OESTROGENS FOR HRT

Cautions

• prolonged exposure to unopposed oestrogens may increase risk of developing endometrial cancer (see notes above);

• migraine (or migraine-like headaches);

• diabetes (increased risk of heart disease);

• history of breast nodules or fibrocystic disease closely monitor breast status (risk of breast cancer, see notes above);

• risk factors for oestrogen-dependent tumours (e.g. breast cancer in first-degree relative);

• uterine fibroids may increase in size, symptoms of endometriosis may be exacerbated;

• factors predisposing to thromboembolism (see notes above);

• presence of antiphospholipid antibodies (increased risk of thrombotic events); increased risk of gall-bladder disease reported; hypophyseal tumours;

• porphyria (see section 9.8.2); interactions:Appendix 1 (oestrogens)

Other conditions

The product literature advises caution in other conditions including

• hypertension,

• renal disease,

• asthma,

• epilepsy,

• sickle-cell disease,

• melanoma,

• otosclerosis,

• multiple sclerosis, and

• systemic lupus erythematosus (but care required if antiphospholipid antibodies present, see above).

Evidence for caution in these conditions is unsatisfactory and many women with these conditions may stand to benefit from HRT.

Contra-indications 

• pregnancy;

• oestrogen-dependent cancer,

• history of breast cancer,

• active thrombophlebitis,

• active or recent arterial thromboembolic disease (e.g. angina or myocardial infarction),

• venous thromboembolism, or history of recurrent venous thromboembolism (unless already on anticoagulant treatment),

• liver disease (where liver function tests have failed to return to normal),

• Dubin-Johnson and Rotor syndromes (or monitor closely),

• untreated endometrial hyperplasia,

• undiagnosed vaginal bleeding,

• breast-feeding

side effects

• nausea and vomiting,

• abdominal cramps and bloating,

• weight changes,

• breast enlargement and tenderness,

• premenstrual-like syndrome,

• sodium and fluid retention,

• cholestatic jaundice,

• glucose intolerance,

• altered blood lipids?may lead to pancreatitis, rashes and chloasma,

• changes in libido,

• depression,

• mood changes,

• headache,

• migraine,

• dizziness,

• leg cramps (rule out venous thrombosis),

• vaginal candidiasis,

• contact lenses may irritate;

• transdermal delivery systems may cause contact sensitisation (possible severe hypersensitivity reaction on continued exposure), and headache has been reported on vigorous exercise

Withdrawal bleeding

Cyclical HRT (where a progestogen is taken for 12?14 days of each 28-day oestrogen treatment cycle) usually results inregular withdrawal bleeding towards the end of the progestogen.

The aim of continuous combined HRT (where a combination of oestrogen and progestogen is taken, usually in a single tablet, throughout each 28-day treatment cycle) is to avoid bleeding, butirregular bleeding may occur during the early treatment stages (if it continues endometrial abnormality should be excluded and consideration given to cyclical HRT instead)

Dose

Counselling on patches

Patch should be removed after 3?4 days (or once a week in case of 7-day patch) and replaced with fresh patch on slightly different site; recommended sites: clean, dry, unbroken areas of skin on trunk below waistline; not to be applied on or near breasts or under waistband. If patch falls off in bath allow skin to cool before applying new patch

• Estradiol with progestogen

   

  • Angelique(Schering Health)

    Tablets, f/c, red, estradiol 1mg, drospirenone 2 mg. Net price 3 x 28-tab pack = ?25.80

    Dose

    Menopausal symptoms and osteoporosis prophylaxis (see section 6.6), in women with intact uterus,

    1 tablet daily continuously (if changing from cyclical HRT begin treatment the day after finishing oestrogen plus progestogen phase)

    Cautions

    use with care if an increased concentration of potassium might be hazardous; renal impairment (Appendix 3)

    Note

     

    Unsuitable for use in perimenopausal women or within 12 months of last menstrual period?s

  • Climagest
  • Climesse
  • Clinorette
  • Cyclo-Progynova
  • Elleste-Duet
  • Estracombi
  • Evorel
  • Femapak
  • Femoston
  • FemSeven
  • Conti
  • FemSeven Se qui
  • FemTab Se qui
  • Indivina
  • Kliofem
  • Kliovance
  • Novofem
  • Nuvelle
  • Tridestra
  • Trise quens
• Conjugated oestrogens only
  • Premarin
• Estradiol only
  • Estradiol Implants
  • Bedol
  • Climaval
  • Elleste-Solo
  • Elleste Solo MX
  • Estraderm MX
  • Estraderm TTS
  • Estradot
  • Evorel
  • Fematrix
  • FemSeven
  • Oestrogel
  • Progynova
  • Progynova TS
  • Sandrena
  • Zumenon
• Estradiol, estriol and estrone
  • Hormonin
• Estriol only
  • Ovestin
• Estropipate only
  • Harmogen

Table 28.1 - TOPICAL OESTROGENS

Preparation	Oestrogen	Company
Ortho-Gynest Pessaries	Oestriol 500 g	Janssen-Cilag
Ortho-Gynest Cream	Oestriol  0.01%	Janssen-Cilag
Ovestin Cream	Oestriol 0.1%	Organon
Ovestin Pessaries	Oestradiol 1mg	Organon
Premarin  Cream	Conjugated oestrogens 625 mg	Wyeth
Vagifem Pessaries	Oestradiol 25 microg	Novo Nordisk
Estring Ring	Oestradiol (7.5 microg release/day)	Pharmacia and Upjohn

The oestrogen can be administered

• orally (tablets –Table 28.2),
• transdermally (patches –Table 28.3 and Table 28.4 or gels),
• subcutaneously as implants (Figure 28.1),
• as a nasal spray (Aerodiol – estradiol hemihydrate - Servier)
• vaginal ring (Menoring – estradiol acetate – Galen Ltd).

The nasal spray and vaginal ring methods have been introduced in 2001.

Table: 28. 2 (29/07/08)

PREPARATION	OESTROGEN	DOSE (mg)	COMPANY
Bedol	Oestradiol	2
Climaval	Oestradiol valerate	1 and 2	Novartis
Elleste Solo	Oestradiol	1 and 2	Searle
Harmogen	Oestrone	1.5	Pharmacia and Upjohn
Hormonin	Oestriol/Oestrone/oestradiol	0.27/1.4/0.6	Shire
Premarin	Conjugated Oestrogens	0.3,0.625 and 1.25	Wyeth
Progynova	Oestradiol valerate	1 and 2	Schering
Zumenon	Oestradiol	1 and 2	Solvay

 

Table 28. 5 Se quential HRT preparations (cyclical progestogen tablets).

PREPARATION	OESTROGEN/PROGESTOGEN	mg	COMPANY
	TABLETS
Nuvelle	Oestradiol / Levonorgestrel	2 / 75mcg	Schering
Climagest 1 mg	Oestradiol / Norethisterone	1 / 1	Novartis
Climagest 2 mg		2 / 1	Novartis
Clinorette	Oestradiol	2 / 1