Welcome to part 2 of my "horomone basics" blog posts, where I answer the most common questions that I receive about HRT from my clients. 

Hi, I'm Dr. Kelly Sadauckas, Pelvic Floor Expert, and founder of Pelvic Floored, where our Vision is to "Save the World, One Pelvis at a Time", and our Mission is to reduce geographic, financial and psychosocial barriers to kick ass pelvic health care and information.  My blog is one of the many ways that I provide evidence based pelvic health information in a fun way :).  As always, this is general health information, not specific medical advice :) 

Onto the topic at hand: 

In General, Topical Testosterone is Recommended Over Pellets

First off, let's set a few things straight: 

1. Total Testosterone Blood Levels alone should NOT be used to diagnose, or prescribe Testosterone

This is hugely important.  A 2019 Global Consensus Position Statement from Davis, et al (link here) is that the role of total testosterone is to screen and ensure that we are NOT using supraphysiologic levels (which. means make sure we are not having ladies grow beards and dangly bits), NOT to "titrate up" to a specific target.  

In layman's terms, if you are a 40 year old female, and you enter your primary care provider's office, complaining of low libido, low energy level, intolerance to cold and poor orgasms, and your total testosterone is tested at 8am in the morning of the 3rd day of your cycle, and it is 10ng/dL, if you are told by your provider that you are not a candidate for testosterone because your levels are "normal", that's bollocks--because your symptoms warrant the trial.  If your levels were 100ng/dL, then that's another story (because those levels would be considered already a bit high).

Your total testosterone is tested for the provider to determine, based on your baseline level, and your size, what an appropriate dose is to address your symptoms; at what timeframe to RETEST you; to ensure the dosing is adequate AND that you do not become supraphysiologic.  

Additionally, The Endocrine Society states that inter-woman variability in testosterone levels are ENORMOUS, and circulating total testosterone levels do NOT reliably identify symptomatic women from non-symptomatic women (NEJM, Davis, 2024).  Davis (YEP, that SAME Davis from 2019), goes on to say that our goal should be to minimize symptoms, without entering "androgen excess".  

That 2024 New England Journal of Medicine study also found that increasing the dose from 300 μg/d to 450 μg/d dose, not only lead to supraphysiologic levels (not our goal), but also did not show additional benefit.  So MORE is ABSOLUTELY NOT BETTER!!

2. So Why Is Topical Testosterone Recommended Over Pellets?

The 2019 Davis study remains the single most authoritative paper on this topic, and is worth a read.  Endorsed by 10 international societies (including the Endocrine Society, International Menopause Society, NAMS, ISSWSH and others).  It explicitly states that "use of any testosterone preparation that results in supraphysiologic concentrations of testosterone, including pellets and injections, is not recommended," and that the only evidence-based indication (HSDD) was established using transdermal formulations — not pellets. 

This is important.  It means that ALL OF THE STUDIES that show significant physiological benefits (without androgen excess) were done with TOPICAL Testosterone, not pellets.  So if you want to reproduce the same result, you need to use the same method of delivery as the studies.  

If you want to get into the weeds of WHY pellets cannot provide the same standardized results as topical Testosterone, in 2023, the American College of Obstetrics and Gynecology (ACOG) came out with a Clinical Consensus Paper, which is the most detailed critique of pellets, to date.  

ACOG specifically recommends "preparations other than pellet therapy" based on the following items:

1. Lack of safety data and the inability to remove pellets once implanted.

2. It systematically dismantles the key pro-pellet studies — noting the Glaser breast cancer study's major limitations including loss to follow-up from 1,267 to 407, addition of anastrozole to 62% of pellets, and not having a distinct control group.

3. There are many documented adverse effects (hirsutism, voice changes, mood swings, abnormal uterine bleeding, 43% discontinuation rate), due to fluctuating delivery levels in pellet therapy.

So Why Did Doctors Ever Use Pellets in the First Place?

This is SUPER IMPORTANT TO UNDERSTAND.  If your doctor has used pellets in the past, they are not a bad human.  

They were likely using pellets because prior to the removal of the FDA "black box" warning, their ability to prescribe FDA-approved, and tested hormone products, was VERY LIMITED.  And using pellets was one way they could attempt to provide "some of the hormone" to a human.  

But the key is that these studies that I am mentioning have been around from 2019-2023, and at present there IS an FDA approved Testosterone (Testim) that can be applied topically, with prescription, and of which you can be certain of the dose you are receiving.  

But...I love my doctor...and I love my pellets!!

I do hear the following arguments, so I DO want to create space for them in this blog, because this is real life.  WHAT IF you can't remember to put on your gel?  (I am SO guilty of this).  What if you feel AMAZING when you use it, but honestly can't remember to use it at all.  

Or what if you just have a full plate "with life" and don't want one more thing to deal with right now, and having the pellet inserted just feels right for you?  

That's 100% okay, and you and your medical team can decide that together.  

Just know that if the pellet therapy "once worked but doesn't any longer," or "never worked for you", that perhaps it's time to try another route :) 

What About A Compounded Testosterone Cream? 

This is a MUCH more nuanced answer.  

IF you have access to a high-quality compounding pharmacy, AND your supervising physician CAN monitor your Testosterone levels to ensure they are rising adequately, so that you are receiving a therapeutic dose, compounding pharmacies can be GREAT.  

This is on you AND your supervising physician, to ensure this monitoring happens, AND that you use your cream regularly (just like you would have to use your FDA gel regularly, AND be monitored) for optimal benefit.  

In the case of Testosterone, the 2019 Davis study was not able to show consistency of percentage of Testosterone delivered in compounded creams.  This means you might be getting "more" Testosterone than you are intending to get, or "less."  There is less likelihood of going supraphysiologic with compounded cream than with pellets (or if you begin to go supraphysiologic, you can at least STOP the cream immediately, whereas you can't remove the pellet), but the FDA-approved Testosterone gel is the best bet, and it is what the studies are based upon.  

Why might some physicians PREFER Compounded Creams?  

You're not crazy--you really might find some physicians prefer compounded creams.  Do not hold that against them.  This is because the world is complicated, and their lives, and medical providers, navigating the complicated world of hormone replacement therapy is complicated.  While "evidence based practice" might currently support FDA testosterone gels as the best was to get testosterone to females, insurance might not always agree.   And in this case, some pharmacies might refuse to even fill the prescription, or attempt to charge a women hundreds of dollars for a monthly supply, rather than fill a monthly supply for a male (which will serve a female for almost a year.  In those cases, a trusted compounding pharmacy, even if a human has to pay out of pocket, is an excellent resource to have on board.  

The key is, as always, and open conversation with your medical provider.  They should never force one specific treatment upon you, but should always offer you informed decision making as to pros and cons of each option, guiding you as to what may be the best option for you and your long term health. 

I hope this was helpful!

HRT is such a new frontier.  For you AND for your primary health care team.  I'll share more about "Why Would I need Testosterone HRT" in another blog, but for now please check out the references yourself, and please, if this has informed you, and helped you think of HRT in new ways, PLEASE share it with your circle, so we can ALL have more educated, and civilized, discussions.  The more we know, the better off we'll all be :) 

Thanks! I'm glad you're here

XOXO
Dr. Kelly 💋