If you have been researching hormone therapy online or have friends who are on hormones, there is a good chance you have heard about testosterone pellets. They are heavily marketed, they have enthusiastic advocates, and the pitch sounds appealing — a small implant inserted under the skin every few months, no daily application, no patches to remember.

So why don't we use them at The Lee Clinic?

Because the evidence, the pharmacokinetics, and the clinical reality of pellets present problems that we are not willing to overlook in the name of convenience.

Here is our honest assessment.

What Pellets Actually Are

Testosterone pellets are small, solid cylinders — about the size of a grain of rice — inserted under the skin, typically in the upper buttock, through a small incision. They release testosterone slowly over four to six months, after which the process is repeated.

The appeal is obvious. No daily application. No remembering to change a patch. No gel to rub in every morning. For some patients and some practices, that convenience factor is the primary selling point.

But convenience is not the same as safety. And with pellets, the convenience comes with tradeoffs that we consider clinically significant.

The Core Problem: You Cannot Adjust the Dose

This is the issue that matters most, and it flows from everything else.

Once testosterone pellets are inserted, it is impossible to reduce the dose or remove them. They are in. They are releasing testosterone. And if the dose is wrong — too high, producing side effects, causing problems — you cannot do anything about it except wait for them to dissolve. That can take months.

With a transdermal cream or gel applied daily, if something is off — a level comes back too high, a patient develops acne, a symptom suggests the dose needs adjusting — we change it immediately. The next day she applies less. Problem addressed.

With pellets, that option does not exist. You are locked into the dose you were given, regardless of what happens next.

The Supraphysiologic Peak Problem

This is where the pharmacokinetics become genuinely concerning.

Pellets provide sustained release over four to six months — but with supraphysiologic early peaks above 100 to 250 ng/dL and wide interindividual variability. To put that in context, the normal testosterone range for a premenopausal woman is approximately 10 to 55 ng/dL. Levels of 100 to 250 ng/dL are two to five times above the upper limit of what is considered physiologic for women.

This is not a minor overshoot. It is a fundamental pharmacokinetic problem with the delivery method — the pellet releases a bolus of testosterone early after insertion that routinely exceeds physiologic female ranges. And because the dose cannot be adjusted, that peak just has to run its course.

Major guidelines — including The Menopause Society — specifically state that pellets and injections should be avoided because they result in supraphysiologic levels. This is not a fringe position. It is the mainstream clinical consensus.

What Supraphysiologic Levels Actually Do

When testosterone goes significantly above the normal female range, the side effects that women associate with testosterone — and that make them hesitant to consider it — become real risks rather than theoretical ones.

At supraphysiologic levels, testosterone can cause acne, oily skin, facial hair growth, scalp hair loss, voice changes, and clitoral enlargement. Some of these — particularly voice changes and scalp hair loss — may not fully reverse even after levels come back down.

There are also concerns about cardiovascular and metabolic effects at supraphysiologic doses, and the data on long-term safety at these levels in women is simply not there.

The Evidence Base Is Weak

Pellet advocates often point to observational data showing improvements in libido, energy, mood, and bone density. And those improvements are real — but they need to be understood in context.

The only randomized controlled trial on testosterone pellets showed improved sexual activity, orgasm, and satisfaction at 24 weeks. But observational cohort findings are limited by non-randomized designs, lack of blinding, and conflicts of interest. Data on cardiovascular, metabolic, and endometrial outcomes remain sparse and inconsistent. Safety cannot be confirmed.

The honest summary from a 2025 structured narrative review covering 38 studies published over 45 years: testosterone pellets provide long-term delivery but at the cost of supraphysiologic peaks, dosing variability, and reliance on observational evidence. Reported benefits for sexual function and well-being are hypothesis-generating, while safety cannot be confirmed.

That is not a ringing endorsement. That is a field built largely on practice-based registries and clinician enthusiasm rather than rigorous clinical trial evidence.

The Business Model Problem

This is the part that rarely gets said out loud — but it is clinically relevant.

Pellet insertion is a procedure. It generates revenue per insertion in a way that prescribing a cream or gel does not. Many of the practices most aggressively marketing pellets have a direct financial incentive tied to the volume of insertions they perform. That does not mean everyone offering pellets has bad intentions — but it does mean the marketing enthusiasm around pellets is not always purely evidence-driven.

We think women deserve to know that.

What We Use Instead

At The Lee Clinic, we use transdermal testosterone — typically a compounded cream or gel applied daily in a small, carefully measured dose. Here is why this approach works better:

Precise, adjustable dosing. We start low and adjust based on labs and symptoms. If something needs to change, we change it — immediately, not in four months.

Physiologic levels are achievable and maintainable. Daily transdermal application produces stable, consistent testosterone levels within the normal premenopausal range — without the supraphysiologic peaks that pellets reliably produce early after insertion.

No irreversible commitment. If a patient develops a side effect, we reduce the dose or stop. The option is always there.

The evidence supports it. Transdermal testosterone is the formulation recommended by every major guideline — The Menopause Society, the ISSWSH, the Global Consensus Position Statement — specifically because it achieves physiologic levels without the pharmacokinetic problems of pellets and injections.

Yes, it requires a daily application. For most women, that is thirty seconds in the morning. We think that is a reasonable tradeoff for being able to actually control what is happening with your hormone levels.

The Bottom Line

Testosterone can be genuinely beneficial for women — for libido, energy, mood, muscle, bone, and cognitive function. We believe in it and we use it regularly in our practice. But the goal is always to restore physiologic levels — what your body used to make naturally — not to push levels into ranges that exceed normal female physiology.

Pellets cannot reliably achieve that goal. They overshoot consistently, they cannot be adjusted, and the long-term safety data simply does not exist to support their widespread use.

You deserve a hormone plan you can actually manage — one that can be adjusted as you change, monitored closely, and stopped or modified if something isn't right. That is what we provide at The Lee Clinic.

The Lee Clinic sees patients in person in Winchester and Reston, VA. Telehealth appointments are available for patients in FL, DC, WV, and MD. Call us at 540-542-1700 to schedule.