FAQ Episode 59: Migraines and "pellet" HRT therapy

Frequently Asked Questions about Natural Migraine Relief

I have watched the evolution of placing hormone implants or pellets under the skin as a form of contraceptive or menopausal therapy for over 30 years. I have seen some patients do very well with it, and other cases were, well… full on disasters. If you don’t have migraine headaches, but the pellet dosages are not right sized, you could have weight gain, anxiety, fluid retention, the dreaded “PMS that never ends” and guess what else? Headaches. If you already have migraines, you could have a four to five month spell of “migraines on steroids,” which they literally are, and not the anti-inflammatory version, either.

This post is a cautionery tale for those with migraines, particularly in the years leading into or including menopause.

Pellet insertion has been promoted to physicians as a well reimbursed procedure that can solve menopausal issues. It is promoted to patients as an “insert it and forget it” therapy providing four to five months of symptom relief. I’m not writing to dissuade those who have had a satisfactory pellet experience, but I would like to help to ensure sure that any woman considering this therapy has a more comprehensive disclosure on the potential downsides. This is particularly true for any woman with migraine headaches. If you are younger than mid-30’s, its less likely that you will need or be offered this therapy until later in life, as it is aimed primarily at peri-menopausal (and beyond) hormone deficits.

Peri-menopause: trading off symptoms

As your ovaries prepare for retirement, they produce less hormones over time until the uterus no longer hears their signaling efforts, and menses fade in intensity and frequency. At times the imbalance between estrogens and progesterone that served as a long time promoter of cyclic migraines clears and for some, headache frequency and intensity can also decline during this time frame. On the other hand, gradually reducing hormone levels can result in many other aggravating symptoms, like:

• heat exchange problems: i.e. hot flashes and night sweats, with related sleep disturbance being one of the major challenges of menopause. Loss of sleep means that the repair and charging of your brain’s neurochemical ‘batteries’ for physical, mental and emotional energy are incomplete. This means that the physical stamina, mental clarity and the emotional energy needed to manage other folk’s drama are not what you need them to be as you go through your day.

• changes in mood – such as low grade depression, anxiety or irritability.

• changes in skin to dry, or even at times ‘adult acne.’

• joint aches and pains, slow recovery from workout, reduced response to exercise effort.

• urinary frequency, urgency, incontinence or urinary tract infections.

• loss of libido with a loss of vaginal lubrication and discomfort with intercourse.

• headaches, including migraines getting either better or worse.

I’ve also found that the migraine response to this time frame can vary significantly-for better or worse, making it difficult to predict:

• how well, and how long your menopausal transition will go.

• how your migraines will respond to this transition process.

• what hormone support, if any, is right for this time of your life.

There are no two women, and no two menopausal transitions that will play out the same. And all of these menopausal symptoms can begin to occur years before your last period. If you’ve been told that “because you’re still having periods you’re just fine” we both know that ain’t necessarily so. I’ve found in life that if you don’t have the tools to manage a problem, you may also just learn to not see the problem. I know I’ve been there. It’s more a human, than a doctor problem. So be aware that you may not get the advice I’m about to offer you at your average migraine or hormone support consult visit.

Problems with Pellet Therapy 101

There are several potential problems with pellet placement for hormone balance. I’ll briefly recount them, with emphasis on how they can affect those with migraine headaches. Then we can talk about alternative therapy options.

1. Estrogen content: Pellets provide estradiol as the only estrogen source. Estradiol is the most potent of the estrogens…for both good and bad. Normally an ovary produces mostly estriol, a weaker but more breast protective form of estrogen. If you are prone to estrogen dominance, which is one of the most common hormonal drivers of migraine, then an estradiol only dominant therapy like a pellet can be a set up for migraine misery. I’ve seen it happen MANY times.

2. Right sizing therapy: When you have the insertion, you will have several small pellets of estradiol and/or testosterone placed under the skin. How do we know how many pellets to use? Honest answer: “We don’t, its an educated and calculated guess.” What if its either too much or two little? Well, we will change it next time…in three to five months. Too little estrogen = lack of symtom relief. Too much estrogen: weight gain, fluid retention, headaches. Too much testosterone (and I see this all the time): hair loss, acne, irritability and anger. Getting one’s “right dose” is a challenge no matter how its delivered, but in my opinion pellets have the least flexibility and the largest margin for symptomatic problems when we guess wrong.

3. Progesterone support: This is where the “place and forget” marketing about pellets falls apart. Progesterone has to be taken daily. Many doctors believe that if you don’t have a uterus, you can forget about progesterone. This is a huge mistake. This misconception is partly derived from decades of synthetic progestins masquerading as a progesterone substitute. It is not. Progestins were a large part of the brouha back in the early 2000s when studies showed that traditional therapy, like Prempro, Provera, etc. were not as safe as advertised. Doctors got the message of “don’t do that,” and not knowing that progestins ARE NOT progesterone, followed with “if you don’t have to use progestins…then don’t.” So if you don’t have a uterus, the thought was “don’t use progesterone.” What is forgotten is that progesterone plays an essential balancing role to estrogens throughout the body-whether you have a uterus or not. And an all estradiol and no progesterone therapy plan is the enemy of migraine relief on so many levels. To summarize:

   -if you have migraines you almost certainly need progestational therapy, especially if you are on estrogens, and specifically if you are given an all estradiol support formula.

   -progesterone cannot be put in a pellet. Most often it is supplemented with a gelcap to be taken daily. So much for the pellet’s “place and forget about it” promise. You’ll still have something to do everyday. Gelcap delivery is an okay way to take progesterone, but it has two main limits: 1) there are two pharmaceutical dosing options: 100 mg or 200 mg. What if you’re best dose is 150 mg? Oh, well. 2) gelcaps have a sharp absorption peak and valley delivery curve over 24 hours, which has its own pro’s and con’s.

4. Testosterone dosing: Peaks and valleys…or is it mostly peaks? The reasonable range of testosterone for women is only about 10-15% of that for males. A very common story I see is for someone to be running testosterone levels two to three times normal for women, even four to six months after the pellet placement. Unless you are anticipating a gender transition, the facial hair and receding hairline are not usually welcome. It can take months for these to return to your previous baseline. Fortunately this rarely impacts headaches.

5. When a pellet is placed, you are locked in for the ride: I do not know of a pellet removal procedure, although I suppose it could be done. It can take months for the imbalances to clear. Sometimes we can devise a supplemental topical therapy to to fill in or alleviate imbalances if you’re on the low side of support, but its a jury-rigged solution, at best.

6. Blood level consistancies: Most pellets are placed in the upper buttock area. The pellet is supposed to dissolve gradually over several months. I have seen this vary dramatically depending on the person’s physical activities. Let me give you two examples of patients I’ve seen who had much higher levels of both estrogen and testosterone than had been anticipated. One was a postal worker whose route included walking five to six miles per day. In the process she got in and out of her delivery vehicle scores of times a day. The other was a runner, whose training for a half marathon coincided with her pellet placement. Both cases resulted in a dramatically augmented rate of absorption. On the other hand, this is probably not an issue if you are a full time CPA.

So what to do for hormone support therapy?

My preference for peri-menopausal and beyond hormone support is delivery by way of a topically absorbed cream. Its not a perfect system. There will be variations from person to person on how well a topical is absorbed and distributed. I can have 10 women the same age, height and weight, use the exact same dosage and get 10 slightly different results, as each of them will vary in body composition, liver metabolite management, etc. If for any reason we feel that you are getting too much or too little hormone support for your situation, we can change what we are doing tomorrow (not in three to four months.) More likely, small changes will be made with the next upcoming refill. Typically we can also put all the desired ingredients in one single topical, for one prescription per month, applied one time per day.

The best hormone support system should be simple, easy, comprehensive, and as readily individualized as possible or desired. I don’t believe that pellet delivery of female hormones fits that description, and I would counsel that women with migraine headaches consider avoiding pellet based HRT in managing midlife hormone challenges.

If you would like a more detailed discussion of hormone balance for women with migraines, consider an inexpensive month by month paid membership to review the following lessons from the Natural Migraine Relief for Women course:

Lesson 11 Reproductive Hormones as a root cause for Migraines: Part I Introduction.

Lesson 12: Hormone Root Causes in Migraine Part II: Reproductive Hormones in Pre-menopause.

Lesson 13: Hormone Root Causes-Part III: Reproductive Hormones in Peri-menopause.

Lesson 14: Reproductive Hormones as a root cause for Migraines: Part IV Post-menopause.

Coming up next: FAQ Episode 60: Migraines and detoxification of heavy metals. We will discuss how toxins like heavy metals can contribute to migraine headache expression, with a simple yet specific strategy for whole body clean up.