HRT - What is the choice of oestrogen only preparations?

What is the choice of oestrogen only preparations?

Oestrogens may be natural or synthetic although both may be manufactured.

When natural oestrogens are taken, the oestrogens in the blood are the same as would be released by the ovaries. Hormone replacement uses natural oestrogens.

After synthetic oestrogen administration, oestrogens structurally different from those released by the ovaries appear in the blood. Ethinyl oestradiol and mestranol are synthetic oestrogens used in combined oral contraceptive pills.

There are several oestrogen only HRT preparations. The oestrogen can be administered orally (tablets –Table 28.2), transdermally (patches –Table 28.3 and Table 28.4 or gels), subcutaneously as implants (Figure 28.1), as a nasal spray (Aerodiol – estradiol hemihydrate - Servier) or by a vaginal ring (Menoring – estradiol acetate – Galen Ltd). The nasal spray and vaginal ring methods have been introduced in 2001.

Table: 28. 2

PREPARATION

OESTROGEN

DOSE (mg)

COMPANY

Climaval

Oestradiol valerate

1 and 2

Novartis

Elleste Solo

Oestradiol

1 and 2

Searle

Harmogen

Oestrone

1.5

Pharmacia and Upjohn

Hormonin

Oestriol/Oestrone/

oestradiol

0.27/1.4/

0.6

Shire

Premarin

Conjugated Oestrogens

0.625 and 1.25

Wyeth

Progynova

Oestradiol valerate

1 and 2

Schering

Zumenon

Oestradiol

1 and 2

Solvay

Doctors tend to have their personal preference for first choice recommendation. As with the combined oral contraceptive pill, the acceptability and side effects for each preparation vary between patients. If you have had a recommendation from a friend or relative it would seem sensible for you to try it.

Premarin is derived from pregnant mares urine. It has been popular for manyyears and much of the research on HRT relates to this product. The pharmaceutical company producing Premarin has documented evidence from veterinary surgeons that there is no cruelty to the animals involved.

Women who have been deprived of oestrogen for more than a few months seem to be prone to side effects and in particular to mastalgia (breast discomfort). It is often wise, particularly if there is a history of mastalgia, to begin with a low dose preparation; the tablets can be taken every few days and gradually increased to the daily regimen.

Oestrogen tablets are broken down in the small bowel where the oestrogen is absorbed. The blood circulating through the bowel then passes to the liver where much is broken down before it has a chance to reach the rest of the body. Sometimes side effects associated with oestrogen tablets may be avoided by using skin patches or by introducing the oestradiol as an implant under the skin. Blood from the skin passes to all parts of the body and not specifically through the liver on its first-pass. Several companies produce patches of different strengths designed to release between 25 and 100 ug (micrograms)/24 hours. Most must be changed twice each week (Table 28.3).

Table 28. 3 Oestradiol skin patches.

PREPARATION	DOSE (mg / 24 hours)	COMPANY
Elleste Solo MX	40 or 80	Searle
Estraderm MX	25, 50, 75 or 100	Ciba
Estraderm TTS	25, 50, or 100	Ciba
Evorel	25, 50, 75 or 100	Janssen-Cilag
Fematrix	40 or 80	Solvay
Menorest	37.5, 50 or 75	Poulenc Rorer

Some patches are designed to be changed at weekly intervals:

Table 28. 4

PREPARATION

DOSE micg / 24 hours)

COMPANY

FemSeven

50, 75 or 100

Merck

Progynova TS

50 or 100

Schering

Some women find that their patches stay in place whilst bathing but most prefer to take the patch off and replace it afterwards. Allergic reactions resulting in irritation and redness can be a problem although the more recent patches seem less likely to cause this.

There are two oestrogen gels (Oestrogel: Hoechst and Sandrena: Organon) for application to the skin. Between two and four measures of Oestrogel are rubbed gently into the upper arms, shoulders or thighs daily usually after bathing. Sandrena comes in 0.5 and 1mg sachets, and the gel is similarly applied each day.

Related Medical Abstracts - Click on the paper title:-

Intranasal versus transdermal matrix oestrogen replacement in Australasian women. (2005-01)

Aerodiol: the efficacy and tolerability of intranasal estrogen administration. (2003-01)

The effect of a novel vaginal ring delivering oestradiol acetate on climacteric symptoms in postmenopausal women. (2003-02)

Efficacy and tolerability of a novel estradiol vaginal ring for relief of menopausal symptoms. (2003-03)

Comparison of a novel vaginal ring delivering estradiol acetate versus oral estradiol for relief of vasomotor menopausal symptoms. (2003-04)

Pulsed estrogen therapy: relieving climacteric symptoms, preventing postmenopausal bone loss. (2002-01)

Efficacy and tolerability of pulsed estrogen therapy: a 12-week double-blind placebo-controlled study in highly symptomatic postmenopausal women. (2002-02)

Efficacy and tolerability of pulsed estrogen therapy: a 12-week double-blind placebo-controlled study in highly symptomatic postmenopausal women. (2002-03)

Clinical e quivalence of intranasal estradiol and oral estrogens for postmenopausal symptoms. (2002-04)

Aerodiol versus the transdermal route: perspectives for patient preference. (2001-01)

Dose-ranging studies of a novel intranasal estrogen replacement therapy. (2001-02)

Randomized comparison of intranasal and transdermal estradiol. (2000-01)

New developments in topical estrogen therapy (1997)

Please click on the required question.

2 How can atrophic vaginitis - dry vagina at menopause - painful sex - be treated? - Topical Estrogen

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This is the personal website of David A Viniker MD FRCOG, Consultant Obstetrician and Gynaecologist at Whipps Cross University Hospital, London - Specialist Interests - Reproductive Medicine including Infertility, PCOS, PMS, Menopause and HRT.