Gleanings from an article on contraceptive patches

Since we're always interested in expanding our understanding of patches and transdermal hormone delivery, we recently clicked through on "Transdermal Contraceptive Patches: Current Status and Future Potential" (free signup required to read) just to see if it had anything to offer that also seemed applicable to hrts.

Delivery from alternative patch placement locations

We've known for some time that butt and belly application differs by 17-25% in the quantity of hormones absorbed from the same patch. This is in the official US FDA patch data sheets. Users have also reported using upper arm and upper back and thighs for patch placement for years, but we're never had any guide other than experimentation to determine the approximate dose equivalency for those locations. This current article, however, lists some of these locations and reports on their delivery:

The patch is designed to be placed on one of four sites: the lower abdomen, upper arm, buttock or upper torso (excluding on the breasts). Two consecutive patches should not be placed over the exact same area. Hormonal absorption from the lower abdomen is approximately 20% lower than that observed from the other three sites

There's no reason at all to suppose that this would not hold true for hrt-sized doses as it does for the higher contraceptive-sized doses referenced in the article. That means that we don't especially need to anticipate making huge changes to our patch dose if we choose to spread our use out over more alternative locations.

What's underneath still matters

This doesn't, of course, guarantee that even the sites with roughly the same statistical deliverability can be trusted to work that way on an individual basis--we still have to contend with individuality of fat-vs-muscle underlayment of the skin to which the patch is applied. That's also supported by this statement from the article:

cautioned that women with body weight in excess of 90 kg may be at higher risk for pregnancy compared with lighter women

In other words, individuals with a thicker fat layer the hormone must traverse to enter circulation may have an overall lower delivery to systemic circulation. For well-padded users, then, a patch may not be an optimal delivery if transmission through thicker fat layers prevents good uptake. Beyond this, though, it supports the notion that underlaying tissue type is pertinent to patch delivery for all users, something that may help in troubleshooting variations in patch performance that result from using multiple locations.

Environmental impact of patch disposal

Also of broader interest is this reminder of the environmental impact of undelivered hormones:

As there is still a considerable amount of hormone left in the patch at the end of its 7-day use, it is recommended that patches not be flushed down toilets, but disposed of folded in half via solid waste collection systems. In some countries, it is recommended that the used patches are returned to pharmacies.

While users in menopause tend to come closer to exhausting the hormone content of their much lower dose patches by the end of the nominal delivery life, we should keep in mind that there may still be enough in them to have impact on others. Our water supplies are growing increasingly contaminated by hormones and drugs, none of which are typically measured (in the US) by EPA-mandated water supply testing. This contamination is increasingly pointed to as a potential factor in the earlier sexual maturity of children and the higher incidence of hormone-mediated disorders we may suffer as adults.

We might be especially concerned about patches discarded prematurely—say, that one that got caught on our underwear on day 1 and peeled up and had to be replaced. But any patch, really, should be disposed of with some care as to where its leftover content might end up, given that it's unfilterable and untested once in our water supplies. Even their suggestion that it go into solid waste disposal would be ineffective in safely sequestering it some places, such as New York City, where much solid waste is simply barged out to sea and dumped. Responsible disposal of our hrts is something to think about for the sake of our children and grandchildren.

Transdermal delivery and the risk of blood clots

The main issue that this article is addressing is risks of blood clots. In general, we know from a growing body of evidence that oral hrts (as compared to transdermal) seem to be associated with a higher incidence of clots, generally attributed to the way that the liver is more heavily involved in oral dose processing. The article reviews that situation:

Estrogen increases VTE risks by altering hepatic production of extrinsic clotting factors, and antithrombin III. With oral contraceptives, hepatic exposure to estrogen is much higher than is reflected by serum estrogen measurements. This is because much of the estrogen absorbed through the intestine into the liver is conjugated and excreted through the gallbladder back into the intestine without ever entering the bloodstream. However, with transdermal systems, all the estrogen to which the liver may be exposed is reflected in the serum levels.

Oral processing is also generally believed to boost inflammatory factors (such as C-reactive protein), which has been suggested as a reason why cancer rates may be higher with orals than other delivery. This is also considered to be a factor in the cardiovascular disease development issue as it relates to route. This research is not yet heavily publicized even though it's incorporated into the major medical group consensus documents on menopause and hrt, so many physicians remain unaware that these are reasons for women to downrate oral hrts when they are evaluating their options.

Transdermal progestins?

We've been discussing progestins lately, both with those who have endometriosis and want to include the suppressive effects of progestogens (progesterone-acting compounds) in their hrt, and with those who have had their ovaries removed but still have an intact uterus and a need to utilize a progestogen to maintain its health.

There's some evidence that progestogens that deliver into pelvic circulation provide better local coverage with lower systemic impact as compared to other routes of systemic delivery, something very attractive where the alternative has long been simply having to tolerate an unpleasant hormone imbalance for the sake of therapeutic effect.

To date, local progestogen delivery has been possible only via IUDs such as Mirena ( dispensing the progestin levonorgestrel) or other higher-dose progestin-dispensing contraceptive IUDs (like Progestasert), or vaginal forms such as the progesterone gel Prochieve, off-label use of oral Prometrium caps vaginally, or various vaginal-application compounded forms of progesterone. That means that for individuals who want the stability of a progestin, which cannot be converted to other hormones as progesterone itself can be, if they didn't have a uterus they were out of luck for anything other than oral delivery and its associated systemic impact.

But this article supports the premise that progestins are in fact capable of being absorbed through the skin (and, by extension because they have similar properties, vaginal lining). Gestodene is the progestin mentioned as being possibly suitable for this kind of delivery in this article and norelgestromin is the progestin in the currently-available patch, but the article also suggests that "other progestins, including those with poor oral absorption, could be utilized in a transdermal patch."

While that doesn't mean that anyone's going to rush a vaginal or transdermal progestin onto the market, especially one suited for the use of those in surgical menopause (a rather small market), it does open up some other avenues for the adventurous to explore.

How? Vaginal use of a portion of a plain progestin tablet meant for oral use might work (it would obviously make sense to try one of the progestins the article mentions unless one can get solid information from a pharmacist that a different progestin is known to be suitable in terms of through-skin absorption capability). Why only a portion? Remember: oral formulations have a lot of wastage from first pass built into them, while lower losses with transdermal delivery mean we have to start at a lower dose level when converting between the two. Clearly, this is really out-on-the-edge experimentation and definitely something to discuss with one's health professionals, but it does provide the hint of a possibility for those willing to experiment a bit in order to get an hrt form and dose they are more comfortable with.

Another approach, although we're not sure if it's feasible or not, would be to see if a compounding pharmacy could custom formulate a progestin meant for oral use into a vaginal-suitable dose and vehicle. We've hesitated suggesting this in the past because we had no reason to suppose it would be absorbed, but given the encouragement of this article, it sounds much more like something to pursue.

Have you tried this? Thinking about trying it? We'd love to hear from you about your experiences on our discussion forum.

Making sense of transdermal HRT doses

While the gel hrts are proving very successful for some users, others are having puzzlingly disappointing results with them. There's a lot of individual difference in how well we each may take up any given transdermal medium, but in the case of gels, this doesn't seem quite in sync with what these same users may find with other transdermal media.

The one way that gels stand out from, say, creams or lotions, is that they dry on the skin rather than having the hrt, medium and all, absorbed into it. Product labels warn of enhanced risk for transferring gel-delivered hormones to others and for diminishing the delivered dose by washing too soon after application (where "too soon" is a much longer period than with other media).

The gels

It's also puzzling to users trying to calculate doses when they switch from one form to another of hrt just how the relatively large amounts of estrogen in the typically-recommended gel hrt doses should be compared to the amounts delivered by other hrt forms.

One of the members of our discussion list shared with us this excellent article that may shed some light on all of this: "Comparison of the transdermal delivery of estradiol from two gel formulations." According to this test, which compares two widely-sold gel hrts, the delivered dose of the hormone was only 13-20% of the amount applied.

All hrt deliveries involve some losses: that's one reason why we can't just convert from one hrt to another of a different route and go on using the same dose numbers. But in the case of gels, we need to recognize that there will be a big difference because such a small amount of the hormone actually gets into our bodies this way. And with such a low proportional delivery when used according to directions, it doesn't take much imagination to suspect that this could be further reduced by incorrect application.

Yes, that's a lot of loss. Where does it go? Well, onto our partners and kids, if we're not careful. Onto our clothing and towels and bed linens, I'm sure. Ultimately, down the drains of our showers and washing machines, into our sewers and septic systems, thus contributing to the contamination of water supplies that today test in community after community as having elevated estrogen contents and perhaps contributing to the cancer and other hormone risks of an entire population. It's not our place to advocate for ethical issues here, but this might be a point that users would want to consider when they make their own choices.

Other transdermals

As we said above, each hrt, even within the family of transdermals, has its own delivery profile. That includes things like how the uptake "feels" to us and how efficiently it moves the hormones it contains into our systems. We've seen way too many users just slam themselves with excessive doses when they thought that because they needed X mg of dose in one transdermal hrt, they needed to multiply normal doses of another hrt to get that same number.

That's not how it works.

We can get a better sense of dose equivalency from the "usual starting dose" figure that's part of the basic prescribing information with any hrt. That's the dose that incorporates enough to make up for losses in delivery and still provides enough to make up "usual" coverage in a user's system.

Yes, this is confusing. One of our discussion list members assembled this very handy chart comparing dose to delivered amounts in transdermal products available in the US and the UK. It doesn't cover every hrt or all the generics, but it does give us a great overview of how much variation there is in all of this.

So how do I use this information?

Basically, it reinforces the premise that we really can't do an absolute conversion from any one hrt to any other hrt. But it does help us feel more comfortable letting go of dose numbers as even a rough conversion factor and switching our attention to more useful figures.

What we can ask, in moving from one hrt to another, is how we felt on what dose of our original hrt. If we felt sort of okay on, say, the usual starting dose of our old hrt, then we might want to start the new hrt at whatever is pegged as the usual starting dose for that one. Similarly if we were one standardly sold dose up or down from the usual starter of our old hrt (or we would have preferred to have been), we might look to that many iterations off of usual starting for the new one. It's a really rough and imprecise system and no, the manufacturers aren't going to provide us with anything better because their profit lies in holding us captive to their brand, not in facilitating our moving to someone else's.

We can also use our understanding of this to help explain why we may feel really different when we switch brands. We typically see this when we're having problems with one brand and our doctor switches us to another and whammo, we're feeling as though our hrt has just evaporated. Many doctors may not be up to date with the trend that some hrts now come out in ultra low doses meant for those in natural menopause who just want a tiny hormone boost for its value in combating osteoporosis. Those doses aren't typically enough for most users in surgical meno, so even swapping to the "usual starting dose" of the ultra-low hrts is a huge dose cut. Again, when we look at the figures for what is being delivered, we can get a sense that we've actually had a big cut in what our bodies have to work with. So in this case, we're not crazy: we actually aren't taking anywhere near the same thing and we need to take this fact back to our doctors to use in troubleshooting our correct dose.

Obviously, dose amount and delivery amount aren't the only factors in working with the behavior of different transdermal hrts, but they are an important factor to understand when we are troubleshooting.

HRTs in the UK

We've limited this list as much as possible to those preparations that are used for menopause, not the stronger varieties used for oral contraceptives that may be used by very young women in menopause. To look up any additional brand or generic names you may want information about, try searching in the Electronic Medicines Compendium and click on the links identified by the squares that say "spc" rather than the ones that say "pil". For more information on packaging, full risk disclaimers and manufacturer, follow the links from each brand name to a full prescribing info listing.

There are many more forms of testosterone licensed for use in the UK than those we've included here, but all of the others are doses appropriate for men in forms that cannot be adequately adjusted downward for the lower amounts safer in women. If you are offered another testosterone, you can also research it in the electronic Medicines Compendium by either brand or generic name.

These listings are as updated as we can make them, but we don't have an efficient way to check them all on a regular basis. If you are told that an HRT has been discontinued, please drop us a quick email so we can look into it and update this page accordingly.

Oral human-identical single-estrogens:

• Bedol
• Climaval
• Elleste Solo
• Progynova
• Zumenon

Oral human-identical three-estrogen combination:

• Hormonin

Oral synthetic estrogens:

• Ethinyloestradiol
• Premarin 
• Livial

Oral human-identical progesterone:

• Utrogestan

Oral synthetic progestins:

• Provera

Oral combination: human-identical estrogens plus human-identical progesterone:

• none

Oral combination: human-identical estrogens plus synthetic progestins:

• Angeliq (continuous)
• Climagest (cycled)
• Climesse (continuous)
• Clinorette
• Cyclo - Progynova (cycled)
• Elleste-Duet
• Femoston (cycled)
• Femoston-conti (continuous)
• Indivina (continuous)
• Kliofem (continuous)
• Kliovance (continuous)
• Novofem (cycled)
• Nuvelle Continuous (continuous)
• Tridestra (cycled quarterly)
• Trisequens (cycled)

Oral combination: synthetic estrogens plus synthetic progestins:

• Premique (cycled)
• Prempak-C (cycled)

Patch human-identical estrogens:

• Elleste Solo
• Estraderm
• Estradot
• Evorel
• FemSeven
• Progynova

Patch combination: human-identical estrogen plus synthetic progestin:

• Evorel Conti (continuous)
• Evorel Sequi (cycled)
• FemSeven Conti (continuous)
• FemSeven Sequi (cycled)

Patch/oral combination: human-identical patch estrogen plus oral synthetic progestin:

• none

Patch human-identical tesosterone:

• Intrinsa (now discontinued: see listing)

Cream/gel human-identical estrogens:

• Oestrogel
• Sandrena Gel

Cream/gel human-identical progesterones:

• none

Cream/gel human-identical testosterones:

• Testogel
• Testim

Transdermal/patch synthetic estrogens:

• none

Subdermal (implanted) human-identical estrogens:

• Estradiol implant

Subdermal (implanted) human-identical testosterones:

• Testosterone implant 

Vaginal human-identical estrogens:

• Estring
• Gynest 0.01% w/w Cream
• Ortho-Gynest
• Ovestin Cream
• Vagifem

Vaginal synthetic estrogens:

• none

Vaginal human-identical progesterones:

• Crinone Gel
• Cyclogest

Angeliq contains 1 mg estradiol (as estradiol hemihydrate), considered human-identical, and 2mg drospirenone, a synthetic progestin that is purported to be closer to progesterone than most synthetics although it has a very low level of androgenic activity. Inert ingredients include Lactose monohydrate, Maize starch, Maize starch, pregelatinised, Povidone, Magnesium stearate, Hypromellose, Macrogol 6000, Talc, Titanium dioxide (E171), Ferric oxide, red (E172). The tablets are film-coated, making them less suitable for dividing into lower dose portions; this hrt is not suitable for transbuccal delivery. As of July 2019, this hrt is no longer listed as available.


Bedol contains 2 mg of human-identical estradiol that is said to be comparable to Zumenon although we don't have data on its transbuccal use suitability. Inert ingredients include lactose, crospovidone, povidone, talc, magnesium stearate, and opadry white.

Climagest comes in two doses of human-identical estradiol valerate, either 1 mg or 2 mg, with 1 mg norethisterone, a synthetic progestin, in 12 of the 28 pills contained in each packet (so, a cycling HRT). Norethisterone was first formulated in the 1950s and purportedly has a very low level of androgenic activity. The tablets are film-coated, making them less suitable for dividing into lower dose portions; this hrt is not suitable for transbuccal delivery. Inert ingredients include lactose monohydrate, maize starch, povidone, talc, magnesium stearate, FD &C blue no.2 lake (E132), purified water. hypromellose, propylene glycol, opaspray blue M-1-6516 (E171, E464, E132). Cycling HRTs are not required by women who no longer have a uterus, and so this sort of HRT is rarely used in surgical menopause.

Climaval contains 1 mg or 2 mg human-identical estradiol valerate. The tablets are film-coated, making them less suitable for dividing into lower dose portions; this hrt is not suitable for transbuccal delivery. Inert ingredients include lactose monohydrate, maize starch, FD & C blue no. 2 lake (E132), povidone (grade 30), purified water, talc (sterilised, white), magnesium stearate, Hypromellose, propylene glycol, Opaspray blue M-1-6517 (E171, E464, E132).

Climesse contains 2 mg estradiol valerate, considered human-identical, and 0.7 mg norethisterone, a synthetic progestin. This is a non-cycling hrt. Norethisterone was first formulated in the 1950s and purportedly has a very low level of androgenic activity. The tablets are film-coated, making them less suitable for dividing into lower dose portions; this hrt is not suitable for transbuccal delivery. Inert ingredients include: lactose monohydrate, maize starch, povidone, purified water, talc, magnesium stearate, Hypromellose, polyethylene glycol, iron oxide red (E172), titanium dioxide (E171), purified water.

Clinorette contains 2 mg human-identical estradiol plus 1 mg norethisterone in a packet that is meant to cycle plain estrogen for 16 days and the combined product for 12. Norethisterone was first formulated in the 1950s and purportedly has a very low level of androgenic activity. Inert ingredients are listed as Crospovidone, Povidone, Talc, Magnesium stearate, Opadry white, Erythrosine lake. The manufacturer's dosing schedule instructions are for the use of women who have a uterus; cycling HRTs are not required by women who no longer have a uterus.

Crinone Vaginal Gel is an 8% human-identical progesterone gel meant for vaginal application. It is supplied in individual-dose applicators that contain 1.45 g of gel and deliver 1.125g of gel for a dose of 90 mg of progesterone. The manufacturer's dosing schedule instructions are for the use of women who have a uterus; cycling HRTs are not required by women who no longer have a uterus. While the dose can be modified, it is not convenient and requires some care to be accurate. We have no data on whether or not this gel can also be used successfully for non-vaginal transdermal application. Because the formulation is specially designed to adhere and be retained in the vagina, it should not be used concurrently with other vaginal products. While timing of dose can alleviate some of the potential hormone exposure to a partner, the long-lasting nature of this gel may nonetheless make it difficult for a partner to avoid it entirely. There are some drowsiness and balance risks inherent in beginning use of human-identical progesterones. Inert ingredients include: Glycerin, Light Liquid Paraffin, Hydrogenated Palm Oil Glyceride, Carbopol 974P, Sorbic acid, Polycarbophil, Sodium hydroxide, Purified water.

Cyclogest is a suppository (pessary) for vaginal or rectal use containing human-identical progesterone. It comes in 200mg and 400mg doses. The manufacturer's dosing schedule instructions are for the treatment of pms in women who have a uterus; cycling HRTs are not required by women who no longer have a uterus. This dose is much higher than that typically used in surgical menopause, but women have reported cutting this product down to provide a source of dose-modifiable human-identical progesterone. While the dose can be modified, the process is not convenient and requires some care to be accurate. When used vaginally, dose timing precautions may be necessary to avoid exposing a partner to the hormone it contains. The only listed added inert ingredient is vegetable fat.

Cyclo-Progynova is a combined hrt meant to be cycled, with 11 pills containing 1mg estradiol valerate, a human-identical estrogen, followed by 10 pills containing 250 micrograms levonorgestrel, a synthetic progestin, plus 1mg estradiol valerate; this sequence of pills is meant to be followed by a 7-day hormone-free period to produce a 28-day cycle. A higher dose pack is also available, containing 2mg estradiol valerate with 500 micrograms norgestrel in 10 of the pills. Inert ingredients include: lactose, maize starch, povidone, talc, magnesium stearate [E572], sucrose, calcium carbonate [E170], polyethylene glycol 6000, montan glycol wax, titanium dioxide [E171], yellow ferric oxide [E172], red brown ferric oxide [E172], glycerin. Cycling HRTs are not required by women who no longer have a uterus, and a cycle that includes a period without any hormonal support is not likely to be especially comfortable for any woman in surgical menopause.

Elleste Solo is human-identical estradiol hemihydrate in tablets for oral use that come in 1 mg and 2 mg doses. It's possible, since the hemihydrate form of estradiol is known to be used in vaginal hrts, that one could also use this hrt transbuccally, and we have several longterm user reports that this hrt actually delivers satisfactorily via this route. It has also been confirmed by the manufacturer that the molecular form is "micronized," a critical factor in allowing it to move through oral mucous membranes. The tablets are film-coated but may be divided for dose customization. Inert tablet contents are lactose monohydrate, maize starch, povidone 25, talc (purified), magnesium stearate; the coating contains hydroxypropylmethyl cellulose (E464), titanium dioxide (E171), macrogol 400.

Elleste Solo is a human-identical estradiol hemihydrate patch that comes in 40 microgram and 80 microgram doses (the dose references the amount calibrated to be delivered per day, not the total amount of estrogen contained in an unused patch) in an acrylic matrix adhesive. The size of the patch is proportional to the dose and it is meant to be changed twice a week. The manufacturer recommends placement on the lower back or buttocks; placement elsewhere can change effective dose delivery. For more on patch application, delivery dynamics, dose adjustments and other patch concerns, please see the "Troubleshooting patches" section of this website.

Elleste-Duet comes in three versions: 1 mg or 2 mg human identical estradiol (as estradiol hemihydrate) plus 1 mg norethisterone acetate meant to be taken as estrogen alone for 16 days followed by 12 days of the combined product or (Conti) 2 mg estradiol plus 1 mg  norethisterone meant to be taken continuously. Norethisterone was first formulated in the 1950s and purportedly has a very low level of androgenic activity. Inert ingredients are Lactose monohydrate, Maize starch, Povidone, Talc, Magnesium stearate, Hydroxypropylmethyl cellulose, Titanium dioxide, Macrogol, Black iron oxide. The manufacturer's dosing schedule instructions are for the use of women who have a uterus; cycling HRTs are not required by women who no longer have a uterus.

Estraderm contains human-identical estradiol that delivers 25, 50, 75, or 100 micrograms/day via an acrylic matrix adhesive. The size of the patch is proportional to the dose and it is meant to be changed twice a week. The manufacturer recommends sites below the waistline, but suggests that wrinkling may be minimized by placing the patch on the buttocks. Inert ingredients include Acrylate, methacrylate, isopropyl palmitate, polyethylene terephthalate, ethylenevinylacetate copolymer, silicone coating (on the inner side of the protective release liner which is removed before patch application). For more on patch application, delivery dynamics, dose adjustments and other patch concerns, please see the "Troubleshooting patches" section of this website.

Estradiol implants  are no longer available through the NHS. Some private clinics continue to advertise them and presumably have sources of their own.

Estradot provides human-identical estradiol hemihydrate in a silicone/acrylic matrix patch meant to be changed twice weekly. The doses are: 0.39 mg estradiol (25 microgram estradiol per 24 hours), 0.585 mg estradiol (37.5 microgram estradiol per 24 hours), 0.78 mg estradiol (50 microgram estradiol per 24 hours), 1.17 mg estradiol (75 microgram estradiol per 24 hours), 1.56 mg estradiol (100 microgram estradiol per 24 hours). The physical size of the patch is proportional to the dose. The manufacturer notes that the lower two doses are not to be used for osteoporosis treatment, although that is likely to be a matter of legality, not the case that lower doses have no effect whatsoever on bone density (in the US, those lower doses have been accepted by the US FDA as effective for bone maintenance). The manufacturer recommends placement on the abdomen. Inert ingrediets are listed as: (Adhesive matrix) acrylic adhesive, silicone adhesive, oleyl alcohol, dipropylene glycol, povidone (E1201); (Backing layer) ethylene/vinyl acetate copolymer, polyethylene, vinylidene/vinyl chloride copolymer, polyethylene, ethylene/vinyl acetate copolymer co-extruded film; (Release liner) fluoropolymer-coated polyester film. For more on patch application, delivery dynamics, dose adjustments and other patch concerns, please see the "Troubleshooting patches" section of this website.

Estring is a silicone ring that dispenses human-identical estradiol hemihydrate. It contains 2.0 mg of the estrogen and is worn continuously in the vagina for a period of three months. It is only used to treat vaginal atrophy, and is not meant to be deliver systemic HRT. Nonetheless because some estrogen can escape from local tissues, especially when vaginal atrophy is already present, it may cause a few symptoms of hormonal fluctuation early in use and it is not considered safe for use by women who cannot use systemic HRTs. Use of progesterone or a progestin is not required by women who have a uterus and use this product because the dose is so low. In dimensions the ring is: outer diameter - 55 mm; cross sectional diameter - 9 mm; core diameter - 2 mm. It is folded into a figure-eight shape for insertion and rides in the area of the cervix or cervical cuff, much like a diaphragm without a center. Women with severe atrophy may require health professional assistance or demonstration of insertion the first time it is used, and some women complain, especially early in use, of feeling as though it's not far enough in or feels as though it might be going to fall out. Some women also notice a feeling of bladder pressure, although that tends to disappear in a few days. More rarely, some women report cramping with the use of a ring, especially when they have irritable bowel syndrome or endometriosis; these women often abandon the use of the ring if symptoms do not resolve within a week or two. The ring should not be used while other vaginal treatment is in place (such as creams). The UK data sheet does not include the information that it can be left in place during intercourse, but the American one does—although it can also be removed and then replaced afterwards if preferred.

Ethinyloestradiol is a synthetic estrogen in doses of 10 mcg, 50mcg and 1mg. The tablets are uncoated and may be divided for dose adjustment; there is no evidence that this estrogen may be taken transbuccally. Inert ingredients include Lactose, Starch Maize, Magnesium Stearate, IMS 99%, Purified water. This is an entirely different synthetic from those found in Premarin and is metabolized relatively more rapidly; therefore this synthetic may provide a different range of effects for women exploring this type of HRT.

Evorel is a human-identical estradiol acrylic matrix patch the size of which is proportional to the dose. It comes in four sizes: 1.6 mg estradiol (25 micrograms of estradiol in 24 hours), 3.2 mg estradiol (50 micrograms of estradiol in 24 hours), 4.8 mg estradiol (75 micrograms of estradiol in 24 hours, and 6.4 mg estradiol (100 micrograms of estradiol in 24 hours). The manufacturer notes that the lowest dose has not yet been demonstrated to be effective in prevention of osteoporosis (although it has been in the US). Placement is specified as simply below the waist. The inert ingredients are listed as Adhesive acrylic polymer, Guar gum (meyprogat 90), Hostaphan MN19 (polyester film - removed before application). For more on patch application, delivery dynamics, dose adjustments and other patch concerns, please see the "Troubleshooting patches" section of this website.

Evorel Conti is a matrix patch containing 3.2 mg of estradiol hemihydrate, a human-identical estrogen, plus 11.2 mg of norethisterone acetate, a synthetic progestin, providing a nominal dose of 50 micrograms of estradiol and 170 micrograms of norethisterone acetate per 24 hours. It is meant to be changed twice a week and the hormone blend is used continuously rather than cycled. The manufacturer recommends application to the trunk below the waist. Inert ingredients listed are: (Adhesive:) acrylate-vinylacetate copolymer, Guar gum, (Backing film:) polyethylene terephthalate foil, (Release liner:) siliconised polyethylene terephthalate foil (removed before application). For more on patch application, delivery dynamics, dose adjustments and other patch concerns, please see the "Troubleshooting patches" section of this website.

Evorel Sequi is a cycling series of matrix patches, each of which is meant to be changed twice weekly. For two weeks the patch used contains the human-identical estrogen 3.2 mg of estradiol hemihydrate (50 micrograms of estradiol per 24 hours) and for two weeks the patch contains 3.2 mg of estradiol hemihydrate plus 11.2 mg of norethisterone acetate (170 micrograms of norethisterone acetate per 24 hours), a synthetic progestin. The manufacturer recommends application to the trunk below the waist. Inert ingredients listed are: (Adhesive:) acrylate-vinylacetate copolymer, Guar gum, (Backing film:) polyethylene terephthalate foil, (Release liner:) siliconised polyethylene terephthalate foil (removed before application). Cycling HRTs are not required by women who no longer have a uterus, and so this patch is rarely used in surgical menopause. For more on patch application, delivery dynamics, dose adjustments and other patch concerns, please see the "Troubleshooting patches" section of this website.

Femoston contains either 1 mg or 2 mg of estradiol hemihydrate, a human-identical estrogen, plus, in 14 of the month's tablets, 10 mg dydrogesterone, a synthetic progestin. Inert ingredients listed include: Lactose, Hypromellose, Maize starch, Colloidal anhydrous silica, Magnesium stearate, Hypromellose, Macrogol 400, Titanium dioxide (E171), Iron oxide black (E172). The tablets are film-coated, making them unsuitable for dividing; this hrt is not suitable for transbuccal delivery. Cycling HRTs are not required by women who no longer have a uterus, and so this sort of HRT is rarely used in surgical menopause.

Femoston-conti contains 1 mg human-identical estradiol hemihydrate and 5 mg dydrogesterone, a synthetic progestin. Inert ingredients listed include: Lactose monohydrate, Hypromellose, Maize starch, Colloidal anhydrous silica, Magnesium stearate, Hypromellose, Macrogol 400, Titanium dioxide (E171), Iron oxides, yellow and red (E172). The tablets are film-coated, making them unsuitable for dividings; this hrt is not suitable for transbuccal delivery.

FemSeven is a human-identical estrogen patch that comes in doses of 1.5 mg estradiol hemihydrate (50 microgram of estradiol in 24 hours), 2.25 mg estradiol hemihydrate (75 microgram of estradiol in 24 hours), or 3.00 mg estradiol hemihydrate (100 microgram of estradiol in 24 hours). The area of the releasing surface is 30 cm2. It is meant to be changed every seven days. It is probably a matrix patch but this is not explicit in the data sheet; the size is proportional to dose. The manufacturer recommends placement below the waist on the buttocks, hip or abdomen, and emphasis is placed on holding the new patch in place long enough for the adhesive to warm through. Inert ingredients as listed as: (Backing layer:) Transparent polyethylene terephthalate (PET) foil, (Adhesive matrix:) Styrene-isoprene block copolymer, glycerine esters of completely hydrogenated resins. For more on patch application, delivery dynamics, dose adjustments and other patch concerns, please see the "Troubleshooting patches" section of this website.

FemSeven Conti is a matrix patch for continuous use that contains 1.5 mg of estradiol hemihydrate (50 micrograms of estradiol per 24 hours), a human-identical estrogen and 0.525 mg levonorgestrel (7 micrograms of levonorgestrel per 24 hours), a synthetic progestin. It is meant to be changed every seven days. The manufacturer recommends placement on the buttocks or hip, and emphasis is placed on holding the new patch in place long enough for the adhesive to warm through. Inert ingredients as listed as: (Backing layer:) Polyethylene terephthalate (PET) foil, (Adhesive matrix:) Styrene-isoprene-styrene block copolymer, glycerine esters of completely hydrogenated resins, (Protective liner:) Siliconized polyethylene terephthalate (PET) foil. For more on patch application, delivery dynamics, dose adjustments and other patch concerns, please see the "Troubleshooting patches" section of this website.

FemSeven Sequi is a matrix patch for cycling hormones that contains a human-identical estrogen and a synthetic progestin. For two weeks out of the month a patch is used that contains 1.5 mg of estradiol hemihydrate (50 micrograms of estradiol per 24 hours); for the other two months a patch is used that contains 1.5 mg of estradiol hemihydrate (50 micrograms per 24 hours) and 1.5 mg of levonorgestrel (10 micrograms per 24 hours). It is meant to be changed every seven days. The manufacturer recommends placement on the buttocks or hip, and emphasis is placed on holding the new patch in place long enough for the adhesive to warm through. Inert ingredients as listed as: (Backing layer:) Polyethylene terephthalate (PET) foil, (Adhesive matrix:) Styrene-isoprene-styrene block copolymer, glycerine esters of completely hydrogenated resins, (Protective liner:) Siliconized polyethylene terephthalate (PET) foil. For more on patch application, delivery dynamics, dose adjustments and other patch concerns, please see the "Troubleshooting patches" section of this website. Cycling HRTs are not required by women who no longer have a uterus, and so this patch is rarely used in surgical menopause.

Gynest 0.01% w/w Cream is a preparation of human-identical estriol meant to be used in the treatment or prevention of urogenital atrophy.  It may be prescribed as the brand name or simply as a generic with the same ingredients and properties. Estriol is a waste product of estrogen metabolism that has very weakly active properties in urogenital tissues (vagina, bladder, surrounding support structures). Because it has little action in other tissues, some practioners feel that this estrogen is less carcinogenic than more active forms; at the same time, because it is so weak, it may provide insufficient strength for some women's needs. The nominal dose recommended by the manufacturer is 0.5 mg, measured by a provided applicator. Dosing is recommended to be daily for two to three weeks and then twice a week thereafter for maintenance. The manufacturer suggests that treatment should be discontinued after about three months to assess whether further use is required but in surgical menopause it is unlikely that treatment will be only short term. Dose customization is achieved by altering the amount and/or frequency of the maintenance dose. Inert ingredients are listed as including: benzoic acid, arachis oil, glyceryl monostearate, glycerin, glutamic acid, and purified water. The product literature notes that because it includes arachis oil (peanut oil), the product should not be used by those with an allergy to peanuts or to soy. As with all vaginal estrogens, care with timing of use and handwashing will help prevent exposure of a partner to this hormone.

Hormonin was an unusual HRT that provided a blend of the three major human-identical estrogens: Estrone 1.4 mg (61%), Estradiol 0.6 mg (26%), and Estriol 0.27mg (12%), making for a non-custom tri-est equivalent. Inert ingredients are listed as including: Sunset yellow, Amaranth, Lactose, Potato starch, Magnesium stearate, Methyl alcohol,Chloroform. This HRT was discontinued in 2016.

Indivina contains a combination of human-identical estrogen with synthetic progestin taken on a continuous schedule. There are three dose strengths: Estradiol valerate 1 mg plus Medroxyprogesterone acetate 2.5 mg; Estradiol valerate 1 mg plus Medroxyprogesterone acetate 5 mg; and Estradiol valerate 2 mg plus Medroxyprogesterone acetate 5 mg. The lowest of the three is designated by the manufacturer as the starting dose. Inert ingredients are listed as including: Lactose monohydrate, maize starch, elatine, magnesium stearate.

Intrinsa was a matrix patch that contained testosterone but it is no longer on the market. An explanation is here.

Kliofem contains a combination of human-identical estrogen with synthetic progestin taken on a continuous schedule: Estradiol 2 mg plus Norethisterone acetate 1 mg. Inert ingredients are listed as including: Lactose monohydrate, Maize starch, Gelatin, Talc, Magnesium stearate, Methyl hydroxypropyl cellulose (E464), Titanium dioxide (E171), Iron oxide (E172), Propylene glycol, Purified water.

Kliovance contains a combination of human-identical estrogen with synthetic progestin taken on a continuous schedule: estradiol hemihydrate 1.0 mg plus norethisterone acetate 0.5 mg. Inert ingredients are listed as including: Lactose monohydrate, Maize starch, Copovidone, Talc, Magnesium stearate, Hypromellose, Triacetin, Talc.

Livial contains 2.5mg of tibolone, a steroid (hormone) that is referred to as "gonadomimetic" because it can carry out some of the actions of all three sex hormones (estrogen, progesterone, testosterone). It's main difference from estrogen is that it is designed to produce an overall lower level of endometrial stimulation (due to its progestagenic qualities), thus ostensibly making it suitable for use by women with endometriosis. It is also said not to stimulate an increase in sex hormone binding globulin (SHBG), thus interfering less with the activity of a woman's own testosterone. In fact, one of the most common negative effects of this HRT is "the greasies"—the typical picture of mild testosterone excess in overall hormone balance. The manufacturer has demonstrated that it reduces hot flashes and can help prevent osteoporosis. Breast density increases are, according to the manufacturer, not seen with Livial as they are with estrogens. The contraindications and risk profile are nonetheless similar to estrogen HRTs, and the data sheet does include a recommendation that a progestagen be used cyclically by women with a uterus (research). Because this is not a direct hormone analog, women considering its use would be well-advised to read the current research and use precautions available (we've got a number of them in our bookmark account). Inert ingredients are listed as including: Potato starch, magnesium stearate, ascorbyl palmitate and lactose.

Novofem combines a human-identical estrogen with a synthetic progestin in a cycling dose schedule. A month's schedule include 16 days of estradiol hemihydrate 1 mg and 12 days of estradiol hemihydrate 1 mg plus norethisterone acetate 1 mg. Cycling HRTs are not required by women who no longer have a uterus, and so this HRT is rarely used in surgical menopause. Inert ingredients are listed as including: Lactose monohydrate, Maize starch, Gelatin, Talc, Magnesium stearate, Hypromellose, triacetin, red iron oxide (E 172), titanium dioxide (E 171), propylene glycol.

Nuvelle Continuous contains a combination of human-identical estrogen with synthetic progestin taken on a continuous schedule: estradiol hemihydrate 2.0 mg plus norethisterone acetate 1.0 mg. Inert ingredients are listed as including: lactose monohydrate, maize starch, pre-gelatinized maize starch, povidone 25 000, talc, magnesium stearate (E572), methylhydroxypropyl cellulose, macrogol 6000, titanium dioxide (E171), ferric oxide pigment, red (E172). As of July 2019 this hrt is no longer listed as available.


Oestrogel contains human-identical estradiol as active ingredient in a 0.06% gel solution for continuous use. Each measure from the dispenser contains 1.25 gm of the gel, two measures (the usual starting dose) of which contains 1.5 mg estradiol. Dosage increase of up to 4 measures is approved by the manufacturer. If you're having trouble understanding how this dose compares to that of other hrts, please check out our article on transdermal hrt doses. The instructions call for application to arms and shoulders, or inner thighs and drying for 5 minutes before covering with clothing. Skin contact with others, washing or use of other skin care products should be avoided for at least one hour after application. Inert ingredients include Ethanol, Carbomer, Triethanolamine, Purified water.

Ortho-Gynest was a pessary for vaginal use that contained 0.5 mg of human-identical estriol meant to be used in the treatment or prevention of urogenital atrophy. It was discontinued in 2013.

Ovestin Cream is a preparation of human-identical estriol meant to be used in the treatment or prevention of urogenital atrophy. It may be prescribed as the brand name or simply as a generic with the same ingredients and properties. Estriol is a waste product of estrogen metabolism that has very weakly active properties in urogenital tissues (vagina, bladder, surrounding support structures). Because it has little action in other tissues, some practioners feel that this estrogen is less carcinogenic than more active forms; at the same time, because it is so weak, it may provide insufficient strength for some women's needs. The nominal dose recommended by the manufacturer is 0.5gm, measured by a provided applicator. Dosing is recommended to be daily for two to three weeks and then twice a week thereafter for maintenance. The manufacturer suggests that treatment should be discontinued after about three months to assess whether further use is required but in surgical menopause it is unlikely that treatment will be only short term. Dose customization is achieved by altering the amount and/or frequency of the maintenance dose. Inert ingredients are listed as including: octyldodecanol; cetyl palmitate; glycerin; cetyl alcohol; stearyl alcohol; Polysorbate 60; sorbitan stearate; chlorhexidine dihydrochloride; lactic acid; sodium hydroxide to pH 4, purified water. As with all vaginal estrogens, care with timing of use and handwashing will help prevent exposure of a partner to this hormone.

Premarin is the great-grandmother of prescription estrogens and once was the most widely-prescribed drug in the US. It comes as a non-dividable coated pill in 0.625 or 1.25 mg dose strengths. The active ingredient is listed as conjugated equine estrogens. It is derived from the urine of pregnant mares (hence the name), leading to ethical objections to its use by some women. It contains a large number of hormonal compounds that are capable of acting in some ways like estrogen and some compounds that are testosterone-related but not testosterone. There used to be a listing that compared what's in Premarin with what Cenestin, a plant-based comparable, contains at the Cenestin website, but it has since been removed. We've transcribed it and posted the list for you. The US FDA has asked the manufacturer for a full identification of everything that's in Premarin—which the manufacturer admitted they haven't quite worked out yet. Because it's not human-identical, it doesn't work the same way or break down the same way as our own estrogens. This can be good or bad, depending upon your needs. One thing peculiar to Premarin that may be relevant as you deal with its various effects or change from it to another form of HRT is that Premarin stays in the body for a considerable period of time after you take it, and the longer you take it, the longer it takes to wear off. For someone who has taken it for only weeks, this clearance is weeks as well; if you've taken it for years, it may take months to fully leave your system. This means that as you switch, you'll have to gradually increase your new HRT as the Premarin wanes—and you may have hot flashes from that dose fluctuation the whole time. While Premarin has the highest rate of side effects in women we've heard from who are having problems with their HRT, obviously a lot of other women are doing just fine on it. Conjugated estrogens taken orally have also been linked to a higher incidence of hypertension, although studies provide conflicting data on this. We've seen it observed by other health professionals that women taking Premarin are often taking a number of other drugs for "other" problems like asthma, depression, allergies, etc. (that all have hormonal links), but it's hard to guess whether that might have to do with the hormone form or the doctor's style. Many doctors will only prescribe Premarin for HRT because it's the one all the studies have been done on and thus it's the one most "proven." However, you have to keep in mind that these studies were paid for by Premarin's manufacturer, who have been agressively pursuing the market since the Women's Health Initiative study led to such losses for their product. The UK version lists the inert ingredients as, for Premarin 0.625mg: Calcium sulphate, carnauba wax, microcrystalline cellulose, glyceryl mono-oleate, lactose, magnesium stearate, methylcellulose, macrogol, shellac solution (pharmaceutical glaze), sucrose, titanium dioxide (E171), and opalux maroon colour AS-3910 (Opalux maroon colour contains sucrose, purified water, erythrosine (E127), titanium dioxide (E171), sunset yellow (E110), indigo carmine (E132), polyvinylpyrrolidone and sodium benzoate) and for Premarin 1.25mg: Calcium sulphate, carnauba wax, microcrystalline cellulose, glyceryl mono-oleate, lactose, magnesium stearate, methylcellulose, macrogol, shellac solution (pharmaceutical glaze), sucrose, titanium dioxide (E171), colours E110, E104.

Premique contains conjugated estrogens (Premarin) 0.625mg and medroxyprogesterone acetate (Provera) 5.0mg. It is also available as Premique Low Dose with 0.3 mg conjugated estrogens with 1.5 mg medroxyprogesterone acetate. Inert ingredients include: (tablet core:) Lactose monohydrate, Methylcellulose , Magnesium stearate, Calcium phosphate tribasic, (tablet coating:) Calcium sulphate anhydrous, Macrogol, Glyceryl mono-oleate, Shellac,Microcrystalline cellulose, Sucrose, Titanium dioxide, Povidone, Carnauba wax, Colour (E132), (for tablets marked with '0.625/5':) Stearic acid, Edible Ink (iron oxide black (E172), shellac, purified water, ethanol, N-butyl alcohol, propylene glycol, ethyl acetate).

Prempak-C comes in two different strengths. Prempak-C 0.625mg consists of 28 tablets containing 0.625mg conjugated estrogens and 12 tablets containing 0.15mg norgestrel, a synthetic progestin more commonly used in oral contraceptives. Prempak-C 1.25mg consists of 28 tablets containing 1.25mg conjugated estrogens and 12 tablets containing 0.15mg norgestrel. This hrt is meant for women who have a uterus; there is no need to cycle hormones without a uterus.

Progynova provides human-identical estradiol valerate in 1.0 mg and 2.0 mg doses. Inert ingredients are listed as including: Lactose monohydrate, Maize Starch, Povidone 25000, Talc, Magnesium Stearate [E572], Sucrose, Povidone 700,000, Macrogol 6000, Calcium Carbonate [E170], Titanium Dioxide [E171], Glycerol 85% [E422], Montan Glycol Wax, Indigo Carmine [E132], Purified Water.

Progynova is also the name of a human-identical estrogen matrix patch that comes in two dose
strengths: 3.9mg estradiol hemihydrate (50 micrograms of estradiol per 24 hours) or 7.8 mg estradiol hemihydrate (100 micrograms of estradiol per 24 hours). The patches are meant to be changed weekly. The manufacturer recommends placement on the trunk or buttocks. Inert ingredients are listed as including: Isooctyl acrylate/acrylamide/vinyl acetate copolymer, ethyl oleate, isopropyl myristate, glycerol monolaurate mounted on a polyester release liner and protected with a polyethylene backing film. For more on patch application, delivery dynamics, dose adjustments and other patch concerns, please see the "Troubleshooting patches" section of this website.

Provera contains medroxyprogesterone acetate and comes in 2.5, 5, and 10 mg doses (as well as 100, 200, and 400 mg tablets that are used for other purposes than menopause). Inert ingredients are listed as: Lactose, Sucrose, Maize Starch, Liquid Paraffin, Talc, Calcium Stearate, Purified Water with the addition of E110 in the 2.5 mg, FD & C Blue No. 2 Aluminium Lake in the 5 mg, and no coloring in the 10mg. MPA is synthesized from progesterone (we don't know whose). It is shown to be effective in reducing hot flashes and decreasing the rate of bone loss. It is less likely to cause your HDL (good) cholesterol to drop than other progestins. It also has an anti-testosterone effect and can decrease libido. As with the estrogen/Premarin linking problem, some doctors hear only "Provera" when you say "progesterone." Provera is one of the hormones involved in the Women's Health Initiative study that was discontinued due to excessive risk and subsequent research is indicating that some of the risks may have been due at least as much to the provera as the premarin.

Sandrena gel is human-identical estrogen gel for transdermal application. It comes in two dose strengths: 0.5 mg estradiol hemihydrate or 1.0 mg estradiol hemihydrate (the latter dose being designated by the manufacturer as the "usual starting dose"). The gel comes in individual dose packets, with the application instructions that it be "applied once daily on the skin of the lower trunk of the right or left thigh, on alternate days. The application surface should be 1-2 times the size of a hand. Sandrena should not be applied on the breasts, on the face or irritated skin. After application the gel should be allowed to dry for a few minutes and the application site should not be washed within 1 hour. Contact of the gel with eyes should be avoided. Hands should be washed after application. The dose can be divided, but care is needed to do so accurately. Inert ingredients are listed as: Carbomer 974P, Trolamine, Propylene glycol, Ethanol 96%, Aq. purif. - Purified water.

Testim is a form of human-identical testosterone HRT intended and licensed for men. Nonetheless, the hormone it contains is the same as female-produced testosterone. The problem with preparations developed for the male market is that they contain too much testosterone for a woman's level of needs. Because testosterone causes some of the most serious—and irreversible— effects when taken in excess of need, this isn't to be taken lightly. Testogel comes in 50 mg dose packets, each measuring 5 gm of gel each. That means that for a dose of 1 mg, you would need to divide the dose up in some fashion that would let you use only 1/50 of that packet. So not only do you need to be sure that you are taking a female-appropriate dose, but you need to be able to do some fairly delicate measuring to be sure of getting only the amount you want. It's not impossible, but it's not trivial, either. Don't try to do the math on this alone—have your pharmacist confirm any dose calculations to make sure that both of you are in agreement over where those slippery decimal points belong and exactly how much volume your dose should be measured out as. This is when a syringe rather than a measuring spoon is more or less obligatory. We have a discussion of female-appropriate dose and testosterone balancing elsewhere on this site. The application instructions are pertinent to male use; check with your doctor for female-use customization or, if you think he's just giving you the same ones as in the linked data sheet that are for men, review the material in the testosterone section of our website. Inert ingredients are listed as: Purified water, Pentadecalactone, Carbomer 980, Carbomer 1342, Propylene glycol, Glycerol, Macrogol 1000, Ethanol, Trometamol.

Testogel is a form of human-identical testosterone HRT intended and licensed for men. Nonetheless, the hormone it contains is the same as female-produced testosterone. The problem with preparations developed for the male market is that they contain too much testosterone for a woman's level of needs. Because testosterone causes some of the most serious—and irreversible— effects when taken in excess of need, this isn't to be taken lightly. Testogel comes in 50 mg dose packets, each measuring 5 gm of gel each. That means that for a dose of 1 mg, you would need to divide the dose up in some fashion that would let you use only 1/50 of that packet. So not only do you need to be sure that you are taking a female-appropriate dose, but you need to be able to do some fairly delicate measuring to be sure of getting only the amount you want. It's not impossible, but it's not trivial, either. Don't try to do the math on this alone—have your pharmacist confirm any dose calculations to make sure that both of you are in agreement over where those slippery decimal points belong and exactly how much volume your dose should be measured out as. This is when a syringe rather than a measuring spoon is more or less obligatory. We have a discussion of female-appropriate dose and testosterone balancing elsewhere on this site. The application instructions are pertinent to male use; check with your doctor for female-use customization or, if you think he's just giving you the same ones as in the linked data sheet that are for men, review the material in the testosterone section of our website. Inert ingredients are listed as: Carbomer 980, Isopropyl myristate, Ethanol 96%, Sodium hydroxide, Purified water.

Testosterone implants are no longer available on the NHS although private clinics may still have a way of obtaining them.

Tridestra is a combination of human-identical estrogen plus synthetic progestin that is given on a quarterly rather than monthly schedule. The recommended dosing is 70 days of 2 mg estradiol valerate, followed by 14 days of 2 mg of estradiol valerate and 20 mg of medroxyprogesterone acetate, followed by seven days of a non-hormonal sugar pill. Cycling HRTs are not required by women who no longer have a uterus, and a cycle that includes a period without any hormonal support is not likely to be especially comfortable for any woman in surgical menopause. Inert ingredients are listed as: Lactose, Maize starch, Gelatine, Purified water, Magnesium stearate, Talc, Indigo carmine (E132), Yellow iron oxide (E172).

Trisequens combines a human-identical estrogen and synthetic progestin in a three-phase dose schedule: 12 days of Estradiol hemihydrate 2mg, followed by 10 days of Estradiol hemihydrate 2mg plus Norethisterone acetate EP 1mg, followed by 6 days of Estradiol hemihydrate 1mg. Inert ingredients are listed as: Lactose monohydrate, Maize starch, Gelatin, Talc, Magnesium stearate, Hypromellose, Purified water, Indigo carmine (E132), Titanium dioxide (E171), Macrogol 400, Triacetin, Iron oxide (E172), Propylene glycol. Note: some lists also show a higher dose product called Trisequens Forte, but we are no longer able to locate a full description for it.

Utrogestan provides micronized human-identical progesterone in an oil-filled gelcap. It comes in a 100 mg dose and also includes refined sunflower oil, soya lecithin, gelatin, glycerol , titanium dioxide, and purified water. The oil is required to provide a timed-release function. This is a much larger dose than is normally taken transdermally because of first pass liver losses, even with the oil doing its best. It's also a larger dose than many women in surgical meno need, and some women must take it at night because it makes them so sleepy. Remember that progesterone has a sedative effect on the brain similar to that of Xanax or Valium, so this isn't really a side effect but rather a desired effect that may simply be too strong at the provided dose. Women who particularly want the sedation to counteract the stimulating effects of estrogen may find they get more sedating metabolites from oral progesterone than transdermal, although from a risk-management standpoint they might be better advised to more tightly tune their estrogen dose. Because prometrium is human-identical, it can be converted into testosterone and estrogen as well as other adrenal hormones such as cortisol. In a pinch, women who wanted to try out the transdermal route (to distinguish between route-related and hormonal effects) have been known to puncture a gelcap and rub the oil on their skin. This should work (they report it does) but it's obviously difficult to measure accurately. Remember that taking a whole 100 mg cap transdermally is four to eight times the normal transdermal dose, so it would seem prudent to cut way back on the amount used if you try this. (Note that there is also a 200mg dose of this product that is meant to be used vaginally for reproductive issues. It is not suitable for surgical menopause, even by women who have a uterus, because it provides five times the typical vaginal dose used for uterine protection.)

Vagifem is a human-identical estrogen tablet for vaginal application. It contains 10 micrograms of estradiol. This is not a systemic hrt but rather is meant to be entirely absorbed locally for treatment of urogenital atrophy, without systemic effect. Nonetheless because some estrogen can escape from local tissues, especially when vaginal atrophy is already present, it may cause a few symptoms of hormonal fluctation early in use and it is not considered safe for use by women who cannot use systemic HRTs. Use of progesterone or a progestin is not required by women who have a uterus and use this product because the dose is so low. The recommended dose schedule is one tablet daily for two weeks followed by a maintenance dose of two tablets per week. The manufacturer suggests that "treatment should be discontinued after about three months to assess whether further therapy is necessary" but in surgical menopause it is unlikely that treatment will be only short term. Dose customization is achieved by altering the frequency of the maintenance dose. Because the dose is low, severe or longstanding atrophy may take more than the two-week period of intensive dosing to respond to treatment. Inert ingredients are listed as: Methyl hydroxypropyl cellulose (E464), Lactose, Maize starch, Magnesium stearate, Polyethylene glycol 6000, Purified water. The data sheet lists no recommendations regarding the use of this product by sexually active women, but wisdom would dictate defering the dose until after intercourse to avoid potential exposure to a partner.

Zumenon is a human-identical estrogen available in two doses: 1 mg and 2 mg estradiol hemihydrate. Inert ingredients are listed as: Lactose, Hypromellose, Maize Starch, Colloidal anhydrous silica, magnesium stearate, Hypromellose, Macrogol 400, Titanium dioxide (E171). We have reports from women that this hrt delivers effectively when taken transbuccally but do not have any manufacturer's confirmation of this and it is not specifically licensed for this delivery.

Troubleshooting patches: location

There are two factors that affect patch performance that involve location.

The first is the purely mechanical. It doesn't matter how much the patch is capable of delivering if you can't keep it flat and adhered fully. This means that folds, rumples, areas of high clothing friction, and places with thick fine body hair are just not going to work well no matter where they are. Upper arm and thigh are some off-label locations that some women have reported satisfactory results with when they don't have enough suitable real estate in the mid-body areas.

As a rule, though, best results are obtained in the outer half of each body half, but not so far "around the edge" that there's a lot of curve to the location and not directly over an area where there is little padding over the bone or over large muscles.

The other location factor is that studies by manufacturers have shown that patch delivery (same patch, same dose, same degree of adhesion, different location) varies by 17-25% depending on whether it's on the front of your body or back. That is, locations on your butt deliver more to your system, from the same patch, than if it were placed on the front of your body.

Our speculation on this—and that's all that it is because it's not elucidated by the manufacturers—is that the large muscles in the butt (the same ones that make it a good location for shots) cause more circulation to the area when you move around, leading to the hormone being pumped away from the patch location at a more rapid pace. On the belly, unless we're seriously into muscle-building, that's less likely to be the case. This would correspond to the experiences women with little body fat or women who undergo a lot of weight/fat loss see, where they find that their patch dynamics are changed such that they may not be able to use patches satisfactorily any longer.

Now it's true that not every manufacturer includes this dosing variability in their product information, and that some state that the patch can only be used in one particular location. These cautions have more to do with the testing and approval process than actual patch dynamics, however. If the manufacturer does not go to the expense and time of specifically testing their product in multiple locations, they can't claim those results—only the ones they actually demonstrated in their FDA application can show up in their licensing. And because they can only claim those specific results, it's obvious that they can tell you that only that location works as specified. It's not that other variations don't work, won't work or have been determined not to work: it's just that they don't have the legal right to allow even that they might work without demonstrating this through specific testing.

There is nothing in the physiology of hormone uptake or the mechanical delivery of hormones from patches that would make one work in a specific location and not the other. In practical terms, it is entirely reasonable to generalize from the specific test data to general patch performance, leaving aside delivery variations due to specific patch qualities.

Further, this can be expanded to general considerations in patch placement. Aside from on or within the immediate circulatory feeders of breast tissue, there's virtually nowhere that is an absolute contraindication to patch placement. We'd have second thoughts about over some moles (for the same reasons as avoiding breast tissue), but otherwise, if the bottom of your foot is the only available real estate and you want to use a patch, there's not an obvious reason beyond the mechanical why that won't work. We have no idea what the delivery efficiency would be, but that can be deduced in practice.

The point is, then, that different underlying tissue types seem to affect your uptake (and provide a subtle way of manipulating that intake) for any two locations where the mechanics of sticking are equivalent. But because delivery is first and foremost dependent upon patch adhesion, locations where a patch won't stick just aren't in the running.

For more information on alternate locations and their dose delivery, plus more documentation on the importance of the tissue type underlying a patch, check out this other post looking at what we can learn from contraceptive patches. For help doing the math on how much difference location makes to a specific patch dose, please join us on our discussion forums.

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.