Switching to transdermal patches

[Tills]

Oh wow, thanks Lori-Dee. That's all extremely helpful information.

As well as the issue about adhesion, I hadn't considered the idea that the patches wouldn't deliver sufficient dosage. I think they're available in four different strengths in the UK so it will be interesting to see what my Gender Clinic advocate.

I have a cis female friend who has no problems with Evorel patch adhesion but I guess it's going to be a case of trying them out, with regular hormone level monitoring in the early stages.

I have reached the point where the gels are pretty invasive. My morning dose is the higher of the two and applied to my thigh. This means I have got into an ingrained habit of waking early (3.30 or 4 am) to apply the dose, waiting an hour or more for it to dry, and then going back to sleep. This has been going on for more than two years and it's a bad sleep pattern. Then the afternoon dose involves hitching up a sleeve and spreading it over my arm: hardly ideal if you are out and about. And both doses require careful planning with baths or showers.

xx

[Lori Dee ✅]

I think you might be happier with the patches. The adhesion could be a factor of skin moisture and maybe even acidity. Just watch for sensitivity. If one leaves a rash, switch to the other brand. If adhesion becomes the only issue, try an IV cover to keep it in place. It can't deliver its dose if it isn't stuck in place.

😀

[Charlotte_Ringwood]

I should really move to patches as they don't really recommend oral after age 40 due to risk of blood clots. But patches are extremely expensive!

Hopefully will be ok as only on 4mg oral so it's not too high.

Does sound from this thread patches have their issues too though. There is a spray Lenzetto available on prescription now in uk giving about 1.5mg per spray. Being DIY though I can't get it 😕

Charlotte 😻

[Lori Dee ✅]

I should really move to patches as they don't really recommend oral after age 40 due to risk of blood clots. But patches are extremely expensive!

Hopefully will be ok as only on 4mg oral so it's not too high.

The biggest problem with oral tablets (not sublingual) is the first-pass through the liver. The metabolites (leftovers) can affect blood coagulation. Hence, the blood clot/stroke warnings. The other problem is that, because of being processed in the liver, the effective dose must be higher so that enough makes it into the bloodstream to be effective. Higher dose = higher risk.

Other methods bypass the liver, such as sublingual drops, sprays, gels, patches, and injectables. They all have their pros and cons, but for some, one method works better than others or is more convenient, as Tills pointed out. Although I would never recommend DIY, I do understand your situation with the availability of a provider.

[Tills]

Quick update from me.

A few weeks ago my blood results showed, after a long period of stability, an Estradiol E2 dip from 500 pnmol/L to 200 pmol/L. This was probably caused by me slightly upping my micro-dose of testosterone. My T level had gone from 'undetectable' to 0.5 nmol/L. It's a long story but I seem to need a micro-dose of T. If I don't I go into the most awful spaced-out world with brain fog and extreme light-headedness. I had tried to strip out my T micro-dose entirely but the results were horrendous. So that little daily pea-sized amount of T does the trick for me. Now my energy has returned and I'm working out loads again every day. I've got my mojo back.

At Lori Dee's suggestion a slight upward adjustment of Estrogen dose seems to have done the trick, as well as I suspect my body settling back. Bloods were re-taken yesterday:

Estradiol E2 453 pmol/L
Testosterone <0.5 nmol/L

I'm putting all this into this thread because on Monday I have my Gender Clinic appointment and I'm still going to ask them if I can switch from the estrogen gels to patches. It's about practicalities. Here I am awake at 4 am UK time typing this. That's because every morning I now wake up early like clockwork to apply the gels and then wait for it to dry which can take at least an hour. Then in the afternoon I have another application.

I don't mind routine or discipline, it's just that the gels are so disruptive, especially to my sleep patterns.

So I'm going to ask to go onto patches. I'll just need to keep an eye on levels and also site irritation and adhesion.

xx

[Tills]

I have my appointment with the Centre for Transgender Health today at 1pm.

Curious situation though. My GP surgery are happy to go ahead and change me without reference to the Trans Clinic. Their position appears to be that because I have a GRC they treat me as a woman not as a transgender woman. In fact, the protected status of the GRC seems to mean that they've deleted references to me being 'trans' from the system.

xx

[Tills]

I'm approved for the switch to patches.

I know we can't discuss doses but my GP was trying to work out the equivalent patch dose from my Sandrena gel.
 
It's looking like she's going to start me on Evorel. Anyway, for complicated reasons to do with holidays at the medical practice it may take a few weeks to get this properly prescribed.

(Apologies Alana Ashleigh for slightly hijacking this thread but it is about patches)

xx

[Lori Dee ✅]

I know we can't discuss doses

Tills,

First, congrats!

On dosage, we have relaxed the rules on that.

It is okay to discuss your dosage and describe your experiences. What we don't want to see are recommendations for dosages for others, because everyone's biochemistry is different, and we don't want to give unlicensed medical advice.

😀

[Tills]

Tills,

First, congrats!

On dosage, we have relaxed the rules on that.

It is okay to discuss your dosage and describe your experiences. What we don't want to see are recommendations for dosages for others, because everyone's biochemistry is different, and we don't want to give unlicensed medical advice.

😀

Oh wow, that's great Lori Dee. Thank you for telling me.

Well I'm currently on 2.25 mg Sandrena gel per day, split into morning and afternoon.

My GP was trying to work out what patch strength to match to that. She says Evorel 75 is the equivalent of 2mg Sandrena, whereas Evorel 100 would be 3 mg Sandrena.

I think one way around that will be to change the patch every 3 days instead of 2 per week which is one of 3 days and another of 4 days. They do that so that people keep the same days and don't forget to change them but with Apple watch Health App I can set a recurring medication reminder for every 3 days (72 hours). Taking two patches in 6 days rather than 7 days should yield a slightly higher strength over time.

As ever though it will come down to blood tests to get the right dosage with patches.

For those of you on patches, does any of this resonate or make sense?!

xx

[Lori Dee ✅]

On the blood work, one of the things they are watching for is "saturation". The patch delivers the medicine into the fatty layer below the skin, where it sits as a "depot". The system leeches out what it needs over time. That tissue can become saturated to where it will not absorb more. This is why changing the application site at each change is important, plus avoiding skin irritation. Spacing the change date by an extra day can also help.

Good luck!

[Tills]

On the blood work, one of the things they are watching for is "saturation". The patch delivers the medicine into the fatty layer below the skin, where it sits as a "depot". The system leeches out what it needs over time. That tissue can become saturated to where it will not absorb more. This is why changing the application site at each change is important, plus avoiding skin irritation. Spacing the change date by an extra day can also help.

Good luck!

That's really helpful Lori Dee: thank you. My GiC have said to take the blood tests 2 days after applying the patch which means a trough reading. But that's very interesting about saturation. I might alternate 3 or even 4 sites then (two thighs, one or two buttocks).

Someone else at the surgery has calculated the equivalent dose from my gel would be Evorel 112.5 not Evorel 75.

I don't know? I think a case of just trying and testing.

xx

[Tills]

More head scratching at my GP surgery. They are a bit flummoxed that my GiC have left the surgery to decide on my dose. This was all worked out by one of the women's health doctors there on Monday at Evorel 75 but she's then gone on holiday for 3 weeks and no one else seems to believe me when I tell them the dose she and I had agreed.

Sigh. This is very typical of the NHS these days, across almost all services. It's opaque at best, downright obstructive at worst, and patients and their carers have to keep at it and keep at it and keep at it.

I'm determined about this switch to patches because I find the gels very disruptive to normal life and they have certainly contributed to broken sleep.

To keep this on thread topic, the one thing no medical professional will countenance is a return to oral estradiol. At the age of 61 this would be considered a big no-no here.

xx

[Lori Dee ✅]

I think a case of just trying and testing.

That won't hurt. Read the literature that comes with the prescription. They have done studies and found the abdomen to be more effective than other areas. Just be aware of how you feel. It is possible that the other areas' "slowness" will compensate for the abdomen's "effectiveness" if that makes sense.

Checking the levels at the trough is the smart way to do it. You can't overdose on estrogen, so the important metric is if you are getting enough. After a month or two, you will know what is working and what is not.

[Tills]

So latest impasse

A clinical pharmacist at the surgery has said that the equivalent of Sandrena 2mg a day is Evorel 50. Having researched this I think they are wrong and are confusing Sandrena and Estrogel.

The main thing though is that three different people at the same surgery have suggested Evorel 100, Evorel 75, and Evorel 50. Little wonder, then, that this afternoon they wrote back to my Transgender Clinic asking for guidance.

The women's health GP, who seemed to speak a lot of sense, suggested Evorel 75 and I think that sounds right to me, with bloods taken in a few weeks.

As ever in this area of hormone therapy we are sometimes dealing with limited professional expertise, at least from mainstream practitioners i.e. non gender specialists.

Any thoughts and insights from any of you gratefully received.

xx

[Lori Dee ✅]

Hi Tills,

Part of the problem with equivalent conversion is that gel formulation differs from patch formulation. The gel is designed to be absorbed quickly for more frequent doses, while patches are designed for slow release over a longer period.

So it isn't a specific ratio but more of an educated guesstimate. Whatever they decide is ok, because they can always adjust (titrate) the dose upward depending on what your labs show. More importantly, your symptoms score higher in relevance than blood tests. If you have issues with hot flashes, night sweats, moodiness, then that is a sign that your body needs a higher dose, regardless of what the blood levels show.

If you are feeling good, they may try to adjust to get the levels they want to see on your labs. But how your body responds should be more important than the numbers.

Let them figure out the initial dose and see how it goes for a month.

Hugs!

[KathyLauren]

The method of administration makes a huge difference to the dosage. For example, oral doses are measured in milligrams, whereas transdermal patch doses are measured in micrograms, for the same blood level.  And individual responses are different too.  When switching methods, you will need to start with a best guess, then adjust with monitoring.

[Tills]

Thanks ladies.

I think I'm going to take the middle path. It appeals to the slight Buddhist tendencies in me

Seriously though, the only one who talked this through properly with me was the women's health specialist and she suggested Evorel 75 to start with.

My last estradiol E2 blood tests were, in the words of my clinic, 'a little on the low side' so I don't think it will do harm to up things and I sense coming from the short-fuse gels it might be better if the Evorel is slightly higher than slightly lower.

I did once spike with my estradiol level about 3 years ago for reasons which no one could quite work out. I went up to 1250 pmol/L. I had slightly tender breasts and nausea but my then brilliant GP (a different one) said it wouldn't be doing me any harm as such and we nudged down my dose.

One thing I have to report that they have all said at my surgery is not to apply it to the abdomen, but waist-down? @Lori Dee

Wow it gets confusing 🤔

Another thing which is interesting is that seemingly no one there wants to take responsibility. But if I try to do so that becomes a big no-no. Not being funny but those of you on here probably have more knowledge about these things than they do: when it comes to gender care I mean. There's a balancing act and that can add to the sense that we're flying solo. For newbies on this journey, or those with mental health issues, this can all add to the fear factor.

I'll also add that that once over a decade ago I self-prescribed and self-sourced and that was a massive no-no. I made myself very ill with the anti-androgens.

So I guess we need to go through the professionals but balance this with awareness that they may not always 'know best'?

xx

[Lori Dee ✅]

One thing I have to report that they have all said at my surgery is not to apply it to the abdomen, but waist-down? @Lori Dee

Wow it gets confusing 🤔

I can't find the article I had that explained this. The best place is the abdomen below the navel. The article was in-depth, but the explanation was concerning the lymphatic system and included a chart. The lymphatic system works like the waste collector. Because of the way the lymph flows, placing patches, gels, or whatever too high puts it closer to major lymph nodes (waste collection points). So the medicine gets absorbed, and the waste collector grabs it before it can do its work. By applying below the umbilicus, the medicine absorbs into the fatty tissue there, then gets transported through the bloodstream, so it can get to where it needs to go.

This is an extremely simplified version of it, but that is how I understood it.

You are correct that most of us here have more knowledge and experience than the healthcare professionals because we are in it every day. They may treat a transgender patient once a week or a month? One of the first things I ask a new provider is how much knowledge and experience they have, and whether they are willing to listen to someone with six years of real-life experience and a lot of research behind them. If not, like a certain VA Regional Center, I stop going to them.

The ones who are willing to listen and learn from us will be the best care providers. When something isn't working for a patient, they have our knowledge and experience to refer to. Maybe we can help the next patient. We must train them because Donald Trump will not.

[Tills]

Thanks so much @Lori Dee That's very interesting about the navel down.

With my gels my morning one has been applied to my thigh - always the same thigh because of the side of bed I'm on so I keep that leg out of the bed whilst it dries (up to 90 minutes). My afternoon dose always goes on my left upper arm because, very simply, I can't drop my skirt or trousers in public

I've not noticed any ill effects with the upper arm application. Also, curiously, the instructions on my micro dose of testosterone specifically say to apply it to the upper arm.

But this is the kind of reason why I have gone off gels. They can be very invasive and impractical over a long term. There have been three principle problems for me: 1. A bad habit of waking very early in order to apply the gels; 2. Applying a gel to your arm at 5pm if you are out and about is very intrusive and can lead to all kinds of looks and questions, plus you need to be careful not to rub it on people; 3. Gels cause problems with bathing or showering: everything has to fit around when you can and can't wash.

xx

[Courtney G]

I alternate thighs twice a week, left on Monday night, right on Friday morning.

I think there might be some confusion about the dose. My "100" patches deliver .100 mg/day. .100 is considering a "full starting dose" by my doctor, with less than that more a microdose. The maximum standard dosage for this type of therapy is .400 mg/day. That's the dose I'm on.

Over the last four years of HRT, I've come to the conclusion that my body absorbs the medication more quickly than most. I made a spreadsheet of blood test results and found that my estradiol levels are pretty high at peak and pretty low at trough. My fast metabolism seems to burn through the medication quickly. It can cause some mood swings, but that's more manageable than a blood clot!

I'll be interested to see if my use of  Tegaderm over the patches affects levels, as I haven't been tested since starting that.