Estradiot: hormone replacement therapy drugs Photo: Supplied
By Niki Bezzant*
It's been happening for several years, but in the past month, the shortages of oestrogen (in the form of oestradiol) patches for use by women in menopause has become more acute.
Women are now routinely being told by pharmacies that their prescriptions can't be filled as written, and that they will need to cut higher-dose patches in half to get their prescribed dose, or alternatively pay extra to top up what's funded to be supplied.
That's if patches are available at all; women describe having to call around pharmacies to find patches, often coming up empty-handed.
Christchurch-based Vanessa says this has happened to her. "I went to my specialist yesterday and got a prescription for the next nine months. I've been to three pharmacies and phoned many more. There's no Estradot [branded patch] available anywhere in Christchurch."
Women elsewhere in the country report similar situations.
The impact is serious. For women in surgical menopause - induced by removal of the ovaries or cancer treatment - a lack of HRT could mean long-term health risks including heart disease and osteoporosis. For others struggling with symptoms of menopause, losing HRT could also be life-changing.
Niki Bezzant Photo: Niki Bezzant
Vanessa says her life without HRT would be "miserable. I feel tearful and worried thinking about life before HRT and that I might end up there again: brain fog affecting my self confidence, so much that I didn't trust myself in social or work situations; sudden onsets of rage so that I didn't trust myself with my family.
"I'm finally starting full time work in two weeks and I'm scared. Until the news yesterday [about patch supply], I was excited."
Why is this happening?
The shortages have been ongoing for a long time, and the 'why' is complicated. Briefly, here are the contributing factors:
Demand for HRT has increased massively. That's not just here in Aotearoa, but all over the globe, with shortages being documented in the UK, Canada, Australia and Europe. This is likely due to GenX women hitting their late 40s and 50s, learning more about menopause and HRT, and general education and awareness about menopause growing. This is a good thing! Menopause has been shrouded in secrecy and silence for generations, and many women in the past simply put up with often debilitating symptoms due to incorrect assumptions about HRT.
The manufacturers of HRT patches are having issues. They include unspecified 'manufacturing issues'; having failed to anticipate increased demand, and a complex web of supply-chain complications stretching from soybean fields in China to manufacturing plants in Europe. It all adds up to not enough patches to go around.
Stocks in NZ are limited and being rationed. Suppliers of the different brands of patches available here are putting what little stock they do have 'on allocation' which means they're rationing it out to pharmacies, in an attempt to make distribution fair. That means even when Pharmac says there are stocks available of a particular brand in a particular dose in the country, it's not always the case when a woman fronts up at her local pharmacy.
Alternative transdermal HRT is not funded. Oestrogen delivered via the skin - transdermally - is acknowledged as the safest, most effective method for oestrogen. In New Zealand, the only transdermal oestradiol that's funded is patches, and this is by far the most widely prescribed. Initially, only one brand (Estradot) was funded but last year Pharmac funded alternative brands to try and deal with some of the shortages. Now though, even the alternative patches (which for some women, do not work as well) are in short supply.
Photo: wikimedia
There are other transdermal products, including gels, that also work well. Though these are available here, they are not funded by Pharmac, so women have to pay for these. To compound the issue, even if women are willing and able to pay, not all doctors or pharmacists know that gels are available here, so women are sometimes being given incorrect information.
Funding is only for two patches per woman per week. This is fine when supplies are good - but if pharmacies can only make up a dose by using, say, two 25mcg patches to make a 50mcg dose, women are being asked to pay for the extra patches.
What is being done to fix this problem?
Pharmac says it's working to try to keep up with demand. Right now, it is in the process of evaluating proposals from oestradiol gel suppliers, and has recently tendered for a new supplier of patches. These two things, it says, 'should provide better supply of patches and a funded alternative treatment.' But the agency also notes: 'Neither the tender nor the RFP are quick solutions and will take time to implement.'
Pharmac chief medical officer Dr David Hughes said in a statement to RNZ that he acknowledged the stress of the HRT shortage and that Pharmac was aware some people were paying for extra patches to reach their required dose. Pharmac was considering reviewing the restriction to two patches per week, he said.
There are updates on the current situation at the Pharmac website including a downloadable flyer. 'We are sorry', the agency says. 'We can understand your frustration at not being able to access this product consistently.'
How long will this go on for?
Pharmac says 'We expect this issue to continue through 2024 and likely for some time into 2025.'
What can I do now?
It's stressful and time-consuming, but one option is to keep an eye on the Pharmac website and keep trying different pharmacies for patches. Right now, some doses of patch will apparently be back in (limited) stock at the end of May. It's ok to cut up patches or to use multiple patches to make up a dose.
Another option is oral oestradiol (in pill form). This is, as endocrinologist Megan Ogilvie told RNZ, "a very valid option for many women", but there is "a significant portion of women for whom it is not as safe."
That's because with oral oestradiol there is a greater risk of venous thromboembolism (VTE). Women with hormone-related migraines could also have problems. For others, it could be worth checking with your doctor if this is an option for you. Oral oestradiol is funded by Pharmac and there seem to be fewer supply issues with it. It works just as well as patches to supply oestrogen to the body.
A third option is to ask your doctor about prescribing an oestradiol gel. This is available in New Zealand and can be prescribed by any doctor. A pharmacy can order the gel in from the wholesaler when they get a prescription for this product; the Estrogel brand (distributed by Pharmaco NZ) is widely available. It comes at a cost, however: this can be upwards of $30 (plus prescription charges and any extra pharmacy charges) for a bottle - which could last up to two months, depending on your dose.
Gynaecologist Olivia Smart says the gel is very easy to use. "One pump of gel is equivalent to 25 micrograms; you just rub it into your skin. Another option could be that if you can get a lower dose patch, like a 25 microgram patch, you could top it up with gel to make up your usual dose."
What else might help?
For those struggling with menopause symptoms, HRT is an important part of treatment. It's not the only piece of the puzzle, though. Looking after yourself with regular exercise; a good nourishing diet; avoiding alcohol and prioritizing sleep will go a long way towards helping you feel better, with or without HRT. So will minimising stress - which could be challenging in the quest for HRT - as much as you can.
Niki Bezzant is a writer, speaker, journalist and author focusing on health, wellbeing and science.
