Troubleshooting patches: skin irriation

Sometimes one of us will settle in on a patch, live with it long enough to be happy with the hormone delivery it provides, and then one day realize, as we are removing the old patch, that our skin doesn't look the same underneath.

It may begin with redness, but it may not be noticeable until there are little red dots, or the skin may peel up, or there may be frank blisters. Sometimes there is itching; sometimes not. What's going on? And can we ignore these signs and wait for them to go away?

A common response, but not an allergy

We hate to have to say this but yes, many of us have this issue and it's usually an indication that the particular patch isn't going to work out. That's too bad, because we know what a triumph it is to finally find an hrt that suits your body.

But the truth is that this usually represents a sensitivity reaction to either the ingredients of the adhesive or to the simple fact of having an impermeable (non-breathing) barrier on your skin for that amount of time. It's not necessarily an allergy and it doesn't at all represent an allergy to the estradiol (or the vegetable source from which it's refined). Please be clear on this. We see users passing along a lot of misinformation about this kind of problem every day, and hrts are difficult enough in themselves without borrowing complications based upon myths.

The question is what you can do about it, of course.

First of all, putting some sort of skin treatment under that patch will interfere with the transfer of hormones into your body and/or the patch's adhesion to your skin. So that's out. Don't bother.

Treating the irritated area after the patch is removed with a mild over-the-counter steroid cream may sometimes help it resolve sooner, but won't prevent it happening at the next location. And not all of us should use those steroid creams, so run this past your doctor unless you know for sure that it's okay for you.

And here's where the whole sorting-for-the-negative thing on the internet comes into it. We don't actually know the proportion of situations in which this inevitably progresses to an extent that prevents continuing with the patch. The reports that are posted suggest that the irritation continues and worsens, but it could be that there is a large body of users out there who are not bothering to mention this, who simply have mild irritation and nothing more. We don't think this is especially the case, but if you are only having a mild reaction and really want to push it further to see what happens, that's an option. You probably won't hurt yourself, other than a risk of discomfort and perhaps light scarring. Again, we don't think this is a strategy that will particularly work out in the long run, but we can't say that it won't, for sure, either.

No, really, it's probably going to mean changing brands

The remaining options, as you may have guessed by now, have to do with changing brands or hrts.

If the patch is otherwise suiting you, then it certainly makes sense to explore the other brands of estradiol patches. Each one differs in the adhesive ingredients and that is the most likely source of your skin reaction, so changing brands holds the most likely chance of dodging the skin reaction while keeping the good hrt delivery dynamic. But because these adhesive differences also mean differences in how the hormones are transported into your body, you may need to try more than one brand to find a good match.

This is where samples from the doctor's office are helpful. You should be able to get the same dose, and they are equivalent across patches, so that isn't something you'll need to worry about to begin with (although transfer differences from the different adhesives may ultimately necessitate a small dose tweak). As a general rule, we read a lot of reports detesting the old-style generic estradiol patch: it's large and thick and stiff and really doesn't seem to adhere well at all, giving it a poor delivery consistency. Otherwise, there are women who have found good success with each brand and the newer generics, so your odds are actually fairly good of finding a good substitute.

But what if they all make me break out?

All that above about adhesives assumes that the problem is a reaction to the specific ingredients rather than your skin's displeasure at being covered so long. If you're someone who has always had problems with blisters under a bandaid or can't wear non-breathing fabrics without a heat rash, you might instead simply be having a mechanical problem to do with ventilation.

If that is the problem, then no patch is likely to be suitable for you—there's no patch that allows the skin underneath to breathe. If that's the case, then it will be necessary to look at alternative hrts. Perhaps some of the other transdermals—a gel or cream or vaginal form—or maybe a transbuccal delivery will work for you in an equally satisfactory way.

The good news in this situation is that you have demonstrated that you can deliver hormones through your skin. The bad news is that you still have some work to do to identify the best possible delivery mechanics for doing so. But the skin thing: probably not going to go away. Sorry.

Troubleshooting patches: adhesion

Because of the way it physically delivers hormones to our bodies, a patch must be 100% adhered to our skin 100% of the time in order to deliver the nominal patch dose. If it's not, even by a bit, the effectiveness of the patch is diminished by that amount. This means that getting a patch stuck down and keeping it that way is absolutely critical to using patch HRTs.

Skin prep

The first part of sticking a patch down involves preparing the skin for the patch. The most effective strategy seems to be washing the site thoroughly with a mild and pure soap—not something loaded with moisturizing oils but rather a something more like a glycerin cake or castile soap, for example.

Then dry it thoroughly. A hair dryer set on low is good for this, so that the site's not picking up lint from a towel.

Since putting a fresh patch on skin with dilated blood vessels from a hot shower can give us a nice little zap from the enhanced uptake, it's important to let the skin cool thoroughly.

Then it's time to apply the patch. Another session with a slightly warm hair dryer or holding a warm hand firmly on the patch for several minutes after it's applied, pressing it down fully and evenly, will help make the seal fully seat onto the skin.

As a final measure, a light dusting of powder (on top of the applied patch, not underneath or before applying it!) will reduce the sticky along the edges and help prevent peeling from sticking to clothing. You may need to renew the powder daily if the adhesive tends to extrude a bit with time.

Do not use benzoin or the skin prep pads sold to people with ostomies to help their appliances stick to the their skin—those will make the patch stick, perhaps, but interfere with hormone transfer from the patch into your body, which sort of negates the whole effort.

Don't use things like acetone or industrial solvents to clean the area before application—that's going to alter the skin's uptake and expose you to risks from those agents. If you have to resort to heavy chemicals, you're not a good candidate for a patch.

If you want to be extra-sure you've cleaned the skin of all oils, one patch manufacturer suggests wiping the area down well with an alcohol wipe. Rubbing alcohol on a tissue or cotton ball will work equally well—you don't need to buy the expensive packets of individual wipes (although they're handy for travel use). Be sure to fan the area (or give it another whoosh with the hair dryer) to be sure all of the alcohol has evaporated and the skin is fully dry before you apply the patch.

Last, do make sure that the skin is well smoothed out before putting the patch onto it. One of our discussion group members shared a tip she got from her patch manufacturer: when applying a patch to the butt, sit down to apply it. This obviously will stretch things out and help assure that when you sit down later, you're not ripping it loose as your skin stretches. Clever, eh? That won't, of course, help with patches in other locations, but we can take a lesson from this and make sure we do smooth and even stretch out the skin if it's an area where there normally is considerable stretch in the course of our daily activities.

Problems

Some women find that they have a lot of body hair and this presents them with adhesion problems. For them, careful shaving may be necessary—careful because nicking or scraping the skin will also alter the uptake of the patch and then provide a risk of infection when sealed beneath the patch for that many days. This isn't something to undertake unless patches spring up obviously standing away from the skin on hair—women who have a history of bandaid failures know what we're talking about here. Don't get into this unless you absolutely have to, and even then, it's a good reason to consider another HRT form.

If that doesn't do it for you, then you need to look at the actual mechanics of the problem. If it's just edges rolling up from clothing, perhaps more careful selection of application location would help. If the powder trick doesn't work, perhaps taping down the edges would—that's okay, so long as the edges are well-sealed to begin with and you're just protecting them, not sticking failed portions of the patch back down. If you tape edges and the patch remains fully stuck down right up until the time when you peel it off to change it, you're okay; anything less than that total adhesion and you're fooling yourself (and not your body) with the tape. Don't take the tape off and replace it if it starts to curl, though—that's just going to lift the patch with it.

Some women who develop rashes under patches like to use an over-the-counter steroid ointment to facilitate that healing. We're not sure that any degree of irritation that takes drugs to recover from is being all that kind to our bodies in the long run, but in the overall scheme of balancing risks and benefits, we'll have to leave that one up to you. Remember, though, that different brands of patch have different chemical constituents in the adhesive, and so a rash from one brand will not necessarily happen with another.

After bathing

If you use body moisturizer after your showers, be sure to skip the place where you're going to put your fresh patch. It's fine to use a regular moisturizer, if it doesn't sting, where the old patch was. After all, that area is probably going to see another patch in a couple weeks, so making sure it's healthy and recovered is just right.

The dreaded goo-and-lint aftermath

Once you've removed the patch, you may be left with that unattractive lint-and-goo ring. This is also not the time to reach for heavy industrial solvents that aren't meant for use on skin that's just spent days underneath an airtight barrier. Instead, try a light coating of vegetable or nut oil or body butter. Let it sit on the goo for a few minutes, then shower. You should be able to wash the now-softened goo off with your usual soap and washcloth.

It still doesn't work

Finally, keep in mind that each patch adhesive is by definition (and patent) different. If one brand doesn't stick for you but you love patches as a concept, for goodness sake try the rest of the brands to see if another might provide better results for you. That's what samples are for.

Special situations: no HRT

There are a number of reasons why some women are unable to take hormones in surgical menopause. A blood clotting disorder or cancer are the most common reasons for this, but occasionally we hear of doctors recommending against hormones for other reasons such as blood pressure, smoking, or fear of the other risks they can carry. Whatever the reasoning, this is a difficult road to follow. While women in natural menopause can often get by with symptomatic relief to augment their own lingering ovarian output, a woman in surgical menopause is most likely going to have to face life in some degree of hormonal deficiency.

Of course there are also women who wish to refrain from taking HRTs or supplementing their hormones (these may not be considered the same thing by some women). We've read comments from many women who are afraid of hormones or HRTs because of some family history of cancer or because they had their hysts for cancer. But not all cancers are the same in the effects hormones may have on them, and if you don't know, for sure and in detail, that your specific cancer or family risk is specifically estrogen-mediated, you may want to discuss your own particular risk factors with an oncologist. Just because cousin Mabel thinks she recalls that Great-aunt Violet died of some sort of cancer doesn't mean that HRT may pose an unacceptable level of risk for you.

By the same token, if you cannot safely take HRTs, please understand that alternative HRTs like nutraceuticals and high-phytoestrogen foods do contain functional hormones and carry those same risks you're avoiding with prescription HRTs. And consider further that if you deem a family or personal cancer risk too high to supplement your hormones, you may want to discuss with an oncologist whether your own hormones also present that level of risk. Remember: your body doesn't stop producing hormones entirely when you lose your ovaries: you are still producing enough for the majority of your needs via body fat and adrenal conversion. If the small increment that HRT use adds is too dangerous, so too might your own production pose an unacceptable risk. An oncologist can help you explore whether you need to take drugs to block all hormone production or use in the body, and this may be every bit as important for you as not adding more to your system.

We also hear from many women who don't want to take "artificial medicines" that "make menopause a disease." Well, neither do we. Alas but HRT has been demonized plenty, both in the popular media and by crusaders who view it as nothing more than an evil plot by doctors/pharmaceutical companies/aliens to enslave women. That ignores, sadly, the real situation of surgical menopause as characterised by a shortage of something normal to the body's functioning and replaceable with equivalent chemically-structured supplements. We're not proselytizing for the use of HRT, but we are, strongly, urging women to research and understand the physiology behind their hormone needs and how they can be met. It's not a case where taking HRT is the only side of the question that has potentially negative impacts on health: not taking it can be just as devastating, can raise mortality risks just as high. And sadder yet are those who try to meet their hormone needs with alternative HRTs all the while denying that they are taking HRT and failing to monitor for those hormone risks. Whatever you do, please understand both the risks and benefits; don't just be swayed by fearmongers and salesmen.

For those, then, who cannot or choose not to supplement their hormones beyond what their own body can produce, there are a number of coping strategies that may be of use in dealing, one by one, with the aspects of hormonal deficiency that most plague you. The big question for women in this situation is well, what can I do? We'll do a rundown here of the most common problems.

Bone density

Weight bearing/strength/balance exercise is the biggest component of bone maintenance, whether or not we take HRT. No matter what raw materials we take in, we need to use our bones daily to produce the stimulus for our body to maintain bone strength. All women, irrespective of hormonal status, are recommended to get a hour's weight-bearing exercise daily. Yes, we realize that this is dull and unappealing for many women, but for women not taking hrt, this is akin to a drug that is required to replace it.

In addition to that, we need to provide our bone-building cells with the raw materials to construct those bones. This means about 1200-1500 mg calcium and 600-750 mg of magnesium, 15-30mg of zinc, and 800 mg of folic acid. We also need to make sure our vitamin D intake is adequate; while the US government standard has been raised from 400 IU daily to 600- 800 IU, the latest numbers we're seeing call for 1000 IU daily (free signup required to read) and many physicians, especially in higher latitudes, are recommending 2000 IU to their patients. It is widely believed that caffeine is a bone-robbing culprit, but that has recently been demonstrated not to be the case (it does boost circulating estrone, an estrogen, and for that reason is not something to binge on if you can't use HRT).

Bone scans are even more important for those who cannot use HRT, and getting a baseline density measurement soon after your hyst may be wise to track changes. There are a number of different drugs doctors can prescribe if we develop osteoporosis, but each of them carries fairly significant and not necessarily reversible risks of their own, and they are all rather expensive for lifelong maintenance. For recent articles on these drugs and other aspects of bone density/osteoporosis, check out the relevant collection in our bookmarks account.

Cardiovascular system

Taking a daily aspirin can reduce your CV risk by 33%, achieving your ideal body weight counts as a 45% risk reduction, regular exercise contributes a 45% reduction, you reduce your risk 2% for every mmHg of hypertension (blood pressure above 140/90) you reduce, quitting smoking is another 50% reduction of risk, and you get a 2% reduction for every 1% you reduce an elevated cholesterol. Sources also attribute a 35% risk reduction to "modest use" of alcohol, but because alcohol ingestion boosts circulating estrogens, we can't recommend it as a strategy in those avoiding estrogen exposure. Needless to say, monitoring blood pressure and lipids should be a part of a menopausal woman's annual physical and this is especially true of women raising their CV risks by practicing estrogen deficiency.

Dry skin, eyes and hair

Make sure you drink plenty (that's at least a quart and a half) of water every day (this doesn't mean sweetened drinks, which don't hydrate you very well). Put on a good moisturizer while you are still wet from your shower, and don't shower in excessively hot water or more than once a day. You may find that a moisturizer that contains urea will help hold moisture in your skin. Taking evening primrose oil may help with your hair, but you need to eat oily fish (salmon, mackerel, sardines, etc) twice a week to make sure that the whole process works right. Ask your eye doctor for a recommendation of moisturizing eye drops (the single-dose packets are great for avoiding contamination). You may not be able to wear contacts, but if you have your heart set on them, look into some of the newest, high-moisture brands. Limit the number of hours you spend staring at a computer monitor (and remind yourself to blink regularly). If eye dryness begins to damage your eyes, your ophthalmologist can insert tiny plugs in your tear ducts to help maximize the use you get out of what moisture you do produce.

Urinary incontinence

Kegel exercises are the remedy most recommended by physicians for this. Antispasmodics such as oxybutynin or hyoscyamine may help. At night, some women get relief using a low dose of the tricyclic antidepressant imipramine (25 mg). A pessary may help support weak pelvic tissues. Simple tricks like emptying the bladder more often, planning for bathroom availability on long outings, and moderating fluid intake when bathrooms are not convenient can help get you through awkward moments during the day. It may be helpful to consult a physical therapist who is licensed with the Women's Health Physical Therapy branch of the American Physical Therapy Association (the website includes a service locator). Many physicians aren't aware of this specialty service, but trained therapists can do a lot by teaching simple pelvic floor exercises (more specific than Kegels).

Vaginal atrophy

Avoid using scented soaps and rinse thoroughly when washing the genitalia. Avoid the use of antihistamines, decongestants or other drying medications. The use of vitamin E as a vaginal lubricant/moisturizer is well-documented as effective (insert a gel-cap of the regular vitamin into the vagina and let it dissolve and absorb—best done at night). External use of soothing creams made with calendula, comfrey or other soothing herbals may help…if you are not allergic to them (test a tiny bit first, please). Oatmeal baths are a classic for soothing skin complaints of all sorts. Commercial lubricants like K-Y or Replens will help during sex, but may not do as much as vitamin E for general moisturizing. Vaginal tissue health is a use-it-or-lose thing, in which regular intercourse or masturbation can greatly combat atrophy. Zinc and evening primrose oil are said to contribute to vaginal tissue health.

Insomnia

The primary problem with sleep is often being awakened by either hot flashes or their aftermath, soaking sweats. We discussed some measures related to hot flashes at night in our overall discussion of flashing, and there are more under a separate section below. For other sleep help, the use of soothing bedtime drinks is preferable to the use of sedative drugs. Try valerian or chamomile (or both combined in a "sleepytime" tea) or non-chocolate Ovaltine as bedtime relaxers. A traditional remedy is to sleep with a pillow stuffed with dried female hops flowers—which sounds rather nice. Finally, consider what your expectations are. It is better to get up and do something than to flop around in bed being furious that you aren't sleeping. Don't go to bed till you are tired, even if that's not till 4 am, as you'll just train yourself to be frustrated. These tips and many more, both medical and non-medical, are available from the National Sleep Foundation's insomnia portal.

Hot flashes

Black cohosh and red clover are about the only two herbals that have actually tested out as effective, but only in a limited way and with some notable risks. Red clover can affect clotting time, thus impacting those on anticoagulants as well as anyone facing surgery, and some of the recent tests proving its efficacy for hot flashes are now being questioned. Black cohosh, as studied in animal tissue, may stimulate metasteses of existing cancers (not cause new ones). This essentially moves it out of the "herbal-alternative" column and into the "estrogen" column as far as level and type of risks go, although it may retain some utility for those whose objections to pharmaceutical hormone preparations are philosophical rather than health-related. There is also a body of research that suggests that black cohosh does not stimulate new cancers, so its use in women who are convinced they are cancer-free may be less objectionable.

Soy, while considered by many naturally-menopaused women to be useful for hot flashes and other estrogenic effects, is shown (research remains conflicted) to be too estrogenic in the biochemistry of its action to be safe for those avoiding estrogen. Soy isoflavones have not been demonstrated as effective as whole soy, although combination products of the two may be a little more potent (or may not). Soy also is considered inadvisable for those with thyroid issues.

Another potentially-useful agent is an SSRI (selective serotonin reuptake inhibitor) antidepressant. Because this family of drugs boost serotonin, which can occupy estrogen receptors in the brain, SSRIs can be very effective in combating both the hot flashes and the depression that can result from lack of estrogen. They are not totally benign drugs and must be used under a doctor's supervision, but they can be true lifesavers. All SSRIs may not be considered suitable for women taking tamoxifen, but citalopram and venlafaxine are considered safe in that situation.

An older drug that was used to treat hot flashes, bellergal, is a less-attractive choice because of its sedative and drying properties. Clonidine, a blood pressure drug, and Gabapentin, an anti-seizure drug, are other non-hormonal drugs used to treat flashes but also have significant side effects. In 2018, oxybutynin, an anticholinergic drug developed for bladder spasms, was shown to be more effective than citalopram or venlafaxine and safe for women who need to avoid hormone exposure, but it is not without its own side effects. More on this new option in this separate post on oxybutynin.

All of these agents may decrease the frequency and intensity of flashes but probably will not eliminate them entirely.

Depression, mood swings, crying, lethargy

In some ways, this can be one of the most extreme and destructive problems a woman in surgical menopause must wrestle with. While doctors are sometimes too quick to offer the easy fix of antidepressants as a bandaid to cover up hormonal balance problems, we have to endorse the validity of this approach when HRTs cannot be used to correct the underlying chemical disruption lack of estrogen causes in the brain. Depression is a life-sapping disorder and one difficult to admit to or to be effective in combating while in its throes. There are lots of useful non-drug interventions available to help with depression but perhaps the best is exercise. Exercise releases endorphins, a feel-good chemical that can improve your mood for a considerable amount of time. Unfortunately, depression can make it difficult to motivate yourself to exercise or use many of the other useful techniques.

Stepping up in intervention is use of an antidepressant. St. John's Wort continues to be well-regarded by some practitioners as a safe and effective antidepressant. For some women, it's all they need; for others, it's not just strong enough. In those cases, treatment with an SSRI antidepressant would seem to us to be a desirable approach. Some of us who cannot use hormones are now using an SSRI, and the rest of us would like you to know, it's making a vast difference that both they and we can see. An article published by CNN in Dec. 2000 cited a Mayo Clinic researcher, Dr. Charles Loprinzi, who reported that "a four-week trial involving 229 women, most of whom had a history of breast cancer, revealed that venlafaxine was 60 percent effective against hot flashes. The optimum dosage was 75 milligrams daily," Loprinzi said. "And the effects we saw were within a week." The report is the end result of ten years of studies looking for the best solution for breast cancer patients, and finds that venlafaxine (Effexor) to be expensive, but far more effective than any other of the traditional medical, herbal or vitamin remedies. This has been further supported by research since then, and an SSRI is now considered a standard of treatment. As with hormones, different women respond differently to each SSRI, so some experimentation may be necessary to find the best, most effective one for any given woman.

Depression in menopause is both over-dramatized and under-appreciated. Women tend to blame themselves (and doctors may help them do it) for not "getting a grip" and "having a positive attitude." Sure, it's a rough adjustment, especially when we're limited in our choices and the transition is traumatic. But there are also real, physiological issues here. For the best explanation we've seen, we highly recommend the book Women's Moods by Deborah Sichel and Jeanne Watson Driscoll for a scientifically-sound but not incomprehensible discussion of the topic, including a number of self-help steps any woman can take to help cushion her brain from the effects of menopause. The link in the book title above takes you to a more in-depth report on this book here, but you can also check your favorite used book store or library for a copy.

[This post last updated: 12/10/18]