? whereas a bioidentical hormone is created, but from things that are naturally found and it's identical. So it will work in our body identical.
hopefully to how our natural hormones work. But interestingly, there are FDA approved bioidentical hormones, because I think the word bioidentical gets a bad rap. Where bioidentical, they just ascribe that to pellets, but that is not the truth. There are many bioidentical formulations out there and many of which are FDA approved, including estradiol, including testosterone, although not approved for women and including
Micronized progesterone, for example.
speaker-1 (03:33)
Yeah, I think it's important that we be very clear about that because often I'll have clients come in and they immediately get drawn to compounded medications, thinking that compounded means bioidentical. And there is a difference just because it's compounded, it's not it's not the compounding that makes it bioidentical. so bio identical just means lock and key. I think the lock and key.
So it fits exactly the way it's supposed to work in the body. If it if that lock and key model works the same way, then it's considered bi-identical. So compounding and pellet aren't the same thing at all.
speaker-0 (04:11)
Exactly. So hormone pellets are tiny solid cylinders. They're about the size of a grain of rice. And you insert them into subcutaneous fat. So just under the skin, into fat. And usually when I'm you know inserting them, they're in the lower back, upper buttoc but there are other places where they can be inserted, sometimes in the flank, just depending where you have some.
Healthy fat, and then also where you're not going to have a lot of stretch in that area or pressure like sitting on that area. And for women, we most commonly talk about estradiol and or testosterone or sometimes both, depending on right, depending on the treatment plan. So testosterone palettes are pretty common practice. And once they're placed under their skin, they dissolve.
And they release hormone into the bloodstream over a period of months. And the way they release is really based off your cardiac output. So the more blood flow, the more active you are, the more blood flow past this area, the more hormone is being utilized. And actually, that's when you feel your best when you're really utilizing it. And another important difference is because they're absorbed through the tissue and directly into circulation. They don't go through the liver.
First. So they bypass the liver metabolism. And so later I think we'll talk a little bit more about avoiding first pass hepatic metabolism. So it's avoiding the way your oral medications you take by mouth are metabolized. And so some of the side effects that can occur are less likely or they don't occur with things that bypass the liver.
speaker-1 (05:53)
Yeah, and I think that's what some women might like about it, or maybe some providers might recommend this kind of treatment for women, because if you have that lifestyle that doesn't allow for you to get up and apply something every day, maybe you travel a lot and you will forget, or you're just somebody that's not very routine, this is someone that may benefit from that kind of a therapy. So
You know, you're not getting up every single day and taking a pill or applying a cream or injecting yourself. you're not having to change a patch. So once that pellet is placed, it is continuously released. You know, some people get freaked out and thinking that maybe you're just getting a dump of hormones into your bloodstream, but it's compounded in such a way that it allows a steady release of hormones for about three, sometimes even four months for some women.
So that appeal is it's in it's, you know, you forget about it. Of course you need to be monitored, make sure that you're tolerating, okay, but of course you can't remove it. So there is a downside to that. But it is the it is the method and it's for the right woman. It's not for everyone.
speaker-0 (06:58)
Exactly. And you know, the amount of hormone that's released and the blood level you ultimately achieve can vary significantly from one person to another and varies based on the dose, on the formulation, of course the individual patient. But you what you alluded to and what you said just now is unlike the patch or gel or
oral medication, once a pellet is inserted, you can't simply stop taking the dose tomorrow. It's in there until it goes away. Whereas other methods you can stop. And so that's going to be important when we talk about some of the advantages and disadvantages. And like any other medication, natural or not, bioidentical or not, they can have side effects. And so if you have a side effect that you don't like, you can't just turn it off.
really quickly. So that's something you have to keep in mind. You know, it's a quick office procedure. There's a local anesthetic involved, like a little lidocaine to numb the area. And and most women are and men are back to their normal activities, you know, very quickly.
speaker-1 (08:03)
Yeah, I think that's what I really enjoy about the you know the process. I've tried both the creams and I've also tried the pellets. And you know, one lady actually thought it was something that you implant and you have to remove, kind of like a next plan or something. And no, you cannot remove it. It's it is it doesn't stay in one spot. We don't have to replace it. We just have to replace it once that level has gotten to a point where it's time for you to kind of get kind of like a refill.
Think of it, think of it as as your refill of you getting your hormones back once you've used it up. So women can start to feel good again, you know? some women start to feel great within a few days, some maybe might need a week or so. and it's great because it it can it can create some kind of consistency and kind of mimic what your ovaries would normally do versus
You know, some folks who are, especially they're on testosterone injections and they're having to inject twice a week or whatever that looks like, or having to remove a patch and put it back on. So some women just like that consistency of having making sure that it's in there, the patch didn't fall off, or the cream is not being absorbed. Not saying that those methods aren't don't work. It's just another way that might work better for some women who are not necessarily getting the benefits from the topical or injectable ones.
speaker-0 (09:16)
Yeah, I think you know who you are. If you are really good at the beginning with your medication, you're taking it as you should, and then you kind of fall off, right? Yeah. When it comes to hormones, when you fall off and then you're getting back on, or your patch stays on a couple of days too late or too far and then you start it again, you're introducing more of that yo yo roller coaster that away from. So themselves a little bit, right?
speaker-1 (09:38)
Exactly. People have to know
You gotta know yourself for sure. If you're not taking your vitamin D every day or your other multivitamins or even prescriptions, then this is probably not the best. Those other methods are probably not the best. Pellets might be an option for you.
speaker-0 (09:54)
Exactly. So even if they all worked very well, when you talk about how effective a medication is, you do have to take into account how well it's being used. Yeah. And so they do have skills that that do that sort of thing. And that's why when, you know, in my world I'm thinking about birth control. And the most effective methods of birth control are things like the intrauterine device, the IUD, because it doesn't rely on a person to remember to take it.
That automatically kind of knocks it down a few notches. So the same with hormones and the way people respond. Some things probably, you know, they may say, okay, the pellet is more effective because you put it in and then that's it. But it's really based on that person not having to think about something. Talk
speaker-1 (10:42)
Exactly.
speaker-0 (10:43)
about like why do pellets have such a bad rap sometimes? There are so many. There's like people, you're like for it.
All the way, and then there's people that are like, This is terrible, nobody should do it. And like pellets sometimes are like a religion, like, this is the only way to do it, and they only have faith in that pellet, like it's going to solve all the problems, which we know that isn't true. But in some places only offer pellets, which I feel is concerning because no one medication is right for every woman.
speaker-1 (11:17)
Exactly. Exactly. Yeah. I mean, it should never feel like an assembly line, like you walking into a clinic and literally everyone in there is just there for their insertion. I I agree that is concerning. So you when you go to a provider's office, you should never be trying to be convinced. And I'm I'm I think you do this as well, Dr. Jill, is educate your patients, sometimes even give them some reading material.
to take home and learn more about the different options that are available. Our job is to try to figure out what will work, what is your goal, what are your symptoms, what's your lifestyle like, what's on your lab work, not your labs are fine, but here is a pellet anyway. That's dangerous. That's not right. There should always, you should always leave with a this is what we think would benefit you. This is what we're trying to prevent. These are the symptoms we're treating and why.
if there are other benefits that maybe you don't necessarily have a symptom, maybe there are some benefits because there are really some really good benefits of hormone replacement. but you should always leave with a why and why this, why this modality of treatment, right?
speaker-0 (12:21)
Exactly. Well, and if you're listening to this episode, we do have a free guide that we will be attaching or you'll find it attached to this episode. And this should help you kind of walk through to see what are the different methods that are out there and kind of have an idea of what you think may be something that would be more effective for you and that would fit well into your life. And we'll include some questions that you may not.
think of to ask that hopefully by asking them we'll give you a little bit more clarity on the method that is will work for you or maybe why the provider chose a specific method. You know? let's talk about some myths, you know, let's
speaker-1 (13:04)
Let's do it.
speaker-0 (13:05)
some myths, I guess. Okay. these are things we hear about pellets all the time. And so let's see if
These things are true or not. So this one is a myth. Myth number one: pellets are more natural.
speaker-1 (13:19)
no.
speaker-0 (13:20)
right? More natural.
speaker-1 (13:21)
Think can
speaker-0 (13:23)
It's a tricky one. so pellets specifically being more natural than others. The hormones inside pellets are bioidentical. So I do consider that natural. That part is true. But there are, as we said, many other
forms, formulations of hormones that are also natural, that are also bioidentical. And so, and many of them are FDA approved. So bioidentical doesn't automatically mean pellet. And pellet doesn't automatically mean more natural than another method. Does that make sense?
speaker-1 (13:58)
Absolutely
agree. And if you've been listening to these our episodes, or if you're new to this, go back and listen to, I can't remember what episode this was, Dr. Jill, but we have talked a lot about, you know, biodental hormones, estrogen progesterone, and what it means for it to be natural and not natural. Natural just means it identifies, it just looks really identical to what your body makes. So that can be FD-approved medications. That can be pellet, pellet.
works the same way, it will work in your body. So that's what that's essentially means. So absolutely agree with Dr. Jill. It is more, it is a more natural form compared to let's say a testosterone injectable, for example, right? Testosterone sipionate is not necessarily, it's not natural because it's it's it's made in a different the structure of that is different from if you get a testosterone pellet, if that makes sense.
All right, myth number two. Pellets are safer. Hmm.
speaker-0 (14:54)
Yeah.
speaker-1 (14:55)
Well, so pellets are safer. So I I I look at it this way. there are risks and benefits to different modalities. no delivery system is safer than another, really. it's really, we have to look at your profile. I'll give you an example of.
estrogen, right? Oral estrogen. it goes through the gut and it is metabolized by the liver. So there's this first pass effect where if it's if it's going through that way, you know, you are you are at more risk for clotting. So if you have liver issues or if you're a smoker or if you have some risk factor, factor five ligin, for example, is another one that
I wouldn't recommend you taking oral estrodiol. Then, of course, that's probably not the best route for you. You may benefit from doing a pellet or a patch. So this is why it's never a one-size-fits all. So non-oral, transdermal avoids the first pass effect. And the evidence suggests that transdermal estrogen has a lower risk of venous blood clots than oral estrogen, which can make it an especially important consideration for women who have like.
cardiovascular disease or clotting risk factors like we talked about. So when we're comparing the different methods, this is the kind of conversation you should be having with your provider, knowing what your risks are, what the benefits are, and then making a choice on that.
speaker-0 (16:16)
Right. You want to know, do you already have other risks of blood clots? Do you other already have other cardiovascular disease risks? So you're adding that on because even with oral estradiol, the it's not an astronomical risk, right? For having a blood clot or having, right? It's actually considered a a low risk.
But if you already have these other risks, then putting those things together, you're adding risk on risk. And so that's increase it altogether. But I think we, you know, we have a lot of fear tactics and scare culture where, you know, everybody's going to die if you do something. And that's just not true. So but there are safer methods than oral. But you know, we can't just say, okay, non-oral.
Is safer, so pellets must be the safest. We don't have any evidence to say that. Among the non-oral methods, all of the ones you mentioned, we simply just don't have any like head-to-head long-term studies to compare the safety amongst them. So then what you want to look at is how well it works in a person individually. So
speaker-1 (17:28)
Yeah. So
speaker-0 (17:30)
I would separate the two questions, right? Like
Dose root, don't does root matter, like the root you take it, oral or topical, yes. Or injections, yes, it matters. And do we have evidence proving that pellets are safer than other non-oral forms? No, we don't have that.
speaker-1 (17:46)
Yes, I absolutely agree. And that's why safety still comes back to the picture we're talking about here. You know, what hormones are you on? What dose? What route? What is your, you know, this woman's medical history? What is their individual risk? You know, this whoever is treating you with hormones should be asking all of these questions. how are you going to adjust or discontinue this therapy if you need to?
and that's how that's how it becomes really personalized. because not everyone is just is taking this for menopausal symptoms. There are women who are not in menopause or perimenopause or women who are just looking to feel better. And maybe that is the route that works best for them. Like I know recently there's a flight attendant that you know just wanted the best route and the best route for her because she's on and off, and now she's gone.
Pellet it is. It's what's going to work for her so she can do her job, so she can have energy. So again, lifestyle and all those other things matter too.
speaker-0 (18:45)
Right. And you know, for flight attendants, it's really difficult to travel with medications and also depending on where you're going, testosterone is a controlled substance. So you do wanna know what laws are in different countries with types of medications that you can travel with, and you'd be surprised. Yeah, you know, we've traveled together and you'll be surprised about things you can't take into specific countries. So
You wanna be careful. And then flight attendants they have so much so much change. And I f I don't remember what it's g gravity change. I don't know, but you know, the pressure. I just worry about
speaker-1 (19:21)
Creams being everywhere. You know, imagine carrying the little toppy clicks around and it just explodes everywhere.
speaker-0 (19:26)
Explodes everywhere. Exactly. So yeah, for them, I think this would probably be the best method for most all of them. But I didn't say that because I know that different things work for different people. So that brings us to myth number three. Pellets work better for hormone therapy. Sometimes, not always, maybe not, right? Some women feel amazing, others don't. Some women metabolize per pellets beautifully.
Others don't. Others may burn through them really quickly. Others they just may sit around and they're not really getting the full benefits of them. So medicine isn't one size fits all. We say it over and over and over. We've said it so many times on this show. But it's not. There's no one size fits all. And if someone tells you otherwise or tells you pellets are the only way, they're trying to sell you something that you may or frankly may not need.
speaker-1 (20:19)
Yeah, no, I agree with that metabolize, you know, the women, different women metabolize this differently. I mean, you have some folks that either they're just very active and they burn through them really quickly, or some women just get, you know, reactions to it, maybe, especially if they have insulin resistance and you put the pellet in and they have all the acne and just even dialing down on the dose. I mean with my experience anyway, dialing down on the dose, they just don't tolerate it. So I found that maybe switching them to something topical.
there's a little bit more leeway. Maybe you can have apply it every other day. And so they still get that benefit, but not with with those reactions. So everybody's different. So yes, it it can work amazingly, beautifully, wonderfully. But for some folks it might not be that case.
speaker-0 (21:02)
What you're describing takes time, you know, and it takes expertise because these aren't standard treatments, timing, dosing to take something every other day. That can work for testosterone. That may not work for estradiol, right? So it's really you do need to work with somebody who knows how these medications are typically metabolized, then can study how your body does it. Yeah. And make adjustments.
I know for me, I do enjoy the beauty of testosterone pellets, and it does wonders for energy and libido. And it's different for everyone, right? Some people may not have the same benefits that I've enjoyed. But at the beginning, when I started, when I did a typical dose, because it is a calculated dose based off of your body weight and your levels and
Also, your your kidney function. So there's a calculated dose, but you know, I over time I learned that calculated dose is a guideline. It's because when I did that calculated dose, I got acne. And I'm like, no, I don't want to be an adult with acne. And so I realized I had to do much smaller, much, much smaller doses. And then I actually I thought I would have to do them closer together, but really I didn't. I could it they would last for quite
some time way more than three months, but just much smaller. So I had not a huge surge. It's the surge that would lead to the problems for me. But some people don't have that problem.
speaker-1 (22:36)
People, yeah, yeah. And then of course, if you fix the underlying root cause, right? If you're someone that has insulin resistance and you fix that, of course, that also fixes the androgen issue. And you can still get the benefits of get maybe getting a pellet if you prov if you prefer. It may not have it. Maybe you we do need to dial down on that dose so that you can get the benefits and still get the pellets, if that's what you prefer. But yeah, it takes time and it takes patience too, because sometimes women will say, Well,
I heard pellets were great and I just didn't feel the way I I expected. But you would rather start at a it a a good dose. Maybe you don't need to start at a really high dose, but we need to gradually get you there, maybe get you get a little bit of a boost so that you can feel better. But I'd rather start low than go s then go really high, and then you have all the crazy potential side effects that comes with it. So it takes patience, gradual dosing, looking at the whole picture before
making judgment that says, well pellets suck, they don't work. So Yeah.
speaker-0 (23:36)
I think that's where the some of the issue comes from is that when you're treating hormone pellets like a factory and you're just calculating dose and putting it in and that's it over and over, people are getting these really high, we call them supra physiologic levels. Yeah. Very high. They may or may not be having side effects, but they could have other issues down the line in
You're not taken into account. Only your lab numbers are really taken into account. So that's that's the issue. But hope the people that I know and that I work with, the people like you that insert hormone pellets aren't functioning in that way. They are taking the whole person into account, right? Yeah. Not greening super well.
speaker-1 (24:20)
Never
and I think that's I think those people who are against pellets and I think I think that's what they're really against when it's a marketing strategy to just make as much money as you can, just pellet anyone who walks in. it it's the the the thing is it's not the only solution. I've seen different methods work for different people. So it you know, that's that's marketing, that's not medicine. You want to treat the whole woman and
Hormone therapy is just part of the solution, right? It may not just be the pellet, it might be we need to fix your metabolic function, we need to optimize your thyroid. So if you're going somewhere in there, well you're not getting better. So there you go. That's probably another sign that it's the wrong place.
speaker-0 (25:00)
That's true. That's true. And you're always thinking whole person. And that's exactly how we should be thinking. You can't just correct this one thing. Because everything is related to something else. Yeah. Another thing that I think is constantly misrepresented is compounding pharmacies. And you spoke on this. but compounding pharmacies are not the enemy here. No. Compounded medications, compounded medications are used.
quite safely every day, all over medicine and pain management and fertility treatments, in pediatrics. Nobody blinks. But the second I feel this is my opinion, the second it's for women's hormone therapy, suddenly compounding gets treated like a red flag all by itself. We we don't buy that double standard.
speaker-1 (25:48)
At all. At all. No, I have to agree. I mean, even just even with dosing, sometimes it's like, well, what do you mean two point five milligrams? I'm like, yes, women women need testosterone as well. It's like there's this pushback. but no, compounding pharmacies are that's what they are. They compound so that we can provide personalized care, right? It's it's meant to be specific. It's these pharmacies aren't just like
little drug dealers on the street. These are they they they have to No, I feel like sometimes that's what they make it seem like it these are licensed pharmacies under professional oversight. So there's nothing wrong with compounding pharmacies. We trust them. Of course there are so many different kinds and if we want to make sure that we are doing our diligence and making sure that they are you know they're approved and they have oversight. But
speaker-0 (26:39)
There's different licenses too.
speaker-1 (26:40)
And
there's different licenses. So it's not compounded versus not compounded. It's whether you are getting the the the most individualized care. And I'm sure you have lots of different examples of when you've had to not necessarily do the FDA approved one, but find something that might work for that patient.
speaker-0 (26:59)
Yeah, actually. specifically for a synthetic medication they're getting at their regular pharmacy. There's fillers and medications, and some of those fillers, it could be corn, it could be soy. but the patient had a severe allergy to the filler, and so they made the same medication without that filler at a compounding pharmacy. No issues. And
speaker-1 (27:22)
No issues at all.
speaker-0 (27:23)
except cost, right? It does cost.
speaker-1 (27:26)
It
just gonna cost a little bit more. Yeah.
speaker-0 (27:28)
But they were able to get the medication that they needed for their issue. It wasn't a a hormone issue, but they were able to get that medication, have the situation treated, and not introduce another problem with their allergy.
speaker-1 (27:41)
Exactly.
speaker-0 (27:41)
And I guess we should probably talk about oral testosterone. I don't know if you get questions that come up about why they can't take testosterone orally. Do you have
speaker-1 (27:51)
Not very frequently actually. No, not really.
speaker-0 (27:54)
Not a lot, not a lot. But sometimes you know, they're wondering why they can't take as a pill and what that does, you know, why why would that be bad if you have estradiol as a pill? Can you take testosterone as a pill? but yeah, can you swallow a pill? You could, but testosterone is just a little different.
With the side effects or the the issues that can arise, it can have a worse effect on your lipid profile. So on your cholesterol, your LDL cholesterol, your triglycerides, similar to some of the like birth control pills also can have an issue with their cholesterol. Some more than others.
speaker-1 (28:36)
Yeah, I agree. I think I've seen that same trend with the injectables as well. The injectable testosterone with the cholesterol just kind of getting a little bit more abnormal, the LDL starts to rise as well. I'm not sure if you see that with the injectables who are are not on the creams or the pellets anyway. So
speaker-0 (28:57)
Yeah. I've seen that with people that have come in. I don't use any injectables in my office, but I have some that have come from other places that have been on it. And it's hard to know have they had this problem all along. You know, if they're my patients, I would have been monitoring them so I would know, you know, from the beginning prior to starting. But some of them you you don't know. But I have seen when they've come off.
benefit, so I can only assume right.
speaker-1 (29:26)
Right.
Yeah. You know, the route really does matter. again, depending on your your risk factors. It's a hormone. So it doesn't mean estrogen, progesterone, and testosterone all behave exactly the way the same way when you swallow them. So it's just good to kind of have that conversation with your with your provider, especially, you know, the these hormones are available and you go to different places. People are getting it from different places, even different countries. I know someone that came from
I can't remember what what country they came from and they were taking everything orally and wanted to come and do the same thing, but this person had a very high risk profile smoker, et cetera, et cetera. And my advice was, hey, I don't, you know, necessarily think that's a good idea. So always have that conversation with your provider. That's what that's all about.
speaker-0 (30:15)
Absolutely. And I'm not saying we never do oral estradiol or oral estrogens because I do have some patients that are on there, but you know, it wouldn't be the smoker, right? It wouldn't be other people that already have an a high risk. Living in Alaska, you know, probably our risk goes up a bit because a lot of people here travel and they're traveling on planes for very long distances. And so that's a risk factor for.
DVT, deep venous thrombosis, so a blood clot, blood clot, excuse me. So yeah, maybe then the oral wouldn't be the best form for them. And we'd want to talk about another method, but it's not a absolutely not sort of thing. side effects. So side effects of pellets are very similar to common side effects of those same hormones and other forms. The difference though with pellets are that they can't be removed.
So they're in there. You wait for your body to absorb and utilize them. Could be three months, could be sooner, could be four months, they could last for a while. So if you wanted to get them out of your system, you kind of really just have to wait. You can't just remove them. So that's a thing. Otherwise, side effects that you could have, let's say from testosterone, some people can have facial hair growth. Some people can have acne on their face or on their chest or back.
this is not common side effects actually in my practice because I really think it has a lot to do with dosages and with optimization of the other hormones as well. Mood changes. You can have mood changes. typically I'm going for the good mood changes that people are usually calmer and have a sense of well-being, let's say with testosterone and with estradiol, also more thick clarity of.
thought more I don't know if it'd be happiness but just more pleasant I guess. Pleasant.
speaker-1 (32:08)
More
speaker-0 (32:09)
Right. But things with too much, you could be more moody, more sad, tearful, right? With too much and with too little hormone, more irritable. breast tenderness can happen with too much or too little of hormones. So very similar whether you're taking a patch or taking a gel.
or having a pellet, side effects really come from these side effects in particular come from dosing and the person and how you respond because you're gonna respond differently than how I am going to respond.
speaker-1 (32:40)
Yeah. And you know, the timing of it can be tricky. I mean, specifically if we're talking about pellets, one thing is if you've been without hormones for a long time, well, relatively a long time, and you get pellets for the first time, you may notice, my goodness, I feel amazing. And it's it's great, but then you may not notice that same feeling.
feeling maybe the third round or the fourth round and women are like, hey, I don't feel the same way. But you gotta realize that sometimes it's like because your body is now used to this new normal, you may not get that same exact you know, I don't know if you've come across that when women just say, Well, I don't feel like I did the first round of pellets. I
speaker-0 (33:22)
Yeah.
speaker-1 (33:22)
want to feel you know, so it's just your body kind of getting used to that. And then of course some women
feel wonderful for a few months and they start to feel those symptoms coming back. Remember, these pellets are implanted and they slowly dissolve over a few months. So they will run out at some point and you need to come back in. some women earlier than others because they're burning through it really quickly. I know some one woman who is a bodybuilder and she burned through her estradiol really quickly. She can tell the moodiness comes back, you know, all of those other things that she the anxiety, all of those things come back. So
Then you know it's time for you to come back for your next insertion. I usually tell women don't wait until we're completely out. You know, sometimes it's better to probably schedule those out so that you're not completely starting from square one. So that's why monitoring is also important, monitoring those labs, checking those levels, getting, you know, your baseline, and then after just make sure you're not getting too much of the hormone. sometimes even with body changes, if you've lost a lot of weight.
let's say you're in a weight loss journey, you may not need, especially when you're doing testosterone. I found you may not necessarily need as much as you did before. so optimizing your your your your metabolism, optimizing your hormones, you definitely need to change things around depending on what's going on. Also, making sure that you are taking the supplements like your Bs, your vitamin D.
It's it's not just taking the hormones alone, making sure that you're eating very well so that all of those things work together. So you don't want to get super physiologic where you're getting the the bad side effects, which is why we have to keep checking the labs. I know sometimes you'll say, well, why are we always doing these labs? I don't want to keep giving you something without knowing how it's doing in your body. So we want to always make sure we're checking.
speaker-0 (35:09)
Yeah, really great point about these supplements. And there are supplements that really help to optimize the metabolism of estrogens and some that help optimize metabolism of testosterone. So that's a really great point. And yeah, nobody wants to have to do labs over and over, but I'm sure you've been surprised by people in the past that you they've taken time from, you know, getting themselves, having monitoring and then
They have levels that are are just really high. Or they're doing okay, but not the best. And you're noticing their absorption is not good. They may be doing something topical and those levels have been remained low. And so you have to change it up. You may have to change the different to a different type of topical. You may have to evaluate what kind of base the medication is made in and
where they're putting it on their body, where you can optimize absorption. So a good a good hormone specialist will know how to make these adjustments, will know how to adjust the dose and the formulation. And they get to know your body and how you metabolize medications and optimize that metabolism of hormones, optimize it with lifestyle changes, with supplements, with dosing, with
The root of the medication and determine what's best for you instead of just relying on a calculated dose. one point we just have to make though is that if you are on estrogen and you have a uterus, you need to be on a progesterone so that you can protect your uterine lining. Estrogen leads to stimulation of the growth of your uterine lining. And so progesterone comes in and counteracts that.
So that it doesn't grow unopposed. So unopposed meaning estrogen simulates it and nothing to kind of shed it. And because you're not having a period, which is what your body would do to shed that lining, because you have natural production of progesterone, you need to take that progesterone in some way. So this is going to reduce your risk of endometrial cancer, so uterine cancer and something called endometrial hyperplasia, which is an overgrowth.
of the tissue, a thickening of the tissue inside the uterus that is a risk factor for a cancer as well. So symptoms that can occur when this is taking place is postmenopausal bleeding or irregular bleeding, abnormal bleeding from the uterus. I have seen women come in that have been on estrogen for quite some time and they have a uterus because they haven't had a hysterectomy
And they've not had a problem. You know, they haven't had bleeding, so nothing was done, but they weren't on progesterone. And then they had some sort of incident where maybe they had an ultrasound where they incidentally found a thickened lining and we biopsied that and we found atypical cells or precancerous cells. other times they just started to have heavy bleeding.
like a period. They're like, I'm having a period again and I'm 60. And we're like, have you been on progesterone? They may have been sent to me for a biopsy. And then we find that they weren't on progesterone. It could be that they weren't prescribed it. It could be that they they didn't take it because maybe they had a side effect that they didn't discuss with their provider. But it doesn't end very well. So you you definitely need to be on some
form of progesterone and there are several forms in order to protect that uterus from just too much simulation from estradiol.
speaker-1 (38:44)
That's great that you brought that up because that is super important. yeah, I have unfortunately come across something like that where there's someone who was not on. Yeah, bad. That's not a good practice at all. on that note, I think our audience would want to know about how is this even implanted in the first place, right? So it's not surgery, it's not a huge procedure, but it's a minor procedure.
it's done in a clinic. really takes a few minutes to do under local anesthesia. You know, we numb the area with some lidocaine and we make a small incision. it's very low risk. Of course, when you're implanting the pellets, there's a risk for infection. So you want to make sure that it's very, you know, clean and the pellets are inserted there into the fatty tissue of the usually the the lower hip, the buttock area.
And you know, that you swap from side to side to make sure that that area has healed, no, making sure as much as you know, as less scar tissue as possible, of course, you are creating some but it's as l as less trauma as possible, right? Because you're you don't want to make you don't want the person to be bruised or or have a permanent wound there. the biggest risk though is infection. so making sure that you're not soaking it in a hot tub, you're not going swimming until that site has healed completely.
you know, there is a ch chance for the pellet to come back out. I haven't personally seen it since I've been doing the procedure, but it is something that's very, very possible. You know, the pellet can extrude. We call it a pellet extrusion where that can come right back out. the cost usually it's not covered by insurance. insurance doesn't, I haven't never really seen it. I have seen men get it covered if they get like a reimbursement letter.
Sent or super bill or letter of medical necessity. But for women, it's been really difficult. I don't think I've ever seen it personally being covered. So the major thing is following those instructions. You know, it's covered usually with stereo strips and a gauze and a bandage, and just making sure that it does not get infected as much as possible.
speaker-0 (40:48)
Yeah, exactly. I will say yes, I've had hormone pellet extrusions for several different reasons. One of them can be if there's any signs of infection. If you have an infection in that region, anything in there, it's kind of like purulent discharge gets into that area and kind of pushes the pellet out. So if that incision isn't healing and it should heal like
in two days or less. Yeah. You know, it's just taped clothes. It's not, it's a teeny tiny incision.
speaker-1 (41:17)
Fingy.
speaker-0 (41:19)
But let's say you are doing, we always say don't do any butt exercises. So no squats or or swimming. so no soaking in tops for like five days. So you can just let this heal. But let's say that you're like, I forgot I'm going to go and climb this mountain. And then there's blood that accumulates in that very tiny incision. So it's not
touching, the skin isn't touching, that's a risk for extrusion because that's also a risk for infection in that region. So that's one of them. There are people, there are some people that have been getting pellets for a long time. And so they have a scar tissue that is in that area and scar tissue doesn't have the great blood flow that the other areas have. So I try not to go exactly into the same area, you know, each time you want some
good healthy tissue. And sometimes I've had to do some injections of steroid. Steroid just stops that overreaction of that tissue. So we can help prevent scar tissue from forming. And I'm talking like a little bit, right? A little, little bit. Diabetes, you you mentioned sometimes, you know, you anything that causes poor wound healing, that could put you at risk for extrusion.
but it is not a very common thing, but it can happen. Yeah. so who is who are pellets good for? I would say probably someone who struggles to remember medications each day. that's a lot of people. I would also probably say somebody who maybe is taking hormones already and they're not doing well with a little surge and release that they have.
If they're doing a patch, a once-weekly patch or twice-weekly is probably more common than that. They're having that little surge in release, very small, but twice a week. And so that if you're really sensitive to hormones, that can really cause an issue for you. I'd say someone who prefers fewer office visits may be good for pellets. somebody who understands that there's pros and cons and benefits and risks to you.
hormones and they want something that's more convenient.
speaker-1 (43:29)
Yeah, I found that women who want more convenience are the ones that tend to do better on that too. And then also if they're just not absorbing. I mean, I've had I recently had to switch somebody to pellets because it just doesn't matter going up on the dose, switching the base of the cream. They just were not getting the benefits. I mean, even the symptoms, like the vasomotor symptoms, weren't completely gone. also, if we're looking for additional
Benefits and getting higher levels, you know, for bone protection and all those things. Sometimes if they're not absorbing it, you definitely want to consider switching over to something like a pellets. women who may do better with another delivery method includes someone who's just starting hormone therapy. And I think that's very correct because if you're new to it, also you know, if if you struggle, I mean there are this again, this is from
Personal clinical experience, women who may struggle with mental health conditions. it might be best to try something that is easily adjustable versus something that's in and you can't take out for three to four months. that way we can adjust it. If there's mood dismood issues, anxiety issues. sometimes we may need to tweak things a little bit quicker, turn things off really quickly, or maybe just switch maybe a couple of days. Of course, estrogen.
Is something that if you are on it, you want to take every single day. someone who is very sensitive to hormones, that can be another thing too. If you're getting estrogen, you know, some women may get some symptoms of if there's if there's too much estrogen in their system. someone again who whose dose may need frequent adjustments. So if you need frequent adjustments, again, you don't want to wait until your pellets run out, waiting three, four months before that for you figure that out.
Or someone who just likes having control. I know some women who just want to be able to control. and we can easily dial back and say, Hey, you know, go from two clicks to one click. And now you have dialed back down really quickly. The next day you don't put on t the two clicks, you put on just one. So this is again, no one size fits all. Yeah, and it really depends on your situation.
speaker-0 (45:30)
It's a lot of thinking and tweaking, right? Yeah. I think one of the reasons probably testosterone is our pellets are so popular, I think is the testosterone. I think that's probably what started the conversation and the excitement of testosterone, because women do report real improvements with testosterone from libido, from energy.
Motivation, that's that's a big one. Motivation, I think, sometimes translates to people as energy, right? Because it's it's not like an energy vitamin, it just does things that make you feel like you you have energy, right? But it's not like I'm giving yourself a B12 injection or something, right? but these improvements are real. muscle strength, increased muscle growth and then fat loss.
These are things that can happen when it's dosed appropriately. But testosterone does have to be prescribed thoughtfully and monitored carefully because the goal isn't to create this superwoman effect with these really high supra physiologic levels. Although at the beginning, when people are getting these, they may feel great. But then when you have all of these side effects that come, that greatness is long forgotten, right? So there's a
good way to do it where you can feel great. You can feel great. And you don't need to have sky high levels. what we want to do is restore you to good levels that relieve your symptoms. So there's not a specific number. People ask me all the time, like what level am I trying to get?
speaker-1 (47:01)
Level in my end too, yeah. Right.
speaker-0 (47:04)
Because I'm monitoring, so they think I have that answer, right? Because like, what are you checking for if you don't know? I don't know what your level is, but we're gonna find out together. What level do you need? You know, what is going to be giving you relief from symptoms without giving you unwanted side effects or without giving you unwanted risks? So the evidence on testosterone therapy keeps evolving.
And there are amazing benefits to testosterone therapy. There's also a downside to testosterone therapy, as with all other medications, natural or not. conversations about cardiovascular risk or cardiovascular safety need to reflect the current data at that time. And it is changing so much. And it's not really that it's changing, it's being
evaluated in in different ways. And some studies are very well done and others aren't. But there's a lot in cardiovascular literature that I wish we had in OBGYN literature, probably you want in in primary care, because the the literature that is coming out, even reflections from old studies are just showing the benefits to our cardiovascular system with optimization of hormones.
speaker-1 (48:18)
Yeah, absolutely. No, I'm really excited that that's there's more conversation around it. I mean, it you know, it you you know how frustrating it is when you look at the lab ranges and you see the normal range is between zero and I forget what the upper limit is. So zero is depending
speaker-0 (48:32)
Yeah, yeah. Depending on the lab, right?
speaker-1 (48:34)
on the lab. Yeah. So it is important and it's you know it's great that this is starting to come out that we are seeing some, you know, even the older studies showing how.
this can benefit women and your your bones and you know cardiovascular all of those things. So this is why I feel like, you know, it it's important to to have that experience. It's not just going to a hormone clinic or whatever that looks like. It's, you know, taking the whole picture into into consideration. And that's what I love about Dr. Jill's and and and my practice is it's not just here is a palette, you know
This is what your dose is, and we're just gonna check your labs and that's it. we're we're not gonna worry about all this. This go your primary care provider. It should be done holistically. The labs matter, your symptoms matter, your lifestyle matters because if we give you the hormones, but all those other things are not in place, we're not really fixing you, are we? So that's that's what you need to think about when you're going to some a practice for hormone evaluation.
speaker-0 (49:35)
Right, and to help you, we've created a free hormone therapy methods guide that breaks down the different ways hormone therapy can be delivered along
with some of the pros, cons, and important questions to consider with each of those options.
speaker-1 (49:52)
Absolutely, because the the goal isn't for you to walk into your next appointment already knowing which hormone therapy you need. The goal is for you to walk in informed enough to have a better conversation with your provider.
speaker-0 (50:06)
That's exactly right. You said that so perfectly. Yes. Yes. So please download the free guide using the link that's in the show notes. Save it to your phone. Take it with you to your next hormone appointment. Use it and ask the questions and give us feedback. Give let us know what you thought about it. Let us know what you wish it had said or what else you need to know. If you're listening.
Today I want you to make sure that you are going into that office or that appointment and you're seeing you're asking, What services do you provide? What types of hormone replacement formulations do you typically use? Do you recommend? If they're only giving you one choice, you need to run. Don't
speaker-1 (50:55)
Yeah.
speaker-0 (50:56)
Unless they're very stringent, like unless they say this is my one choice and I choose people that will do well, that I think will do well with this one method, right? You can't just take everybody because we know not everyone will do well with one method.
speaker-1 (51:11)
That's right. That's right. Okay. Now we're down to FAQs, frequently asked questions regarding hormones, especially pellets. okay, let's start with this one. Can pellets cause weight gain? All right, so this is very common. I'll put the pellet in and then a few days later I get a call saying, my gosh, I've gained such and such amount of weight. I'm worried. So
Hormones themselves aren't the culprit. Sometimes it's fluid retention. And think about this. If you haven't had, you know, hormones for a while, your your body is trying to get adjusted to what's happening. So, you know, it it it will shift around. It's trying to make some, it's trying to come to its new normal, I guess you can say. So this may impact your appetite as well. maybe you feel good and you're eating more.
there might be a shift in your body composition. You may gain more muscle versus, you know, fat. I see that quite a lot, actually. you know, especially women who are on a weight loss journey if they're on testosterone replacement or testosterone optimization, or underlying menopause symptoms get blamed on the pellet. So there are lots of different things that can be happening at the same time. so it's not necessarily the pellet or the testosterone that's causing this.
So these are just some ideas of what could be going on.
speaker-0 (52:28)
Yes, I agree with that. Another question we've received are pellets FDA approved? I think we have answered that within this conversation today. Pellets themselves are not FDA approved for women. So estradiol and testosterone pellets are made from compounding pharmacies, and those pellets are not an FDA-approved method.
For delivering hormone therapy. There are FDA approved pellets. They are testosterone pellets, but they are used for men. And there are no approved methods of or formulations for testosterone for men. I mean for women. No method, pellets, creams, gels. There's not a formulation in the US that's specific to the treatment of women. So I find that to be very sad.
Yeah. So if you want testosterone, yes.
speaker-1 (53:21)
Off-label male versions for women. So that's what you get. Okay.
speaker-0 (53:26)
Yes.
speaker-1 (53:27)
the next one is does insurance cover pellets? I've never seen it in my practice that it's covered for women. again, there's the FD-approved version for men. so these are testosterone pellets that are typically used by urologists and typically at lower doses than men desire.
it is used to achieve just normal ranges, or as many men that see me for hormone pellets want to optimize their health and vitality. So what I found in in the insurance world is that they want you to prove on your labs that you have low testosterone. So you may have to go in in the morning a couple of times, it's gotta be low a couple of times. This is specifically for men now. I'm talking about so all that document.
speaker-0 (54:10)
Normally low.
speaker-1 (54:12)
Normal
exactly. This is not low normal. This is like it's low, low. there has to be documentation that this is the reason why we're choosing to do so there's this is it's not just a straight line here, you get your reimbursement. There's gotta be justification for that. with the diagnosis of hypogonadism and all of that. So again, going back to women, no it's it's not covered for women.
speaker-0 (54:34)
Now you could use your flexible spending account or your HSA for coverage for that. It is a medical treatment. It is just that the formulation is one, just like other medications or things that may not be covered by your insurance plan. Some of the weight loss medications aren't covered for patients who don't have, let's say, obesity coverage. So it's much, much like that.
speaker-1 (54:58)
Yeah. All right. We may get into trouble for this, but we aren't on the anti-pellet bandwagon. Okay. Far from it. We just think it's it's just honestly, I really, you know, been practicing for a while now and I see different women with different experiences. I just it's really hard for me to say pellets are bad, don't use pellets. as long as it's for the right patient, you're not just being sold one option.
speaker-0 (55:25)
Exactly. But we're also not anti-patch. We're not anti-cream. We're anti-gel. We're not even anti-oral. We're not or anti-injection. Well, me, I I may be anti-
speaker-1 (55:38)
I think you are anti-jection.
speaker-0 (55:40)
Take that out. I'm anti-injection, I guess. Okay. well, we would need a full episode to talk about that. It I don't know if it deserves it. So there you go.
speaker-1 (55:50)
Right everyone, if today's episode helped clear up some of the confusion around pellets specifically, please share with a friend who's been wondering about hormone pellets too.
speaker-0 (55:59)
Yeah. And please subscribe to the Modern Midlife Collective podcast. Leave us a review. We do want to hear from you. We want to know if we are talking about things you actually want to hear about, you know, and if we could be doing more or doing things differently, let us know. Send us your questions. So you can go on to our website at modern midlife collective.com or you could email us at connect.
at modernmidlife collective.com and we answer all of those emails and we love to form shows around the questions that you're asking and hopefully they'll be featured on a future episode. And then don't forget to grab that free guide that we have here. And on the website you can see the previous guides that we've put out there.
speaker-1 (56:45)
Until next time. Bye bye.
speaker-0 (56:46)
Yay.
Bye. Thanks.