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TREATMENT
There are many formulations and dosages of estrogen and estrogen-progestin combinations on the market today for treating conditions that result from estrogen deficiency, for birth control, and for regulation of hormone-related processes such as menstruation.
Hormonal contraception
Oral contraceptives
Most combination oral contraceptives contain between 20 to 50 mcg of estrogen, a lower dose (one-fourth or less) than those marketed 20 to 30 years ago.
Oral contraceptives containing estrogen are now prescribed by some health care professionals for health benefits beyond contraception. For instance, they can:
- Regulate and shorten a woman's menstrual cycle
- Decrease severe cramping and heavy bleeding.
- Reduce ovarian cancer risk.
- Reduce the development of ovarian cysts and ovarian fibroids.
- Decrease benign breast disease.
- Reduce the severity and incidence of pelvic inflammatory disease (PID).
- Protect against ectopic pregnancy.
- Reduce the risk of uterine (endometrial) cancer.
- Minimize perimenopausal symptoms.
- Decrease perimenopausal symptoms.
Contraceptive patches and vaginal ring
The patch and ring contain hormones similar to oral contraceptives and provide many of the same benefits, although through a different route of administration.
Hormone-containing Intrauterine Device
The hormone-containing IUDs provide contraception and, in the case of the Mirena IUD, greatly reduce menstrual bleeding.
There are side effects and risks associated with estrogen-containing birth control pills, however, although many have been reduced through the introduction of lower-dosage versions in recent years. These include heart attack, stroke, blood clots, pulmonary embolism, nausea and vomiting, headaches, irregular bleeding, weight gain or weight loss, breast tenderness and increased breast size.
According to a 1997 World Health Organization study, smoking cigarettes while taking birth control pills dramatically increases the risk of heart attack for women over 35. Smoking is far more dangerous to a woman's health than taking birth control pills, but the combination of oral contraceptive pill use and smoking has a greater effect on heart attack risk than the simple addition of the two factors.
If the primary reason you are taking an oral contraceptive is to prevent unwanted pregnancy and you are worried about potential estrogen-related side effects, the "mini-pill," which contains progestin (a synthetic form of the natural hormone progesterone), may be an option.
Hormone Therapy for Menopausal Symptoms
There are two types of therapy used to replace hormones that decline with the onset of menopause or are deficient as a result of medical conditions.
Estrogen-progestin
Postmenopausal hormone therapy, until recently referred to as "hormone replacement therapy," or "HRT," is now termed "hormone therapy" or HT. HT typically refers to a combination of estrogen and either a synthetic form of the hormone progesterone (progestin) or a natural form of the hormone. Progesterone or progestin is necessary in women with an intact uterus to decrease the stimulating effect of estrogen on uterine tissue—a risk for uterine cancer.
Estrogen-only
"Estrogen therapy" (ET) refers to the use of estrogen alone. Estrogen therapy may be prescribed for women who have had a hysterectomy (and therefore are not at risk of uterine cancer).
A variety of estrogen medications containing various types of estrogen are available. These include pills, patches, lotions, gel, and vaginal creams, rings or tablets.
Conjugated estrogens: Premarin is the most frequently prescribed conjugated estrogen therapy product. It contains several types of conjugated estrogen derived from the urine of pregnant mares. It is available in oral, intravenous and vaginal cream formulations. Cenestin is a blend of nine plant-derived, synthetic conjugated estrogens and is FDA approved for treating menopausal symptoms.
Esterified estrogens: These estrogens may be made from plant sources or be prepared from the urine of pregnant mares. Brand names are Estratab and Menest. Estratest is a combination of esterified estrogens and methyltestosterone, a male hormone. It is the only testosterone currently FDA approved for women. Do not take these medications if you are pregnant or are planning a pregnancy.
Estradiol: This type of estrogen, normally produced during the reproductive years, is available in many brand name oral and transdermal preparations. Oral estradiol is available as Estrace, Gynodiol and generic estradiol. Transdermal patches include Alora, Climara, Esclim, Estraderm, and Vivelle. A new, ultra low-dose estrogen patch, Menostar, has been approved for prevention of osteoporosis. Estradiol gel (EstroGel) is a transdermal gel; Estrasorb is a transdermal estradiol lotion. Femring is a vaginal ring that provides estradiol acetate as full-dose systemic estrogen therapy. Estring is a vaginal ring that releases very low levels of estradiol and is used only for local vaginal therapy. Vagifem vaginal tablets provide extremely low doses of estradiol for local estrogen therapy.
Estrone: The predominant natural hormone in menopausal women, and a product of the metabolism of estradiol. Some forms of estrone are present in conjugated and esterified estrogen preparations, as well as in combination with piperazine.
Estropipate (Ogen, Ortho-Est). This natural estrogenic substance is available in a pill.
Ethinyl estradiol (Estinyl). This synthetic estrogen is available in tablet form.
Synthetic conjugated estrogens, B (Enjuvia). This plant-derived, synthetic conjugated estrogen product includes an additional estrogen component in the form of delta 8,9-dehydroestrone sulfate. It is approved for the treatment of menopause-related vasomotor symptoms, such as hot flashes and heart palpitations.
Local vaginal estrogen therapy
Several forms of estrogen are available as creams applied vaginally for treating vulvar and vaginal atrophy. They include: conjugated estrogen cream (Premarin), micronized estradiol (Estrace), dienestrol (Ortho dienestrol) and estropipate cream (Ogen).
Estradiol is also available as an inserted vaginal ring (Estring) for treating those conditions as well as urethritis. A vaginal tablet form of estradiol, Vagifem, is also available.
Combination hormone therapy: estrogen and progestin
Taking estrogen daily, and progestin for two weeks every month, may result in monthly bleeding similar to menstruation. Many women prefer taking both hormones every day to eliminate bleeding, which usually stops after three to six months of daily combination therapy.
Combination pills include:
- 17 beta-estradiol and norgestimate (Ortho-Prefest) continuous estrogen and pulsed progesterone.
- Conjugated estrogens and medroxyprogesterone (Prempro: three different doses; Premphase: cyclic progestin dosing)
- Plant-derived estrogen and progestin p (Activella)
- Ethinyl estradiol and norethindrone acetate (Femhrt)
Combination transdermal products include:
- CombiPatch (estradiol and norethindrone acetate)
- ClimaraPro patch (estradiol and levonorgestrel).
Any of these products may be prescribed for menopausal symptoms, including vulvar or vaginal atrophy.
Bioidentical, natural or compounded estrogen
The term "bioidentical hormones" is used to refer to hormones that are identical to the form of hormone made in the body. They may also be called "natural." Sometimes hormones sold in a compounding pharmacy are called "natural," or "bioidentical." All of these estrogen or progesterone produces are made in a laboratory and then mixed with a cream or put into a pill form.
There is no evidence that bioidentical, natural or compounded hormones are safer or more effective than FDA-approved hormones. There are FDA-approved bioidentical estrogens and progesterones on the market.
You should not take any form of estrogen if you are pregnant or have or have had:
- Breast or ovarian cancer
- Abnormal uterine bleeding of an unknown cause (until the cause has been determined)
- A very high triglyceride level (in this case, some women can take estrogen via a patch, lotion or gel.)
- Active liver disease
- Blood clots or pulmonary embolism
Women taking estrogen alone are advised to have yearly breast exams and receive annual mammograms. Potential side effects of taking estrogen alone include increased risk for blood clots, heart disease, heart attacks, stroke and breast cancer. Other possible side effects include:
- Vaginal bleeding (starting or returning)
- Breast tenderness (which often goes away after three months)
- Nausea (which often goes away after your body adjusts)
- Fluid retention (bloating)
- Headache
- Dizziness
- Depression
- An increased risk of ovarian cancer and gallbladder disease
- Change in vision, including intolerance to contact lenses
Estrogen can interact with a variety of other commonly prescribed medications, including thyroid hormone, so be sure to tell your health care professional about all medicines you are taking, including alternative/complementary products and supplements.
In making the decision about whether to use estrogen to treat your condition, you and your health care professional will discuss your personal health history. This discussion will include considering if you are at increased risk for one or more of the conditions with which estrogen is associated.
