Joy’s Question: Is the Vivelle patch good to use? My gyno prescribed it for hot flashes, vaginal burning, vaginal itching, and mood issues during ovulation before my period. I have not tried it yet, though.
Short Answer: Some women do fine with the Vivelle patch. However, in our experience, many women do not tolerate the patch very well, or it does not provide full relief of menopausal symptoms. The key to this question is the fact that Joy was prescribed the patch, but is still having a regular period. We don’t agree with using the patch for women who are still menstruating. There are some better options that we discuss in this episode.
PYHP 106 Full Transcript
Dr. Maki: Hello, everyone. Thank you for joining us for another episode of the Progress Your Health podcast. I am Dr. Maki.
Dr. Davidson: And I am Dr. Davidson.
Dr. Maki: Well, we are back. It has been a little bit of a hiatus. We had a really amazing summer, right? You know, summer is always a fun time. So we took a little bit of time off on the podcast, but now the weather has changed a little bit. We are into fall, the perfect time to kind of get back into the podcasting routine.
Dr. Davidson: Definitely. Ready to hit the ground running. Although fall was really beautiful here with the leaves changing. So yeah, it is good. I am definitely ready to get back into the podcasting seat.
Dr. Maki: For some reason, when it was really nice out and the sun was shining every day, it was really difficult to come and sit down and do a podcast. It was really challenging, but nonetheless, we kind of decided ahead of time that we were going to do that anyways. But now we have lots of questions that people have reached out to us with. So we have just a tremendous– [laughter] in some ways, we probably should not have taken that time off because now we have so much work to do, but this is good.
These are legitimate questions that people are asking us, and we feel that without coming up with topics of our own, this makes it so relevant when people ask us question because we get to hear our listeners. We get to hear our readers for the blog post. We get to hear what problems they are actually dealing with.
And I think that is really valuable because now we have a chance to sit down, kind of discuss them, give everybody our opinion. So that one person really is helping a lot of people because now we are giving our answer to that very specific question to lots and lots of people.
Dr. Davidson: Exactly. When you write in or email us with your question, know that you are not alone. The question you have, trust me, we have heard it over and over and over again so it is really great to get it from a reader or listener’s perspective, and then when we can apply it to the masses, it helps everyone.
Dr. Maki: Yeah, right. So we are going to dive in this question. Now, we are changing everybody’s name just to keep it so there is no question about identity or anything like that. So the name that we are going to give is not the actual name of the person, but nonetheless–
Dr. Davidson: Just for protection, anything that looks like it would be something that– we would just change even if it is descriptions about themselves or jobs or where they live. We always change all that, that privacy information. Just to keep the question valid but without feeling like anybody has to be pinpointed where they are.
Dr. Maki: Yeah, right. So go ahead. Dr. Davidson, won’t you go ahead and read the question.
Dr. Davidson: Okay. So this question is from Joy. This is actually a question we get all the time over the years, over the span here. “Is the Vivelle patch good to use? My gyno prescribed it for hot flashes, vaginal burning, vaginal itching, and mood issues during ovulation before my period. I have not tried it yet, though.”
So there is a couple aspects to this. One, of course, we want to talk about the Vivelle estrogen patch or the estradiol patch, and then also a little bit about Joy and why she is using it and when she is using it.
Dr. Maki: Right. So there is not a lot of information here, right? So when you just read that question without having a little bit more background like you and I do, this is kind of a loaded question in some respects. I did not catch it the first time until you just read it. I read the first part of it and I kind of just– I did not see the other part.
What I am referring to is the fact that it says “during ovulation before my period.”
Dr. Davidson: I get that question a lot over the years because we are looking– because we do a lot of– we do bioidentical hormone replacement. That is [inaudible]. Everybody talks about HRT, Hormone Replacement Therapy, and that is a big umbrella for all hormones. What we do though, in particular, the bioidentical, and we specifically will use more compounding pharmacy so we can make something tailored to that individual for their particular symptoms.
So it is interesting with this is a Vivelle patch which we are going to get into in a minute is more conventional. You are going to get that from your big box pharmacy. There is four different doses and that is all you have.
Women will tell their practitioner, their gynecologist, “Hey, listen. I feel great this time of my cycle, but I do not feel great this time of my cycle. What do I do?” So they are trying to really sort of take a huge– I would not even say like a one-size-fits-all and try to morph that into something more tailored for that individual.
So of course, during ovulation to her period, that could be from day 14 to day 28. The doctor is trying to give her a little extra estrogen thinking she is needing it, but it is really kind of like taking a shotgun approach and trying to shoot a little dart on the wall or a little pinprick on the wall.
Dr. Maki: Using an elephant gun to shoot the fly off the wall.
Dr. Davidson: Yes. [chuckles]
Dr. Maki: Something that is– one that you actually just kind of made me realize recently. [inaudible] another patient that was dealing with the Vivelle patch on how strong– you look at the dosage. I know there is a 0.5–
Dr. Davidson: There is four different doses. The lowest is 0.025, then there is 0.0375, 0.05, 0.075. So there is a lot of zeros there, but know that the 0.025 is, of course, less strength compared to the 0.075.
Dr. Maki: Right. The confusing part is that those dosages seem really, really low.
Dr. Davidson: When you try to think about it compared to the type of hormone replacement we do, like we might do an estradiol or a biased that has a combination of estriol and estradiol, or estriol E3 and estradiol E2. So when a doctor takes somebody on a Vivelle patch that is on a 0.075mg of estradiol for that patch–
Dr. Maki: Which is the highest one.
Dr. Davidson: That is the highest one. You have to apply it twice a week. So usually you get eight of them a month and then you apply one twice a week. When they say, “Listen. This is really strong. I do not want to be on this Vivelle patch anymore. I want to do that bioidentical things and stuff I have heard about.”
When the practitioner that is not super familiar or maybe experienced with the compounding biased or the creams of the estradiol is all look at Vivelle patch at 0.075, that they are applying this patch twice a week, and they will try to use that same exact dose or compounded cream. They will say, “Okay. We want the estradiol to be 0.075, or a bias to be 0.5 or even 1.0.
They think, “Oh, that could be too high.” That is going to be higher than the Vivelle patch when you are trying to say the dosages between these milligrams, and I hope that this is coming across, okay, or it makes sense, but in some ways, it is not supposed to make sense because when you are trying to transition or somewhat switch someone from a Vivelle patch to an actual bioidentical compounded hormone cream with estriol and estradiol in it, you cannot. I mean, you can, but there is no equation to equivalate for that transition or that changeover.
Dr. Maki: There is no chart that the pharmacy can give you or no conversion that you can do that is equivalent from a Vivelle patch to bioidentical hormones. That does not exist. I know that you have done a very good job over the years of nothing more just observing, but being able to kind of figure out based on the woman’s symptoms, based on how old she is, based on who she is, based on where she lives, based on the stress in her life, based in her sleep, based on her goals, all those things–
Dr. Davidson: And what dose of the Vivelle patch she is on, if it is straight estradiol, and how long she has been on it. Because that is why sometimes, bioidentical hormone replacement or the compounded creams get a really bad wrap because they will say, “Oh, I was on this patch and then I got on that bias cream and I felt terrible.” And that was really because they always end up under-dosing the cream.
Dr. Maki: Yeah, right. So really, when you are going from the Vivelle patch to bioidentical hormones, you have to really increase that dose, and dosing to a dosing level that most doctors, to be honest, are probably not comfortable with which is why we always see people asking us all these questions. “I am on half a milligram.” “I am on 1.25mg.” “I am on one and a half milligrams.”
Dr. Maki: If you are going from the conventional things to the bioidenticals, that is not nearly enough. Of course, they are going to feel worse because it is like they are pulling the rug out from underneath them, going from, let us say, like you said earlier, 0.075 Vivelle to 2mg. Even 2mg of a biased, that is not nearly enough and they are going to feel worse. They are going to feel terrible going that way.
Dr. Davidson: To be honest, I find that the bioidentical hormone compounded creams like a bias that has the estriol and the estradiol in it is much more safe and gentle than a Vivelle. But I can understand a conventional practitioner not really familiar thinking, “Oh my gosh. [inaudible] 7mg of a biased 80/20 ratio.” Or even sometimes, I have to go even change the ratio to 50/50. So there is a little stronger estradiol to really bridge that transition from the Vivelle patch over.
They might think, “Oh, that seems like a lot.” But really, truly, when I see a woman on a Vivelle patch, that is a lot of estradiol. For me, just in my experience in watching how the breast tissue morphology changes, the weight, their symptoms, I feel like– or if they have a uterus or they do not, I feel like that can be pretty much a pretty strong heavy hitter to be on the Vivelle, that if they are going to be on it, that we definitely want to monitor the symptoms. Try to keep it as low as possible.
Sometimes I even have them do it once a week or they cut the patch in half and do that one patch twice a week when we are trying to transition or change or just to really keep that level low. So I know I am kind of digressing away from Joy, but we kind of wanted to talk about the Vivelle patch in particular.
But also kind of like Dr. Maki was saying, the elephant gun trying to shoot a fly on the wall, as I understand her practitioner probably really wants to help Joy feel better from day 14 to day 28, but does not really have a lot of resources available to understand how to bridge that or how to give her a good treatment because if Joy is going to put on that Vivelle patch for half of the month, number one, it is going to down-regulate all her estradiol receptors so that from day 1 to day 14, she is going to feel kind of crummy, and for two, she probably is not going to feel great on that patch.
She will probably sleep better and definitely the hot flashes would be better, but she would have a lot of symptoms of estrogen dominance because you really do not need to give a woman of Vivelle patch which is pretty strong if they are still cycling.
Dr. Maki: Yeah. Pretty much, that was the part that I missed the first time when I just glanced over this, but you are right. I mean, the fact that she is still menstruating, ovulating, and we do not know how old she is, more than likely I would say if she is having hot flashes, vaginal burning and itching, mood [inaudible], she is probably in perimenopause.
Dr. Davidson: That might be in the mid-40s. Probably in her mid-40s, maybe early, but even then a doctor is pretty hesitant about giving a woman in her 40s estrogen. [laughter]
Dr. Maki: Yeah, right, but she is right off the bat. She is really not a candidate for estrogen at all. Maybe a little bit like that is where the bioidenticals would really kind of work well here because they are not as strong as the Vivelle patch. Vivelle patch, even the lowest dose, is probably just not going to make her feel very good.
And like you said, from ovulation to her period, that is more of a progesterone window. That is not an estrogen window. It is going to cause some irregular bleeding and it is just going to make her feel worse.
Dr. Davidson: I was going to say that right there. That extra estrogen would probably make her cycle– as soon as she put it on on day 14, she would probably get a period on day 20. Day 19, day 20, as soon as– and it probably would even overtime thicken the inside of her uterus or that endometrial lining so her periods become, I imagine, they are probably not super great if she is having these symptoms already, but they will get worse. Her periods will get heavier and longer and more painful.
Dr. Maki: So what she needs, just as a side kind of flip the script a little bit. So what will we be doing differently in this case, and for this particular situation, the Vivelle patch, we do not really like it anyways. We have had a few patients use it over the years. Some do okay with it on the lower dosing, not so much on the higher dosing, so we will tend to switch them away because we can control those prescriptions.
Now, they might need more. They might need a higher dose of the bioidenticals, but that is better in some respects because we are able to control the symptoms more.
Dr. Davidson: Exactly. The only time I really find that the Vivelle might– seems like it is a match is when a woman’s definitely post-menopausal, those ovaries have decided not to– they are not working, and really, women that have had a hysterectomy because you think about if they have had a hysterectomy there, you do not have a uterus so they can kind of tolerate a little bit more estrogen because when you think about somebody on a pretty strong form of estrogen and they have a uterus, estrogen loves to grow things.
So it will grow that endometrial lining in the uterus, and that is where you see women in their postmenopausal in their 50s and early 60s having like they feel like their periods are come back, but no. It is only because that lining is inappropriately thick which is a risk factor.
So when you see a woman with a uterus taking a Vivelle patch for menopause, they always have to take a progesterone counterpart if they have a uterus. So that is just on a side note. It is just one thing that I see. If you are going to do the patch, it does seem to fit better with women if they do not have a uterus.
Dr. Maki: Right, right, and we even recommend that woman still takes the progesterone even if they do not have a uterus which is very common that gynecologist say, “Well, you do not have a uterus anymore. You do not need any progesterone.” But we do not agree. We think that they– one of our rules that we never break is you never give a woman unopposed estrogen. You always give them both.
So in this case, we are assuming, making a big assumption here because Joy did not tell us how old she is, but like you said, she is probably 45, probably somewhere between 45 to her late 40s, maybe even–
Dr. Davidson: 40 to 50. 40 to 47.
Dr. Maki: Well, she mentions the word ovulation and before a period. If she is in that window, more than likely she is not ovulating unless she is a lot younger than that. But maybe a lot of women do believe if they are menstruating that they are ovulating. And you can menstruate without ovulating. You can ovulate without menstruating, but you can menstruate without ovulating.
Dr. Davidson: Exactly.
Dr. Maki: Hopefully, that was not too confusing, what I just said.
Dr. Davidson: [laughter] No, that was perfect. So I would say with Joy, since she sounds like she is having regular periods and sounds like probably 28 days, maybe 27, maybe 29, as we test her blood work. We check her hormones. We check her hormones, probably post what would be ovulation so anywhere right around day 17 to day 22, if she is a perfect 28 day cycle.
So you can kind of get that window to find out, well, is she ovulating? Does she had progesterone? Are her estrogen levels actually low the second half of her cycle? So that would probably be the first thing, and then from there, pairing those symptoms up with what the objective hormones data shows us, then like Dr. Mackey said, is we might do some progesterone and then we may even do a very, very low dose of a biased, maybe not even do the estradiol at all. Just do a little estriol or just a very tiny, tiny dose of some estradiol with some estriol.
That is where we, depending on Joy’s age and her symptoms and then her blood work and her, of course, health and family history, that is where we would kind of move forward with that.
Dr. Maki: I was thinking that we would do some progesterone and maybe like an estriol cream for the vaginal burning and itching. Very simple. You think a gynecologist would kind of know that.
Dr. Davidson: Well, you can see they are trying. They really are trying with what they have.
Dr. Maki: With a limited tool belt. They do not really have a lot of– certainly, the hot flashes that makes you think estrogen, but the fact that she is having a period every month or at least what we understand is every month, probably somewhat regular, that tells you that her estrogen threshold is still relatively pretty good because she is still having a period every month.
A little shameless plug for your book that is going to be coming out fairly soon, which is The Perimenopause Plan. This is kind of a classic. They are still menstruating but having hot flashes. For women, that is a really tough place to be because they are not necessarily estrogen candidates like we have been discussing.
Vivelle patch for her is not really the best option. One, it is too strong, and two, it is not really a lack of estrogen because of the regular period. It is more of a lack of progesterone and also looking at stress level. If she has got a lot going on with COVID and everything, who knows. Everybody’s stress is all over the place. For some, that could make some of those symptoms a lot worse. Then the estriol that we talked about, that would just help on a local level, help some of the vaginal issues.
Dr. Davidson: No, thank you. Like I said, you are making me blush because you mentioned the book that we have coming out.
Dr. Maki: Yeah. It is going to be– I am not exactly sure when this episode is going to be posted, but just pay attention. We will certainly let you know when the book is ready to go. It is going to be on Amazon.
Dr. Davidson: Or go ahead and send us your email so we can put you on our list, right? What email would they–?
Dr. Maki: So for the podcast, if you have any questions or if you are curious or you want to be, just send us an email to email@example.com. That way, if you have any questions you want to ask us, maybe we will read it on the podcast. Any questions about the book, any questions about anything.
Dr. Davidson: The book is going to be about perimenopause. [laughter] You know that. Kind of that in-between stage.
Dr. Maki: Because of all the questions that we get collectively, women in their 40s, for the most part, maybe late 30s or early 50s, but women in their 40s are the majority of the people that we treat as patients, and the majority of people that we get questions from on the podcast because I think that is which is the reason why you wrote the book.
For one, you are kind of in that demographic yourself, but two, we think it is really the most underserved demographic of all the different female-related, the age range but also the female-related problems.
Menopause, okay. Menopause, a lot of people understand menopause, but perimenopause is a bit more specific and not quite as well addressed out there in the conventional space.
Dr. Davidson: And what we do, especially like you said, a lot of our patients are in their 40s, but I have had patients that I have been treating for years. So that is the best time is to catch them so we can balance those hormones and then make menopause a really easy gentle transition. So that is the ideal time. So definitely, like I said, what did you say? firstname.lastname@example.org?
Dr. Maki: Yeah. That is the email that we like to use for the podcast. That way we know that if you do send us an email, it has come either from the blog or from the podcast. That way, we cannot get back to everybody. We get too many of them, but we do try to screen them as much as we can and it is a great way to be able to communicate and to be able to answer questions like this.
So for Joy, Vivelle patch is probably not the best option. When you go back to your gynecologist, she is going to probably want to give you perimetrium, which we do not necessarily– that is a whole note. We had some other podcast in the past that talk about perimetrium, so go back and look at our archive about perimetrium.
We would recommend for sure bioidentical progesterone sustained release. Start with usually fifty to a hundred milligrams, something like that. That would be more appropriate for a situation like this as opposed to the Vivelle patch.
Besides plugging the book, do you have anything else to say, Dr. Davidson?
Dr. Davidson: No, this was a great question and I appreciate Joy sending this in because it kind of was able to cover a few things where we could talk a little bit about what Vivelle patch is and the different doses and what we would deem it appropriate for, but then also too for a menstruating female that might be having– they are still menstruating, but they are still having symptoms of what they would consider menopause. Is it truly that?
So it was a good question. I think it applies to a lot of people that are listening because we get questions like this all the time.
Dr. Maki: Yeah, and we are thinking about– we have not really asked for much from any listeners, but we are asking for you, if you do like the podcast, to give us a review on whatever platform it is that you listen to whether it is iTunes, Spotify, I Heart Radio, Stitcher. We are going to be, I think, in Amazon music now. It has podcast. We are going to be putting our podcast on there as well.
So if you liked our podcast, please give us a review. We are going to start a promotion at some time soon where we are going to pick out random reviews that we like and we are going to read them on the podcast. We have not decided like what we are going to offer for that promotion. Some kind of incentive which in some ways is kind of maybe a little bit incongruent. You are giving a promotion to get a review, but at the same time, that is how our audience grows and more people that find us because of those positive reviews. So we are going to offer something in return for that. We just have not quite figured out what that is yet.
We are open to suggestions. If you have any, send us an email. Other than that, if you have nothing else to add, I think this is a good one. It is nice to be back into the swing of things.
So until next time. I am Dr. Maki.
Dr. Davidson: And I am Dr. Davidson.
Dr. Maki: Take care. Bye bye.