Can testosterone pellets cause tremors in a patient who recently had them implanted?

Can Testosterone Pellets Cause Tremors?

Testosterone pellets are not a recognized cause of tremor, and tremor is not listed among the documented adverse effects of testosterone replacement therapy in any formulation, including pellets.

Evidence Review

Known Side Effects of Testosterone Pellets

The documented adverse effects of testosterone pellets (Testopel®) and other testosterone formulations include 1, 2:

• Local complications: Pain, soreness, bruising, erythema, swelling, nodules, furuncles, or pellet extrusion at the implantation site 1
• Hematologic effects: Erythrocytosis (elevated hematocrit), which occurs in approximately 2.8-43.8% of patients depending on formulation 3
• Fluid retention: Uncommon and generally mild, but requires caution in men with congestive heart failure or renal insufficiency 1
• Dermatologic effects: Acne, oily skin, increased body hair 1
• Endocrine effects: Breast tenderness, gynecomastia, testicular atrophy, suppression of spermatogenesis 1, 3
• Sleep disorders: Exacerbation or development of sleep apnea 1

Drug-Induced Tremor: Established Causes

A comprehensive 2022 review of drug-induced tremor identifies the most common offending medications 4:

• Antiarrhythmics: Amiodarone
• Psychiatric medications: SSRIs/SNRIs, amitriptyline, lithium
• Anticonvulsants: Valproate
• Bronchodilators: β-adrenoceptor agonists
• Antipsychotics: Dopamine receptor antagonists, VMAT2 inhibitors
• Substances of abuse: Ethanol, cocaine

Testosterone is not mentioned among the drugs associated with tremor 4.

Clinical Interpretation

If Your Patient Has Tremor After Pellet Implantation

Investigate alternative causes rather than attributing the tremor to testosterone:

1. Review all medications for known tremor-inducing agents (SSRIs, lithium, valproate, β-agonists, antipsychotics) 4
2. Assess for essential tremor, which is the most common movement disorder and may have coincidentally manifested around the time of pellet insertion 4
3. Evaluate for Parkinson's disease if the tremor is unilateral, resting, and accompanied by bradykinesia or rigidity 4
4. Consider metabolic causes: Hyperthyroidism, hypoglycemia, or electrolyte disturbances 4
5. Screen for alcohol use or withdrawal, as ethanol is a common cause of tremor 4
6. Assess for anxiety or functional (psychogenic) tremor, particularly if the tremor is sudden-onset, distractible, or entrainable 4

Pharmacokinetic Profile of Testosterone Pellets

Testosterone pellets provide stable, physiologic testosterone levels over 4-6 months with predictable zero-order absorption kinetics 5, 2. Peak levels occur at 1 month, then gradually decline 5. This steady-state delivery makes acute neurologic side effects like tremor even less plausible compared to injectable formulations that produce marked peaks and troughs 1, 3.

Common Pitfalls to Avoid

• Do not discontinue testosterone pellets based solely on temporal association with tremor onset without investigating other causes 4
• Do not assume causation from correlation—the patient may have developed essential tremor, medication-induced tremor, or another neurologic condition coincidentally 4
• Do not overlook polypharmacy, which is a major risk factor for drug-induced tremor, particularly in older men 4

Bottom Line

Tremor is not a recognized adverse effect of testosterone replacement therapy in any formulation 1, 3, 4, 2. If your patient developed tremor after pellet implantation, conduct a systematic evaluation for alternative etiologies including medication review, essential tremor, Parkinson's disease, metabolic disorders, and substance use 4. The temporal relationship is likely coincidental rather than causal.