Estradiol

Estradiol

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Questions & Answers

Side Effects & Adverse Reactions

See BOXED WARNINGS.

1. Cardiovascular Disorders

Estrogen and estrogen/progestin therapy has been associated with an increased risk of cardiovascular events such as myocardial infarction and stroke, as well as venous thrombosis and pulmonary embolism (venous thromboembolism or VTE). Should any of these occur or be suspected, estrogens should be discontinued immediately.

Risk factors for arterial vascular disease (e.g., hypertension, diabetes mellitus, tobacco use, hypercholesterolemia and obesity) and/or venous thromboembolism (e.g., personal history or family history of VTE, obesity, and systemic lupus erythematosus) should be managed appropriately.

 a. Coronary heart disease and stroke

In the Women’s Health Initiative (WHI) study, an increase in the number of myocardial infarctions and strokes has been observed in women receiving CE compared to placebo. These observations are preliminary, and the study is continuing (See CLINICAL PHARMACOLOGY, Clinical Studies).

In the CE/MPA substudy of WHI, an increased risk of coronary heart disease (CHD) events (defined as nonfatal myocardial infarction and CHD death) was observed in women receiving CE/MPA compared to women receiving placebo (37 vs. 30 per 10,000 women-years). The increase in risk was observed in year one and persisted.

In the same substudy of WHI, an increased risk of stroke was observed in women receiving CE/MPA compared to women receiving placebo (29 vs. 21 per 10,000 women-years). The increase in risk was observed after the first year and persisted.

In postmenopausal women with documented heart disease (n = 2,763, average age 66.7 years), a controlled clinical trial of secondary prevention of cardiovascular disease (Heart and Estrogen/Progestin Replacement Study; HERS) treatment with CE/MPA (0.625 mg/2.5 mg per day) demonstrated no cardiovascular benefit. During an average follow-up of 4.1 years, treatment with CE/MPA did not reduce the overall rate of CHD events in postmenopausal women with established coronary heart disease. There were more CHD events in the CE/MPA-treated group than in the placebo group in year 1, but not during the subsequent years. Two thousand three hundred and twenty one women from the original HERS trial agreed to participate in an open label extension of HERS, HERS II. Average follow-up in HERS II was an additional 2.7 years, for a total of 6.8 years overall. Rates of CHD events were comparable among women in the CE/MPA group and the placebo group in HERS, HERS II, and overall.

Large doses of estrogen (5 mg conjugated estrogens per day), comparable to those used to treat cancer of the prostate and breast, have been shown in a large prospective clinical trial in men to increase the risks of nonfatal myocardial infarction, pulmonary embolism and thrombophlebitis.

b. Venous Thromboembolism (VTE)

In the Women’s Health Initiative (WHI) study, an increase in VTE has been observed in women receiving CE compared to placebo. These observations are preliminary, and the study is continuing (See CLINICAL PHARMACOLOGY, Clinical Studies).

In the CE/MPA substudy of WHI, a 2-fold greater rate of VTE, including deep venous thrombosis and pulmonary embolism, was observed in women receiving CE/MPA compared to women receiving placebo. The rate of VTE was 34 per 10,000 women-years in the CE/MPA group compared to 16 per 10,000 women-years in the placebo group. The increase in VTE risk was observed during the first year and persisted.

If feasible, estrogens should be discontinued at least 4 to 6 weeks before surgery of the type associated with an increased risk of thromboembolism, or during periods of prolonged immobilization.

2. Malignant Neoplasms

a. Endometrial Cancer

The use of unopposed estrogens in women with intact uteri has been associated with an increased risk of endometrial cancer. The reported endometrial cancer risk among unopposed estrogen users is about 2- to 12- fold greater than in non-users, and appears dependent on duration of treatment and on estrogen dose. Most studies show no significant increased risk associated with use of estrogens for less than one year. The greatest risk appears associated with prolonged use, with increased risks of 15- to 24-fold for five to ten years or more, and this risk persists for 8 to over 15 years after estrogen therapy is discontinued.

Clinical surveillance of all women taking estrogen/progestin combinations is important (see PRECAUTIONS). Adequate diagnostic measures, including endometrial sampling when indicated, should be undertaken to rule out malignancy in all cases of undiagnosed persistent or recurring abnormal vaginal bleeding. There is no evidence that the use of natural estrogens results in a different endometrial risk profile than synthetic estrogens of equivalent estrogen doses. Adding a progestin to estrogen therapy has been shown to reduce the risk of endometrial hyperplasia, which may be a precursor to endometrial cancer.

b. Breast cancer

The use of estrogens and progestins by postmenopausal women has been reported to increase the risk of breast cancer. The most important randomized clinical trial providing information about this issue is the Women’s Health Initiative (WHI) substudy of CE/MPA (see CLINICAL PHARMACOLOGY, Clinical Studies). The results from observational studies are generally consistent with those of the WHI clinical trial and report no significant variation in the risk of breast cancer among different estrogens or progestins, doses, or routes of administration.

The CE/MPA substudy of WHI reported an increased risk of breast cancer in women who took CE/MPA for a mean follow-up of 5.6 years. Observational studies have also reported an increased risk for estrogen/progestin combination therapy, and a smaller increased risk for estrogen alone therapy, after several years of use. In the WHI trial and from observational studies, the excess risk increased with duration of use. From observational studies, the risk appeared to return to baseline in about five years after stopping treatment. In addition, observational studies suggest that the risk of breast cancer was greater, and became apparent earlier, with estrogen/progestin combination therapy as compared to estrogen alone therapy.

In the CE/MPA substudy, 26% of the women reported prior use of estrogen alone and/or estrogen/progestin combination hormone therapy. After a mean follow-up of 5.6 years during the clinical trial, the overall relative risk of invasive breast cancer was 1.24 (95% confidence interval 1.01 to 1.54), and the overall absolute risk was 41 vs. 33 cases per 10,000 women-years, for CE/MPA compared with placebo. Among women who reported prior use of hormone therapy, the relative risk of invasive breast cancer was 1.86, and the absolute risk was 46 vs. 25 cases per 10,000 women-years, for CE/MPA compared with placebo. Among women who reported no prior use of hormone therapy, the relative risk of invasive breast cancer was 1.09, and the absolute risk was 40 vs. 36 cases per 10,000 women-years for CE/MPA compared with placebo. In the same substudy, invasive breast cancers were larger and diagnosed at a more advanced stage in the CE/MPA group compared with the placebo group. Metastatic disease was rare with no apparent difference between the two groups. Other prognostic factors such as histologic subtype, grade and hormone receptor status did not differ between the groups. 

 
The use of estrogen plus progestin has been reported to result in an increase in abnormal mammograms requiring further evaluation. All women should receive yearly breast examinations by a healthcare provider and perform monthly breast self-examinations. In addition, mammography examinations should be scheduled based on patient age, risk factors and prior mammogram results.

3. Dementia

In the Women’s Health Initiative Memory Study (WHIMS), 4,532 generally healthy postmenopausal women 65 years of age and older were studied, of whom 35% were 70 to 74 years of age and 18% were 75 or older. After an average follow-up of 4 years, 40 women being treated with CE/MPA (1.8%, n = 2,229) and 21 women in the placebo group (0.9%, n = 2,303) received diagnoses of probable dementia. The relative risk for CE/MPA vs. placebo was 2.05 (95% confidence interval 1.21 - 3.48), and was similar for women with and without histories of menopausal hormone use before WHIMS. The absolute risk of probable dementia for CE/MPA versus placebo was 45 versus 22 cases per 10,000 women-years, and the absolute excess risk for CE/MPA was 23 cases per 10,000 women-years. It is unknown whether these findings apply to younger postmenopausal women. (see CLINICAL PHARMACOLOGY, Clinical Studies and PRECAUTIONS, Geriatric Use).

It is unknown whether these findings apply to estrogen alone therapy.

4. Gallbladder Disease

A 2- to 4-fold increase in the risk of gallbladder disease requiring surgery in postmenopausal women receiving oral estrogens has been reported.

5. Hypercalcemia

Estrogen administration may lead to severe hypercalcemia in patients with breast cancer and bone metastases. If hypercalcemia occurs, use of the drug should be stopped and appropriate measures taken to reduce the serum calcium level.

6. Visual Abnormalities

Retinal vascular thrombosis has been reported in patients receiving estrogens. Discontinue medication pending examination if there is sudden partial or complete loss of vision, or a sudden onset of proptosis, diplopia, or migraine. If examination reveals papilledema or retinal vascular lesions, estrogens should be permanently discontinued.

Legal Issues

There is currently no legal information available for this drug.

FDA Safety Alerts

There are currently no FDA safety alerts available for this drug.

Manufacturer Warnings

There is currently no manufacturer warning information available for this drug.

FDA Labeling Changes

There are currently no FDA labeling changes available for this drug.

Uses

Estradiol tablets are indicated in the:

1.    Treatment of moderate to severe vasomotor symptoms associated with the menopause. 

2.    Treatment of moderate to severe symptoms of vulvar and vaginal atrophy associated with the menopause. When prescribed solely for the treatment of symptoms of vulvar and vaginal atrophy, topical vaginal products should be considered. 

3.    Treatment of hypoestrogenism due to hypogonadism, castration or primary ovarian failure.

4.    Treatment of breast cancer (for palliation only) in appropriately selected women and men with metastatic disease.

5.    Treatment of advanced androgen-dependent carcinoma of the prostate (for palliation only).

6.    Prevention of osteoporosis. When prescribing solely for the prevention of postmenopausal osteoporosis, therapy should only be considered for women at significant risk of osteoporosis and for whom non-estrogen medications are not considered to be appropriate (See CLINICAL PHARMACOLOGY, Clinical Studies).

The mainstays for decreasing the risk of postmenopausal osteoporosis are weight bearing exercise, adequate calcium and vitamin D intake, and when indicated, pharmacologic therapy.

Postmenopausal women require an average of 1500 mg/day of elemental calcium. Therefore, when not contraindicated, calcium supplementation may be helpful for women with suboptimal dietary intake. Vitamin D supplementation of 400 to 800 IU/day may also be required to ensure adequate daily intake in postmenopausal women.

History

There is currently no drug history available for this drug.

Other Information

Each tablet, for oral administration, contains 0.5, 1 or 2 mg of micronized estradiol. Estradiol (17β-estradiol) is a white, crystalline solid, chemically described as estra-1,3,5(10)-triene-3,17β-diol. It has a molecular formula of C18H24O2 and molecular weight of 272.39. The structural formula is:

structure image

Estradiol tablets, 0.5 mg contain the following inactive ingredients: anhydrous lactose, magnesium stearate, microcrystalline cellulose, and polacrilin potassium.

Estradiol tablets, 1 mg contain the following inactive ingredients: anhydrous lactose, D&C Red No. 30 (aluminum lake), D&C Yellow No. 10 (aluminum lake), FD&C Blue No. 1 (aluminum lake), magnesium stearate, microcrystalline cellulose, and polacrilin potassium.

Estradiol tablets, 2 mg contain the following inactive ingredients: anhydrous lactose, D&C Yellow No. 10 (aluminum lake), FD&C Blue No. 1 (aluminum lake), magnesium stearate, microcrystalline cellulose, and polacrilin potassium.

Estradiol Manufacturers


  • Golden State Medical Supply, Inc.
    Estradiol Tablet [Golden State Medical Supply, Inc.]
  • Proficient Rx Lp
    Estradiol Tablet [Proficient Rx Lp]
  • Blenheim Pharmacal, Inc.
    Estradiol Tablet [Blenheim Pharmacal, Inc.]
  • Preferred Pharmaceuticals, Inc.
    Estradiol Tablet [Preferred Pharmaceuticals, Inc.]
  • Stat Rx Usa
    Estradiol Tablet [Stat Rx Usa]
  • Physicians Total Care, Inc.
    Estradiol Tablet [Physicians Total Care, Inc.]
  • Kaiser Foundation Hospitals
    Estradiol Tablet [Kaiser Foundation Hospitals]
  • Heritage Pharmaceuticals Inc
    Estradiol Tablet [Heritage Pharmaceuticals Inc]
  • Rebel Distributors Corp
    Estradiol Tablet [Rebel Distributors Corp]
  • Pd-rx Pharmaceuticals, Inc.
    Estradiol Tablet [Pd-rx Pharmaceuticals, Inc.]
  • Pd-rx Pharmaceuticals, Inc.
    Estradiol Tablet [Pd-rx Pharmaceuticals, Inc.]
  • Lake Erie Medical & Surgical Supply Dba Quality Care Products Llc
    Estradiol Tablet [Lake Erie Medical & Surgical Supply Dba Quality Care Products Llc]
  • Watson Laboratories, Inc.
    Estradiol Tablet [Watson Laboratories, Inc.]
  • Pd-rx Pharmaceuticals, Inc.
    Estradiol Tablet [Pd-rx Pharmaceuticals, Inc.]
  • Stat Rx Usa Llc
    Estradiol Tablet [Stat Rx Usa Llc]
  • Kaiser Foundation Hospitals
    Estradiol Tablet [Kaiser Foundation Hospitals]
  • Bryant Ranch Prepack
    Estradiol Tablet [Bryant Ranch Prepack]
  • Cardinal Health
    Estradiol Tablet [Cardinal Health]
  • Pd-rx Pharmaceuticals, Inc.
    Estradiol Tablet [Pd-rx Pharmaceuticals, Inc.]
  • Barr Laboratories Inc.
    Estradiol Tablet [Barr Laboratories Inc.]
  • Aidarex Pharmaceuticals Llc
    Estradiol Tablet [Aidarex Pharmaceuticals Llc]
  • Preferred Pharmaceuticals, Inc
    Estradiol Tablet [Preferred Pharmaceuticals, Inc]
  • Readymeds
    Estradiol Tablet [Readymeds]
  • Bryant Ranch Prepack
    Estradiol Tablet [Bryant Ranch Prepack]
  • Mylan Pharmaceuticals Inc.
    Estradiol Tablet [Mylan Pharmaceuticals Inc.]
  • Bryant Ranch Prepack
    Estradiol Tablet [Bryant Ranch Prepack]
  • Bryant Ranch Prepack
    Estradiol Tablet [Bryant Ranch Prepack]
  • Avpak
    Estradiol (Estradiol) Tablet [Avpak]
  • Kaiser Foundation Hospitals
    Estradiol Tablet [Kaiser Foundation Hospitals]
  • Directrx
    Estradiol Tablet [Directrx]

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