Pellets are the highest dose and most expensive option of all methods of obtaining hormones.

Who places them? Healthcare providers trained in the procedure, often by the pellet companies themselves. Providers may be midwives, nurse practitioners, physician assistants, or physicians, eager to ride the ever-growing wave of cash-based “women’s wellness and hormone optimization.”

You may also be wondering why women are clamoring for testosterone. It’s true: we’re hearing a lot more about estrogen and progesterone and their proven benefits in perimenopause, menopause and beyond (although, according to the Menopause Society 2024 conference announcement, only about 1.8% of postmenopausal women in America take prescription hormones). But testosterone is also a vital female hormone, and this starts to decline after your twenties. Most people don’t know that the ovaries produce four times more testosterone than estrogen during fertile years. Little research has been done on testosterone therapy in women compared to estrogen research, but based on the articles we have, it can improve mood, cognition, and libido (libido is a mood , BTW, created in the brain). A paper published in 2024 showed that after several months of testosterone treatment (given in non-granulated form), a group of women saw an improvement in mood of about 47 percent, an improvement of 39 percent in cognitive function and a 52 percent improvement in libido. There is also data from pellet therapy showing that testosterone added to estrogen therapy improves bone health more than estrogen alone and that high testosterone levels in women aged 40 to 60 are a positive predictor lumbar bone density. However, we have no data on whether testosterone reduces the rate of bone fractures, and this use is not authorized.

One of the fundamental problems with pellets, however, is that they deliver a supratherapeutic, or higher than usual, dose (often around 200 to 400 nanograms per deciliter; normal levels in men start at 300 ng/dL ), so there may be side effects. effects (lowering of the voice, acne, enlargement of the clitoris, hair loss where we do not want it and hair growth where we do not want it). And again, you get stuck with these effects for months. We’re not talking about low, safe doses that can be titrated up and down and stopped. My analogy is you’re at sea level and they take you to Everest base camp, where two things can happen: first, it can be really unpleasant. Second, it can be really awesome. I met women who said, “It was horrible! I wasn’t myself until it went away,” and others who say, “It was amazing…and then it went away. » I’m friends with a perimenopausal TikTok influencer who says pellets saved her life and her marriage, while others say pellets should be banned and the companies that make them should go out of business . That’s what I mean by “polarizing.”

So what should you do?

There are many different ways to get hormones that are cheaper and covered by insurance, as well as many ways to get a much lower dose, what doctors call physiological. There isn’t an FDA-approved female testosterone product (yet), so we have to do a little more work for our T. The two most common methods: (1) Using a male product, usually a testosterone gel, at one-tenth the dose. , or (2) obtain a compounded cream dosed appropriately for women, usually starting with three to five milligrams per day. You can also get injections, but these are used less often. I prefer to take women from sea level to Denver, Colorado: a little higher, but not supratherapeutic. With levels below 150 ng/dL, side effects such as hair loss, clitoral enlargement, and deepening of the voice are very rare. There are numerous articles and even a meta-analysis on safety and side effects in women, so anyone who tells you that “there is no data” or that testosterone is dangerous at these levels is not unaware of his research.

The second problem I have with pellets is that for someone who is going to live 40 years after menopause, they are not financially viable: they cost a few hundred dollars, usually per trimester. Pellets are not covered by insurance (and until the FDA approves a dose for women, no T is). I have women for whom money is no object and they like the convenience of treatment two or three times a year. But this shouldn’t be the main menu item.

Why don’t providers offer women the full menu of hormonal options? Let’s be real: if you make money putting pellets up someone’s butt and the company offers you incentives to administer them to the same people over and over again, you are biased towards the Hormonal option that makes money. Why would you tell the patient that there is another way? To me, this is a questionable medical practice. It’s unethical. Or maybe the supplier isn’t so nefarious; they just don’t know any better.

For all these reasons (highest cost, highest dose, no other options offered), I can understand why the Menopause Society (formerly the North American Menopause Society) does not support pellets. I think it’s fair. But at the same time, I understand why the industry exists. There are approximately 80 million women over the age of 40 in this country. Our health care can’t take care of everyone, and the truth is that many women feel better because of hormones.

I would say that testosterone is a each body hormone, and it should be covered by insurance for every organism. Women so often get the other side of the coin because of the blanket excuse of “Oh, but we have to protect them!” » By trying to protect women, we deny evidence-based care and harm them. I think we can give hormones and maybe even pellets to women in a very caring, balanced, safe way, and validate women who TO DO I feel much better with them.

Here’s what would make this possible:

• Deregulating testosterone from the DEA’s scheduled list so that it can be prescribed via telemedicine indefinitely (telemedicine approval of controlled substances is currently only allowed until 2025) and without the patient’s name being named. added to a state watch list of people prescribed scheduled medications. (The DEA program’s designation comes from the Olympic doping scandals of the 1980s, but East Germany is long gone and the majority of humans don’t use hormones to win gold medals.)
• An FDA-approved product for women that delivers a safe, consistent dose and is covered by insurance. But be careful: if it’s dosed for women, comes in a pink box, and costs $480 a month, and we have to jump through several hoops to get insurance coverage, we’ll always use the male product or compound less Dear.
• Education! All health care providers need to understand the data about women and testosterone (all hormones, TBH), including its benefits for bone health, mood, sexual function, and healthy metabolism.
• Research. Hormones are generic, meaning cheap, but no one funds research on them. With over a million women entering menopause every year, this needs to change.

Ultimately, if women had better health care, maybe high costs and high doses wouldn’t be commonplace, and we’d get all the personalized hormonal care we deserve.

Kelly Casperson, MD, is a urologist, podcaster, and author of You are not broken. You can find her on social media @kellycaspersonmd.