Transcript New options in estrogen preparations

New options in estrogen preparations
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Megan Fitzgerald, RN-C, MS, WHNP
Kelly Kruse-Nelles, RN-C, MS,
WHNP
Topics to be addressed
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New birth control options
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Transdermal Patch
Vaginal Ring
New HRT options
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Vaginal rings
Vaginal creams
Vaginal tablet
Low dose orals
Transdermal
Catalyst for new options of birth control
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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
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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
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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
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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
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Do not use if over 198 pounds
Avoids first-pass metabolism
Maintains steady drug
concentrations, without peak &
troughs associated with OC’s.
Contraceptive Ring
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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
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Vasomotor symptoms
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Hot flashes/night sweats
Vaginal symptoms
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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
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Urinary Tract Symptoms
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Weakening/shrinking of bladder and
urethral tissues
Leaking of urine
 UTI’s
 Frequency of urination
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Bone Loss
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≈ 3% loss/year, tapers to ≈ 2%
loss/year
Vaginal Ring
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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
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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
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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, 0.52g/24hours, given cyclically (3
weeks on, 1 week off)
Vaginal Creams
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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
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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
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Prempro: CEE 0.3mg/MPA 1.5mg or
CEE 0.45mg/MPA 1.5mg
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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
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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
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Estrogen only
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Vivelle
Vivelle-Dot
Esclim
FemPatch
Climara
Alora
Estraderm
Transdermal Patches
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Estrogen only
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Avoids first pass metabolism
Applied twice weekly
May have application site irritation
Increases BMD
Transdermal Patches
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Estrogen/progestin
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CombiPatch
Ortho-Prefest
ClimaraPro
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With all patches
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May have application site irritation
 Use lowest dose estrogen that will control
symptoms
 Increases BMD
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Percutaneous Formulations
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EstroGel: 1.25g/24 hours, metereddose pump dispenser; applied to
one arm from wrist to shoulder
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Avoids peak/trough
Avoids first pass metabolism
Treats vasomotor and urogenital
symptoms
Reduces LDL and triglycerides
Ultra-low-dose transdermal estrogen
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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
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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
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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.