ABOUT THE AUTHOR
Dr. Nathan Bryan is an Assistant Professor of Molecular Medicine within the Brown Foundation Institute of Molecular Medicine, part of the School of Medicine at the University of Texas Health Science Center at Houston (Texas, USA). He is also on faculty within the Department of Integrative Biology and Pharmacology and Graduate School of Biomedical Sciences at the University of Texas Houston Medical School. Dr. Bryan is an active member of the Nitric Oxide Society, Society for Free Radical Biology and Medicine, and numerous other organizations.
Chapter 5
Testosterone Pellet Implantation
Stephen Center, M.D.
Medical Director, BodyLogic MD of San Diego
ABSTRACT
Evidence suggests that testosterone pellet implantation (TPI) is the best available method of testosterone delivery, yet transdermal and injectable forms of testosterone continue to be the delivery methods of choice for testosterone replacement therapy (TRT) with many practitioners. The aim of this paper is to familiarize health practitioners with TPI and to encourage its use in TRT.
INTRODUCTION
Testosterone replacement therapy (TRT) has proven to be a valuable option in bioidentical hormone replacement therapy since its inception. All physicians who prescribe testosterone are familiar with commonly used form of testosterone. Transdermal and injectable forms (cypionate, the longer acting enanthate, and others) dominate the list of therapeutic options. While some still prescribe oral testosterone, its use is more controversial due to the familiar problems with orally administered sex hormones – second pass hepatic metabolism altering what reaches the cellular receptors, among other caveats. Continuous testosterone delivered by subcutaneous implant has been safely used in women since 1938 and until recently, was the only licensed form of testosterone for women in England.
In the 1990’s and thereafter Dr. Edward Lichten, an extensively published Michigan gynecologist, bioidentical hormone specialist and a long-time member of A4M’s teaching faculty, has touted testosterone pellet implantation for men and women as a potentially better option for TRT. Among the many studies done on the benefits and safety of pellets, Dr. Lichten emphasized the benefits for diabetic patients, as testosterone pellets appear to enhance insulin sensitivity, improving diabetic control. He also showed that testosterone pellet implantation (TPI) improved circulation in these patients. Moreover his experience convinced him that pellets were superior to other forms of TRT.
Over the past 10 years or so one of the major champions of TPI therapy has been Dr. Rebecca Glaser, an Ohio surgeon. Her practice used to focus on breast cancer but evolved to pellet therapy combined with the use of other bioidentical hormones given vaginally. Dr. Glaser first trained me in the procedure in 2009.
However, despite these two physicians’ effort to expose their colleagues to TPI therapy the general recognition of this safe and remarkably effective from of TRT has been limited. Furthermore, knowledge of its use and relevant clinical and scientific studies, as well as knowledge of training venues to allow interested practitioners to learn how to use TPI has been lacking. At the December, 2012 A4M national conference in Las Vegas where I spoke on TPI, many well trained anti-aging physicians came up to me after my presentation and told me they have never heard of it, or if they have they are in the dark as to its benefits and safety. This article is designed to familiarize health practitioners with TPI and encourage them to consider adding it to their therapeutic armamentarium.
TESTOSTERONE DEFICIENCY
Some of the many symptoms of low testosterone include:
•Reduction of muscle mass despite adequate protein intake;
•Decreased muscle tone;
•Weight gain;
•Fatigue, low energy;
•Low self-esteem;
•Decreased level of HDL (high density lipoprotein) the so-called “good” cholesterol;
•Decreased sex drive;
•Mild depression;
•Dry, thin skin;
•Loss of pubic hair;
•Thinning and dry hair;
•Anxiety;
•Hypersensitive, hyper-emotional states;
•Erectile dysfunction (men only).
TRT can alleviate these symptoms. Restoring testosterone to normal levels can help to:
•Improve libido;
•Boost self confidence and self-esteem;
•Increase skeletal and cardiac muscle strength and mass;
•Improve stamina;
•Shed excess body fat;
•Stimulate growth of pubic and underarm hair;
•Maintain bone strength.
Testosterone also has vasodilating properties, which is valuable for patients with atherosclerosis. It also elevates neurotransmitters (especially dopamine), which can help to improve low motivation, depression and memory (especially in men). Finally, it also provides central negative feedback in order to temper overproduction of ACTH (adrenocorticotropic hormone) and cortisol.
When talking about TRT it is very important to consider the symptoms of testosterone excess, which include aggressiveness, facial hair or unwanted hair growth, acne or oily skin (face and body), and edema.
Interestingly there is a very poor correlation between scalp hair loss in men and women with elevated testosterone. Patients with these problems, both men and women, may have elevated dermal dihydrotestosterone (DHT), but almost all of these patients have low serum or salivary testosterone and serum DHT.
TESTOSTERONE DELIVERY VIA PELLETS
Testosterone can be delivered in a number of ways: topically (compounded or commercial), by injection, via patches, sublingually, or by pellet implantation. Each method has advantages and disadvantages. Table 1 lists the advantages and disadvantages associated with the use of commercial gels, compounded creams and gels, and injectable testosterone.
| Table 1. Advantages and Disadvantages of Different Methods of Testosterone Administration | ||
| Commercial Gels (Testim or Androgel) Advantages: •Well-absorbed; •May be more easily covered by insurance; •Single-use tubes, packets, or pumps. Disadvantages: •Strong alcohol odor; •Fixed dosages – not customizable; •Very expensive if not covered by insurance; •Limited to only 1 type of vehicle delivery (a problem if allergic to the gel); •Requires daily compliance – drop-out rate is a factor. |
Compounded Creams and Gels
Advantages:
•Well-absorbed;
•Dosage is customizable;
•Multiple delivery forms (pumps, Topi-Click® syringes, tubs (with 1/8+ or 1/4 tsp spoons);
•May be covered by insurance, but if not, not too expensive;
•Multiple hypoallergenic vehicles available if skin allergy is a problem.
•
Disadvantages:
•Thicker than commercial gels – hairy patients may have problems;
•Lack of large multicenter studies;
•Available only from quality compounded pharmacies (often requiring mail order);
•Not uncommon adverse reactions include acne in both sexes and
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