Subcutaneous estrogen replacement therapy often referred to as “Pellet Therapy” is not a novel idea. It was initially described in 1938 as an alternative treatment for menopausal symptoms. Subcutaneous estrogen replacement involves the placement of crystalline, biodegradable pellets of estradiol subcutaneously into the buttocks. Placement is performed in the office using local anesthesia.
Estrogen replacement therapy (ERT) is very advantageous. ERT is superior to any other remedy for the treatment of hot flashes and vaginal atrophy. It has also been found to be cardio-protective, to improve cognitive effects, and to aid in the prevention of osteoporosis.
Despite these advantages, many patients discontinue their ERT for various reasons — the most common include irregular bleeding and or concern about breast cancer. However, other women discontinue therapy due to unreliability in taking pills, skin reactions to patches, nausea, or incomplete relief of symptoms. These patients may benefit from alternative routes of ERT like “pellet therapy”.
Subcutaneous ERT, unlike oral estrogen therapy, is better able to mimic premenopausal physiologic levels of estradiol and estrone. Subcutaneous estrogen has a favorable effect on lipid profiles with an increase in “good” cholesterol HDL and decreased level of LDL’s “bad” cholesterol. Although estradiol levels differ among patients, individual levels within each patient have very little variation, and implants provide more stable circulating estrogen levels than any other route of administration.
Insertion is easily performed in the office. After a small area of skin is prepared with local anesthesia, a 5 mm skin incision is made in the subcutaneous fat of the buttocks. The trocar with cannula is advanced through the incision. The trocar is removed and the pellets are loaded into the barrel of the cannula. The obturator is inserted forcing the pellets out of the instrument into the subcutaneous layers of the buttocks. Complications, albeit rare, include bleeding from the insertion site, bruising, or wound infection.
Another potential benefit of pellet therapy is the ability to combine subcutaneous estradiol and testosterone replacement. Testosterone therapy has been used for patients who complain of reduced libido. A combined dose of estrogen and testosterone has been shown to significantly improve libido, sexual enjoyment, and menopausal symptoms lasting for 5-6 months.
Appropriate patients include peri/postmenopausal women seeking to relieve hot flashes, vaginal atrophy, maintain or increase bone density, and produce favorable lipid changes. Patients with an intact uterus require progesterone therapy to protect the endometrium, as do patients using other forms of estrogen replacement.
Subcutaneous ERT or “Pellet therapy” is a convenient form of estrogen replacement therapy, eliminating the need for daily pill or patch. Furthermore, combined therapy adding testosterone can also be used to adjudicate symptoms of decreased libido, leading to more sexual enjoyment.
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