The Hormone Pellet Insertion Procedure: A Provider Overview

Written by Empire Medical Training Editorial Team

Medically reviewed by Betsy Greenleaf, DO Board-Certified OB/GYN & Urogynecologist; Empire Director of Anti-Aging

Updated June 2026 ·12 min read

Hormone pellet insertion is the delivery step that makes hormone pellet therapy distinctive. The pellets themselves are small, compounded compounds placed under the skin for a slow, steady release of hormone over several months. But getting them there safely is a procedural skill: a minor surgical insertion performed in the office, under local anesthesia, using a sterile trocar. This guide is a provider-facing overview of how that procedure works conceptually. It situates the technique within bioidentical hormone replacement therapy and is written as clinical education, not as a step-by-step protocol or a substitute for hands-on training.

One point should be stated plainly up front, because it shapes everything below: this is a surgical procedure and it carries risk. The descriptions here are deliberately conceptual. Specific pellet sizing, the number of pellets per track, insertion depth, dosing, and the exact stepwise mechanics are taught and practiced in Empire's hands-on course, where a clinician can do them under supervision rather than read about them in the abstract.

A brief, in-office minor procedure

Pellet insertion does not require an operating room, general anesthesia, or sutures. It is a minor surgical procedure done in the treatment room under local anesthesia, and the insertion portion itself takes only a few minutes once the patient is positioned and the field is set up. That brevity is part of the appeal of pellet therapy: relative to therapies that require daily or weekly dosing, a single short visit every few months delivers a steady, high-bioavailability release that bypasses the liver and the variability of gut absorption.

Convenience, however, is not the same as casualness. Because the pellets sit deep in the subcutaneous tissue and the body is being entered with a trocar, the same disciplines that govern any minor surgical procedure apply: informed consent, aseptic technique, thoughtful anatomy, and clear aftercare. The sections that follow walk through each in turn.

Patient preparation: consent, site selection, and asepsis

Good outcomes begin before the trocar is ever opened. A candidate for pellets should already have been worked up as a hormone patient — detailed history and physical, appropriate laboratory evaluation, and up-to-date age-appropriate screenings such as mammograms, Pap tests, prostate evaluation, and colonoscopy as indicated. Contraindications and bleeding risk are screened specifically for the procedure. Patients are asked about anticoagulants and the many supplements and dietary agents that thin the blood — NSAIDs, aspirin, vitamin E, fish and flax oil, garlic, ginkgo, ginger, turmeric, and others — and these are typically stopped well in advance, in coordination with any prescribing physician. A patient on anticoagulation for a condition such as atrial fibrillation may simply not be a good pellet candidate.

Once eligibility is settled, informed consent is obtained and documented, covering the nature of the minor surgery and its risks. The patient is then positioned comfortably — prone or in a lateral recumbent position — and the instruments are set up. The provider selects and marks the insertion site, then cleans the skin aseptically and establishes a sterile field before any incision is made. Asepsis is not a formality here; the most preventable serious complication of this procedure is infection, and it is prevented at this step.

The trocar technique

The standard site is the upper outer gluteal region — the lateral buttock and hip area on the patient's back side. There is a clinical reason for this. The back side has the fewest critical structures that a trocar can injure, whereas placement on the abdomen risks the abdominal cavity or a hernia, and the thigh and arm carry the risk of striking named vasculature or nerves. Within the gluteal region the pellets are placed lateral to the sacrum, never directly over it, because the midline carries a higher risk of contacting nerves. The site is also chosen to sit where a waistband or the act of sitting will not irritate it. Body habitus matters too: a very lean patient may simply not have enough subcutaneous fat to place safely.

With the site numbed and a small stab incision made, the sterile trocar is introduced. The conceptual move that defines the technique is the change in angle: the trocar enters through the skin at roughly a forty-five-degree angle, and then, once it has passed through the dermis and into the subcutaneous fatty layer, it is laid down and advanced horizontally, tunneling a track beneath the skin in the intended direction. A correctly placed trocar should glide easily. Resistance means stop and reassess — the trocar is never forced, both to avoid buttonholing the skin and to avoid straying out of the safe subcutaneous plane. The pellets are then deposited deep within the track using the blunt obturator, the trocar is withdrawn, and additional tracks are created as needed.

That is the technique in concept. The details that turn it into a reproducibly safe procedure — trocar selection and sizing, how many pellets a single track will tolerate before the body extrudes them, the depth that keeps them seated, and the choreography of swapping sharp and blunt obturators — are exactly the things that are difficult to internalize from text and straightforward to learn with your hands on a trocar. They are covered in Empire's training.

Aftercare and site care

Aftercare is simple but it matters, and it should be given to the patient in writing. The general shape of post-procedure instructions, which a practitioner adapts to their own practice, is the following:

• Wound care: remove the outer bandage after about a day; the steri-strip closing the incision comes off in roughly three to seven days.
• Water exposure: showering is usually fine within a day, but soaking or submersing the site — baths, pools, hot tubs — is avoided for several days while the entry point seals.
• Activity restriction: no heavy lifting or vigorous exercise for the first few days, which lowers the risk of bleeding and of working a pellet loose before the tissue settles.
• Comfort: ice over the first day, heat thereafter for any bruising; an over-the-counter anti-inflammatory is appropriate, and an antihistamine helps adhesive itching. Narcotics are not typically needed.

Patients should be told what is normal so they do not panic: the site may be tender for a couple of weeks, some redness can linger, mild swelling from the anesthetic solution is expected, and a little clear, pink, or mildly bloody oozing from the incision is ordinary. Setting these expectations before the patient leaves is part of the procedure, not an afterthought.

Complications and signs to watch

As a minor surgical procedure, pellet insertion has a defined set of complications — most of them uncommon, and most of them preventable with technique and screening.

Bruising and bleeding

Bruising is the most common, and it is largely a function of bleeding risk: the careful pre-procedure review of anticoagulants and blood-thinning supplements is the main defense. A bruise follows a predictable color timeline over roughly two weeks; arnica or vitamin K cream and supplements that support tissue healing can help. Minor bleeding at the incision usually responds to steady, firm pressure for several minutes without peeking, since it most often comes from the skin edges. A counseling point worth giving every patient: epinephrine in the local anesthetic can suppress bleeding during the procedure and let it surface later once it wears off.

Extrusion

Extrusion — a pellet working its way back out through the incision — occurs in a small minority of cases and is largely technique-dependent. Placing pellets deep, and not crowding too many into a single track, is how it is avoided; pellets set too shallow or too close to the incision are the ones that get spun out by the body.

Infection and scarring

Infection is the complication that asepsis exists to prevent, and patients are counseled on its warning signs. Scarring or keloid is a risk of any incision, so a patient's scar history is assessed beforehand; those prone to keloids can be planned for in advance.

How often pellets are re-inserted

Pellets are not permanent; they dissolve and must be re-inserted on a recurring basis. The conventional rhythm is every few months, but the clinically interesting point is that the calendar should not drive the decision by itself. Because pellets produce a true steady state, and because the body keeps receptors sensitive partly through the natural fluctuation of hormone levels, leaving a patient at an unvarying level indefinitely can blunt the response over time — a hormonal insensitivity seen most often with testosterone, where a patient reports that the pellets "worked for a while and then stopped."

The practical countermeasure is to space re-insertions thoughtfully rather than reflexively — stretching the interval where a patient tolerates it, and sometimes bridging the gap with an adjustable daily preparation, such as a transdermal, to preserve receptor sensitivity. Re-insertion timing is therefore a clinical judgment anchored in labs and symptoms, not a fixed numeric schedule, and the specifics of that judgment are part of the dosing protocols taught in training.

Why hands-on training matters

Everything above can be read and understood. None of it can be performed well from reading alone. Pellet insertion is a procedural skill, and procedural skills are learned the way every other minor surgery is learned — with an instrument in your hand, a sterile field in front of you, and an experienced clinician watching. The judgment calls that decide outcomes are tactile and situational: the feel of a trocar gliding in the correct plane versus catching on resistance, the angle change from entry to tunneling, how deep is deep enough, when the field is genuinely sterile, and how to recognize and manage a complication in the moment.

This is precisely why Empire teaches the procedure live. A provider who has placed pellets under supervision, on the day they first do it solo, is operating from muscle memory rather than from a remembered paragraph — and the patient on the table is the beneficiary of that difference.

Training and certification

Empire Medical Training's hormone pellet therapy course is built around this hands-on reality. Developed by Dr. Betsy Greenleaf, DO — board-certified in obstetrics & gynecology and urogynecology, and Empire's Director of Anti-Aging — it pairs the underlying hormone science with supervised procedural practice: trocar technique, sterile field setup, site selection, complication management, and the dosing protocols that govern how much, how deep, and how often. For clinicians integrating this into a broader practice, it connects naturally to the wider BHRT picture and to related topics such as testosterone replacement therapy, where pellets are one of several delivery options a provider learns to weigh.