If the patient elects to proceed with the insertion he/she is laid on the side. The fleshiest part of the upper outer quadrant of the buttocks is located and cleansed. This is usually midway between the iliac crest and the greater trocanter. A 10cc syringe of Lidocaine is used with 2cc of N/S using a inch 25 gauge needle to infiltrate an area parallel to the table. A very small shallow puncture is made at the point of infiltration. A female trochar or male trochar is inserted through the puncture site and quickly angled parallel to the table anteriorly along the path of the local anesthesia to the hub of the trochar. The stylus is removed and the appropriate size pellets are placed in the trochar and inserted with the plunger.
Comparisons between orally administered pill and transdermal patch suggests that when estrogens are taken orally the risks of thrombophlebitis and pulmonary embolism are increased, an effect which is not seen with topical administration. Transdermal and transvaginal administration are not subject to first pass metabolism , and so lack the anabolic effects that oral therapy has on hepatic synthesis of Vitamin K dependent clotting factors .  This effect refers only to patches for post menopausal hormone replacement, which contain estradiol , not those used in oral contraceptive therapy, which contain ethinylestradiol . The latter is associated with an increased incidence of venous clot.  The WHI also showed an increased incidence arterial disease, namely stroke, in patients who began HRT after the age of 65, although this effect was not significantly present in those who began therapy during their fifth decade.