Switching to transdermal patches

[Tills]

Lots of really valuable comments and advice above: this forum at its best. Just to pick out a couple to respond to:

[...]

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.

This is sooooo true!!!

When I was on gels everything was pretty settled but these patches are proving far less so, not helped by all sorts of treatment-blocking problems by my health authority.

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

[...]

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.

I have no adhesion issues with Evorel. I put it on, place the palm of my hand on it for c. 45 seconds, and there it remains until day 3 removal. I find no need for any tape or any other sticking material. In fact, the biggest pain is the line around the edge after removal which is remarkably stubborn and causes a red patch when I rub it off. @Lori Dee you mentioned a while back using oil to get it off: which oil did you use for that if I may ask?

I have wondered about the bath / shower thing. If I have a deep bath and momentarily submerge the Evorel it does turn an opaque white colour.

However, I don't really think I can blame the problem with my levels on that. I just don't think Evorel 100 is delivering me sufficient estrogen, despite changing it every 3 days (as opposed to twice a week).

I'll up to Evorel 125 pending Nottingham's comments on the situation. They may agree to switch me onto Lenzetto which sounds pretty good.

I know too that my GRS hospital won't be happy with the low state of my estradiol reading. They require it to be a lot higher.

xx

[Tills]

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😻

One thing I wonder about, and which @Lori Dee referred to a while back, is about the way patches leech into the fatty tissue.

So I hike every day: at least 10kms. Prior to that I was a pretty serious marathon runner. My legs have no observable fat on them. They're very lean. I rotate the Evorel patches from right thigh to tummy to left thigh and back. The thighs look to me like they have zero fat. Might this be an issue I wonder??

Sigh.

It's quite annoying. And it's also tempting to go back to the gels. I have 3 months supply still and as it was entirely my request to switch from gels to patches there would be no real issue about doing my own thing, providing I liaise with my clinic about doing so.

[Tills]

By the way, @Dani nice to see you back on here and thank you for your very thoughtful post. You are absolutely right in what you said.

On the other hand, it's interesting for me to note that before I switched to patches my transgender clinic asked me if I was happy now to be discharged. After 12 years and a very steady estradiol level they saw no need to continue monitoring me. They were happy for me to carry on ticking over under my GP. I have another friend who transitioned years ago and she certainly has no transgender clinic overseeing her any more.

(My response to my clinic was that I wanted to go through the GRS and into a settled state after that before considering discharge.)

xx

[Lori Dee ✅]

using oil to get it off: which oil did you use for that if I may ask?

I have wondered about the bath / shower thing. If I have a deep bath and momentarily submerge the Evorel it does turn an opaque white colour.

Any oil should work. I was using baby oil, but any oil helps. Using the cover over the patch helped too. The residue is where the adhesive at the edge of the patch collected dust and lint from clothing, so it was minimized.

The patches I used were a thin plastic film, so they were waterproof. If yours are changing color, they may not be waterproof. Also, check the instructions that come with them. Mine said to apply to lower abdomen (below the navel), or the upper buttock. My Endo had warned me not to apply them to the thigh for just the reason you state: lack of sufficient fatty tissues. I don't know if that is the problem you are having, but it could be.

On the insert that came with mine, they reference a study they did about application sites. They found the lower abdomen to be best, with the upper buttock second-best. Your package may include similar advice. I realize different countries, so difference in what disclosures are required for prescription meds. But perhaps there is similar information packaged with yours.

[Tills]

Any oil should work. I was using baby oil, but any oil helps. Using the cover over the patch helped too. The residue is where the adhesive at the edge of the patch collected dust and lint from clothing, so it was minimized.

The patches I used were a thin plastic film, so they were waterproof. If yours are changing color, they may not be waterproof. Also, check the instructions that come with them. Mine said to apply to lower abdomen (below the navel), or the upper buttock. My Endo had warned me not to apply them to the thigh for just the reason you state: lack of sufficient fatty tissues. I don't know if that is the problem you are having, but it could be.

On the insert that came with mine, they reference a study they did about application sites. They found the lower abdomen to be best, with the upper buttock second-best. Your package may include similar advice. I realize different countries, so difference in what disclosures are required for prescription meds. But perhaps there is similar information packaged with yours.

Okay that's so helpful @Lori Dee thank you

I think I'll try the buttocks instead of thighs then on my rotation. Every third one I do apply to my tummy below my navel but the other two have been on my lean, mean, thighs 😀 I'll stick 'em on my ass and see if that helps!

Re covering the patches I'm so confused. I don't need to cover them for adhesion reasons but is the idea to cover them to protect against water ingress? If so, doesn't that stop them from breathing? Don't they need air to work? If they're hermetically sealed do they still work?

[Lori Dee ✅]

The covers are porous, so they breathe. The purpose was to keep clothing from pulling at the edges and loosening the patches. The side effect was that it covered the edges, reducing the gunk that stuck to the exposed adhesive.

The IV covers, even though breathable, seem to have a waterproof adhesive that keeps them in place. This was important since the application site is very close to my waistband. Bending and twisting caused the waistband to rub on the patches. The IV covers helped smooth the edges.

I also just stayed more mindful of where I put the patches so they were high enough, but not so high that my waistband or beltline would rub on them.

On the buttocks, go high enough that you aren't sitting on them (they flex more and loosen there), but also low enough that your underwear covers them. That should work better than your thighs.

Let us know how it works out.

[KathyLauren]

Re covering the patches I'm so confused. I don't need to cover them for adhesion reasons but is the idea to cover them to protect against water ingress?

It depends a lot on the adhesive. 

Some brands (Sandoz generic, for example) use a water-soluble adhesive.  They will come off in the shower if not protected against water by covering.  You can clean up the residue with soap and water.

Other brands (Estradot, for example), use an oil-soluble adhesive.  They will stick in the shower, and don't need to be covered.  Water won't take the adhesive residue off your skin.  You need to use oil or scraping to get it off, because soapy water won't do it.

[Tills]

Any oil should work. I was using baby oil, but any oil helps.

I'm not finding the baby oil makes any difference.

These Evorel patches seriously stick!

[ChrissyRyan]

So why have you all decided to try patches over other alternatives?

[KathyLauren]

I'm not finding the baby oil makes any difference.

These Evorel patches seriously stick!

Oils vary in their ability to remove gunk.  Avon Skin-So-Soft, in addition to repelling mosquitoes, does a good job of removing adhesive.  (I can't vouch for its skin-softening ability, though.)

[KathyLauren]

So why have you all decided to try patches over other alternatives?

Recommended by my doctor.  She wanted to avoid oral administration, in order to avoid making the liver process it.  And I don't know if sub-lingual is even available here.  I have never heard of anyone local using it. 

Between patches and injectable, patches are easier to administer and give a steadier dose.

[ChrissyRyan]

Recommended by my doctor.  She wanted to avoid oral administration, in order to avoid making the liver process it.  And I don't know if sub-lingual is even available here.  I have never heard of anyone local using it. 

Between patches and injectable, patches are easier to administer and give a steadier dose.

Sublingual is just dissolving the tablet under the mouth to avoid as much as possible the liver processing it before the med goes into the bloodstream.  I think it would not work for a coated pill but mine are not coated.

[Devlyn ✅]

When I was on the Sandoz patches I could barely get them off; they were the rectangular ones. Baby oil would eventually get the glue residue off, but I had to work at it.

[Lori Dee ✅]

Paint scrapers, steam cleaners, and sandpaper should work. Ouchies!  🤣

My levels were not high enough on oral. When I hit the maximum oral dose, my doctor switched to patches. To reduce the risks of blood clots from liver processing, but also to provide a higher dose. Of course, even with three patches twice a week, it was still insufficient, so they switched me to injectables. Problems solved.

[ChrissyRyan]

Paint scrapers, steam cleaners, and sandpaper should work. Ouchies!  🤣

My levels were not high enough on oral. When I hit the maximum oral dose, my doctor switched to patches. To reduce the risks of blood clots from liver processing, but also to provide a higher dose. Of course, even with three patches twice a week, it was still insufficient, so they switched me to injectables. Problems solved.

That is somewhat surprising Lori.  Did you have a high E target level you wanted to maintain that was still a safe level, and that prompted the switch? 

We are all different though.

Chrissy

[Tills]

We may all be different but if you live in the UK once you reach 60 there really isn't any other recommended route of administration than transdermal and you'll find it increasingly difficult to attempt to do so. The new guidance is quite clear on this:

People who continue HRT intake over the age of 60 should be advised to have estradiol administered transdermally.

https://cks.nice.org.uk/topics/menopause/prescribing-information/hormone-replacement-therapy-hrt 🔗

This isn't just theory. The cis female friend with whom I reside in Surrey has had her doctor badgering her by phone to switch HRT from oral to patches.

I took sublingual estradiol for many years but that was then and this is now.

If you're of a certain age then unless you're prepared to bypass the NHS to obtain medications, and to run the risk of thromboembolism, it's one of the transdermal methods or nothing in the UK.

I flew back long haul just a week after my 9 hour FFS surgery in Thailand. I landed in London with a sharp pain in my left calf and redness. I was whisked straight from the plane to A&E for an emergency anti-DVT injection.

Thromboembolism isn't something I'd want to play Russian roulette with again. And there are one or two members of this forum who I believe have experienced it first hand.

[Lori Dee ✅]

That is somewhat surprising Lori.  Did you have a high E target level you wanted to maintain that was still a safe level, and that prompted the switch? 

No, my doctors wanted a target of 200. In four years of oral and patches, my levels only went over 100 three times. And with T-blockers, my levels were all so low I had hot flushes and night sweats almost every day... for four years!

When I was switched to injectables, my levels went up to 150, then 200, then 250 and held stady at 250. When I started moving to Colorado, I was much more active and lost a few pounds of belly fat. That released the stored estradiol, and my levels jumped to 400.

I explained this to my doctor, and she said to space my injections out to every ten days instead of once a week while I am active. She was not concerned at all.

Once I got settled in and had my labs drawn here, my levels were still at 400, but I think the test was wrong. I was at 400 three days before my next injection. Three days after my injection, my GP had labs drawn, and I was at 156. The logic doesn't hold up.

So anyway, now the new Endos are freaking out that I had a level of 400 twice.

[Tills]

I await a response from Nottingham, which may be slowed by switching GP surgery. Fortunately I have a 3 month supply of patches AND a 3 month supply of Sandrena gels, so once they give me their advice I can act on it without having to wait for a new prescription to come through.

Unless they put me onto Lenzetto spray, which I don't have in stock in my private pharmacy 😀

[Tills]

Well my Doctor in Nottingham rang me this morning. I'm very impressed: I only emailed them yesterday.

They asked me what I wanted to do and we discussed options, all transdermal I hasten to add. They said we could keep increasing the Evorel patch dose but we agreed that this might not be the most advisable course of action for a number of reasons.

We could switch me back to the Sandrena gels.

Or, drumroll, she offered to switch me to the Estrogen spray which, she said, "is brilliant". So I leapt at that.

She has already sent the new treatment plan to my equally new GP surgery:

Treatment plan
We would be most grateful if you would change treatment as below:

•   Please change to Oestrogel pump pack (0.75mg per 1.25g measure) 3 measures twice daily (4.5g daily dose)

Gel should be applied to dry and unbroken skin to the lower trunk or thighs.  It is important to alternate application sites and allow for the gel to dry before putting on clothing. It is also important to try and avoid venepuncture sites to reduce risks of contaminated blood samples

•   10 weeks after starting treatment on Gel please carry out the following blood investigations:

Oestradiol, Testosterone, LFT's, LH, FSH, SHBG and Prolactin
It is important blood investigations are carried out 4-6 hours after gel application

We are aiming for an Oestradiol level in the range of 400-600pmol/L.

•   Please forward on a copy of the blood investigations to us, preferably by email

[Lori Dee ✅]

Gel should be applied to dry and unbroken skin to the lower trunk or thighs.

I thought you were trying to avoid the gels by switching to patches. What did I miss?