An in-depth Guide to Bioidentical Hormone Delivery Methods.

Bioidentical hormone replacement therapy (BHRT) is a form of hormone therapy that uses hormones that are chemically identical to those produced naturally by the body. These are often derived from plant sources. BHRT is used to treat hormonal imbalances and can alleviate symptoms associated with menopause, perimenopause, and andropause.

The method by which these hormones are delivered can significantly impact their effectiveness, absorption, and overall patient experience. This article will outline the pros and cons of five standard delivery methods: pellets, topical creams, patches, injectables, and sublingual troches.

1. Hormone Pellets

What they are: Hormone pellets are small, rice-sized cylinders of compounded bio-identical hormones (such as estradiol or testosterone) that are inserted under the skin, typically in the hip or buttock area, during a minor, in-office procedure.

How they are broken down: Pellets are designed to provide a continuous, steady release of hormones directly into the bloodstream. They dissolve slowly over time, a process that is regulated by the body’s cardiac output. This means that during times of increased activity or stress, the body may absorb more of the hormone as needed.

Blood levels and peaking: One of the main benefits of pellets is their ability to deliver a stable, physiologic dose of hormones, avoiding the significant peaks and troughs on a daily or weekly basis as with other methods. While there may be a slight initial spike in hormone levels after insertion, levels generally remain consistent for the duration of the pellet’s life, after a potential transient surge in hormones post-insertion.  Hormone pellets typically last about 3-5 months. As the pellet is depleted, hormone levels will slowly decline. For a small %, this decline can happen more rapidly.

Pros:

• Set it and forget it: The most significant advantage is convenience. A single procedure provides a consistent dose for months, eliminating the need for daily application or administration. This can lead to very high patient compliance rates.
• Steady levels: The continuous release of hormones avoids the daily/weekly fluctuations that can occur with other delivery methods, which may lead to more stable symptom relief and fewer side effects like mood swings or energy dips. 
• Bypasses the liver: Pellets are absorbed directly into the bloodstream, bypassing the “first-pass effect” of the liver that occurs with oral hormones. This reduces the risk of certain side effects, such as blood clots, associated with oral estrogen.

Cons:

• Minor surgical procedure: The insertion requires a small incision and carries a slight risk of bruising, infection, or the pellet being expelled from the body.
• Not easily reversible: Once inserted, the pellets cannot be easily removed. If the dosage is too high or causes unwanted side effects, the patient must wait for the hormones to be absorbed, which can take months. This makes it difficult to make rapid dosage adjustments.  We tend to dose on the lower side to begin and monitor dosage changes if needed based on labs and symptoms.
• Dosage limitations: The dose is fixed for the pellet’s duration. While some adjustments can be made with subsequent insertions, it may require a period of trial and error to find the optimal dose.
• Transient surge/drop of levels in a small %: Some patients will have a transient surge of hormone levels post insertion, and then this tends to level out. Some will have a drop off towards the end of the cycle.  Similar to other methods ups and downs with levels happen.

2. Topical Creams or Gels

What they are: Topical creams and gels are compounded hormone preparations that are applied daily to thin areas of the skin, such as the inner arms, thighs, or shoulders.

How they are broken down: The hormones are absorbed through the skin and then enter the bloodstream. The absorption rate can vary significantly from person to person.

Blood levels and peaking: When applied daily, topical creams can create a “peak and trough” effect, where hormone levels are highest shortly after application and then decline over the next 24 hours. The consistency of these levels depends heavily on the time of day the cream is applied and the individual’s absorption rate.

Pros:

• Customizable dosing: The dose can be easily adjusted by the patient or their provider. This makes creams a good option for people who need to fine-tune their hormone levels.  Of course, not everyone absorbs them well.
• Bypasses the liver: Like pellets, topical applications bypass the liver’s first-pass metabolism, which can reduce the risk of certain side effects.
• Non-invasive: There is no need for a medical procedure.

Cons:

• Risk of transference: The hormones can be transferred to others through skin-to-skin contact, which can be a concern, especially for children or pets.
• Absorption issues: Absorption can be inconsistent and may be affected by factors like skin type, location of application, and the presence of lotions or other products. Some people may be poor absorbers and not get the full benefit of the hormone.
• Compliance: Daily application is required, but some people may forget, resulting in inconsistent hormone levels and inadequate symptom relief.
• Blood levels and peaking: When applied daily, topical creams can create a “peak and trough” effect, where hormone levels are highest shortly after application and then decline over the next 24 hours.

3. Patches

What they are: Patches are a form of transdermal hormone therapy that adheres to the skin and is typically replaced every few days to a week. Estradiol is the only hormone offered in patch form. At this time, patches do not work with progesterone and/or testosterone.

How they are broken down: Patches provide a continuous, controlled release of hormones through the skin and into the bloodstream. This is a passive process that doesn’t rely on the body’s metabolism in the same way pellets do.

Blood levels and peaking: Patches are known for providing relatively stable, sustained hormone levels, although there is usually a peak on Day 1 after patch application and a trough on Day 3-4, before changing your patch. The level of the hormone may fluctuate every 3-4 days. 

Pros:

• Relatively steady release: Patches provide one of the most stable delivery methods, which can lead to consistent symptom relief and fewer side effects.  There will still be a peak on the day of patch application and a tough @ day 3-4 before changing the patch.
• Bypasses the liver: Similar to other transdermal methods, patches bypass the liver, reducing the risk of specific side effects.
• Convenience: While not as long-lasting as pellets, patches are more convenient than daily creams or troches.

Cons:

• Skin irritation: Some patients may experience a skin reaction or irritation at the application site.  Adhesive reactions are relatively common.
• Adhesion problems: The patch may peel off, especially with sweating, swimming, or vigorous activity, which can disrupt the dosage.
• Limited availability: Patches may not be available for all types of bioidentical hormones or in all dosages.

4. Sublingual Troches

What they are: Troches (pronounced “tro-keys”) are small, medicated lozenges that are placed under the tongue or in the cheek to dissolve and absorb the hormones through the mucous membranes.

How they are broken down: The hormones are absorbed directly into the bloodstream through the rich network of blood vessels in the mouth. This delivery method avoids the gastrointestinal tract and the first-pass effect of the liver.

Blood levels and peaking: Sublingual troches result in a rapid peak of hormone levels after the troche dissolves, followed by a quick decline. The effect is short-lived, which is why they are often prescribed for use multiple times a day.

Pros:

• Customizable dosing: Like creams, troches can be compounded to precise dosages and easily adjusted.
• Rapid absorption: The hormones enter the bloodstream quickly, which may provide rapid symptom relief but does cause a peak and usually a trough in levels a few hours later.
• Bypasses the liver: This method avoids the first-pass effect, which is a key advantage over oral pills.

Cons:

• Inconsistent blood levels: The rapid peak and decline of hormones can lead to fluctuations in blood levels, which may cause symptoms like mood swings or energy shifts.  It isn’t easy to keep levels balanced with troches.
• Compliance: Requires administration multiple times a day, which can be a challenge for patient compliance. If a dose is missed, it can lead to inconsistent symptom relief.
• Taste and texture: The flavor and texture of the troche may be unpleasant to some patients. If swallowed, the hormone will be metabolized by the liver, negating the benefit of this delivery method.
  

  5. Injectable Hormones

  What they are: Injectable hormones are medications delivered by injection into the fatty tissue (subcutaneous) or muscle (intramuscular) to increase or replace specific hormones in the body. They are used for managing hormone optimization. Hormone preparations, such as testosterone or estrogen, are formulated into a solution for injection.

  How they are broken down: After injection, the hormones enter the bloodstream and travel to target cells throughout the body. This method avoids the first-pass effect of the liver that we get from oral hormones. 

  Blood levels and peaking: Following an injection, hormone levels in the blood rise and reach a peak. The peak may occur within a day or two. The hormone levels then gradually decline until the next injection. This results in a cycle of highs and lows (peaks and troughs).  Blood tests can be used to monitor these levels over time. We like to capture levels on Day 2 and then again on Day 6.  Although most insurance companies will deny labs done too frequently, the out-of-pocket expense can add up. 

• Pros:
  • Customizable dosing: The dose can be precisely measured and adjusted by a healthcare provider to achieve a specific therapeutic range for each patient based on bloodwork and symptom response.
  • Rapid absorption: Injections, particularly intramuscular ones, provide a fast boost to hormone levels, which can lead to quick symptom improvement.  This can also lead to a transient peak post-injection.
  • Bypasses the liver, like all of our hormone options. Injectable hormones avoid the “first-pass effect” associated with oral medications, where the liver heavily metabolizes the drug before it reaches systemic circulation. This can lead to greater bioavailability and less strain on the liver. 

  Cons:

  • Inconsistent blood levels: The fluctuating hormone levels between injections can cause mood swings and other side effects for some people.  Many people prefer the injectable method because they do not experience highs and lows. Injecting a smaller dose, 2x weekly, can also help keep levels more consistent.
  • Compliance: Regular administration is required, and inconsistent adherence can affect treatment outcomes. Some people may find the process difficult or painful
  • Need for self-injection: This can be a barrier for individuals who are afraid of needles, and it necessitates proper training to ensure a safe and correct injection technique. 

Conclusion

The “best” form of bioidentical hormone delivery is highly individual and depends on a patient’s specific needs, lifestyle, and preferences. For those who value convenience and consistent, stable hormone levels, pellets are a strong option. For individuals who prefer flexibility and a non-invasive approach, creams or troches may be more suitable. Patches offer a good balance of consistency and convenience with estradiol. A thorough discussion is essential to determine the most appropriate and effective form of BHRT for your unique situation.