New options in estrogen preparations

Megan Fitzgerald, RN-C, MS, WHNP

Kelly Kruse-Nelles, RN-C, MS, WHNP

Topics to be addressed

New birth control options Transdermal Patch Vaginal Ring

New HRT options Vaginal rings Vaginal creams Vaginal tablet Low dose orals Transdermal

Catalyst for new options of birth control

Failure rate of OC’s should be 1%, but first-year typical use failure rate is 6.2%

60% of all unintended pregnancies occur in women who are using birth control

Quick Update

DMPA (Depo Provera Injection): Now has a black box warning regarding risk to BMD with prolonged (>2 years) use

Depo subQ Provera: Has same black box warning, 104 mg medroxyprogesterone acetate

LNG-IUS (Mirena IUD):Progesterone releasing IUD. Approved for up to 5 years of use. 50% of women develop amenorrhea within 12 months of insertion

Quick Update

Etonogestrel implant (Implanon): Provides 3 years of contraceptive protection in a single rod

Copper T 380A (ParaGard): 10 years contraceptive protection, increase in MBL, menses may increase by 1 day

Contraceptive Patch

150mcg of norelgestromin/20mcg EE every 24 hours

Placed on abdomen, buttocks, upper arm, upper torso weekly for 3 weeks, fourth week is patch-free

Contraindications are identical to OC use SE’s include: application site reactions,

breast tenderness, dysmenorrhea

Contraceptive Patch

Do not use if over 198 pounds Avoids first-pass metabolism Maintains steady drug

concentrations, without peak & troughs associated with OC’s.

Contraceptive Ring

120mcg etonogestrel/15mcg EE Flexible, 2.1 inches in diameter Inserted into vagina by patient,

remains for 21 days, 7days ring free If ring is outside the vagina for more

than 3 hours, backup barrier method is needed for 7 days

New options in managing menopause

Vasomotor symptoms Hot flashes/night sweats

Vaginal symptoms Vaginal mucosa can become dry, can

lead to irritation, itching, discharge, infection

Vaginal atrophy Dysparuenia May be associated with loss of libido

New options in managing menopause

Urinary Tract Symptoms Weakening/shrinking of bladder and

urethral tissues Leaking of urine UTI’s Frequency of urination

Bone Loss ≈ 3% loss/year, tapers to ≈ 2%

loss/year

Vaginal Ring

Femring: 0.5mg/24 hours or 0.1mg/24 hours, used for treatment of systemic symptoms and vaginal atrophy

Avoids first pass metabolism Worn for 3 months Protects against osteoporosis

Vaginal Ring

Estring: 7.5µg/24 hours Avoids first pass metabolism Worn for 3 months Used to treat urogenital symptoms Not intended for treatment of

vasomotor symptoms

Vaginal Creams

Estrace: Estradiol 0.1mg/g, initial dose 2-4g/24hours for 1-2 weeks, then decrease to ½ initial dose for similar period

Premarin: CEE 0.625mg/g, 0.5-2g/24hours, given cyclically (3 weeks on, 1 week off)

Vaginal Creams

Ortho Vaginal: Estropipate 1.5mg/g, 2-4 g/24 hours, given cyclically (3 weeks on, 1 week off)

Creams noted on this and previous page are indicated for treatment of urogenital symptoms associated with postmenopausal atrophy of the vagina & lower genital tract

Vaginal Tablet

Vagifem: Estradiol 25µg/24 hours, for 2 weeks, then decrease to 1 tablet twice weekly

Relieves urogenital symptoms, no systemic relief

Has an applicator provided Avoids first pass metabolism

Low-Dose Oral

Prempro: CEE 0.3mg/MPA 1.5mg or CEE 0.45mg/MPA 1.5mg Standard Prempro dose for WHI was

CEE 0.625mg/MPA 2.5mg HOPE study showed all of these

estrogen doses reduced frequency and severity of vasomotor symptoms

Low-Dose Oral

Daily peak/trough First pass metabolism occurs Increase C-reactive protein Increases triglycerides Increase in SHBG Can increase cholesterol saturation

of bile (risk of gallbladder disease) Decrease of antithrombin III

Transdermal Patches

Estrogen only Vivelle Vivelle-Dot Esclim FemPatch Climara Alora Estraderm

Transdermal Patches

Estrogen only Avoids first pass metabolism Applied twice weekly May have application site irritation Increases BMD

Transdermal Patches

Estrogen/progestin CombiPatch Ortho-Prefest ClimaraPro

With all patches May have application site irritation Use lowest dose estrogen that will control

symptoms Increases BMD

Percutaneous Formulations

EstroGel: 1.25g/24 hours, metered-dose pump dispenser; applied to one arm from wrist to shoulder Avoids peak/trough Avoids first pass metabolism Treats vasomotor and urogenital

symptoms Reduces LDL and triglycerides

Ultra-low-dose transdermal estrogen

Only indicated for women with osteopenia

Deliver 14µg of 17βestradiol/24 hours

Changed weekly No increased risk of endometrial

hyperplasia was observed (unopposed estrogen)

References

Fitzpatrick, L.A. (2004). Estrogen and bone health. The Female Patient, supplement February, p.4-9.

Freeman, S.B., Moore, A., Wysocki, S. (2004). Menopause Hormone Therapy: Where do we go from here? Women’s Health Care Journal, 4(3), p.8-17.

Freeman,S.B., Wysocki, S. (2005). New Option for Osteoporosis Prevention: Ultra-low-dose transdermal estradiol. The American Journal of Nurse Practitioners, 9(6), p.23-35.

Lewis, V. (2004). New hormone-therapy formulations and routes of delivery: Meeting the needs of your patients in the post-WHI world. OBG Management Supplement, July, p.11-17.

Minkin, M.J. (2004). Considerations in the choice of oral vs. transdermal hormone therapy: A review. The Journal of Reproductive Medicine, 49(4), p.311-319.

References

Schnare, S.M. & Shulman, L.P. (2004). The changing paradigm of reversible contraception. The Female Patient, supplement April, p.8-10.

Shulman, L.P. (2005). Nonoral contraception: Improved compliance with newer hormonal methods. The Female Patient, supplement April, p.6-10.

Thorneycroft, I.H. (2004). Unopposed estrogen and cancer. The Female Patient, supplement February, p.19-25.