HRT Options- Pill, Pellets, Creams??
One of the questions that I get asked the most frequently is: “What is the best way to take hormones?” Or “Why can’t I just take that estrogen in a pill?” So, to clear some confusion I’m going to share with you the different methods of taking hormones, what I use in my practice and what I would recommend you to avoid.
Let’s start with hormones that come in pill form and lets consider anything that is a pill form to be something you swallow that will be absorbed in your stomach/gut. This would basically be a capsule or a tablet...which seems obvious, I know, just bear with me. Estrogen is available to be taken by mouth, but it increases the risk of blood clots (remember all those birth control commercials that say you shouldn’t take this medication if you are over the age of 35 and you smoke?) - so, oral estrogen is cheap and effective but I rarely recommend it to anyone because there are safer ways to administer this medication. Progesterone can absolutely be given by mouth, and when taken by mouth it increases relaxation and improves sleep. This is why most prescribers give oral Progesterone at bedtime. Testosterone is useless when given orally because it is heavily metabolized in the liver, so much so, that the body really doesn’t get to use it.
Now, let’s move on to buccal/sublingual absorption. This would be a troche, lozenge, or a small tablet that gets dissolved under your tongue. In these circumstances the medication is absorbed through the lining of your cheeks or through the glands underneath your tongue--which makes your body handle the medication differently than a regular tablet or capsule. Very little of the drug is actually swallowed and absorbed through the stomach. All of the hormones can be dosed this way, but it makes a salivary hormone test inaccurate because of the proximity of the hormone absorption to the salivary glands. I believe this is a good way of administering the medication, but a poor method if you are planning to adjust doses based on lab levels.
One of the most common methods of administering hormones is through the use of creams. Creams can be used on specific areas of your skin or vaginally, depending on your symptoms and individual needs. For instance, vaginal application of hormones is great for improving vaginal dryness. I’ll often have my patients to use their hormones vaginally 2-3 times a week and on their skin the rest of the week.
The best thing about topical hormones is that they produce reliable drug levels on a salivary hormone test. This allows your provider to adjust the dose based on your levels COMBINED with your symptoms. I can’t tell you how many times I have had someone with persistent hot flashes, which leads me to first believe that I should raise her estrogen level, only to test her and find out that her estrogen level is perfect! I can’t stress the need for follow-up testing enough in patients with persistent symptoms. The final thing I’ll mention about topical hormones is that they allow for quick, responsive dosage changes. If I have a patient that has initiated therapy and 2 weeks in she is still miserable- I can tell her to increase or decrease the amount of cream she is using, or to split her dose and use half in the morning or half in the evening. That is a HUGE benefit! You can’t do that with a capsule, or a pellet. That reminds me...pellets.
Here’s the deal with pellets. As a dosage form, they are great! You take some hormone and a tiny bit of filler, squash it together, attempt to make it sterile (more on that), insert it into someone’s hip and BAM! great absorption and reliable hormone testing in blood. Plus, you don’t have to remember to take your hormones everyday. Oh, how I wish that were the whole story....but it isn’t.
First of all, there isn’t a standard process for making hormone pellets so there are a lot of variations in the way they are made and sterilized, which can lead to variation in the way that your body handles the pellet and the rate that the pellet dissolves. The takehome point here is to be sure your provider uses a reputable pharmacy and sticks with them.
Here is the bigger issue that I have with pellets. Once they are in, they are in. So, if your dose isn’t right you are stuck with it for 3-6 months. And, in my experience with a lot of people that are providing pellets, they dose people way too high, probably because they want to be sure that you are feeling the effects of the hormones but it can lead to some unpleasant side effects like weight gain, acne, increased facial hair (not so glamorous, right?)
Now, I know it sounds like I am completely against pellets. Let me be fair; there are some providers who do a great job of dosing pellets and choosing reputable pharmacies to purchase the pellets from. I’m a fan of the bioTe providers and their practice guidelines. Also, I have known many patients that are very satisfied with their pellet therapy. If you decide to go the pellet route I would recommend that you get as much information as possible about the actual pellets that are being used and the experience level of the provider.