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Fatigue While on Testosterone Pellets

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.