Hormones: What You Should Know About BHRT & Pellet Therapy

Discover the benefits of BHRT and pellet therapy for effective hormone replacement and overall health and wellness.

Abstract

We are witnessing a significant paradigm shift in how we approach hormonal health and aging. This post outlines an integrative and evidence-based framework for managing the symptoms of menopause in women and andropause in men, with a deep dive into Bioidentical Hormone Replacement Therapy (BHRT) using pellet insertion. I will guide you through our clinical workflow, from initial patient contact and comprehensive symptom assessment to detailed lab analysis and the art of personalized treatment planning. We will explore real-world case studies, delving into the physiological underpinnings of hormonal decline and the rationale behind specific therapeutic interventions. A key focus will be on interpreting crucial lab markers—such as thyroid panels, ferritin, inflammatory markers, and hormone levels—to create a comprehensive picture of a patient’s health. Furthermore, I will explain how integrative chiropractic care serves as a foundational element, enhancing nervous system function and structural integrity, which is crucial for maximizing the benefits of hormonal therapy and achieving optimal wellness. This guide is designed to empower both patients and practitioners with the knowledge to navigate hormone optimization safely and effectively.

The Modern Patient Journey in Hormone Optimization

The way we manage patient care for hormone optimization has evolved dramatically. The goal is to create a streamlined, educational, and efficient journey for every individual who walks through our doors. It’s no longer just about a single consultation; it’s about a continuous, supportive process built on education and partnership.

Our clinical workflow is designed to be highly organized and patient-centric. Here is a step-by-step look at how we guide our patients:

• Initial Contact and Education: When a potential patient expresses interest, we don’t just schedule an appointment. We initiate a process. We start by ordering preliminary labs tailored to their initial concerns. Simultaneously, we provide them with access to educational resources through QR code campaigns. I developed this system years ago after recognizing that we were repeating the same information to patients who, understandably, had similar questions. These short, targeted videos explain the basics of hormone therapy, what to expect, and why we test certain markers. This empowers the patient, clears up common misconceptions before the consultation, and makes our time together far more productive.
• Comprehensive Symptom Assessment: Before their first major consultation, patients complete detailed symptom checklists, such as the Menopause Rating Scale (MRS) or the Aging Male Symptoms (AMS) scale. These tools provide a quantitative score for symptoms like hot flashes, mood changes, decreased libido, and fatigue, giving us a baseline to measure progress against.
• The In-Depth Consultation and Informed Consent: During the consultation, we review their symptom scores and lab results. This is a crucial moment where we discuss all available treatment options. For menopause, this might include pellets, injections, creams, or capsules. We present the evidence, benefits, and considerations for each, allowing the patient to make an informed choice that aligns with their lifestyle and goals. This is also where the thoroughly informed consent process occurs. Our consent forms are detailed, reference-backed documents that explain why we are recommending a treatment, the “off-label” use of compounded pellets, and all potential risks and benefits. This transparency is paramount for building trust and ensuring the patient is an active, knowledgeable participant in their care.
• Post-Treatment Follow-Up: Effective follow-up is non-negotiable for retention and optimal outcomes. We schedule follow-up labs before the patient even leaves their initial treatment appointment.

• For women, we typically schedule follow-up labs at 14 weeks (3.5 months) and the next pellet insertion at around 16 to 18 weeks.
• For men, the interval is often longer.

• The Importance of Follow-Up Labs: Years ago, the common practice was to tell patients to return when their symptoms came back. This was a flawed model. Hormonal decline is often a slow, insidious process. Patients might not notice the gradual return of fatigue or brain fog until their levels have dropped significantly. By proactively scheduling follow-up labs, we can objectively see their hormone levels and adjust their treatment before symptoms return, ensuring they consistently feel their best. This proactive approach is key to long-term success and patient satisfaction.

Case Study 1: A 59-Year-Old Woman Navigating Post-Menopause

Let’s examine a common scenario I see in my practice. The patient is a 59-year-old female, well into post-menopause. She presents with a cluster of persistent symptoms despite being years past her last menstrual cycle.

Symptom and Lab Analysis

Her Menopause Rating Scale (MRS) scores are high, indicating severe symptoms. Despite being post-menopausal, she scores significantly for depressive moods, irritability, and diminished sexual desire. She mentions a “pot belly” that she never had before, even though her diet and exercise routine—walking her dog—haven’t changed. This is a classic story I hear from women in this phase of life.

Her lab work reveals several critical areas for intervention:

• Vitamin D: Her level is 25 ng/mL, which is profoundly deficient. Optimal levels are closer to 60-80 ng/mL. Vitamin D is not just a vitamin; it’s a prohormone essential for immune function, bone health, mood regulation, and inflammation reduction. A deficiency this significant requires an aggressive repletion strategy. I would start her on a daily dose of 5,000 IU of Vitamin D3, likely paired with Vitamin K2 for proper calcium utilization.
• High-Sensitivity C-Reactive Protein (hs-CRP): Her hs-CRP is elevated, indicating systemic inflammation. This could be linked to lifestyle, diet, a hidden infection, or the hormonal imbalance itself. This finding signals that we need to investigate the root cause of the inflammation, not just treat the hormones.
• Thyroid Panel:

• TSH (Thyroid Stimulating Hormone): 3.8 mIU/L. While technically within the conventional “normal” range, functional medicine practitioners recognize that an optimal TSH is closer to 1.0-2.0. A TSH of 3.8 suggests the thyroid is struggling.
• Free T4: 0.8 ng/dL. This is suboptimal. Free T4 is the inactive thyroid hormone, and low levels mean less raw material is available for conversion to the active form.
• Free T3: 2.2 pg/mL. This is also suboptimal. Free T3 is the active thyroid hormone that drives metabolism in every cell of the body.
• Thyroid Antibodies: We would also test for TPO and TG antibodies to rule out Hashimoto’s thyroiditis, an autoimmune condition that is a common cause of hypothyroidism.

• Hormone Levels:

• Estradiol: 11 pg/mL. This is very low, contributing to her hot flashes, mood issues, and vaginal dryness.
• Free Testosterone: Essentially zero. This is a critical finding. Women need testosterone for energy, muscle mass, cognitive function, mood, and libido. The absence of testosterone is a major reason for her fatigue and diminished sense of well-being.
• SHBG (Sex Hormone-Binding Globulin): 118 nmol/L. This is extremely high. SHBG is like a sponge that binds to hormones, particularly testosterone, making them unavailable to the tissues. Her high SHBG means that even if she had some testosterone, it would be tightly bound and inactive. The brain, sensing this hormone starvation, signals the liver to produce more SHBG, creating a vicious cycle. A primary goal of her therapy will be to lower this SHBG, thereby increasing her free, usable hormone levels.

The Integrative Treatment Plan

My approach for this patient is multifaceted, addressing each physiological imbalance we’ve identified.

1. Hormone Replacement: The primary intervention is bioidentical hormone replacement therapy (BHRT), likely using pellets. The pellets provide a steady, consistent release of estradiol and testosterone, mimicking the body’s natural rhythms. This will directly address the root cause of her menopausal symptoms by replenishing her deficient hormones. Over time, as her estradiol levels rise, her SHBG will naturally decrease, freeing up more testosterone and further improving her symptoms.
2. Thyroid Support: Her thyroid is sluggish. I would support it with key nutrients like iodine, selenium, zinc, and tyrosine. If her symptoms and labs don’t improve, a prescription for thyroid hormone (such as Armor Thyroid or a compounded T4/T3 formula) may be necessary.
3. Nutritional and Inflammatory Support: We must address the inflammation indicated by her high hs-CRP. This involves dietary changes—removing inflammatory foods such as sugar, processed grains, and industrial seed oils—and adding anti-inflammatory support, such as Omega-3 fatty acids and curcumin. Her Vitamin D deficiency will also be corrected. We may also use supplements such as DIM (diindolylmethane) and calcium D-glucarate to support healthier estrogen detoxification pathways.
4. The Role of Integrative Chiropractic Care: This is where we bring in another powerful modality. The hormonal chaos of menopause places immense stress on the neuro-musculoskeletal system.

• Stress and the Adrenals: Chronic stress from symptoms like poor sleep and mood swings dysregulates the HPA (Hypothalamic-Pituitary-Adrenal) axis. Chiropractic adjustments have been shown to help modulate the autonomic nervous system, shifting the body from a “fight-or-flight” (sympathetic) state to a “rest-and-digest” (parasympathetic) state. This helps calm the adrenal response, which is crucial because the adrenals are the backup system for hormone production after the ovaries cease functioning.
• Structural Integrity and Pain: Hormonal changes affect tissue laxity and can exacerbate joint pain and stiffness. The “pot belly” she describes is not just fat; it’s often accompanied by a change in posture (anterior pelvic tilt) due to weakening core muscles and visceral fat accumulation. Chiropractic care directly addresses these biomechanical shifts through adjustments, soft-tissue work, and the prescription of corrective exercises. By restoring proper spinal alignment and function, we can alleviate pain, improve posture, and enhance the body’s overall ability to adapt and heal.

Assessing Hormone Therapy- Video

Case Study 2: An Aging Male with Metabolic Dysfunction

Now let’s turn to a male patient, presenting with symptoms of andropause. He completes the Aging Male Symptoms (AMS) scale, revealing a significant decline in energy, stamina, and mood. He reports gaining visceral fat, particularly around his midsection, and has GI issues.

Symptom and Lab Analysis

His lab work paints a concerning picture of metabolic disease, which is tightly interwoven with low testosterone.

• Lipid Panel and A1c: He has high cholesterol and a pre-diabetic A1c.
• Kidney Function: His elevated creatinine requires monitoring and a referral to his primary care physician to evaluate kidney function.
• PSA (Prostate-Specific Antigen): His PSA is within a normal range.
• Hormone Levels:

• Total Testosterone: 250 ng/dL. This is significantly low for an adult male.
• Estradiol: 40 pg/mL. This is on the high side for a male, often a result of the aromatase enzyme converting testosterone into estrogen, a process that is accelerated by inflammation and obesity.
• SHBG: Low. Unlike the female patient, his SHBG is low, which is common in men with insulin resistance and metabolic syndrome.

The Integrative Treatment Plan

This patient is a classic example of metabolic syndrome driving hormonal imbalance. You cannot fix one without addressing the other.

1. Testosterone Replacement Therapy (TRT): He is a clear candidate. Restoring his testosterone to an optimal range (e.g., 800-1000 ng/dL) will have profound effects. It will help him build lean muscle mass, lose visceral fat, improve insulin sensitivity, boost his energy, and enhance his mood and cognitive function.
2. Managing Estrogen: Because he tends to aromatize testosterone into estrogen, we need to manage his estrogen levels. This can be done with an aromatase inhibitor (AI) if needed, but the primary strategy should be to address the root cause: inflammation and excess body fat. As he loses weight and his inflammation decreases, his aromatase activity will naturally decline.
3. Metabolic and Lifestyle Overhaul: This is the cornerstone of his treatment. TRT is a powerful tool, but it is not a substitute for diet and exercise. We would implement a nutritional plan focused on whole foods, lean proteins, healthy fats, and complex carbohydrates to reverse his insulin resistance and lower his A1c.
4. Integrative Chiropractic and Functional Support:

• Neurological and Structural Support: Low testosterone is linked to muscle loss (sarcopenia), joint pain, and poor recovery. Chiropractic adjustments ensure that the nervous system communicates effectively with the muscular system, which is essential for rebuilding strength. Targeted rehabilitation exercises will help him activate his core and posterior chain, counteracting the effects of a sedentary lifestyle and visceral fat accumulation.
• Gut Health: His GI issues are a red flag. An unhealthy gut microbiome can drive inflammation, which in turn fuels aromatase activity and worsens metabolic syndrome. As a Certified Functional Medicine Practitioner (CFMP), I would order a comprehensive stool analysis to identify dysbiosis, infections, or other imbalances, and develop a targeted gut-healing protocol. A healthy gut is foundational to reducing systemic inflammation and optimizing hormone metabolism.

Advanced Pellet Insertion: The Art and Science of Technique

The physical procedure of inserting hormone pellets has evolved dramatically. Modern medicine now allows for a minimally traumatic technique that prioritizes patient comfort, safety, and optimal hormone absorption.

Pre-Procedure Preparation

The success of the procedure begins with careful preparation. My first focus is the patient’s anatomy, specifically Langer’s lines in the skin, which correspond to the natural direction of collagen fibers. Making a “belt line” incision parallel to these lines is paramount for efficient healing and minimal scarring. After mapping the ideal incision site in the upper gluteal region, I thoroughly cleanse the area to create a sterile environment.

The Ultrasound-Guided Insertion Process

To elevate the standard of care, I integrate ultrasound guidance. Before making the incision, I use ultrasound to visualize the layers of tissue, measure the depth of the subcutaneous fat, and identify the ideal plane for pellet placement. This evidence-based method removes guesswork and ensures precision.

The primary tool is a trocar with a conical, blunt tip designed to gently separate tissue fibers rather than sever them, thereby significantly reducing trauma and bruising. I make a micro-incision, just large enough for the trocar to enter the subcutaneous fat layer. Then, the most crucial part begins: the fanning technique. Instead of creating one large pocket, I use the trocar to create multiple, small, separate tracks in a fanning pattern, depositing one or two pellets into each track. This method avoids creating a “gaping hole” where pellets can bunch together and fail to absorb properly. By maximizing the surface area of the pellets in contact with the rich network of capillaries in the fatty tissue, this technique promotes steady, consistent absorption of the hormone into the bloodstream over several months.

The Critical Role of Post-Procedure Care

The procedure is not complete once the pellets are in place. The final steps—closing the incision and providing clear aftercare instructions—are vital.

My method involves a multi-layered bandaging technique. First, I close the incision with Steri-Strips to pull the skin edges together. Then, I apply a sterile gauze pad secured with a “T” shaped application of medical tape for protection. Finally, a larger, waterproof bandage shields the area from the external environment.

Essential patient instructions for optimal recovery include:

• Keep the Area Dry: The Thareaner bandage must remain in place for five to seven days. No baths, swimming, or hot tubs.
• Avoid Strenuous Activity: For the first few days, avoid intense workouts or activities that strain the gluteal area to prevent infection and disruption of the pellets.
• Monitor for Infection: Watch for signs such as increasing redness, swelling, warmth, or pain, and contact my office immediately if any occur.

Integrating Chiropractic Care for Foundational Stability

As a Doctor of Chiropractic and an Advanced Practice Registered Nurse, I see the body as a deeply interconnected whole. Hormonal health is intrinsically linked to our neuro-musculoskeletal system. The nervous system is the body’s master control system, regulating everything, including hormone production. The spine houses the spinal cord, the primary conduit for this communication. Vertebral subluxations, or misalignments of the vertebrae, can create nerve interference that disrupts the delicate signaling between the brain and the endocrine glands.

In my clinical observations, patients with hormonal imbalances often exhibit significant spinal misalignments. By performing specific, gentle chiropractic adjustments, we can correct these subluxations and restore proper nerve flow, optimizing the function of the entire endocrine system. An adjustment can improve blood flow to the pelvic organs and reduce stress on the adrenal glands by calming the sympathetic nervous system. This integrative model addresses both the biochemical need for hormones (through BHRT) and the biomechanical and neurological integrity of the body (through chiropractic care), leading to more profound and lasting results.

References

• Hohl, A., de Souza, M. V., & Ronsoni, M. F. (2017). Menopausal hormone therapy and cardiovascular risk. Arquivos Brasileiros de Cardiologia, 109(2), 162–168.
• Holtorf, K. (2009). The bioidentical hormone debate: Are bioidentical hormones (estradiol, estriol, and progesterone) safer or more efficacious than commonly used synthetic versions in hormone replacement therapy? Postgraduate Medicine, 121(1), 73–85.
• Lunenfeld, B., Mskhalaya, G., Zitzmann, M., Arver, S., Kalinchenko, S., Tishova, Y., & Morgentaler, A. (2015). Recommendations on the diagnosis, treatment, and monitoring of functional hypogonadism in men. The Aging Male, 18(1), 5–15.
• Ruiz-Núñez, B., Pruimboom, L., Dijck-Brouwer, D. A. J., & Muskiet, F. A. J. (2013). Lifestyle and nutritional imbalances associated with Western diseases: causes and consequences of chronic systemic low-grade inflammation in an evolutionary context. The Journal of Nutritional Biochemistry, 24(7), 1183–1201.
• Seaman, D. R. (2013). The diet-induced proinflammatory state: a cause of chronic pain and other degenerative diseases? Journal of Chiropractic Medicine, 12(3), 238-243.
• Snyder, P. J., Bhasin, S., Cunningham, G. R., Matsumoto, A. M., Stephens-Shields, A. J., Cauley, J. A., … & Ellenberg, S. S. (2016). Effects of testosterone treatment in older men. New England Journal of Medicine, 374(7), 611-624.
• Taylor, H. S. (2020). The Menopause Transition and the End of an Era. The New England Journal of Medicine, 382(12), 1168–1170.

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