new options in estrogen preparations
DESCRIPTION
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. - PowerPoint PPT PresentationTRANSCRIPT
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.