There's an estrogen-patch shortage - but these other menopause treatments can help

By Sharon Malone

The good news here is that more women in perimenopause and menopause are getting the message about hormone therapy

More women are using hormone replacement therapy during perimenopause and menopause.

Not a day goes by that I don't read a headline that trumpets the shortage of estrogen patches, which are used to treat the bothersome symptoms of perimenopause and menopause. But is this really a hair-on-fire moment?

Through the wonders of social media, awareness about perimenopause and menopause is growing. Women are now pursuing treatment for symptoms like hot flashes, brain fog, insomnia and dry, itchy skin.

Although there are many alternative remedies for menopause, hormone replacement therapy remains the most effective treatment for the symptoms of menopause. And the secret in the secret sauce of HRT is estrogen. Those with a uterus should use both estrogen and progestogen, to prevent uterine cancer.

One example is Pfizer's (PFE) Premarin, which was approved by the Food and Drug Administration in 1942. It's a unique and proprietary blend of multiple estrogens derived from pregnant mares' urine that is prescribed less frequently than it used to be. And if you ask why use mares' urine, it's because we hadn't yet figured out how to make bioidentical estradiol, which is chemically identical to the estrogen that human ovaries make.

If we've known that estrogens effectively treat the symptoms of menopause for over 80 years, why are women just now finding this out?

This is where the story gets interesting. Prior to 1999, almost 40% of eligible menopausal women were on HRT - primarily Premarin, one of the most commonly prescribed drugs in America at the time. Although we had decades of clinical data validating its effectiveness, it was an observation from a longitudinal study of healthy nurses in the 1980s that spurred the largest bump in hormone usage. The women in the nurses study who were taking HRT had half the risk of developing cardiovascular disease compared to the women who were not. This finding, if proven, would have been seismic.

It is for this reason that the Women's Health Initiative, the largest and most expensive study investigating hormone therapy in postmenopausal women, was conceived in 1991. Its goal was to test the hypothesis: Does using hormone therapy decrease the risk of heart disease? Heart disease was then and is now the No. 1 cause of death in women older than 40. We didn't need to test the effectiveness of symptom relief.

Unfortunately, only five years into what was supposed to be an eight-year study, the investigators in 2002 abruptly halted the arm that included women taking estrogen and progestin. The anticipated decrease in heart disease was not substantiated, and, more alarmingly, they cited "excess harm." The WHI safety board reported that HRT not only increased the risk of cardiovascular disease, blood clots and gallbladder disease, it also raised the risk of invasive breast cancer by 26%. Of all these findings, only the risk of blood clots was statistically significant. (In other words, it's not likely to occur by chance).

You can imagine the horror of these findings. I don't have to imagine it. I lived it. Women felt betrayed and, worse, endangered.

After 2002, HRT use plummeted almost overnight to 5%, and that's where it has stood until today. For African-American women whose symptoms start earlier, last longer and are more severe, hormone therapy usage is far lower.

The WHI study was misinterpreted and overgeneralized. The only estrogen used in the study was oral Premarin. Bioidentical estradiol, which is the most common form used today, was not included in the WHI. It has taken 20 years for the misconceptions about the increased risks of HRT to be corrected - and for the FDA to partially lift the black-box warning on some estrogen products.

The evidence does not support the finding that estrogen causes breast cancer. For most women without contraindications, the benefits of HRT outweigh the risks if used within 10 years of menopause or before age 60. In fact, the guidelines on hormone use clearly state the same if it's used at or near the time of menopause. And for women with early (before age 45) or premature menopause (before age 40), it is recommended.

So what does all of this have to do with the estrogen patch shortage? As awareness increased in recent years, the demand for bioidentical estrogen and the transdermal patch as the preferred delivery system has gone up. Oral estrogens have been unfairly maligned, while transdermal patches have been deemed a safer option. (They are preferable in certain circumstances.)

Demand is up for several reasons; more doctors are prescribing the transdermal bioidentical estradiol, and the manufacturing process for patches is more labor-intensive and time-consuming than making pills. This has led to a supply-chain issue. There is also little incentive for new companies to step in and start making generic patches, due to low profit margins. That said, could the manufacturers of estrogen patches have seen this coming? Yes. The steady increase in demand is years in the making.

But do not despair. Here's what some of those headlines are missing: We still have many safe and effective options for hormone therapy:

Not all patches are in short supply: The most commonly used patches are twice-weekly patches, and these are the ones that are difficult to find. There are once-weekly patches, patches that combine estradiol with progestin, and different doses that may be close to the original prescription and can be substituted. Branded options are available but may be more expensive.

There are other forms of transdermal delivery systems: Transdermal estrogen can be applied as a daily spray, gel or vaginal ring that is good for three months.

Let's not forget oral estradiol: Bioidentical estradiol tablets are considered both safe and effective for most women. There are surprisingly few contraindications to oral estradiol, and women can talk to their doctors to see if this is an option. If you so choose, you can still use Premarin. Oral generic estradiol is also the least expensive option for most patients.

Compounded estradiol products are also available: They come with caution and are frequently the most expensive option. Compounded hormones are only as good as the compounding pharmacy. Know your source.

The good news here is that more women are getting the message about hormone therapy. Despite the shortage of some estrogen patches, what we must not forget is that there are many options in hormone therapy. We know the science. This is the art.

What we are done with is fear-mongering. Women have spoken. We deserve to be our best selves as we navigate perimenopause and menopause. And if the patch shortage means we have done our jobs in getting the word out that women don't have to suffer, then so be it. But know this: We have options. Don't be afraid to try them.

Sharon Malone is an obstetrician-gynecologist and chief medical advisor at Alloy Health, a telehealth platform dedicated to evidence-based care for perimenopause and menopause. She is a Menopause Society certified practitioner, the author of "Grown Woman Talk: Your Guide to Getting and Staying Healthy," and the host of the podcast, The Second Opinion with Dr. Sharon.

-Sharon Malone

This content was created by MarketWatch, which is operated by Dow Jones & Co. MarketWatch is published independently from Dow Jones Newswires and The Wall Street Journal.

(END) Dow Jones Newswires

05-13-26 0936ET