By Julie Alvin
From the outside, Marcella Hill’s life looked good. At 38, she lived in Utah with her husband and four children, ages five to 15. The serial entrepreneur was writing a memoir about her spiritual awakenings, and delivering lectures to midlife women and entrepreneurs about how to find joy. But despite these external markers of happiness and success, something was off.
“I was having a hard time getting out of bed,” she says. “I couldn’t get myself to really do anything that I actually loved. And it was scary.”
Like many women entering perimenopause — a term Marcella wasn’t even familiar with at the time — her mood was low, her body hurt, and her sex drive was gone. And her marriage was suffering.
“I would think about sex during the day, and then as it got later, I just was indifferent. I didn’t care. It seemed like a chore,” she says. “I felt like I could just go without sex for the rest of my life.”
She enjoyed spending time with her husband, he was a great dad, she thought he was cute — it didn’t make sense to her that her body wouldn’t turn on for him, that she cringed at being touched. She thought she just needed to loosen up, and found herself drinking too much to get in the mood for sex. They went to couples therapy and tried to bring romance back into their marriage with the usual playbook — date nights, vacations, lingerie — but it didn’t work. As their connection frayed, they started to talk about splitting up. It was in the middle of these conversations that, at the urging of a friend, she looked into testosterone pellet therapy to help ease her symptoms.
Testosterone pellets are a form of hormone-replacement therapy that the FDA has approved for use in men with low testosterone levels. They, along with other forms of testosterone, are meant to relieve associated symptoms like decreased sex drive, energy, and muscle mass. They’re also used off-label in masculinizing hormone therapy for trans men looking to take on secondary sex characteristics like facial hair or a deeper voice. In perimenopausal or menopausal women, pellets are administered off-label to treat symptoms like mood, energy level, and low libido, but they aren’t approved for women by the FDA – nor are any testosterone-only therapies.
For this story, I spoke to multiple medical experts, and none recommended pellets as a first-line treatment for women in midlife. Some thought pellets could be part of a menu of options, while others were staunchly opposed to any use of pellets – though all understood why women are taking a risk on an unapproved treatment. As urologist Dr. Kelly Casperson said, “Women are pushed to the pellets because a lot of pellet people only offer pellets, and a lot of regular western medicine, like your traditional doctor’s office, don’t do anything [about libido concerns].”
While testosterone can be administered via ointments, injections, transdermal patches, or dissolvable tablets, pellet therapy involves making an incision in the fatty part of the butt or hip and then inserting solid pellets of testosterone the size of a small pill under the skin and fat, where they then release a steady dose of the hormone into the bloodstream over the next two to six months. And patients can see changes quickly, for better or for worse.
Marcella had been unimpressed with previous advice from her OB/GYN on how to address her symptoms. She says they checked her hormones, told her they were normal, and gave her testosterone cream but no information on how to use it. Skeptical of returning to that doctor and desperate for relief, she googled “hormone therapy clinic in my area” and was directed to an aesthetics clinic (the kind that administers Botox) where family nurse practitioners prescribe pellets to patients. She called and described her symptoms, and they told her they could help.
“I remember just sitting there being like, ‘Take all my money. I literally don’t care,’” she says. “I didn’t do any research. I had no idea there was anything else.”
Videos about the wonders of pellet therapy are all over Tiktok and Instagram. Women who’ve tried them, and clinicians who administer them, say that they restore energy levels, improve mental clarity, and amp up sex drive, talking with almost religious fervor about the transformation. A few weeks after her first pellet was inserted, Marcella says her evening energy levels went up. She was sleeping through the night. She could go for a jog without pain. After three months, “my body just zinged.” Her sex drive was back.
“I didn’t know you could just want your person just because you want them,” Marcella says. “Even when there are dishes and when we haven’t gone on a date and when there’s laundry … Not because they earned it and not because they did all the right things and they said all the right things. My body just wanted to be with him. And that was all new.”
Medical experts urge caution. Dr. Corinne Menn, an OBGYN with Alloy digital health (a platform for menopausal and perimenopausal women), says women using pellets may see acne, oily skin, and hair growth where they don’t want hair and hair loss where they do, due to sky-high testosterone levels. Less common, but still possible, are vocal changes or clitoral enlargement. There’s also little safety information on the health implications of women having very high levels of testosterone for prolonged periods of time, and any injection comes with a risk of pain or infection, says Dr. Menn.
“The biggest risk is that once they are inserted, we can’t take them out. If you have a bad side effect, we can’t do anything about it,” says Dr. Menn. “We have no idea what the absorption rate is because everyone is different.”
Alloy was started when the founder Monica Molenaar was in search of relief for her menopause symptoms. She wound up getting pellets and experienced months of adverse symptoms due to hyper-physiologic (above normal) levels of testosterone. Menn attributes this kind of experience to a “menopause-care vacuum.” Less than seven percent of OB/GYNs and primary-care providers are educated in how to treat menopausal women, she says. For the 60 million menopausal women in the U.S., there are but 1,500 OBGYNs certified by the North American Menopause Society, the organization that sets essential standards for menopause care. Furthermore, only a small percentage of NIH funding for medical research goes to women’s health in general, and an even smaller percentage of that bucket goes to menopause care – a reality that Menn attributes to gender bias in medicine. “It’s a huge crisis of medical school curriculum and residency education.”
“If you have a void, the market is going to fill that void,” Menn says. “The pellet industry is highly profitable. It’s unregulated and it’s a cash cow for practices.” Insurance doesn’t cover these treatments, so patients often have to pay cash for the pellets, monitoring, and administration. The companies who produce the pellets also typically do the training, teaching PAs and nurse practitioners at sex med or aesthetics clinics how to inject pellets via weekend workshops. Practitioners at these places may give pellets to patients as the first line of defense, rather than offering a full, evidence-based toolbox of options to treat symptoms.
The ideal toolbox, Menn says, includes first taking full stock of the range of symptoms – classic menopausal symptoms like hot flashes, night sweats, and vaginal discomfort can be treated with an FDA-approved, well-studied regimen like menopausal hormone therapy (MHT) using progesterone and estrogen (which is typically low cost with insurance). Then, Menn recommends taking a more “bio-psycho-social” treatment approach to low sex drive, making sure to consider all potential contributing factors – which can include hormone imbalance, but also things like poor sleep, relationship dissatisfaction, or physical symptoms like poor lubrication or diminished vaginal tissue that make sex painful. Testosterone therapy can be layered in, but the gold-standard prescribing guidelines from experts in the space would recommend doing so using an FDA-approved transdermal testosterone product for men, typically a gel, at one-tenth the dose given to men.
“We actually have evidence-based guidelines on how to safely use it [testosterone] in a way that is really preferred, much more cost-effective, and we’ve got better data on,” Menn says.
According to internist and menopause expert Dr. Heather Hirsch, the risks of pellets aren’t worth it. “Pellets are very, very harmful,” she says. “We will get women off them when we have more clinicians who know who to prescribe FDA-approved hormone therapy.” Hirsch has taught hundreds of clinicians herself with an online course called How to Prescribe and Manage Hormone Therapy with Ease and Confidence.
The best option for using testosterone to treat low libido in women, Casperson says, is a physiologic-dosed testosterone that’s FDA-approved for women and covered by insurance. Why doesn’t this exist yet, when there are 20+ such products approved for men? “Gender bias, obviously,” she says. “Sexuality with men is considered a birthright. And sexuality with women is considered extra, or dangerous, or not necessary, or a nice-to-have.” And so women go seeking imperfect solutions, entering the breach where menopause education and the medical establishment have failed them.
“Right now, the most dangerous thing is that women don’t want to get out of bed. The most dangerous thing is women…don’t want to live. What is more dangerous than that?” says Marcella, now a pellet convert who is happier in her body and her marriage. She’s since built a hormone therapy directory where a community of 50,000 women can informally trade stories and share what is working for them. “We don’t have time for policy change. We need help today.”
What would Dr. Hirsch say to that? She would take people like Marcella off pellets and put them on FDA-approved hormone therapy. “They would feel just as good, if not better,” she says.
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