Keywords: Pellets Dermal Transdermal Subdermal Implants testosterone methyltestosterone estrogen estradiol oestradiol androgen menopause medication drugs energy sex drive libido appetite cholesterol ovary hormone depression reproductive endocrinology

Sometimes, it is necessary to use an pellets or implants made of estrogen. This is a compounded substance where each pellet consists of a hard crystal of 17 beta estradiol-- the natural estrogen produced by the human ovary, which releases into the blood stream, attains a steady state, and then will get used up as the estrogen is metabolized in the body. This will provide a very steady estrogen level of approximately 150 - 250 picograms per ml, which is a therapeutic level.  Each pellet lasts from 3-4 months.

The pellets are under investigation by the FDA at the present time and have not been approved. However, they have been available for use in this country for over 40 years.   There have been no adverse effects demonstrated.

Use of this substance has dramatically decreased the amount of physician visits by these patients for other related problems. We can show that, once the patients have been stabilized, the number of physician visits and the number of tests for these patients declined dramatically, most patients requiring pellets two to three times a year and requiring very little in the way of other medical therapy in between times.

The requirements for us of these pellets include a normal gynecological exam, a normal mammogram, no previous history of breast or uterine cancer, and no history for clotting disorders.  This is no different than the contraindications for any other estrogen use.

The ovary also produces male homones, such as delta 4 androstenedione, which has similar effects to testosterone.  Other sources of androgen (male hormone) in a woman is the adrenal gland, which produces a substance known as dehydroepiandrosterone sulfate. There is a dramatic fall in both of these products around the time of menopause.

The resulting loss of androgens causes a decrease of energy and decrease in sex drive and vaginal lubrication in a percentage of women. The effect of androgen in women has been well documented in many papers, including papers by Barbara Sherwin, Ph.D., Nelson Watts, and Morris Notelowitz. Oral androgens are administrated in the form of methyltestosterone. Methyltestosterone is not an ideal androgen in some patients since it can cause reductions in HDL cholesterol to some extent, reversing the beneficial effect of the estrogens.

For women who have problems with low male hormones, we have been adding a testosterone pellet along with the estradiol.  This is particularly useful for women whose ovaries have been surgically removed.  This is approved by the FDA. This provides an androgen level which is compatible with that of the normal range of female patients.  Much less androgen is used than one gets from an oral androgen, which requires 2.5 mg per day, or 75 mg per month, as opposed to 75 mg every four months.

The use of this pellets causes a feeling of well being, increased energy, increased sex drive, and this is very much noticed by the patients who have been taking it again. I feel that the addition of androgens in this form causes less lowering of HDL cholesterol, as this does not pass through the liver and goes through the peripheral circulation and has the benefit of being pure testosterone, which, unlike methyltestosterone, gets converted to estrogen peripherally in the body, thus, increasing the available pool of estrogen.

It also adds to the bone density and, in recent studies by Nelson Watts and Morris Notelowitz, the addition of androgens was noted to cause 25% increase in the density of bone. Also, androgens are known to have an ameliorating effect on breast tenderness in a woman, as they do reduce ductal hyperplasia.

The hormone pellets should be used with caution in women who have their uterus because continuous exposure to estrogen on the uterus may increase the risk of uterine cancer unless the patient faithfully uses progesterone.

The implant procedure consists of a small incision through which a trocar and cannula are inserted. The pellets are inserted through the cannula, and then the cannula is withdrawn. The incision is then closed with a Steri-Strip, and pressure is applied until bleeding stops, and the area is then covered with a dressing. We have not had any major problems in terms of side effects from this procedure. Some expertise is required in terms of placing the pellets so that underlying structures are not traumatized. This has been acquired with a great deal of experience. Costwise, the procedure currently costs approximately $160.00. The pellets each cost $33.00, which is the cost of the pellet plus the administrative costs and ordering costs of the organization.

Average procedure per patient would be in the range of $250.00 to $300.00. This compares very favorably with the cost of medication during this period of time, since at these visits the patients are checked, including often breast and vaginal check, and any other medical problems are dealt with. The physician's visit part of the procedure is really not billed as an extra item. Thus, I do believe that, since the average woman does see her physician at least two or three times a year, and primary care to that woman is taken care of during the course of this visit, that total cost for the procedure per year is extremely cost effective if one adds in the cost of drugs used for hormone replacement therapy. The fact that these procedures are extremely effective and, therefore, tend to cut down dramatically on additional physician visits for other related problems mentioned previously, makes me believe that any which is instituted to look at the cost effectiveness of this particular approach with find that these women have fewer doctor visits on average compared to patients who exhibit similar problems in terms of the hormone replacement.

It must be emphasized that this only seems to affect 10% to 20% of women this way, since 80% to 90% of women do quite well on ordinary methods of hormone replacement. However, these women who do not seem to respond well to normal methods of hormone replacement often require many doctor visits and much testing and are extremely expensive patients in a pool of patients.

I feel, therefore, that if we were to study this procedure, looking at the patients that we would normally treat, and split those into conventionally treated patients versus patients treated with this method, we would see a tremendous cost savings for the patients treated with the hormone replacement.

It cannot be overemphasized that patients who are inadequately replaced will have many more visits for emergency room for symptoms such as heart palpitations, migraines, urinary dysfunction, visits for sexual dysfunction, chronic aches and pains. These patients will probably have many unnecessary tests for arthritis, for chronic fatigue syndrome, for lupus, and many other complaints.

These can be obtained from Cathy Crowley at the Pavillion Compounding Pharmacy, 3193 Howell Mill Road NW, Atlanta GA 30327.  Her E-Mail address is pavilionrx@aol.com.  A special needle and trocar are needed to insert these and it should be done only by a trained physician.

Dr. Andrew Dott  teaches advances hysteroscopic and laparoscopic surgical techniques, is on the speaker's panels for several American pharmaceutical companies and is a professional lecturer.  Among his lecture topics are female and male menopause, menopause, herbs and medications, endometriosis, and contraception.  He is available to travel and give seminars on the topics covered in this website both nationally and internationally.