Troubleshooting patches: Adjusting patch dose

While the obvious answer in customizing patch dose is to have your prescription rewritten for another of the doses in the range offered by the manufacturer of the particular patch brand you are using, it can be difficult to guess which new dose might offer the improvement you are looking for. It's a good idea, when your doctor suggests altering your dose, to ask for a few samples so you can try out a new one before paying for a whole prescription's worth of them.

But what if your doctor is unreceptive to the idea that your dose isn't exactly right, or there are other considerations that make the most obvious course less of an option for you? There may be times when, in order to clarify your own thinking, you want to try a very small iteration of change, not a whole different prescription. There may be times when you're not sure of the direction you need to go, or you may feel that the next regular dose increment is too much of a change and you'd like some smaller degree of adjustment. The available dose range is not sacred; it's simply a marketing decision made both to cover the range in terms of something-for-the-majority and to match the offerings of their closest competitor. It doesn't mean that other doses might not work—and might not work better—for you.

You can change your dose by moving the patch

In the discussion of location, we looked at how repositioning your patch allows for one sort of dose adjustment: where the patch is placed may affect the amount of hormone you take up from it.

Depending upon where you're placing your patch right now, you may be able to increase or decrease your dose just by moving it. That only works if the right direction is available to you, of course, but it's a quick and easy way to tweak your dose when it does work.

You can change your dose by adding and subtracting from your patch

When you need something different than just location can provide, your next option is directly acting upon the amount of patch available to deliver the dose. If you decide, for example, that you want to double your dose, then you can slap an extra patch of the same size on and, just as simple as that, you are getting that doubled dose. This works with any type of patch.

But what if you want less than a doubling of dose or some form of decrease? That can still be done, but now you are into the trickier realm of cutting patches. There are some very important considerations that govern patch cutting, so pay close attention here.

To begin with, not all patches can be cut. All of the reservoir patches, which contain a glob of hormone gel between two membranes, cannot be cut. To cut a reservoir patch would simply allow the contents to leak out onto the skin in an unmetered way. So if you're using a reservoir patch (and this is part of the information we cover for each patch on our estrogen HRTs page), stop reading here: this isn't an option for you. Your options are either changing prescription dose or changing prescription.

If, however, you are using a matrix patch, in which the hormones are distributed through the adhesive, you do have some additional options. Again, be sure to check that your patch does fall into this category before you try this.

The important thing to understand about matrix patches is that the dose of hormone delivered is proportional to the area of the patch. That means that half of your patch will deliver roughly half of your dose, one quarter of your patch will deliver one quarter of your dose, all the way down to 1% of your patch delivering 1% of the dose. Because of that, if we cut our patch in half, we now have two smaller patches, each of which delivers roughly half of what the original patch did. And so forth.

Obviously, there are limits to where we can go with this--a 1% patch slice is going to be laughably difficult to cut accurately. And we must make our cuts accurate if we are to have any hope of reproducing our dose adequately from one patch change to the next. Depending upon the original patch's physical size, you may be able to accurately make a 1/4 or 1/8 cut, but beyond that, it's not likely that the cut will be accurate. Still, that's a finer degree of adjustment than may be available with the regularly prescribed dose range, and is probably about as fine a distinction between one dose and the next as we'll be able to feel. Remember about making hormone dose changes: the greater the degree of change, the greater the symptoms likely to be caused by the fluctuation of the transition. So a 1/4 or 1/8 or 1/6 patch change is plenty for one change cycle and about as small as is practical.

How do you do this? It's a good idea, when you first are working this out, to trace a patch on paper and use a ruler to evenly mark off whatever grid will produce the size block you'll be cutting out. Trimming off an edge makes the most sense from a functional standpoint, since it doesn't leave corners that will be more likely to peel up, but in fact a small change may mean taking out a squared chunk. Do the best you can within the limits of being as accurate as you can. From your paper template, cut out the piece you'll be working with. That becomes a stencil you can use from one patch to the next, tracing it on the patch backing, to make sure each patch is cut the same way.

Use sharp, pointed scissors to make your cuts. You may need to clean the blades afterwards with something like acetone or alcohol to remove patch "sticky" from them so they will cut sharply the next time and not contaminate other things/people with the hormones that adhesive contains. Make the cut with the backing paper still on the patch. If possible, align your cuts across the division in the backing, not parallel to it. That way, you can still grab the two halves easily to remove them.

Can you save the unused portion to use next time, as you might if you were cutting your patch in half? Yes, if you don't remove the backing from it and you fold it back into its container so it doesn't dry out. It's probably not good to save cut patches longer than until the next change, just because they will indeed be drying out, no matter how tightly you've resealed them. Take a marker and write on the package when it was cut and how much you cut it--don't rely on remembering this.

Once you have your modified patch, you apply it as normal at the usual interval for that patch brand and type. That modified dose may be a patch cut down or a part of a patch worn in addition to a whole patch--it depends upon which way you're going with your dose modification. If you're in doubt about your math or that you've done this correctly, have someone else check your figures. Don't be embarrassed—nurses routinely and by policy often ask another nurse to check their work, even if it's just drawing up a particular dose in a clearly-labeled syringe, if the medication has important and potentially negative effects. It's always, especially, when you may not be thinking as clearly as you'd like due to hormonal upheavals, fine to ask another person to check your work. This is, for example, a perfect real-world teaching opportunity for those high school math students.

One thing that women using partial patches have discovered is that the fresh cuts tend to be very sticky, and the patches may adhere to their clothing and lift once they've been cut. You can get around this by powdering over the patch edges once the patch has been firmly applied. And keep an eye on the edge--you may need to repeat the powdering if it's quite hot/sweaty or especially being abraded by your clothing.

The great big disclaimer

You may ask your doctor or pharmacist whether you can cut a patch to modify the dose and be told no.

In the case of a reservoir patch, they are completely correct: you'll destroy the patch if you do so. Don't do this.

If you are using a matrix patch, however, the reason for their answer is different. Each patch is licensed by the FDA to deliver a specific dose. When you alter the size of the patch, you alter the dose. That new dose is not licensed, so it's not "proven" to work. The manufacturer, the pharmacist and the doctor all are legally unable to assure that it will work because it's neither tested nor licensed at that dose. You are, by modifying your patch, creating an "off label" use, and they are forbidden to participate in this if they interpret their responsibilities to you literally.

You may also be told that the dose, from a modified patch, will not be accurate. This is kind of obvious: you'll be using scissors and pens, not accurately-calibrated cutting lasers, so, no, your accuracy won't be precise. You may be told that the hormones will seep out along the edges and you'll lose some that way, or that the hormones may not be distributed exactly through the adhesive, so that your cut won't accurately remove that exact percentage of them even if you are pretty close on the area.

Again, these are valid points. But the magnitude of this inaccuracy is probably not going to be functionally significant enough to be noticeable, given the other factors that render our hormone supplies constantly in flux. That cut edge will expose a tiny increment more hormone, sure--but if you powder that edge, you're decreasing that exposure again. When you look at the total hormone-releasing surface, what increment increase in area is that fresh edge? Not much, right?

As for the failure of the hormone to be evenly dispersed, again, that's literally true but we're not sure how important that is in practical terms. We haven't witnessed the manufacturing process for patches, but we strongly suspect that each patch isn't individually crafted but rather cut from larger stock to specific size. In order, then, to have dose accuracy from one patch to the next, mixing must be adequate on that scale to distribute it fairly evenly. Women who have cut their patches have not reported wide dose fluctuations apparent from one patch to the next. This, then, does not appear to have functional significance for women who report their experiences with this process.

Remember, then, that the answers you get to this question are based on legality and strict uniformity of provided dose. But our practical experience of HRT is more variable: we will take a little bit more up when we're warm than when we're cold; we'll take a little bit more up when we exercise than when we're asleep; our hormone levels once in our system will be affected by diet and stress and metabolic cofactor availabilities and a whole host of other things that do vary from moment to moment and day to day.

The added increment of potential variation from careful cutting and and use of partial matrix patches is not likely to be of functional significance to many women. It may be to you—just as any other element of HRT use may make a difference to any one woman. But there is nothing inherent to the process of cutting a patch that would rule out adequate dose stability in functional terms. Many women have successfully tried out dose alterations through this method and some women have continued to use doses modified in this way for long term HRT because the commercially-available dose sizes do not meet their exact needs.

You probably shouldn't try to change your dose by these other methods

We're everlastingly impressed by the endless creativity women have shown in trying to modify their patch delivery characteristics. Unfortunately, some of these techniques don't work, and so to save you time and turmoil, we'll look at them right now.

One obvious one is to alter the patch change frequency. It kind of seems as though putting a patch on more often should increase exposure, and hence dose, while changing it less frequently might decrease dose. Nice idea, but it doesn't work that way.

It's your body that draws the hormones out from the patch (more on this if you're not clear on why that is the case), and the patch is designed to meter the rate of that process. We can and do speed that up a bit when our deficit is extreme, but there are limits to how fast it can go. Changing the patch more often more often does not equate to delivering more estrogen; all it does is waste patches by discarding them when they still contain part of the dose.

So too does changing them less frequently not slow down the dispensation of the hormones. The hormones will travel into the body at the same rate as ever and the patch will be exhausted at the usual time. The extra time that patch subsequently spends on skin will be as an empty patch, not a functional delivering patch. This means that leaving a patch on past its depletion will cause huge fluctuations in hormone levels from, first, normal dispensation and then, no hormones at all. Since a woman using a patch is not likely to have many hormones stored, she relies on that continuous trickle and can't manage to keep herself supplied when the patch isn't providing more. Unless you're really really fond of roller coasters, this is just not likely to be an effective strategy.

Another good-idea-but-no-cigar attempt is trying to leave some of the backing paper on the patch, with the idea of preventing that part from dispensing. Unfortunately, this seems to interfere with adhesion, resulting in premature patch loss or interrupted delivery. Even, yes, leaving the backing piece in the middle. It just doesn't work out in real life. Go ahead and try it if you don't believe us, but it's not likely to make you happy.

So those are your options for altering the dose you'll get from patches. The fact that it may or may not be possible doesn't say anything about whether altering the dose is the right thing for you to do—that's still something you must work out for yourself.