FAQ: Where do testosterone pellets stand for women?

This FAQ is a summary of the discussion in the fourth and final episode of the Special Report series Testosterone in women: The evidence-practice gap in the US. In the episode, Maria Uloko, MD, a board-certified urologist specializing in comprehensive sexual health, and Bruce Dorr, MD, FACOG, URPS, FMCP-M, a board-certified ob-gyn with subspecialty training in urogynecology, address testosterone pellet therapy and offer advice for clinicians who hesitate to prescribe hormones.

Uloko opened by noting that the complexity of dosing and monitoring helps explain why many physicians avoid leading conversations about hormone therapy. The answers below come from the panelists' remarks in the episode.

Why do patients end up with misinformation about pellets?

Uloko said doctors often do not lead the conversation about testosterone therapy, and “that's where a lot of patients can actually get a lot of misinformation.” She said pellets are one of the biggest areas of misinformation.

Why don't current guidelines recommend pellets?

Uloko said pellet therapy is widely used in community practice but is not recommended by current consensus guidelines, which cite concerns about dose adjustability, supraphysiologic concentrations, and limited long-term safety data.

Dorr, who has considerable experience with pellets, said the guideline concerns hold up. “Guideline concerns are legit,” he said. “My clinical experience doesn't change that hierarchy.”

What are the drawbacks of pellets?

Dorr said pellets can work well for some patients, but cost is a drawback. “I think they're an expensive way to go, so it's not for everybody,” he said. He added that absorption varies with the vascularity of the subcutaneous tissue and that, once implanted, a dose is hard to adjust.

If a clinician uses pellets, Dorr said, “you've got to go very low, figure that patient out, and then monitor the labs and the dosing.” He also stressed informed consent.

Is any delivery method right for every patient?

No, according to Dorr. “No delivery method is universally right,” he said, noting that creams and gels can also produce “roller coastering levels.” When a patient is a non-responder or over-responder to any method, he tells them that “any level better than zero with your signs and symptoms that you have going on, you're going to feel better,” while watching for adverse effects. Labs guide him but are not the end-all, he said.

Dorr named his career goal: “the whole goal for my career is to see finally an FDA-approved formulation of testosterone for women in America.”

What advice do they have for hesitant prescribers?

Uloko urged clinicians to examine their fear of prescribing hormones. “At one point we were all beginners,” she said, and confidence builds with experience and good patient outcomes. Her advice was to “interrogate the fear, face the fear,” and move past it.

Dorr urged clinicians not to avoid the conversation. “Don't do nothing. Don't be afraid,” he said. “Just start out low, monitor your patients, go slow.”

This FAQ was developed as a summary of the Special Report series discussion. To hear the full conversation, watch the complete series, Testosterone in women: The evidence-practice gap in the US.