Which Estrogen Patch dose to use?

[janebob99]

This plot shows the median serum estrogen (E2) concentration (in pg/mL) versus total Weekly Estrogen patch dose (mg/wk) from five different references ranging from 2000 to 2019.

The data set from Smith et. al (2019) is for castrate-resistant prostate cancer men (CRPC), who are not taking ADT.

Overall, the serum E2 concentration increases as the number of E2 patches used per week (Total weekly E2 dose) increases. For reference, the E2 range for a healthy, pre-menopausal woman is [200-400] pg/mL.

There is no evidence of a rollover or saturation in the serum E2 as the applied E2 patch dose increases. In fact, the dataset from Smith et. al (2019) is best fit by a rising quadratic curve (red dashed line), instead of a straight (linear) line.

Differences between the linear fit (green dashed line) and the quadratic fit (red dashed line) may be due to men belonging to different PCa groups (i.e., castrate-sensitive or castrate-resistant).

These curves can be used to titrate the serum E2 concentration to a desired target by adjusting the number of patches used per week. When using a common 100 microgram/24 Hr estrogen patch, then 10 patches per week provides a weekly absorbed dose of 1.0 mg E2 per week.

[Ramp7]

Have you ever considered estrogen topical paste. There were a few people using this approach. One guy up in Canada has been employing this for years.

[janebob99 in reply to Ramp7]

Prof. Wassersug in Canada showed me a picture of a tube of estrogen containing paste from Thailand that was quite inexpensive.

[ragnar2020]

Hi janebob99,

Richard Wassersug, a co-author of the definitive book about ADT management, has been using TDE for over twenty years. You can find him on the HU forums. He uses TDE gel daily and avoids the swapping of patches. Using the gel, I'm told by those who use it, requires one to experiment with the amount to use daily by monitoring one's E, T and PSA with blood tests until the correct amount of gel is obtained.

[janebob99 in reply to ragnar2020]

Thanks for the info.

Prof. Wassersug is a fantastic resource and a friend. I phone and FaceTime with him on a regular basis. He's probably the leading expert in North America on transdermal estrogen.

I agree that the gel may be more difficult to titrate than patches. In principle, equivalent doses should give equivalent responses, all other things being equal.

Implanted E2 pellets is another option.

Do you use Estrogen Patches or Gels?

I just made this graph today...

Bob

E2 vs # of patches

[ragnar2020]

Hi janebob99,

I'm not using TDE get yet, but as they say, it is probably on my horizon. I am not using any HT at this point in my PCa care, but my PSA is inching upward following a RARP in '19 and then SAT in '22 and BCR when it reached 2,1. My PSA is at .73 now.

I have osteoporosis and have been urged to use the SOC bone mineral density (BMD) drugs. I'm resisting those SOC drugs (Prolia & Zometa) because of their SEs and considering the use of TDE at a level that might reduce my testosterone level slightly from its present 350-400 level, but offer BMD help without the SEs of the alternative SOC BMD meds.

I'm reading the supporting med journal articles about TDE and BMD health.

[janebob99 in reply to ragnar2020]

TDE will help prevent osteoporosis, and can actually grow bone.

Here is a slide that I made yesterday...

% in BMD versus time

[maley2711 in reply to janebob99]

so, Lupron showed a slight decrease in BMD, and patch a slightly higher increase in BMD...correct? More important IMO would be what are the differences between the 2 when a man already has low BMD ? If a man is "normal " BMD, probably not a big risk of approaching osteoporosis.....it is the osteopenic men who have the big worry I think.

[janebob99 in reply to maley2711]

Actually, a +6% change in BMD on estrogen is a big change, not a slight increase.

Other spots on the body, Hip, femur, forearm, etc. were also measured in the PATCH study (see attached Figures). For these other locations, Lupron produced a negative 5-6% drop in BMD, versus a +1% change for estrogen. Those are big changes in BMD.

Older, non-cancerous, men often have osteopenia and osteoporosis because their T and E have naturally declined significantly. This leads to increased risks of fracture.

I had osteoporosis decades ago, before I was later diagnosed with hypogonadism due to a pituitary microadenoma. Now that my T and E are normalized, I have normal BMD.

All men doing Lupron ADT should have a yearly DEXA scan, or every 6-months.

Estrogen "add-back" can help prevent osteopenia and osteoporosis (it's dose dependent).

BMD vs time: Lupron vs Estrogen

[maley2711 in reply to janebob99]

Is one of those addback?? That is, normal Lupron dose plus estrogen supplement? Hmmm, I thought loss of BMD was permanent, more or less, so this is encouraging. I'd be happy just to not worsen BMD while doing RT + ADT? Wonder f anyway in hell a Kaiser Doc would agree to something different. All I can do is bring some ammunition to meeting in 2 weeks.....truly appreciate the best you have found ! I haven't looked..PATCH trial is so close to endpoint.....any preliminary results published??? I was one of the 1st...maybe the 1st, at our regional Kaiser to undergo MRI fusion biopsy....took an appeal!!! Would be great to be first to try some form of ADT that would pose less risk in so many areas!!!! I've been dreading it.....even delaying treatment for my 4+5 !!!!! I don't know how perfectly well men, except the PCa diagnosis, are able to quickly rush into treatment that can ultimately be almost as damaging to QOL IMMEDIATELY as the PCa is eventually?

I started at PSA 8 5 years ago, went from 8 two years ago to 12 a month ago....urologist was not panicked, but I was slightly!! PSMA PETS aren't perfect, but mine still negative??? With 4+5 , horse might already be out of barn, and the RT of little value....bring on the ADT of some form...sigh. Meanwhile , we try to live normally!!!

[janebob99 in reply to maley2711]

I always enjoy your posts!

I believe that figure from Ockrim is for high-dose estrogen patch therapy, taken from the PATCH trial. I don't have data handy for low-dose add back estrogen. It may be in of my 20+ papers on estrogen, though.

Ruth Langley told me recently that the phase-III PATCH trial results will be published this Fall. Stay tuned !

My email address is [e-mail]. If you send me an email, I will send you my complete library of estrogen papers.

Bob

[dhccpa in reply to janebob99]

I appreciate your posts as well.

Regarding bone density scans, Medicare in USA seems to only pay for one every two years, according to my MO.