If you’re using or considering using estrogen as part of your hormone replacement therapy, let’s talk about how that can be taken.
In this article we will discuss delivery routes for systemic estrogen - meaning estrogen that we want to circulate through our whole body.
The options for delivery of estrogen are: oral, transdermal (through the skin with a patch), vaginal ring and pellet.
Oral
To me this seems like the most obvious route because we tend to think of medications being taken in pill form.
The benefit of this can be taking with other medications, so it’s easy to incorporate into your current routine.
There also isn’t a concern for falling off or rubbing off the way that topical formulations can.
In general though, I prefer patch (transdermal, discussed below) because of the downsides to the pill form.
Because this is taken orally, our body then has to process the medication through our gut and our liver. This results in a few things:
variable metabolism of the drug, meaning the amount actually circulating in your body is unpredictable
needing an overall higher dose than the patch to compensate for this metabolism
increased triglycerides (part of a cholesterol panel)
potentially increase in blood clotting risk (a blood clot in your leg or lungs which can be dangerous) because clotting factors are made in the liver
A benefit though is an increase in HDL, or the “good cholesterol”.
Transdermal
The dosing here is more consistent with what will circulate in your body and the dosing tends to be lower than oral form. That means if we have concerns about side effects and risks, they could potentially be lower with a lower dose.
There’s a potentially lower risk of dangerous blood clotting, like in our leg or lungs, because again we are avoiding that metabolism through the liver.
We don’t get the benefit to HDL here, but we also don’t get the increased triglycerides.
The downside to topical preparations is that patches can fall off and some people may react to the adhesive.
Ring
Similar to the vaginal ring that can be used for birth control, various vaginal rings exist that can be used for HRT dosing. This can be used for someone with vaginal symptoms - dryness, itching, pain with sex - because the estrogen is being released into the vagina only.
There is one vaginal estrogen ring called Femring that also releases enough estrogen to treat more than the vaginal symptoms (the hot flashes, night sweats, etc).
These typically will stay in the vagina for 3 months, easily get removed and replaced with a new ring. Depending on dexterity, patients can do this themselves.
Pellet
Ah, pellet hormone therapy, we’ve all heard of it. This can get very nuanced depending on what hormones are contained in the pellets and this discussion will come up in other articles, but I want to start it here.
What are pellets?
Pellets contain hormones that when inserted under your skin, release the hormones into your system over time. The placement is in an office setting.
The pellets themselves also dissolve over time, they are not removed. Owing to that, to continue the hormone therapy, you need to have more placed.
Typically offices that offer this type of hormone therapy will check hormone bloodwork frequently.
ACOG and the Menopause Society both state that there is no role for hormone bloodwork of this kind, or following it over time with hormone therapy because it’s unreliable. I would say the one exception to that is using testosterone (covered in another article) where testosterone levels should be kept in a normal female range and that is followed over time.
So what is the controversy over pellet therapy?
Well, usually these are advertised as bio-identical, suggesting a more natural approach than prescription hormones. This is a term (also discussed in another article) speaks to a lot of people especially due to fears of traditional hormone therapy. They may advertise that they are compounded specifically for you.
The problem that term is that there are prescription hormone therapies that are bio-identical. Bio-identical means the hormone being given is the same as the hormone we naturally make. For example, estradiol is one form of estrogen that we make in our reproductive years and that decreases at menopause. Prescription estradiol is available in the form of pills, patches, and rings.
In summary, don’t let the term bio-identical make you think it’s somehow superior to prescription bio-identical hormones.
The Menopause Society states on this that compounded hormones should be used only if prescription, FDA-approved hormones cannot be used by a patient due to allergies or intolerance of some kind.
A study was done in Ohio, Michigan, and Pennsylvania where records were reviewed for practices offering pellet hormone therapy: whether they have a National Certified Menopause Practitioner (NCMP) and whether they were more likely to stray from guidelines. The results showed that most practices did not have an NCMP, and having an NCMP meant the practice was more likely to practice by guidelines. If you’ve heard the term “evidence-based medicine” that means practicing by guidelines, based on studies that are done and what evidence they show.
For me, I don’t usually like if something can’t be removed, so that part of pellets doesn’t suit me as a prescriber. When I start HRT for a patient, I see her back to see what’s improved, what’s not improved, and what gripes we have with the medication. I like wiggle room to increase, decrease, or change formulation if we need to. That’s how I adjust - based on her symptoms, not based on bloodwork.
I will also say there is growing evidence that pellet hormone therapy has harms. A review was performed comparing pellet hormone therapy to FDA approved therapy, showing that more women on pellets had hormone levels above normal and hysterectomy.
Resources:
Some of the information contained in this article is the result of my training, medical knowledge, and personal experience without a specific source to be cited.
This is not medical advice.
https://biote.com/bioidentical-hormone-replacement-pellet-therapy/faq#:~:text=Pellets last up to three,before feeling the full benefits.
