"Doctor, is the patch better, and how do I use it?"

The benefits of using the patch for hormone replacement, with a few exceptions, are not significantly different from those when taken in a pill form. The choice should depend primarily upon the woman's preference, and for those choosing the patch there are a few small tricks for making it easier to use.

· Patch - small plastic adhesive patch that a woman puts on her lower abdomen or upper buttocks and changes once or twice weekly. It has hormones on the patch that are absorbed slowly through the skin

· Pills - the more traditional way of taking replacement hormones; there are many different types of hormones, both natural and synthetic, that can be taken in a pill form

The patch contains hormones that are absorbed transdermally (through the skin), and allows a woman to receive hormone replacement without taking anything by mouth. The patch originally was available only with estrogen, and this posed a problem in the woman who also needed progestrone to protect the uterus. If a woman still had her uterus, then she would end up still taking a pill in spite of using the patch. Fortunately there is now a patch with both estrogen and a type of progesterone; it has been available in Europe since 1995 and recently became available in the United States.

The patch allows the replacement hormone to be absorbed through the skin, as opposed to a pill where it is absorbed by the stomach. Because the contents absorbed by the stomach (e.g., pills) first pass through the liver for digestion, some doctors feel it is an advantage if the hormone is absorbed through the skin (as with a patch) thus avoiding passing through the liver. However, after a minute or two even the hormone absorbed through the skin is mixed through the entire blood system, and also begins to pass through the liver at this time. Thus, this probably makes little difference to most women; however, if they do have a history of liver disease or gallbladder problems then they probably should consider using the patch instead of a pill. Some women have problems taking any kind of pills by mouth, and they also would probably be best served by choosing the patch.

On the other hand, some women either have trouble keeping the patch on or have a reaction to it (see below). Moisture tends to make it come off, and women who exercise a lot or live in humid climates often have difficulty with the patch. Obviously if the patch is always falling off, the woman is not absorbing much of the hormone. In addition there is a question of whether the patch may elevate the cholesterol in women, so an increased cholesterol level is a reason to choose the pill. And many women take other medications every day, and would rather just take another pill every day rather than have the additional hassle of wearing a patch and changing it.

The patch may be placed on the skin of the lower abdomen or the buttocks. Some women tend to have more reactions when it is placed on the lower abdomen. The skin of the buttocks is slightly thicker, and reactions are less common here. Women who tend to have skin reactions should consider placing the patch over the upper buttocks. However, because of the increased thickness of the skin over the buttocks the absorption is about 10% less here. So if women become symptomatic when placing the patch on the buttocks, then they should try placing the patch on the lower abdomen in front.

Problems

· Skin irritation - some women an develop a skin irritation underneath the patch

· Inability to keep patch on - some women have trouble keeping the patch on the skin

The two most common problems with the patch are that women may develop a skin irritation where they had applied the patch, or they may have trouble keeping the patch on the skin. If the patch continues to fall off, it is wise to thoroughly cleanse the skin and allow it to completely dry before applying the patch. Usually a skin irritation is due to the adhesive in the patch, and this is usually an alcohol based adhesive. Women can buy an over the counter 1% hydrocortisone cream to use on the skin irritations, and some authorities even recommend putting it on the area and allowing it to dry before placing the patch on the skin. Certainly when the patch is changed the application site should be rotated. Use of a non-alcohol based adhesive remover on the skin after removing the patch will also help to reduce the skin irritations.

The bottom line is that the method that women are most comfortable with is the method they are most like to continue to use and realize the benefits, and thus is the one they should ultimately choose for replacement hormone therapy.