Supplementing oestrogen as the levels fall, whether naturally or other reasons such as switching off the ovaries or surgical removal, can be achieved with different types of oestrogen replacement:
Transdermal (through the skin)
Gel – this is one of the most popular forms of oestrogen replacement prescribed. It is massaged into the arms or legs daily or twice daily although as the effects can wear off after 10-12 hours, it is generally better to split the dose rather than have a loading dose once a day which can have a beneficial effect but then wears off as the day goes by. In women with fairly thick skin or poor circulation it can be advisable even to apply the gel every 6-8 hours rather than once or twice a day to keep the blood levels steady. Brands available include:
Patches – patches are applied to the skin and changed usually twice weekly but occasionally weekly. The benefits are it can be easier to remember than gel and gives a background steady delivery. The disadvantages are that they are not aesthetically nice to look at and can cause irritation and therefore poor absorption underneath the patches. Additionally, if you partake in activities such as swimming or physical sports that induce sweating then patches may not be a good option as these are more likely to peel off or not absorb adequately. Dosages relate to the amount of oestradiol released over 24 hours –between 25mcg and 100mcg. If absorption is poor then occasionally the dose may need to be increased by adding in an extra patch if the highest dose is not adequate.
Brands of twice weekly patches include:
Spray – sprayed onto the arms or wrists or legs daily or twice daily can be a good alternative to gel as it could have a quicker absorption time but individual response may vary. Brands include:
Implants – these are inserted by a gynaecologist under local anaesthetic every 6-12 months and it delivers oestradiol slowly into the circulation. Benefits includes higher levels of oestradiol without having to apply extra gel, patches or spray. Disadvantages include the effects wearing on after 4-5 months and may need to supplement with other forms of transdermal oestrogen in this time until the next implant is due.
Tablets – Oestradiol
Oestrogen tablets convert via the gut wall and liver to a different type of oestrogen from transdermal or oestrone. Tablets can be extremely effective at delivering steady levels of oestrogen into the circulation with better absorption in some cases than just other types of oestrogen. These can be used on their own or in conjunction with transdermal. Because oral oestrogen delivers via the liver, some studies indicate a more beneficial effect on cholesterol lipid profile compared to transdermal alone.
Although many doctors (general practitioners and even gynaecologists) advise avoiding oral oestrogen because of potential clotting risk, this in fact relates to outdated studies regarding Premarin (horse oestrogen) which was reported 20 years ago in the WHI study. The study therefore no longer relates to modern prescribing which uses bioidentical - oral oestradiol which is a completely different molecule and much weaker than Premarin and does not increase the risk of clotting significantly and certainly only a tiny fraction of that compared to smoking, being overweight and other lifestyle factors.
Therefore, taking oral oestrogen, with or without transdermal, may be a beneficial addition to your HRT regimen, depending upon your absorption and symptom response to transdermal alone. This will depend upon whether you can continue to have symptoms and the FSH response.
Brands of oestradiol tablets include:
Dosages of these tablets start from 1mg per day up to 8mg, starting at the lowest dose and increasing in increments, monitoring symptom response and FSH to indicate whether absorption is adequate. SHBG may need to be checked when doses greater than 2mg per day. SHBG is a protein produced in the liver in response to oral oestrogen and can block the effects of oestrogen in circulation.
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