Drug reference
ESTRING ® Postmenopausal urogenital conditions (not suitable for vasomotor symptoms or osteoporosis prophylaxis) ▶BY VAGINA ▶Adult: To be inserted into upper third of vagina and worn continuously; replace after 3 months; max. duration of continuous treatment 2 years VAGIFEM ® Improve the vaginal epithelium in menopausal atrophic vaginitis ▶BY VAGINA ▶Adult: 1 tablet daily for 2 weeks, then reduced to 1 tablet twice weekly
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Active arterial thromboembolic disease (e.g. angina or myocardial infarction). history of breast cancer. history of venous thromboembolism. oestrogen-dependent cancer. recent arterial thromboembolic disease (e.g. angina or myocardial infarction). thrombophilic disorder. undiagnosed vaginal bleeding. untreated endometrial hyperplasia
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Acute porphyrias p. 1120. diabetes (increased risk of heart disease). factors predisposing to thromboembolism. history of breast nodules—closely monitor breast status (risk of breast cancer). history of endometrial hyperplasia. history of fibrocystic disease— closely monitor breast status (risk of breast cancer). hypophyseal tumours. increased risk of gall-bladder disease. migraine (or migraine-like headaches). presence of antiphospholipid antibodies (increased risk of thrombotic events). prolonged exposure to unopposed oestrogens may increase risk of developing endometrial cancer. review treatment at least annually to assess need for continued treatment. risk factors for oestrogen- dependent tumours (e.g. breast cancer in first-degree relative). symptoms of endometriosis may be exacerbated . uterine fibroids may increase in size CAUTIONS, FURTHER INFORMATION ▶Risk of endometrial cancer The increased risk of endometrial cancer depends on the dose and duration of oestrogen- only HRT. ▶Risk of ovarian cancer Long-term use of combined HRT or oestrogen-only HRT is associated with a small increased risk of ovarian cancer. This excess risk disappears within a few years of stopping. ▶Risk of venous thromboembolism Women using combined or oestrogen-only HRT are at an increased risk of deep vein thrombosis and of pulmonary embolism especially in the first year of use. In women who have predisposing factors (such as a personal or family history of deep vein thrombosis or pulmonary embolism, severe varicose veins, obesity, trauma, or prolonged bed-rest) it is prudent to review the need for HRT, as in some cases the risks of HRT may exceed the benefits. Travel involving prolonged immobility further increases the risk of deep vein thrombosis. ▶Risk of stroke Risk of stroke increases with age, therefore older women have a greater absolute risk of stroke. Combined HRT or oestrogen-only HRT increases the risk of stroke. ▶Risk of coronary heart disease HRT does not prevent coronary heart disease and should not be prescribed for this purpose. There is an increased risk of coronary heart disease in women who start combined HRT more than 10 years after menopause. Although very little information is available on the risk of coronary heart disease in younger women who start HRT close to the menopause, studies suggest a lower relative risk compared with older women.
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→Appendix 1: hormone replacement therapy
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▶Common or very common Abdominal pain. headaches. nausea. skin reactions. vaginal haemorrhage. vulvovaginal disorders ▶Uncommon Hypertension. vulvovaginal fungal infection. weight increased ▶Rare or very rare Diarrhoea. embolism and thrombosis. endometrial hyperplasia. fluid retention. genital pruritus. increased risk of ischaemic stroke. insomnia. neoplasm malignant. neoplasms. vaginismus SIDE-EFFECTS, FURTHER INFORMATION Cyclical HRT (where a progestogen is taken for 12–14 days of each 28-day oestrogen treatment cycle) usually results in regular withdrawal bleeding towards the end of the progestogen. Continuous combined HRT commonly produces irregular breakthrough bleeding in the first 4–6 months of treatment. Bleeding beyond 6 months or after a spell of amenorrhoea requires further investigation to exclude serious gynaecological pathology.
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HRT does not provide contraception and a woman is considered potentially fertile for 2 years after her last menstrual period if she is under 50 years, and for 1 year if she is over 50 years. A woman who is under 50 years and free of all risk factors for venous and arterial disease can use a low-oestrogen combined oral contraceptive pill to provide both relief of menopausal symptoms and contraception; it is recommended that the oral contraceptive be stopped at 50 years of age since there are more suitable alternatives. If any potentially fertile woman needs HRT, non-hormonal Genito-urinary system contraceptive measures (such as condoms) are necessary. Measurement of follicle-stimulating hormone can help to determine fertility, but high measurements alone (particularly in women aged under 50 years) do not necessarily preclude the possibility of becoming pregnant. VAGIFEM ® No evidence of damage to latex condoms and diaphragms.
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Not known to be harmful.
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Avoid; adverse effects on lactation.
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Manufacturer advises caution; avoid in acute or active disease.
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▶History of breast nodules or fibrocystic disease—closely monitor breast status (risk of breast cancer). ▶The endometrial safety of long-term or repeated use of topical vaginal oestrogens is uncertain; treatment should be reviewed at least annually, with special consideration given to any symptoms of endometrial hyperplasia or carcinoma.
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There can be variation in the licensing of different medicines containing the same drug. Pessary ▶Vagifem (Novo Nordisk Ltd) Estradiol 10 microgram Vagifem 10microgram vaginal tablets | 24 pessary P £16.72 DT = £16.72 Vaginal delivery system CAUTIONARY AND ADVISORY LABELS 10 ▶Estring (Pfizer Ltd) Estradiol (as Estradiol hemihydrate) 7.5 microgram per 24 hour Estring 7.5micrograms/24hours vaginal delivery system | 1 device P £31.42 DT = £31.42
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To be inserted into upper third of vagina and
First-line fragment. Read the complete Indications and Dose section above.
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1 tablet daily for 2 weeks, then reduced to
First-line fragment. Read the complete Indications and Dose section above.
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