Commercial skin patches are an effective and reliable mode of steroid hormone administration. They are more stable than topical creams and gels. Since they sit on the skin continuously, they emit an even flow of hormone on a steady basis. Because the patient is on the patch, rather than the hormone inside, bioidentical hormones can still be used while the manufacturer maintains a patent on their product. Hormones used only in tiny doses can be given by a skin patch. There are several bioidentical estradiol patches. Although they could be made, no manufacturer has yet received approval for a female testosterone patch. Progesterone is given in doses twenty to one hundred times that of estradiol. There will probably never be a bioidentical progesterone patch. The combination patches use oral contraceptive synthetic progestins, not real progesterone.
Advantages of skin patches: The estradiol patch gives a very steady output of hormones. Estrogen is not used up as it stimulates protein manufacture in the nucleus of target cells. Under normal circumstances, estrogens are made intermittently. Capsules, tablets and creams are used only once or twice a day. Blood levels rise after administration, and then fall. Constant exposure has a more powerful effect than intermittent exposure. Therefore, it takes only a very small amount in a patch to be effective. I first began using patches in women who were rapid metabolizers of estradiol. They would run out of hormone by the end of the day. Initially, looking at the small daily output of the patch, I used the strongest ones. I found that many patients exhibited signs of estrogen excess. I have gradually moved over to the lower dose patches. Even though the serum estradiol levels are not that high, the physiologic effect is great.
Disadvantages of skin patches: They only work if they stay on. Avid swimmers, hot tub users and women who perspire a great deal may not be able to keep them on. Some women are allergic to the glue that adheres to the skin. I initially thought a once a week patch would be more convenient than a twice a week change. I have found that many more women are irritated by the once a week Climara than the twice-weekly Vivelle Dot. The serum levels seem to be about the same. I now use Vivelle Dot almost exclusively.
Available patch options:
There are two choices of vaginal rings. The Estring is a very low dose used for vaginal atrophy. It is a good choice for the elderly and it also adds some pessary like support. If the uterus is in place, a small amount of progesterone cream may add protection from endometrial cancer, but the risk is low.
Femring is an entirely different product. It is a high dose HRT and is equivalent to the highest doses of the patch-- probably too high a dose for many women. The Femring 0.1 is probably only useful in a young woman after surgical sterilization. I have seen heavy yeast infections result from using the Femring. As with any estradiol product, full progesterone replacement will also be needed (with or without a uterus).
Advantages of vaginal rings: It is easy therapy — once placed, the patient receives 90 days of continuous therapy.
Disadvantages of vaginal rings: The Estring is not full HRT. I use it only on the elderly. If the patient does not have a drug plan, the cost is about $90.00.
Vagifem is the only product in this category. Each tablet is 0.025 mg of estradiol. If used daily, it would be equivalent to the lowest dose patches. Even taken a few times a week, there would be some risk of endometrial cancer if no progesterone or a progestin were given. There are eighteen to a pack and expensive. They do help with vaginal atrophy because the hormone is concentrated where it is needed. A vaginal cream of equivalent dosage made by a compounding pharmacist would probably be much less expensive. For the elderly, medications may not be covered by insurance.
The advantages of vaginal creams are described in the Compounding Pharmacy section. Estrace works out to one mg/ml of cream. Depending on the absorption in the individual patient, one half to one ml/day would probably give adequate HRT. Again, these are therapeutic levels and progesterone will be needed. The price of Estrace has significantly risen in the last few years. The compounded equivalent would probably be cheaper.
Pump dispensers for topical creams:
There are now several commercial gels and creams. One would have to obtain blood levels for a group of patients to see what type of levels are achieved. It should be bioidentical. This is full HRT. The issues of hormone balance still hold. Commercial topical products could be used instead of compounded products. The actual cost and relative costs (including insurance concerns) may make the decision. When considering multiple co-pays, if purchased in quantity, the compounded creams and gels might be less expensive.
There are many branded and generic estradiol tablets and usually are available in three dosages: 0.5 mg, 1 mg and 2 mg. For menopausal women, these are high doses. If necessary, tablets could be split with a pill cutter. When working with bioidentical hormones, decisions for going the oral versus non-oral route will always come into play.
Prometrium is bioidentical, micronized progesterone mixed with peanut oil. The purpose of the peanut oil formula is mostly to acquire a patent. Prometrium comes in 100 mg and 200 mg strength. For women on low dose HRT, I often use only 75 mg or 50 mg of oral compounded progesterone. Occasionally, for PCOS patients, I will go up to 150 mg of oral progesterone capsules. Many women become too sleepy on the 200 mg strength.
Advantages of Prometrium: Available in all pharmacies and is covered by most insurance companies.
Disadvantages of Prometrium: Many women feel faint or nauseated after taking it, especially the 200 mg dose. It has been speculated by some holistic physicians that the oil mixture is picked up by the lymphatics and somehow results in a fainting reaction. I find that many women tolerate Prometrium while others do not. I have not experienced any problems with the Belmar Pharmacy progesterone tablets or the capsules from other local compounding pharmacies.