Hormone Pellets vs. Injections vs. Cream: How to Choose

Pellets are small, compressed cylinders of hormone (estradiol, testosterone, or both for women; testosterone for men) placed under the skin of the upper hip through a small incision during a brief office visit. They dissolve slowly over a few months. The pellets used by most clinics, including ours, are compounded by a licensed compounding pharmacy and are not FDA-approved. One FDA-approved testosterone pellet exists for men.

Injections deliver testosterone (or, less often, other hormones) on a schedule, usually weekly or split into two smaller doses, given at home under the skin or into muscle. Injectable testosterone is FDA-approved for men. For women, low-dose injections are used off-label.

Creams and gels are applied to the skin daily. The hormone absorbs through the skin into the bloodstream. For women's testosterone, a compounded cream is common because no FDA-approved women's product exists; FDA-approved estrogen gels and patches exist for menopause symptoms.

This is the thing to understand before anything else.

• A cream can be adjusted or stopped within days.
• An injection dose can be changed at the next injection, and stopping it clears within a couple of weeks.
• A pellet cannot be adjusted once it's placed. It releases its dose for the whole cycle, roughly three to four months for women and four to six for men. It's designed to dissolve, not to be removed.

That's why, at Peak Medical Wellness, pellets usually come after a stable dose has been established on an adjustable method, not as a first step.

Pellets tend to produce higher hormone levels in the first weeks after insertion than other methods, and levels vary more from person to person. A 2021 study in the journal Menopause reviewed the charts of 539 postmenopausal women. Women on pellets had higher peak estradiol and testosterone levels than women on FDA-approved therapy. They were also more likely to report side effects, including abnormal uterine bleeding. It was a retrospective study, so it shows an association rather than proof. But it matches what the societies have been saying.

• The American College of Obstetricians and Gynecologists (2023) advises against routinely prescribing compounded hormone therapy when an FDA-approved option exists. It specifically recommends forms other than pellets for testosterone in women, because pellets can't be removed and the safety data is limited.
• The Menopause Society (2022) says compounded hormones should be considered only when an FDA-approved product doesn't fit. Examples are an allergy or a dose that isn't made. Preference alone isn't enough.
• The 2019 Global Consensus on testosterone for women does not recommend any form that pushes levels above the normal female range, and names pellets and injections as forms where that can happen.
• The National Academies of Sciences, Engineering, and Medicine (2020) raised concerns that compounded pellets are difficult to make consistently because their absorption isn't tested the way approved products are.

We tell you this because you should hear it from your own clinic, not only from a search result. It doesn't mean pellets are never appropriate. It means they call for the right patient, the right timing, and careful labs.

Injections are the most adjustable long-acting option, and for men, FDA-approved injections and gels have the longest track record. The main drawback is the rhythm: levels rise after a dose and fall before the next one. Splitting the weekly dose into two smaller injections is a common way to smooth that out. Men on injections have their red blood cell count (hematocrit) checked before starting and on a schedule. PSA is checked based on age. Estradiol is checked when symptoms call for it. For women, low-dose injections are off-label and less studied than cream; the goal is a dose that keeps levels in the female range, confirmed by labs.

Creams are the most adjustable of all, and the research supporting testosterone for women was done with hormone applied to the skin at physiologic doses. The trade-offs are daily use, some variation in how much absorbs, and transference: the hormone can rub off on partners, children and pets before it's absorbed. Apply to clean, dry skin, let it dry, cover the area, and wash your hands. Your provider will tell you when to time your blood draw on lab days.

The appeal of pellets is simple: no daily routine and no weekly injection. The costs are the ones above. There's no adjustment during the cycle. There's an in-office procedure, with small risks of bruising, infection, or a pellet working its way out. And there are a few days of aftercare. After insertion, women keep the site dry and skip baths, hot tubs, swimming and hard exercise for three days; men for seven. Labs are rechecked about four to six weeks after insertion so the next cycle's dose is based on real numbers, and your provider follows you between insertions.

Ask: What do my labs show now? Which form fits my history? How adjustable do I need this to be? What will we recheck, and when? If I start on one form, when would it make sense to change? Your answers, and your provider's, are the decision.

To see what each visit includes, start with women's hormone therapy or men's hormone therapy in Fort Collins.