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: 

Why 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.  See Glaser, et al, 2019 for more deets.  If you didn't read my earlier posts about why blood values alone are not valid to use as a sole method of prescribing HRT, read it.  The Global Consensus Position Statement states that the role of total testosterone is to be used to screen and ensure there is NOT overuse or supraphysiologic levels of testosterone.  The goal of blood testing is NEVER to titrate up to a "specific target."

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 goes on to say that our goal should be to minimize symptoms, without entering "androgen excess".  

That same New England Journal of Medicine study in 2024 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 Davis 2019 study is 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.  

What About A Compounded Testosterone Cream? 

This is another "no."  It is nothing against the compounding pharmacies.  They are GREAT.  But 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.  

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 an upcoming blog, but for now please check out the references yourself, and please, if this educated you, PLEASE share it with your circle.  Please share it with your family and friends.  The more we know, the better off we'll all be :) 

Thanks! I'm glad you're here

XOXO
Dr. Kelly 💋