When choosing Bio-identical hormone replacement therapy (BHRT) for men and women, there are multiple options available. For men, options include testosterone pellet therapy, testosterone injections, creams or gels and lozenges. We will focus on the pellet therapy and topical therapy.  Women have all those options as well as oral forms. Bio-identical testosterone is not effective orally because it has to go through the liver and is broken down before reaching the bloodstream so this is not an option for men. 

Going back to the beginning of hormone replacement women took their hormones orally as capsules or tablets. Then as we began to learn more about hormones when they pass through the liver after absorption (First Pass Effect) it became clear that even the bio-identical estrogen estradiol could be a problem by converting to the “bad” estrogen estrone.  So other methods of delivery have been increasing in popularity since then.  

Implantable hormone pellet therapy has been around in some form since 1938. Hormone pellets are implanted into the subcutaneous fat in an office setting by a Physician, Physician Assistant or a Nurse Practitioner. The hormones are then slowly released at a consistent rate from the pellet into the body over the next 3 months or more.   Advantages of pellet therapy include that it is a customizable method with many different strengths of hormone available and the convenience of not having to remember to dose yourself on a daily basis.  This adds to the effectiveness of that form since there are not many women who are perfect at compliance with their instructions. It can be hard to remember to apply topical formulations twice a day or change the patch every 3 days. 

The number of different hormones available in pellet form is limited.  Some pellet programs do not have the human estrogen estriol available to make Bi-estrogen which is a combination of estriol and estradiol. For women who have not had a hysterectomy, it is necessary to protect the uterus with progesterone. While some pellet programs have a progesterone pellet available for use, there is no information to show that the uterus can be protected with the pellet dosage form. So that woman has to take progesterone on a daily basis in some way, either orally or topically. When deciding on progesterone oral versus topical, it is worth noting that one of the advantages of the oral progesterone is that it can function as a sleep aid for many women.  Another potential problem with pellets is that once the pellet is implanted the dosage cannot be changed. This means that a knowledgeable, well trained provider is extremely important since you are unable to make significant changes to the therapy once the pellet is implanted.  Another downside is that it is a minor surgical procedure required to be done in an office setting.

For the topical forms of therapy like creams and gels, there are more different hormones available and any dosage required is available.  The dosage can be adjusted more rapidly, it is non-invasive, and it does not require as many office visits. Downsides include the possible transference of the hormone to other people and compliance.

For men there are fewer downsides to pellet therapy compared to topical use. Men typically require only testosterone replacement instead of multiple hormones. They are notorious for not being compliant with therapy so the fact that they don’t have to remember their dose is a big advantage. A disadvantage is the need to go to the provider’s office 2 to 4 times a year for implantation. 

When considering these therapies there are many factors to consider. Neither method is clearly superior to the other, so the decision comes down to personal preference and patient characteristics.