Switching to transdermal patches

[Tills]

Nottingham's own NHS Area Prescribing Committee appears to suggest one can tritrate Evorel up to 400 mcg:

https://www.nottsapc.nhs.uk/media/qaafcl52/feminising-hormones-information-sheet.pdf 🔗

Leeds and Yorks NHS Area Prescribing Committee suggest up to 200 mcg twice weekly but exceptionally up to 300 mcg

https://www.leedsandyorkpft.nhs.uk/our-services/wp-content/uploads/sites/2/2023/03/Information-about-hormone-regimens.pdf 🔗

Any, non-AI, thoughts or opinions anyone?

xx

[Charlotte Kitty ✅]

Ive always thought both patches and gel are too weak for MTF applications,  which is why i avoided them as impractical. I think the spray will depend on the effective mg dose. I'd expect to need 4-6mg per day to be effective considering my own experiences. These products are designed to give the approx 1-2mg doses needed for menopause.

In comparison DIY market sprays deliver 4mg on a full spray.

Sorry i don't have easy answers here.

Charlotte 😻

[Tills]

Well there's nothing wrong with gels for achieving levels. On 2.25 mg Sandrena, divided into 1.25 mg morning and 1mg afternoon my oestradiol reading was consistently in the range 400-600 pmol/L for many years.

I switched not because gel wasn't very effective but because of the faff involved.

xx

[Lori Dee ✅]

I never had a good result with patches. I never tried gels.

My Endo kept upping my dose, and I was finally wearing three patches at once, changed twice a week, and my levels were still below 100.

We changed brands and tried changing only one patch at a time every other day. It still wasn't enough.

I asked them if they were seriously considering adding more patches. I was running out of real estate to apply them to and didn't want to put them in the same spots.

I suggested (jokingly) that I could start wearing them on my forehead and arms. They got the message.

That is when I switched to injectables, and I have had no real problems since then.

[Tills]

Thanks @Lori Dee  . That's really helpful to know. You wrote that I was typing. I am seriously beginning to wonder if patches are sub-optimal for transgender care, to put it mildly. I increased my dose and it has made zilch difference to my levels. Very much like an early form of your own experience.

Gels are fine for levels, or they were for me, but a real pain in the ass for convenience.

I think I'm going to tweak my letter to Nottingham to see if Lenzetto estrogen spray is an option. But fortified by your message I think I'm also going to mention injectables.

xx

[Lori Dee ✅]

@Tills

For some people transdermal route is fine.

What is important to remember is that skin is our natural defense system that protects our inner organs from the environment. So penetrating that can be difficult for some.

In my case, my Primary physician suggested that I might be a "fast metabolizer" so my system was eliminating it before it was able to achieve the levels I needed. The patches I was using were designed to be worn for an entire week before being changed, so they did not reach peak absorption until the second or third day. That was why we had three in place at all times and only rotated, changing one at a time.

By going the injectable route, it bypasses the skin's protective layer and is absorbed directly into fatty tissue. There, it gets released into the bloodstream. This also bypasses the "first pass" through the liver, which reduces the effectiveness of oral medications.

The liver is not completely bypassed, as it still processes everything passing through the bloodstream, but at least estradiol levels are higher before that happens. My current Endo's concern is that a higher dose means more metabolites (side effects) after it is processed by the liver. We still argue about that, but for now, he has accepted my suggestion to wait and see if I have any side effects from it.

[Charlotte Kitty ✅]

Well there's nothing wrong with gels for achieving levels. On 2.25 mg Sandrena, divided into 1.25 mg morning and 1mg afternoon my oestradiol reading was consistently in the range 400-600 pmol/L for many years.

I switched not because gel wasn't very effective but because of the faff involved.

xx

Thats very good as I needed double to get correct levels which as you say is a faff to apply. This is with blockers! Its odd patches are this ineffective when you only seem to need a low intake of E.

C😻

[KathyLauren]

I have been on 150 μg/day via patches for eight years (and lower doses prior to that).  My levels fluctuate from 150 pmol/l to 600 pmol/l, generally averaging about 350-ish.  My target level is 400 pmol/l +/- 200, so anywhere between 200 and 600 is good.

There is a great variation on adhesives in different brands of patches.  One role of the adhesive is to stick, of course.  The other role is to make the skin more absorbent to the medication.  So it might be worthwhile to try different brands.  You might not be getting the nominal daily dose due to differences in your skin and/or the adhesive.  Your blood levels are indicating that your dose is low.

I normally use 2 patches at the same time.  My prescription says 1x 100 and 1x 50.  Due to past shortages, I have sometimes had to use 2x 75.  Right now, neither the 50 or the 75 is available, so I have to cut a 100 in two!

I have used only patches, from day 1.  I have had good feminization of my skin, face, body hair, and especially breasts.

[Stottie Girl]

Thanks @Lori Dee  . That's really helpful to know. You wrote that I was typing. I am seriously beginning to wonder if patches are sub-optimal for transgender care, to put it mildly. I increased my dose and it has made zilch difference to my levels. Very much like an early form of your own experience.

Gels are fine for levels, or they were for me, but a real pain in the ass for convenience.

I think I'm going to tweak my letter to Nottingham to see if Lenzetto estrogen spray is an option. But fortified by your message I think I'm also going to mention injectables.

xx

I would be interested in the outcome Tills. I was under the impression it was impossible to get injectables here in the UK, NHS or private. It is pretty universally accepted that injectables are the better option but as usual the bean counters at the head of the NHS have intervened.

[Devlyn ✅]

I would be interested in the outcome Tills. I was under the impression it was impossible to get injectables here in the UK, NHS or private. It is pretty universally accepted that injectables are the better option but as usual the bean counters at the head of the NHS have intervened.

There's a pretty universal misconception that injectables are the better option. 🙂 The molecule is the same regardless of how it is in your body.

In all cases, the best route of administration is the one that's worked out between you and your doctor to be the best treatment plan for your individual needs.

[Courtney G]

Like Lori, I seemed to metabolize the patches too quickly. My peak levels looked fine but my trough levels were quite low, even on four .100 mg patches per day. Patches were a good choice for me at this age and they got me to where I'm at now, but injections seem to have really brought my levels up. As a matter of fact, my doctor is going to reduce my dosage at the next appointment.

One thing I will say about the increase in E levels is that I seem to be seeing the start of a more female body fat pattern after a few months on injections. Of course, this might just be because I'm over four years on E and it takes a while for that to happen.

In summary, I have no issue with patches but it took injections to sustain my levels throughout my weekly cycle.

[Charlotte Kitty ✅]

There's a pretty universal misconception that injectables are the better option. 🙂 The molecule is the same regardless of how it is in your body.

In all cases, the best route of administration is the one that's worked out between you and your doctor to be the best treatment plan for your individual needs.

I hope thats the case as injections are an absolute no from me! A few people claim breast growth suddenly improves switching to injections, but entirely anecdotal. But methods bypassing the liver are interesting to me as at 44 using large oral doses is not optimal. Certainly in a few years i want to be off oral so all of these discussions are useful.

[Lori Dee ✅]

There's a pretty universal misconception that injectables are the better option. 🙂 The molecule is the same regardless of how it is in your body.

In all cases, the best route of administration is the one that's worked out between you and your doctor to be the best treatment plan for your individual needs.

This is absolutely true!

The only difference is how to get it into your body effectively and safely. The reason there are so many different methods is because everyone responds differently. It is very important to discuss the options with your medical team. Sometimes, they would point out something that I had not considered.

[Tills]

There's a pretty universal misconception that injectables are the better option. 🙂 The molecule is the same regardless of how it is in your body.

In all cases, the best route of administration is the one that's worked out between you and your doctor to be the best treatment plan for your individual needs.

Yeah I have to say that when I've tried injectables I've not enjoyed the experience very much. I had some low troughs for example: I mean days when I was noticeably reaching the end of the course.

@Stottie Girl that's surprising that injectables aren't available on the NHS. When did it all change? I used to have them on the NHS. I would have to go and find a qualified nurse to do the deed. Walk-in centres would administer them to me. I can't really understand it: aren't injectables licensed just about everywhere else in the world?

xx

[Devlyn ✅]

Like Lori, I seemed to metabolize the patches too quickly. My peak levels looked fine but my trough levels were quite low, even on four .100 mg patches per day. Patches were a good choice for me at this age and they got me to where I'm at now, but injections seem to have really brought my levels up. As a matter of fact, my doctor is going to reduce my dosage at the next appointment.

One thing I will say about the increase in E levels is that I seem to be seeing the start of a more female body fat pattern after a few months on injections. Of course, this might just be because I'm over four years on E and it takes a while for that to happen.

In summary, I have no issue with patches but it took injections to sustained my levels throughout my weekly cycle.

I don't think people fully consider that if you switched to injections, it indicates time already on HRT. Puberty is all about time and exposure to hormones.

I hope thats the case as injections are an absolute no from me! A few people claim breast growth suddenly improves switching to injections, but entirely anecdotal. But methods bypassing the liver are interesting to me as at 44 using large oral doses is not optimal. Certainly in a few years i want to be off oral so all of these discussions are useful.

Same, I get the vasovagal response, so injections are contraindicated for me.

Yeah I have to say that when I've tried injectables I've not enjoyed the experience very much. I had some low troughs for example: I mean days when I was noticeably reaching the end of the course.

@Stottie Girl that's surprising that injectables aren't available on the NHS. When did it all change? I used to have them on the NHS. I would have to go and find a qualified nurse to do the deed. Walk-in centres would administer them to me. I can't really understand it: aren't injectables licensed just about everywhere else in the world?

xx

My wife was recieving injectable T blockers through the NHS, she had to find someone to administer them, too.

[Dani]

Lately, I do not participate as much as I have several years ago, however I still do occasionally stop by just to see what you all are talking about. Pharmacy is my profession and gender affirming hormone therapy (GAHT) has saved my life which I now live in a low profile manner.

Over the years, I have seen many hormone regimens being promoted and then fall out of favor, mainly due to newer medical studies. The WPATH Standards of Care is where I go the learn the most current thoughts on what and how much we should be taking for GAHT. We are now up to SOC 8 and a few things has changed since I first started on GAHT.

Section 12 of the Standards of Care talks about hormone therapy. Table 4 talks about doses and Table 5 talks about blood levels. There is not much new here except when I was first transitioning, my Endocrinologist gave me a blood level goal of 300 pg/ml for a peak blood level. Today WPATH recommends a little less.

The big change is that for everyone transitioning who is over the age of 45, Estradiol Patches are recommended. I was a late transition and my Endocrinologist prescribed sublingual tablets, but that was then and today I am using 7 day Sandoz Estradiol patches which I cover with a 4 x 3 inch Tegaderm cover. It works for me.

What I really want to say is that what works for you or me may not work for someone else. Any discussion on GAHT really needs to be referenced to current therapy as outlined in the WPATH Standards of Care. We are all individuals and we all respond to GAHT in our own way. GAHT is serious therapy and GAHT must be monitored by medically trained professionals to get the dose correct for safety and effective results.

[Lori Dee ✅]

Yeah I have to say that when I've tried injectables I've not enjoyed the experience very much. I had some low troughs for example: I mean days when I was noticeably reaching the end of the course.

This is my experience now, but only occasionally. My Endo wants to reduce my dose, so he suggested lowering the dose and injecting twice a week. I am not comfortable with that. It's not like I enjoy stabbing myself, and my last Endo changed from once a week to once every 10 days instead of dropping the dose. My current Endo is unconcerned with the troughs (because he doesn't have to live with hot flushes and night sweats). He is more concerned with the peak being at 400. My question to him was, "How long do you think they stay that high?"

He didn't answer, so I answered for him and said three days... out of ten. So we agreed to wait and run more lab tests between now and September to see exactly what is happening and whether there is reason to be concerned. My Gynecologist and my Primary (both ciswomen) are not concerned. They know what those symptoms feel like.

I would rather be too high than too low. But I understand his concern with managing the risks. I'm approaching 70 in a year and a half, so I am listening to him. My Gynecologist was 74, and specializes in Women's and Transgender Health. The Endo, not so much. But at least he is listening.

[Courtney G]

The whole delivery method/levels struggle is exhausting. I so wish I could wear a monitor for a year, as folks do in order to monitor blood sugar levels. This all would be so much easier if I could chart my levels during each day of my injection cycle. In addition, it would be useful to know what levels are in the morning rather than later in the day, for example.

But instead, I get labs done, we make some sort of adjustment, I wait three months, get tested again, another adjustment and repeat ad nauseam. After 4 years of doing this, I'm still not quite where I should be.

[ChrissyRyan]

I do not know if I will ever switch to patches.  The tablets seem to be just fine.

Perhaps the patches are more expensive.  They may fall off or be hard to get off too.

I take half a tablet twice a day, sublingually.  It spreads out the dosage throughout the day better (there are half life's for all meds) to get it in my blood.  Not as much at one time a day but half a dose each half a day.  Same total daily dosage as one tablet a day.

I think the patches spread out the dosage over time too. Might be good if people are forgetful of taking pills.

But I wonder if you are in water a lot, take showers and baths a lot, or get sweaty, perhaps that may cause issues with the patches staying on or the medicine itself leaking away.


Chrissy

[Lori Dee ✅]

But I wonder if you are in water a lot, take showers and baths a lot, or get sweaty that may cause issues with the patches staying on or the medicine itself leaking away.

I had that problem too. As a gold prospector, I spend hours in the hot sun and in the water. The patches are supposed to be waterproof, but I had a hard time keeping them on. The generic brand Mylan was the worst, and reviews showed that I wasn't the only one having issues.

We switched to the Grove brand, and they were better. We tried covering the patches with Tegaderm. But the edges would peel up, then catch on clothing and pull the patches off. I spoke with our head Pharmacist at the VA and explained the issue. She suggested we try IV covers. They are very thin, breathable, and stay stuck. No more adhesive problems!

That was when we realized the problem was not the patches staying on; they just were not delivering enough meds the way I needed them.