Bioidentical Hormone Replacement Therapy, Mexico How to Dose Estrogen and Testosterone pellets in Women
Bioidentical Hormone Replacement Therapy, Mexico
How to Dose Estrogen and Testosterone pellets in Women
Jake Ames, MD, HMD
I have implanted one to three estradiol and testosterone pellets daily in women and men since 1994. I have some pearls of information I would like to share with physicians and patients reading this blog.
Bioidentical testosterone pellets have been used in the U.S. and Europe since 1938. Testosterone pellets have been FDA approved since 1972, and are usually inserted subcutaneously in the buttock for men and women. Estradiol pellets are not FDA approved.
Application of Hormones
Bioidentical hormones are compounded topically, orally, and sublingually or made into a pellet for subcutaneous insertion. One problem taking estradiol sublingually or orally is that your liver will convert the estradiol to estrone, which is more carcinogenic. The ideal ratio of estradiol (E2) to estrone (E1) is 2:1. This can only be achieved with estradiol hormone pellet implants. I have seen maybe two or three women who maintained a 2:1 E2 to E1 ratio with hormone creams.
Estrone metabolites
Estrone has two metabolites, which could possibly promote breast cancer. They are 16-alpha hydroxy estrone and 4-hydroxy estrone. The favorable metabolites are 2-hydroxy estrone and Estriol (E3).
I prefer to use estradiol and testosterone hormone pellet implants in women because they work the best in controlling their estrogen and testosterone deficiency symptoms. The Estradiol hormone pellets consistently give women a 2:1 estradiol (E2) to estrone (E1) ratio, which many physicians believe protects women the best from getting breast cancer.
The estradiol and testosterone pellets usually last 4 months in most women. Some women the pellets only last 3 to 3.5 months. In elderly women above age 70, the pellets may last 6 months
I’ve only had two women get diagnosed with breast cancer while on hormone pellets since 1994. The average percentage of women getting breast cancer in their lifetimes is 12.5% or 1 out of 8 women. The two women that I saw might have already had microscopic breast cancer since it did not show up on their mammograms. One has to have millions of cancer cells before it can be seen on an MRI or CT scan.
I also have my patients taking Lugols iodine, vitamin D3, vitamin C, selenium, vitamin K2 (MK-7) and other minerals and supplements. I work on their diets constantly. Some are on a ketogenic diet with high olive oil. Olive oil contains a very powerful phenolic antioxidant, oleocanthal, which kills cancer cells within an hour in vitro.
Women need to have a breast exam, mammogram, and PAP smear before getting on any type of hormone replacement therapy. The physician needs to take a very thorough history including a family history of cancer. Has she had any prior cancers? Did any of her siblings, mother or maternal grandmother have cancer? Some women opt to have breast infrared thermography instead of a mammogram. X-rays are carcinogenic, but the mammogram is a more sensitive test for detecting breast cancer.
Pellet dosing in females
Estradiol
This has to be an educated guess for a woman receiving estradiol and testosterone pellets the first time.
Women should minimally have the following blood tests before estradiol and testosterone pellet insertion:
FSH, Estradiol (E2), Estrone (E1), Progesterone (P4), Total Testosterone (TE), free Testosterone, DHEA-Sulfate, Pregnenolone, and Sex Hormone Binding Globulin (SHBG)
If their afternoon oral temperatures five days in a row are below 98.2 ° F. or 36.7 ° C. they should be tested for total T4, total T3, free T3, free T4, TSH and reverse T3. If there is a family history of hypothyroidism they should have the antithyroglobulin and antimicrosomal (thyroid peroxidase antibody) tests performed.
The FSH test is the most important test to look at when determining the amount of estradiol to give women. Women should do labs 5 weeks after pellet insertion, since the estradiol and testosterone pellets reach maximum blood levels in 4-6 weeks. Strive for an FSH level between 5 mIU/mL and 20 mIU/mL. Some women need to be around 10 mIU/mL to feel good. Less than 5 mIU/mL can be too much estradiol. I like to get the FSH between 15 mIU/mL to 20 mIU/mL.
At the 5-week post-estradiol pellet insertion blood test, if the FSH is between 20 mIU/mL and 25 mIU/mL, she had the correct dose of estradiol. Next time, use the same estradiol pellet dose, and the following five-week blood labs should see the FSH below 20 mIU/mL. If it is not below 20 mIU/mL, then increase the estradiol dose by 2 mg next insertion.
If women have been on a synthetic estrogen like Premarin ® or a birth control pill, they will have to receive a higher dose of the estradiol pellet. Their liver detoxification enzymes have increased considerably to metabolize the synthetic estrogens, and they “eat up” the estradiol pellets too quickly.
IV vitamin C at 100 grams daily also may metabolize estradiol pellets too quickly. I have seen this in around 10 patients. Also, women who drink a fair amount of alcohol may require high estradiol pellet doses.
Do not use a 10 mg estradiol pellet, for they are too thin and can break inside the body and not last 3-4 months. If women need only a 10 mg estradiol pellet they should either be on 12 mg of an estradiol pellet or take estradiol topically.
If a women’s FSH is over 80 mIU/m, and she has a uterus, I would start her out on an 18 mg estradiol pellet. If she does not have a uterus, I would give her 20 mg, 22 mg or a 25 mg Estradiol pellet. If she has been taking Premarin ® at a dosage of 0.9 or 1.25 mg, and she is in her 50’s, she might need a 25 mg estradiol pellet or more.
If a woman with a uterus has an FSH around 20 mIU/mL to 40 mIU/mL, and has symptoms of estrogen deficiency (hot flashes day and/or night, vaginal dryness, brain fog, decreased libido, dry skin, head hair loss or dry, brittle hair she might only need a 15 mg estradiol pellet. You can try an 18 mg estradiol pellet, but watch out, she may get vaginal spotting or a very long period on this dose.
If a woman is still getting hot flashes 4-6 weeks after estradiol pellet insertion, then she could receive an extra 12-15 mg estradiol pellet or be on topical estradiol creams.
I just charge for the pellet, not the insertion fee.
Women who are currently on estrogen replacement therapy should continue with it for one week after estradiol pellet insertion.
Always error on the side of being conservative, especially when women have a uterus. Too much estrogen can cause menstrual spotting, painful breasts, PMS, and full periods lasting many days or twice a month. Sometimes if women have not had a period in a few years, they can start menstruating again on the estradiol pellet. This can usually be remedied with the optimal dose of progesterone cream or capsules. The progesterone capsules may have to be given twice a day.
If men or women are low on thyroid hormone, their testosterone, estradiol pellets and progesterone cream or capsules will not work well.
Read, “Hypothyroidism Type 2: The Epidemic” by Mark Starr, M.D., “Hypothyroidism: The Unsuspected Illness” by Broda Barnes, M.D., “Overcoming Thyroid Disorders” by David Brownstein, M.D., “Iodine: Why You Need It, Why You Can’t Live Without It” by David Brownstein, M.D., “Salt Your Way to Health” David Brownstein, M.D., “Healing With Iodine: Your Missing Link To Better Health” by Marc Sircus, Ac., OMD, DM (P).
Physicians should be using hormone pellets that usually last 3.5 to 4 months in most of his patients. I have tried pellets where they were not compressed properly and broke in the vial or dissolved too quickly in the body.
I trust hormone pellets made from Solution Pharmacy (https://solutionspharmacy.com)
5517 Little Debbie Pkwy, Ooltewah, TN. 3736
1-800-523-1486
Phone: (423) 894-3222
Fax: (423) 499-8435
and College Pharmacy
(www.collegepharmacy.com)
3505 Austin Bluffs Pkwy # 101, Colorado Springs, CO 80918
Phone (719) 262-0022
If the estradiol or testosterone pellet is broken do not use it. The exception is if the male testosterone pellet is broken. It can still be used. A broken pellet gives more surface area, so it may behave differently in the body. Two 35 mg testosterone pellets may behave differently than one 75 mg testosterone pellet.
Estrogen Side Effects in Women
Enlarged breasts and breast tenderness (Sometimes this is a good thing as the breast tissues are rebuilding themselves.)
Menstrual spotting, long periods or two periods a month.
Mood swings
Fluid Retention
Peripheral edema
May feed an underlying breast, uterine or ovarian cancer
If a woman has an estrogen side effect, she can be given evening primrose oil 1,300 mg 4-6 a day, and DIM (Diindolylmethane) 250 mg 1 to 4 a day. Too much DIM can cause decreased libido in women and cause erectile dysfunction in men. Sometimes increasing progesterone and/or testosterone will help.
All of us are low on cobalt doing RBC cobalt testing. Cobalt helps women to retain their estrogen longer, and it helps regulate it. Dr. Jonathan Wright in Seattle gave me this pearl. I put all patients on cobalt chloride 100 mcg a day. (Mother Earth Minerals, Inc. (http://www.meminerals.com)
Estrogen Allergy
Yes, you can become allergic to any of your hormones or anything in your body. The most common steroid hormone allergy is progesterone, then estrogen. I rarely see testosterone, DHEA, DHEA-Sulfate and pregnenolone allergies. I use kinesiology testing, and then I can usually cure these allergies in one to two 5-minute acupressure with intention treatments. I am 95% accurate with kinesiology testing for food and environmental allergies. This has been verified a few thousand times with IgG, IgA and IgE blood tests for foods and IgE testing for environmental allergies.
Kinesiology testing is the most reliable way to check for steroid hormone allergies. Gynecologists probably see a few patients daily with estrogen and progesterone allergy, but they cannot recognize it, because they are not allergists trained in kinesiology. Women with allergies to any of their hormones can be an emotion wreck with very volatile mood swings, insomnia, and fatigue. It can take a toll on their marriages. All of you doctors need to check ALL of your patients for steroid hormone allergies.
Testosterone Pellets in Women
My average female patient needs a testosterone pellet in the dose of 100 mg to 112.5 mg. I usually start them on a 75 mg testosterone pellet. I then have them do a blood test 5 weeks after pellet insertion for free and total testosterone, sex hormone binding globulin (SHBG), estradiol, estrone, FSH, and progesterone.
I asked them how was their libido? Did you have any acne, facial hair, or hair in unwanted places (areolas, pubic hair traveling up to the navel like a man). Do you have a short fuse and want to beat up your husband? If they had plenty of libido, I keep them on the same dose of testosterone. If they had low libido, I might increase their testosterone to 25 mg more next visit.
Fat black women tend to need more testosterone. I usually have worked them up to 125 mg or 135 mg of a testosterone pellet. I might give a little 70-80-year-old lady a 25 mg testosterone pellet. Small Mexican women around ages 50 to 60 may do well on a 50 mg testosterone pellet. Be conservative. You can’t take the pellets out of women. Women do not want to get acne. They won’t like you much if you give them too much testosterone. Sometimes, women will have some mild acne as their body is getting used to being on testosterone again. They may have greasier facial skin and a healthy glow. Their eyes will shine, and their “aura” increases in size. They become more vibrant on the testosterone and estrogen pellets.
Testosterone Side Effects in Women
Acne, facial hair, especially above the lip, more leg and axillary hair, short fuse – fighting with her mate and children, hair on the areolas and pubic hair traveling up to the navel like in a man. Too much testosterone can cause enlargement of the clitoris and permanent lowering of the voice, unfavorable lipid profiles.
Progesterone
Some pharmacies make progesterone pellets. I have tried them and they can work fine. However, do not ever use progesterone, testosterone and estradiol pellets combined in a woman who is having pellets for the first time. You are asking for big trouble! If your patient has a side effect, you may have to wait 4 months until the pellets wear off. It is easier to figure out the side effects using only estradiol and testosterone.
Gynecologists typically do not give progesterone to a woman who has had a hysterectomy. This is a big mistake! Progesterone is needed for a woman’s brain, bones, ovaries, breast and possibly other tissues.
If a woman has had a hysterectomy, I usually wait one month until I put her on progesterone after estradiol and testosterone pellet insertion in case she has any side effects.
Most women who have a uterus need a minimum of 100 mg of either oral progesterone capsules at bedtime or a topical cream. Some women use a fast or slow release sublingual progesterone lozenge or oral capsule.
I usually use a progesterone capsule 200 mg at night or 100 mg in the morning and 100 mg at night. If some women are having menstrual spotting, I may increase the dose of the oral progesterone capsule to 200 mg at night and 100 mg in the morning. Rarely, I had to use a three times a day dosing. Some women prefer topical progesterone creams.
Too much progesterone in women can cause fatigue and weepiness.
I have spent over $2,000 on hormone books, and I consider myself an expert on bioidentical hormone replacement therapy, and treating women is still confusing at times. Some women need more estrogen to stop menstrual spotting; some need less estrogen and more progesterone.
Basically, find what makes her happy. That’s the Art of Medicine. Treat her, not the lab! Use the lab as a guide to help you.
Menstrual spotting or menstrual periods can be due to too high of a dose of the estradiol pellets, low progesterone, an endometrial fibroid, endometrial or endocervical polyps, or stress (low cortisol). If a woman has no uterus, she can be on anywhere from 25 mg to 100 mg of oral progesterone at bedtime or topical progesterone given every 24 hours. Topical progesterone usually does not promote somnolence like oral progesterone.
Remember, I see progesterone allergy the most out of all of the steroid hormones. Some women hate progesterone. Do not believe all of these websites saying progesterone is so great. Most of my female patients could do without it if they had no uterus. A woman must take progesterone if she has a uterus; otherwise, she is at risk for endometrial hyperplasia (menstrual spotting and more periods) or endometrial cancer.
The Trocar
The Trocar from Elemis Corporation (https://www.elemiscorp.com/) is my favorite trocar. I have tried other brands and they do not compare to the Elemis’ trocar. Their new version has a diamond tip. It works very well. Buy it! It comes in a 3.2mm size for female estradiol and testosterone pellets and 4.5mm size for the 200mg testosterone pellets for men.
Don’t buy a plastic one-time use trocar. It’s not as sharp. Spend the money and buy quality.
Your Tools
# 11 blade, scalpel to fit the number 11 blade, #3-0 Nylon sutures, (wide needle), stainless steel cup for the pellets (A bigger one is better in the case you drop the pellets.), tweezers, forceps, scissors, sterile paper, drapes for the patient, rubbing alcohol, chlorhexidine, 2% Lidocaine, no epinephrine, sodium bicarbonate, 10 cc syringe, 22 gauge 1 ½ inch needle, sterile gauze, surgical tape, surgical tray
Procedure
Your patient should be on her side on the examination table. Give her a pillow. Have your nurse drape her properly. Have your patient pull down her pants to the mid-thigh. Have her take off her panties unless she is wearing string panties.
Wipe the entire buttock with alcohol, and then use chlorhexidine. Use a liberal amount of chlorhexidine. Where the buttock starts (the crack) is where you want to put the pellets in. Put the pellets in the mid-buttock. If the patient is very skinny, you will want to tent the skin, so you do not cut the sciatic nerve. This is no problem with most women. Put 7 cc’s of 2% lidocaine (no epinephrine) and 3 cc’s of sodium bicarbonate 5% injection into a 10 cc syringe. Make a bleb on the skin and slowly infiltrate the area where the trocar will go. Some women are so sensitive that you will have to go very slowly or use an allergy need at first to infiltrate the skin.
Make a vertical incision in the skin. Just use ½ of the #11 blade. Have your nurse keep a sterile gauze under the incision.
With the cutting, diamond tip trocar, go through the incision and stay subdermal, don’t go deep. Rotate your wrist fast clockwise and counterclockwise while pushing the entire trocar in up to the stop.
Put the testosterone and the estradiol pellets in the trocar, then insert the pellets with the non-sharp rod.
Withdraw the rod slowly so the pellets won’t follow the rod, and then use two 3.0 nylon sutures. Put gauze on first with tape if in case any anesthetic fluid leaks out. Put Silvadene, or Bactroban on the sutures if she is allergic to sulfa drugs.
Use a new Band-Aid daily with Silvadene or Bactroban. Sutures to be removed in 10 days. No swimming, hard exercise, squats for 10 days.
There will be some pain for 1-2 days and irritation pain from the two sutures. Some doctors use streristrips. I’ve used them. I like sutures. I had my streristrips separate climbing stairs going into the airplane. Sutures stay in.
It is amazing and a little scary how these microgram to picogram doses of hormones can change your health and personality. I sometimes wonder how much free will we have.
Once women try the correct dose of hormone pellets, they do not want to go back to pills or creams. Have fun! It’s nice to have your hormones go back to age 25 again!
© 2018 Copyright Jake Ames, All Rights Reserved. No part of this document may be reproduced in any form without written permission.