Fatigue While on Testosterone Pellets

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Initially when both men and women come to me for midlife symptoms, fatigue is the second most common complaint.

Frequently I hear my patients complain that they are “tired” even though they have been on testosterone pellets (some with estradiol) for over a year and their testosterone and estradiol levels are excellent.  When I first started practice this complaint brought me worry that maybe something had changed in the compounding of the testosterone pellets or that the lab values were incorrect, but over time I have disproven those assumptions repeatedly.  What I discovered as the real causes of these complaints is interesting, and does not result in one simple answer.

Initially when both men and women come to me for midlife symptoms, fatigue is the second most common complaint. On the initial evaluation when my patients discuss this symptom, I find multiple causes.

Top 10 Causes Of Fatigue Before Pellets


  • Low testosterone levels
  • Hypothyroidism (low thyroid)
  • Elevated Cortisol
  • Anemia
  • Over scheduled with work and play, or caretaking
  • Hypoglycemia (low blood sugar) from too much sugar and carbohydrate in the diet, or not eating for long periods of time.
  • Lack of exercise
  • Difficult relationships with loved ones (husband, wife, children)
  • Multiple medications eg high blood pressure meds, and psychiatric drugs
  • Autoimmune diseases


All of these diseases, conditions, situations, and emotional turmoil can cause a feeling of fatigue and malaise.  In medicine, the causes of fatigue is an even longer list than the  top 10 causes I have listed above.  For this purpose I am providing experience from my own practice to help you get a handle on what we see initially so you can relate to the causes of fatigue even after we have normalized testosterone levels.

At our first BioBalance visit, I discuss all of the possible causes of each symptom with my new patient. First I review the sex hormones that are usually at very low levels and we replace them with subcutaneous pellets (to limit the side effects and prevent inadequate dosage since the pellets are administered by my office once every 4-6 months). Then I address abnormal levels of other hormones that often result in fatigue, and I replace or suppress those hormones at the same visit.  Next we discuss lifestyle and I provide an optimal program (when necessary) for my patient including a low carb diet, water requirements, ridding the body of junk food and sugared sodas, and increasing exercise in accordance with the ability of my patient in question.

Next I review the work, caretaking and travel stresses of my patients either suggesting a counselor to counsel my patient in a parallel fashion with my hormone therapy, or I suggest a few changes to decrease stress and improve relationships.  Next we review medications and supplements to supplement the diet and my plan to decrease dosages on some medications in conjunction with their primary care doctor.

Lastly we discuss the improvements that they can expect, and in general by the end of the 8th month (2 insertions in women and 1.5 in men) my patients are completely better.  Their lives are more manageable, they have used their energy well and are not fatigued anymore, and their sex lives and relationships are much improved. That sounds like and feels like success, but then a small percentage of my patients come in and say, “I felt great for the first __ years or ___months, but now I am tired again.  I don’t think the pellets are working!”. Now we hit the second round of diagnosis and treatment.

Most of the time the testosterone levels are excellent and all the other hormones are in balance, but then what is causing fatigue?  The list below delineates the causes and then we will discuss the treatment.

Causes of Fatigue After T Pellet Treatment


  • New hormone imbalance
  • New illness
  • Noncompliance with diet
  • Noncompliance with exercise
  • Re-upping responsibilities, and increasing the load even more
  • New stresses: eg. the death of a parent
  • Adding new weight lifting supplements that interfere with health (you know who you are!)


Most of the time the body re-equilibrates as we replace our sex hormones, and then we increase stress, and try to take on too much because the pellets make us feel so good! The final outcome is that we out match what we are provided in terms of pellet energy, with more work, more charity obligations, more responsibilities and we again are TIRED!  In this case it is not the pellets that are the problem but the person who has the pellets, drifting back into life-long co-dependent activities that cause them more stress than their bodies can accommodate. The fatigue is a wake up call to change their lifestyle, not to increase the dose of pellets.

The next most common cause of fatigue is the patient-factor again. Patients feel better, lose weight, and comply with diet and exercise plans for only a short time and then they go back to unhealthy lifestyles that counter the benefit the pellets have provided and they are TIRED.  Not as tired as they were before pellets, but they became accustomed to the energy of the pellets and when it goes down they can’t remember how bad it was before and they blame the pellets instead of themselves!  That is such a common issue that now I know the problem by the first words from my patients mouths in my interview!

Next, patients, usually men, feel good again and after a short time they want to feel even better….these patients have a somewhat addictive personality where good is never good enough.  They start adding supplements, following fad diets, listening to guys at the gym and come into the office angry and red in face with their blood work looking like a bomb went off inside of them!  All these men need is some common sense and moderation . It may often take a psychologist or counselor to teach them to do this.  It is my job to identify the disaster they have made of their health by mucking around with substances they don’t understand and bring them back to earth with realistic goals and send them for counseling . (….which they never go to. ) These patients have a 50-50 chance of staying healthy with pellets by doing what I recommend instead of what their pumped up trainer suggests.

The last type of patient is the one we find very infrequently and I am thankful for that!  These patients have developed another unrelated illness that is not a factor of hormone imbalance.  I find autoimmune disorders which might be better or delayed with pellets, yet still cause fatigue, or anemia from a GI bleed, severe periods in women, or colon cancer in both sexes.  I evaluate and refer these patients to the appropriate specialist or I send them to their PCP to refer them, but usually the pellets help them recover from the majority of their diseases, so they stay on them and will feel energetic again as the secondary illness is treated.

So if I have left you out of the litany of pre and post pellet causes for fatigue, I hope you send me an email with your story so Brett and I can talk about your situation in another health cast.

This Health cast was written and presented by Dr. Kathy Maupin, M.D., Bio-identical Hormone Replacement Expert and Author, with Brett Newcomb, MA., LPC., Family Counselor, Presenter and Author. www.BioBalanceHealth.com.  

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