Evorel

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Evorel on Prescriptsy

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Evorel is a transdermal hormone replacement therapy (HRT) patch containing estradiol (oestradiol), the primary naturally occurring oestrogen produced by the ovaries.

It is used to relieve menopausal symptoms including hot flushes, night sweats, vaginal dryness, urogenital discomfort, mood disturbance, and sleep disruption caused by declining oestrogen levels during and after the menopause.

Evorel is also licensed for the prevention of postmenopausal osteoporosis in women at increased risk of fractures when other therapies are unsuitable.

Manufactured by Theramex (formerly Janssen), Evorel patches are available in four strengths delivering 25, 50, 75, or 100 micrograms of estradiol per 24 hours.

They are prescription-only medicines (POM) in the United Kingdom.

The menopause is a natural biological process that typically occurs between the ages of 45 and 55, with the average age in the UK being 51.

Approximately 75% of women experience menopausal symptoms, and around 25% report symptoms that significantly affect their quality of life, work, and relationships.

The decline in ovarian oestrogen production is responsible for the classic vasomotor symptoms, as well as longer-term consequences including urogenital atrophy, accelerated bone loss leading to osteoporosis, and adverse changes in cardiovascular risk markers.

HRT remains the most effective treatment for menopausal vasomotor symptoms, and transdermal delivery offers specific advantages over oral therapy.

This page provides a detailed clinical guide to Evorel for patients in the United Kingdom, covering how it works, who it is suitable for, application technique, dosing, side effects, safety considerations, and how to obtain a prescription through the NHS or an authorised online prescriber.

Important safety information about Evorel

Before reading further, note the following essential safety points. Evorel is a prescription-only medicine and must be used under medical supervision.

• Women with an intact uterus must use a progestogen alongside Evorel to protect against endometrial hyperplasia and cancer.
• Evorel must not be used in women with known or suspected breast cancer, oestrogen-dependent tumours, undiagnosed vaginal bleeding, or active thromboembolic disease.
• The benefits and risks of HRT should be reviewed at least annually with your prescriber.
• Transdermal oestrogen carries a lower risk of venous thromboembolism than oral oestrogen.
• Report any new breast lumps, persistent vaginal bleeding, or symptoms of blood clots immediately.

Understanding the menopause and oestrogen deficiency

The menopause is defined as the permanent cessation of menstruation due to loss of ovarian follicular activity.

It is diagnosed retrospectively after 12 consecutive months without a period (in the absence of other causes).

The perimenopause refers to the transitional period leading up to the final menstrual period, during which oestrogen levels fluctuate and symptoms may begin.

Premature ovarian insufficiency (POI) occurs when the menopause happens before the age of 40, and early menopause is defined as occurring between the ages of 40 and 45.

Women with POI or early menopause are generally advised to use HRT at least until the average age of natural menopause (51) to protect cardiovascular and bone health.

Declining oestrogen causes a range of symptoms that vary in type and severity between individuals.

Vasomotor symptoms (hot flushes and night sweats) are the most common reason for seeking treatment and affect up to 80% of women.

Other symptoms include vaginal dryness and pain during intercourse, urinary frequency and recurrent urinary tract infections, joint aches, reduced concentration and memory, low mood and anxiety, reduced libido, and changes in body composition.

These symptoms may persist for years and can significantly impair daily function and wellbeing.

How Evorel works: transdermal oestrogen delivery

Evorel uses a matrix patch technology in which estradiol is dispersed within an adhesive polymer layer.

When applied to the skin, estradiol diffuses from the patch through the epidermis and into the dermal capillary network, entering the systemic circulation directly.

This transdermal route bypasses first-pass hepatic metabolism, the process by which orally administered oestrogen is extensively metabolised in the liver before reaching the general circulation.

Bypassing the liver confers several clinical advantages.

Transdermal oestrogen does not increase hepatic production of clotting factors, which is why it carries a lower risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) than oral oestrogen.

It does not raise triglyceride levels and has minimal effect on sex hormone-binding globulin (SHBG), C-reactive protein, and other hepatic proteins.

These pharmacological differences make transdermal oestrogen the preferred route for women with risk factors for VTE, those with obesity (BMI above 30), women with migraine, and those with hypertriglyceridaemia.

Each Evorel patch delivers a controlled release of estradiol over 3 to 4 days.

Serum estradiol levels reach a steady state within the first 24 hours of application and remain stable until patch removal.

The patches are designed to be changed twice weekly, providing consistent oestrogen levels without the peaks and troughs seen with oral dosing.

Clinical evidence and UK prescribing guidance

NICE guideline NG23 (Menopause: diagnosis and management, updated 2024) provides comprehensive recommendations for HRT prescribing in the UK. Key recommendations relevant to Evorel include the following points.

HRT is the most effective treatment for vasomotor symptoms and should be offered after a discussion of the short-term and longer-term benefits and risks.

Transdermal oestrogen is associated with lower VTE risk than oral oestrogen.

Transdermal HRT is the preferred route for women with risk factors for VTE, including those with a BMI above 30.

The lowest effective dose should be used, and treatment should be reviewed annually.

The British Menopause Society (BMS) endorses these recommendations and emphasises that for most women under 60 who start HRT within 10 years of the menopause, the benefits outweigh the risks.

The BMS also notes that oestrogen-only HRT (for hysterectomised women) does not increase breast cancer risk for at least 15 years of use.

Combined HRT is associated with a small increase in breast cancer risk after prolonged use, but the absolute risk is small and must be weighed against the benefits of symptom relief and quality of life improvement.

Applying Evorel patches: practical guidance

Choose a clean, dry, non-hairy area of skin on the lower trunk, preferably on the buttock or hip.

Avoid the breasts, waistline, and any skin fold or area subject to rubbing.

Do not apply to skin that is broken, irritated, or has been treated with lotions, oils, or powders, as these may impair adhesion.

Remove the patch from its sachet and peel off the protective liner.

Apply the adhesive side to the skin immediately and press firmly with the palm of your hand for approximately 10 seconds, paying particular attention to the edges.

Wear the patch continuously for 3 to 4 days, then remove it, fold it in half (adhesive sides together), and dispose of it safely out of reach of children.

Apply the replacement patch to a slightly different area of the lower trunk.

Do not use the same site for at least 7 days to allow the skin to recover and minimise irritation.

The patch should remain in place during bathing, showering, and swimming. If a patch becomes loose or falls off, a new patch should be applied immediately.

Do not attempt to reattach a used patch.

If a patch change is forgotten, apply the new patch as soon as you remember and then resume your regular twice-weekly schedule.

Choosing the right Evorel strength

Treatment is usually started with Evorel 50 (50 micrograms per 24 hours). After 4 to 8 weeks, the dose may be adjusted based on symptom response and tolerability.

If symptoms are well controlled, a step down to Evorel 25 may be appropriate. If symptoms persist, the dose may be increased to Evorel 75 or Evorel 100.

The aim is always to use the lowest effective dose. Your prescriber will review your symptoms and adjust the dose accordingly at follow-up appointments.

Progestogen requirement for women with a uterus

Oestrogen stimulates growth of the endometrium (womb lining).

Without progestogen opposition, long-term oestrogen-only HRT in women with an intact uterus increases the risk of endometrial hyperplasia and endometrial cancer.

For this reason, women who still have their uterus must take a progestogen alongside Evorel.

This can be provided in several ways: sequential (cyclical) progestogen tablets (such as norethisterone or medroxyprogesterone acetate) taken for 12 to 14 days of each 28-day cycle; a combined patch (Evorel Conti, which contains both estradiol and norethisterone acetate); or a levonorgestrel intrauterine system (Mirena coil), which provides local endometrial protection.

Women who have had a hysterectomy do not require progestogen and can use Evorel as oestrogen-only HRT.

Side effects of Evorel

Common side effects

Application site reactions (redness, itching, irritation) are the most specific side effect of transdermal HRT and affect approximately 10 to 15% of users.

These are usually mild and can be minimised by rotating application sites.

Breast tenderness or swelling, headache, nausea, bloating, leg cramps, and irregular vaginal bleeding or spotting (especially in the first 3 to 6 months) are also common.

These effects often settle with continued use.

Uncommon and rare side effects

Uncommon effects include mood changes, depression, dizziness, migraine, changes in libido, vaginal discharge, weight changes, and fluid retention.

Rare effects include venous thromboembolism (deep vein thrombosis, pulmonary embolism), arterial thromboembolic events (stroke, myocardial infarction), gallbladder disease, and hypersensitivity reactions.

The risk of VTE is lower with transdermal than oral oestrogen.

Breast cancer risk

Combined HRT (oestrogen plus progestogen) is associated with a small increase in breast cancer risk after more than 5 years of use.

The absolute risk increase is approximately 1 additional case per 1,000 women per year of use. Oestrogen-only HRT carries a smaller or neutral risk.

All women on HRT should attend regular breast screening (mammography is offered every 3 years from age 50 in the NHS Breast Screening Programme) and report any new breast lumps promptly.

When to seek urgent medical advice

Call 999 or attend A&E if you develop sudden severe chest pain, breathlessness, painful swelling of a leg, sudden severe headache, visual disturbance, or weakness on one side of the body.

Contact your GP if you experience persistent vaginal bleeding after the first 6 months, new breast lumps, or worsening mood.

Report suspected adverse reactions to the MHRA Yellow Card scheme at yellowcard.mhra.gov.uk .

Warnings and precautions

Contraindications

Evorel must not be used in women with known or suspected breast cancer, oestrogen-dependent malignancies, undiagnosed abnormal vaginal bleeding, untreated endometrial hyperplasia, active or history of venous thromboembolism (unless on established anticoagulant therapy), active or recent arterial thromboembolic disease, active liver disease with abnormal liver function tests, or porphyria.

Conditions requiring caution

Evorel should be used with caution in women with a history of uterine fibroids, endometriosis, risk factors for oestrogen-dependent tumours, hypertension, diabetes mellitus, migraine, epilepsy, asthma, otosclerosis, gallbladder disease, systemic lupus erythematosus, hepatic impairment, or renal impairment.

Women with a strong family history of breast cancer should discuss their individual risk with a specialist before starting HRT.

Drug interactions

Hepatic enzyme-inducing drugs including carbamazepine, phenytoin, phenobarbital, rifampicin, and St John's wort may accelerate oestrogen metabolism and reduce the effectiveness of Evorel.

Oestrogens may increase the clearance of lamotrigine, potentially reducing seizure control. Oestrogen replacement may increase the requirement for thyroid hormone replacement in women taking levothyroxine.

HRT may affect the anticoagulant effect of warfarin; INR should be monitored.

How to get Evorel in the UK

Evorel is a prescription-only medicine available on the NHS from your GP, a menopause specialist clinic, or an authorised online prescriber.

A clinical assessment including personal and family medical history, blood pressure measurement, and breast awareness review is required before prescribing.

The NHS prescription charge in England is currently 9.90 pounds per item; prescriptions are free in Scotland, Wales, and Northern Ireland.

An HRT prepayment certificate may reduce costs for women using multiple HRT products.

When to seek medical advice

Contact your GP or NHS 111 if your menopausal symptoms are not adequately controlled, if you experience persistent or heavy vaginal bleeding, or if you develop any new or concerning symptoms during treatment.

Seek emergency care (call 999 or attend A&E) if you experience sudden chest pain, leg swelling, breathlessness, severe headache, visual changes, or one-sided weakness.

Report suspected adverse reactions to the MHRA Yellow Card scheme at yellowcard.mhra.gov.uk .

Sources

• Evorel 50, Summary of Product Characteristics (EMC)
• Estradiol, British National Formulary (BNF)
• NICE NG23: Menopause: diagnosis and management
• British Menopause Society
• Menopause, NHS
• MHRA Yellow Card Scheme