How to apply HRT so you absorb it properly

Sometimes clients come to the perimenopause clinic of Dr Shahzadi Harper, GP,  Instagram's The Perimenopause Doctor, complaining that they’re feeling off,  despite being on HRT gel, cream, spray or patches.

The natural assumption might be that the dose isn't strong enough.  But hang fire, says Dr Harper; there may be a simpler solution than upping it: "Before we increase the dose, we go back to basics. I ask them to show me how and where they’re applying it.”  

The issue of high doses of HRT was highlighted in the BBC Panorama programme The Menopause Industry Uncovered, which found that private clinic Newson Health was prescribing higher than licensed doses of HRT, particularly oestrogen, to patients. A  small number experienced adverse effects. 

While the documentary raised concerns about the scale of very high dose prescribing (and Newson Health responded that it had "addressed all points raised by the Care Quality Commission and have not been notified of any resulting concerns"), it is known that some women don't absorb topical HRT as well as others. As with any medication, absorption rates can vary. And for these women, a higher dose, overseen by a doctor, may be appropriate. 

Something else to bear in mind: you need to find the best HRT delivery system for your body. "If you’re not absorbing one version of HRT well then instead of ramping up the dose, consider a different type," says Dr Harper. "For example, if you’re not a patch absorber you may do better with a gel, spray or an oral, or vice versa. This is what I do in my practice to avoid high doses and to stay within guidelines for most women."

Then there's the matter of using it properly. HRT  'not working'  can be a case of incorrect application, where the topical HRT may simply not have the chance to absorb properly, says Dr Harper. For example, you might get dressed before your oestrogen gel is dry and it comes off on your clothes.  Or if a patch is applied to skin that is oily, it may slide off.  It is important to note that when we sweat, swim and use SPF  in the same areas in which we apply our HRT, there's even more margin for error.

“You want to ensure you’re getting the right dose, so you’re not wasting the prescription you’ve paid for, and also to maximise the gel or patch’s efficiency. In this way,  you are less likely to think your HRT isn’t working for you and increase or ask for a bigger dose unnecessarily,” says Dr Harper.

They are easy mistakes to make, says Dr Harper, so to inform us on how to apply HRT, she has made a video for Get The Gloss, below, addressing the problem and other specifics to applying your HRT as the seasons change. 

How to apply HRT correctly all year round

1.  Ensure the skin is well-exfoliated and free from oil
   Dr Harper recommends using a body scrub to get rid of dry skin on your arms, bum or hips, which can hinder absorption. But keep it away from your HRT. “Don’t put HRT on straight after using an oily exfoliator or a moisturiser in the morning, wait until the end of the day.” 
2. Wait at least an hour before putting anything wet on your skin
   Whether that's showering or body lotion,  give your gel, cream or spray a chance to absorb properly.
3. Avoid putting oestrogen gel on the upper arms if you have keratosis pilaris or bumpy skin
   If you have those annoying bumps on the back of your upper arms – keratosis pilaris – apply your HRT elsewhere. Not only will the gel find it harder to soak in here but, Dr. Harper points out, “those bumps are blocked sebaceous glands, so if you add a layer of gel, you could be making things worse.” Regular exfoliation should help clear them up.
4. Poor circulation? Apply HRT straight after the shower
   Especially in colder weather our circulation can suffer, points out Dr. Harper. “I suggest tapping your arms, legs, or bum repeatedly just before you apply the gel as this will help improve circulation and so help absorption. Or apply it just after a shower, when your body is warm.”
5.  Let it dry properly – don't get dressed for at least 3 minutes
   HRT gels need three to five minutes to dry, so wait a few minutes before getting dressed.
6. Wait an hour before putting on leggings or tight jeans.
   Otherwise, most of the good stuff will end up soaking into the fabric, she says. Hang on, who has a free hour to twiddle their thumbs in the morning? “If you are somebody who is in a rush first thing, doing school runs and getting to work, don’t put your HRT on then. Do it in the evenings. Find the time of day that best suits you and stick to it.”
7. Split dose your gel
   If you’re using more than two pumps of gel, split them up, says Dr Harper.  For a four-pump regime, for example, "apply two on your arms and two on your legs. Don’t apply all four in the same place, as you’ll be there forever. You might get impatient and end up putting on your clothes too quickly.”
8. Take oral progesterone an hour before dinner if possible
   Keeping to a routine also applies to oral progesterone, which should be taken either an hour before you eat or a couple of hours afterwards and taken at night because it can make you sleepy.  Dr. Harper recommends you take it before dinner if you eat late, in case you fall asleep before you have a chance to take your meds.
9.  Be militant about your HRT patch’s lifespan
   “They must be re-applied every three and a half days, not every three and then every four days,” says Dr Harper. “Because by the time you get to the end of the fourth day, it’ll be falling off and there won’t be much left to absorb. Put an alarm on your phone to remind you."

How to apply HRT on sunny holidays and during the summer

The main takeaway from Dr. Harper is to switch all your HRT, apart from testosterone, to the evening to avoid interacting with sun cream or sweat or getting washed off if you are swimming.

1. Wait an hour before sun cream
   You can go out into the sun straight away after applying your gel or cream, but of course, you’ll be applying your sun cream. “If you are applying any lotions on top of your HRT, leave it at least an hour,” says Dr Harper. “The manufacturers say there’s no interaction with sun cream, but sometimes the high alcohol content of sunscreen can impair the absorption of your HRT,“ she adds. So keep the two an hour apart.
2. Consider changing to a patch for summer
   HRT patches need to be changed only every 3.5 days, they can be applied to your hip or bottom in a place under your swimwear that’s shielded from the sun. But will they survive the sea or pool? “Previously, I had a few women mention to me that their patches came off when they were swimming," says Dr Harper, "but the manufacturers have improved the stickiness and I haven’t had a single patient report any problems this year." If your patch does come off, stick another one on and re-start your three and a half days of wear count from then, she advises.
3. Wait an hour before you swim
   As for swimming, the showering rule applies – wait at least an hour before going in the water.
4. If you sweat a lot in summer, switch to applying at night
5. Keep testosterone for the morning
   “Testosterone is meant to give you energy and improve your mojo and because of this, I would stick to the morning. It’s only a small amount on the inner wrist or hips. Again wait an hour before swimming or showering.”

What if you feel your HRT still isn’t working properly?

If you’ve ticked all the boxes above, then it’s time to see your doctor for a review. “You may need a blood test, you may need to change the preparation of the HRT, as not all suit everyone,” says Dr Harper.

theharperclinic.com

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