Diabetes and Lipid Clinic of Alaska



Testosterone Replacement Therapy for Men Through Subcutaneous Pellets

“Why pellets?”

The most difficult hurdle to over common regarding androgen (testosterone) replacement therapy is compliance. Whether using it once daily gels, patches or weekly injections, compliance is a common problem which quickly results in ineffective treatment. Pellet therapy offers an opportunity to obtain a smooth, consistently effective treatment that eliminates issues with compliance.  

"What are testosterone pellets and how large are they?"

Testosterone pellets are small, compressed cylinders of testosterone, with the size of the pellet varying with the milligram strength of the pellet.

"How are the pellets administered?"

The pellets are injected into the subcutaneous fat (fat beneath the skin) of the buttock just below the waistline. To accomplish this, with the patient lying on their side, the skin is anesthetized with an injection of a small amount of anesthetic. After the area is anesthetized, a small 5 mm incision is made by a sterile blade. A stainless steel trocar, which looks like a metal syringe, is then inserted through this incision. Once in place, the needle is removed from the trocar so the testosterone pellets can be placed inside the barrel of the trocar followed by a plunger which allows the pellets to be inserted into the subcutaneous area. Once this is completed, the trocar is removed and the wound is covered by a series of bandages/Steri-Strips. There is no suture material in utilized for closing the wound. The procedure lasted approximately 10-15 minutes. 

"How is the dose determined?"

Most men utilize 1200-1600 mg of testosterone (6-8 pellets) but the dose will be individualized to your needs based on your blood levels of testosterone and your clinical response.

"How long does it take to work and how often will I require pellet insertions?"

It may require a 3-4 weeks before patient's notice an improvement in her symptoms though it may require adjustments over the first 3-6 insertions to determine your ideal long-term dose (maintenance dose). Insertions the first year are every 3 months with the time interval widened to 4-6 months thereafter depending on the patient's response. Based on the inherent properties of the pellet and the results of clinical studies utilizing pellets, it is expected that the average patient will require insertions every 4 months during maintenance.

"If I am currently on another form of testosterone, will I experience a recurrence of symptoms after starting pellet therapy while am waiting for my levels to build up?"

In patients being switched from one form of testosterone, it is possible that such patients could experience an increase in symptoms during the first 3 weeks of pellet therapy. However, there are various options available to try and minimize such recurrent symptoms which will be discussed with you prior to starting pellet therapy.

"How often will I require other office visits and blood work?"

One your maintenance dose has been determined (usually after 12-18 months of therapy), lab work and office visits may be as little as once a year excluding pellet insertion visits. However, this is individualized based on the patient's other medical problems and course of therapy. Patient's with chronic medical diseases or treated for other conditions will require office visits and lab work based on what is recommended for such therapy. While your optimal, long-term dose has been determined during the first 12-18 months of pellet therapy, blood levels will be taken at 4 weeks (peak levels) and at 10-14 weeks (trough levels) after each insertion. Office visits will be scheduled 6 weeks after each insertion to review your clinical improvement and blood levels. This will allow for continued, methodical adjustment of your dosing until your ideal maintenance dose is determined.

"Are there any special preparation is required prior to my insertion?"

When medically appropriate, we ask patients to stop aspirin therapy at least one week prior to insertions. In all patients taking any form of blood thinner, we require that you discuss this with the prescribing doctor so that they can determine the appropriateness of stopping such medication and the timing of such. In some cases, like patients who have cardiac stents and/or artificial valves, it is not appropriate under any circumstances to stop such blood thinners. Such patients may want to consider another form of testosterone replacement therapy.

"Are there any complications particular to the insertion procedure?"

As with all surgical procedures involving the skin, wound infection is a rare but really possibility. Further, the physician will occasionally injure a more prominent blood vessel resulting in a larger bruise at the site. Very rarely, eye hematoma, which is a collection of blood under the skin, may form at the wound site. Again, this is very rare and usually happens in patients on some form of blood thinner. Finally, pellets may rarely extrude (back out of the wound) and be lost.

"How much does it cost?"

All discussions of the costs must be done with the understanding that insurance coverage varies between companies and plans and is constantly changing. To assess this more appropriately, patients are always encouraged to ask their insurance company directly about payment for such services. The CPT (procedure code) for pellet insertion is 11980 and the diagnosis code (ICD-9) is 257.2. Our most recent analysis suggests that most of the insurance carriers, including Medicare, reimburse at their typical, negotiated level of reimbursement for the procedure code, associated office visits and labs. The level of reimbursement for such, and a portion which you are required to pay, will vary depending on your plan. It is generally cheaper to have the procedure performed than the typical out-of-pocket cost for the gel or patches for hormone replacement therapy.

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