HORMONE Q & A
Why would pellets be better than oral hormones or creams?
Pellets are the only formulation than provide a completely stable blood level for months. All of the other formulations will produce fluctuating blood levels, to which some individuals will not respond as well. The pellets are also more potent, by virtue of their constant concentrations. Individuals who feel unsatisfied with their response to other hormone preparations, with issues of low energy, reduced libido, and a lack of well-being, are very likely to fare better with pellet implants.
How does the doctor determine what hormones you need and in what dose?
Your doctor will take into account your age, weight, medical history, symptoms and physical findings. Laboratory measurements of hormone levels are usually obtained both before and after initiation of hormone therapy, to assess response and determine the need for dosage changes.
- Women with low testosterone levels and reduced libido benefit more from higher testosterone dosage. Women with osteoporosis should receive higher estrogen doses, preferably supplemented with testosterone.
- Men with osteoporosis should receive higher testosterone doses, as should men with heart disease.
- Women with sleeping problems should take progesterone by mouth, and always at night since it improves sleep.
- Women who develop breast tenderness or weight gain should have the dose of estrogen reduced.
- Women with a history of breast cancer or with risk factors for breast cancer should be treated with the lowest effective doses of estrogen and followed carefully. We always add progesterone as well, for its breast cancer protective properties.
- Women past the age of 60 require lower doses of estrogen, and the dose will further decline in their 70s and 80s.
Is there any age at which hormones should no longer be used?
In our opinion, age alone is not a contraindication to hormone replacement. In fact, much older people may obtain the greatest benefits from hormone replacement. One gentleman was 102 years old when he was started on testosterone replacement. He noted great improvement in energy and activity level within a month.
Does it hurt when pellets are inserted?
For most patients, there is no pain at all. We inject lidocaine under the skin at the site of pellet insertion and wait ten minutes for it to take effect. The actual process of pellet insertion takes very little time, about one minute in women, and 3-5 minutes in men.
How often do you have to get re-tested and administered more hormones?
We usually obtain blood tests of hormone levels a month after hormone therapy starts, to determine what levels of estrogen, testosterone, and progesterone are attained. Testing should be performed 1-2 hours after hormone administration, to obtain peak levels. In the case of pellets, testing can be done at any time of day. We repeat hormone levels 3-4 months after pellet insertion, to see what changes have occurred. Patients can often feel when hormone levels are falling. Depending on hormone levels and symptoms, new pellets are inserted. If the patient has been doing well, hormone doses are kept the same. Once a pattern of hormone levels is established, retesting can be performed at the physician’s discretion.
Do insurance companies pay for hormone replacement?
Some insurance companies will pay, and others will not. It is best to call the company and inquire what the reimbursement policy is for hormone replacement therapy.
Does having breast cancer rule out any future use of estrogen therapy?
Not necessarily. Breast cancer cells are routinely tested for estrogen receptors on their surface. The absence of estrogen receptors means the cancer is estrogen receptor negative. Hormone receptor negative cancers are not affected by estrogens, and women with this type of breast cancer can still be treated. In women with hormone receptor-positive cancers, cancer should be treated, with no evidence of spread or recurrence for 3-5 years. At that point, we may initiate treatment using the lowest effective estrogen dose.
What about treating men who have had prostate cancer with testosterone?
Again, cancer should be treated with no evidence of metastases, preferably for at least one year. If cancer has been surgically removed, or treated with radiation, and the PSA is zero, testosterone may be started after one year. The PSA should be closely monitored for any sign of recurrence. Some therapies, especially external beam radiation, may have the effect of permanently suppressing testosterone production, and testosterone supplementation may be of great benefit.