Probably the biggest advantage the patch has over tablets is that, because the oestrogen is absorbed through the skin (doctors call this ‘transdermal’ HRT, meaning ‘across the skin’) and does not have to go through the liver and the rest of the digestive system, it is taken in a much lower dose and has fewer side-effects. It is easy to use, and easy to stop if you find it doesn’t agree with you. Also, the oestrogen is absorbed at a slow, constant rate, whereas if you use oral HRT you are taking the hormone in one dose all at once, which can increase the likelihood of side-effects, particularly in the digestive system.

The patch is simple to use: you just stick it on to a well-padded area of clean, dry skin, such as the buttocks, abdomen or upper thighs, and change to a new patch every 3-4 days, by which time all the alcohol and oestrogen will have been absorbed. You must not stick it on to the breasts. The main drawback with this form of HRT is that about one-third of women find they develop red and itchy skin at the site of the patch, and in a very small percentage this becomes so severe that they have to give up. This is caused by the alcohol contained in the patch and there are two possible solutions. One is to move the patch to a new area of skin every day (but still only having a new patch every 3-4 days), and sticking it down with a piece of elastoplast across it. The other is to wave the patch about in the air for a few seconds before applying it so that some of the alcohol evaporates. Don’t do this for too long, however, as it is the alcohol that transports the oestrogen through the skin; no alcohol means no oestrogen. More of the oestrogen is absorbed through the abdomen than through the buttocks or upper thigh, but the buttocks usually give the least skin irritation. (Before long, a new HRT patch will be available without an alcohol base; this should eliminate the problem of skin irritation.)

The skin reacts more to the patch in a hot, humid climate, so some women find it a problem if they go to a hot country on holiday. Leaving the patch off when you lie in the sun is one solution, or possibly changing to tablet HRT while you are away, but this might cause undesirable side-effects. If the patch comes off after swimming or a bath or shower, just stick the same patch back on again with some elastoplast.

The patch comes in three different strengths: 25, 50 and 100 micrograms of a form of oestrogen called oestradiol. If you find it is not having the desired effect, don’t be tempted to change to a new patch more frequently as this will not increase the amount of oestrogen you absorb. If you are not happy with its effect, ask your doctor about changing to a patch with a higher or lower dose.

The patch is generally well tolerated, and many prefer it to tablets and are less likely to give up. As before, if you haven’t had a hysterectomy, you will have to take progestogen for 10-12 days a month. Until fairly recently, progestogen was only available in tablet form, but there is now a combined oestrogen and progestogen patch called Estracombi, manufactured by Giba-Geigy. For the first two weeks of the cycle, oestrogen-only patches are worn for 3-4 days each; for the following two weeks, the double oestrogen and progestogen patches are worn for 3—4 days each. Because each double patch contains both hormones, it is not possible to use only the oestrogen patch for this phase of the cycle and to leave the progestogen patch in its box! The manufacturers report that symptoms similar to premenstrual syndrome may be a problem for up to three months, but these should diminish after that time.

The patch method of taking HRT has die same beneficial effects as oral HRT on hot flushes, night sweats, disturbed sleep, changing moods and vaginal dryness. Research suggests that, except at the lowest doses, it also preserves bone in 85-95 per cent of women, but because it is a comparatively new form of HRT it is not yet known for certain the extent to which it provides the same protection against arterial disease. Like oral HRT, the patch can cause breast tenderness, spotting, bloating and feelings of nausea, but these are seldom severe.

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Whatever the source of calcium, taking some of it in the evening will help to minimise bone loss overnight. The traditional warm milky drink before bedtime may have more going for it than merely being an aid to sleep!

People with existing osteoporosis absorb calcium less efficiently than others, and this is often linked with a deficiency of vitamin D, which is produced by the skin in the presence of sunlight. By ensuring regular small amounts of exposure to sun (sometimes a problem for elderly people with mobility problems), or by taking vitamin D in a multivitamin capsule, you can improve calcium absorption. Osteoporosis researchers urge women taking vitamin D supplements not to overdo it, as this can worsen the body’s calcium balance.

Various non-hormonal medications are being studied for an effect on bone health, including calcitonin, thiazide, sodium fluoride, anabolic steroids and etidronate. It is too early, as yet, to advocate any of these as an aid to preventing or treating osteoporosis.

Giving up smoking, if they have a cigarette habit, is one of the most helpful things women can do to reduce their risk of developing osteoporosis, according to a US study reported at the Fourth International Symposium on Osteoporosis in 1993. Among a group of nearly 8000 postmenopausal women, those who smoked were nearly three times more likely to sustain a hip fracture than non-smokers when all factors were taken into account. Other research has found that women who do not smoke, or who stop smoking before menopause, cut their risk of a hip fracture by 25 per cent.

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Women on HRT are more likely to be examined by a doctor and to have regular screening tests and monitoring of their general health than those who are not. This might result in a false picture of risks to health posed by HRT (because diseases not picked up in the general female population may be recognised in the HRT group as a result of their seeing doctors regularly and having more investigations). Paradoxically, the HRT group might survive longer, not necessarily because of any benefits conferred by their hormone treatment but because their routine monitoring might result in earlier disease detection, when the chances of successful treatment tend to be better.

The current upsurge of interest in HRT is occurring at a time when heart disease rates are declining and breast cancer rates are increasing in countries like Australia and the US. HRT may be contributing to these trends, but the extent of this contribution is controversial.

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A small number of women with oestradiol implants experience an earlier than normal return of their symptoms — as if the implant had run out — despite adequate levels of oestrogen in their blood. These women return for further implants at shorter and shorter intervals. The cause of this phenomenon, called tachyphylaxis, is not known. With each implant inserted, the amount of oestradiol in the blood rises, usually to high levels. Though the consequences of persistently high levels are unknown, further implants are not recommended until levels return to the normal premenopausal range. Affected women go through a difficult withdrawal phase and require regular blood tests until normal levels are attained. If their symptoms are severe, relief may be obtained with the higher-dose oestrogen patches. Regular testing of oestradiol levels will help to avoid this phenomenon in implant users.

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