How To Take Your Medicine: 
Estrogens 

  How you take a drug makes a big difference in how well it will work and 
how safe it will be for you. Dose timing, what and when you eat, and many 
other factors can mean the difference between feeling better, staying the 
same, or even feeling worse. This drug information page is intended to help 
you make your treatment work as well as possible. It's important to note, 
however, that this is only a guideline. You should talk to your doctor or 
pharmacist about how to take any prescribed drug. 
  This installment in a series of articles on commonly prescribed drugs is
about estrogens. The focus is on estrogen deficiency problems. For
information about another major estrogen use, oral contraceptives, see "'The
Pill' May Not Mix Well with Other Drugs" in the March 1987 FDA Consumer.
  Estrogens are the hormones mainly responsible for female sex
characteristics. They assist in preparing girls' bones for rapid growth in
adolescence. In women, estrogens maintain tone and elasticity of the urinary
and reproductive organs and protect against bone thinning.
  Men also make the hormone, but only a small amount. In both men and women,
estrogens help stabilize the opening and closing of blood vessels.
  Women manufacture most estrogens in the ovaries and adrenal gland, with 
increases during pregnancy from the placenta. Men produce low levels of 
estrogens in the testes. Fat cells also may produce estrogens.
  Therapeutic estrogens made synthetically or derived from pregnant mares'
urine are formulated as oral, injectable and vaginal preparations and, most 
recently, as stick-on patches.

Uses for These Drugs
  The most common treatment use for these drugs is estrogen replacement 
therapy to treat symptoms of menopause (including menopause surgically
induced by removal of the ovaries) to prevent the sweating episodes called
hot flashes and the shrinking and irritation that sometimes occur in the
vulva, vagina, and urinary organs. Because of the effects estrogen
deficiency can have on the vagina, some menopausal and postmenopausal women 
have pain during or after intercourse. Estrogen therapy helps relieve this
symptom by thickening the vaginal wall. Medical evidence hasn't proven that 
estrogens keep a woman feeling young or foster soft or unwrinkled skin. 
There is no evidence that they ease emotional and nervous symptoms, except
in association with other postmenopausal symptoms such as hot flashes.
  Other deficiency conditions that can be treated by estrogen use include 
failure of the ovaries to develop and premature failure of the ovaries. 
  In addition to the above uses, the Food and Drug Administration has 
approved estrogens to treat the following conditions: 
* abnormal uterine bleeding due to hormonal imbalance 
* breast cancer in some men and women whose disease has spread to other 
organs
* advanced prostate cancer
  FDA has approved Premarin?the original brand of conjugated (blended)
estrogens for use in menopausal and postmenopausal women to help prevent
bone loss due to osteoporosis, a bone-thinning condition. 
  In June 1990, FDA's Fertility and Maternal Health Drugs Advisory Committee
concluded that estrogen replacement therapy with Premarin may reduce a
woman's risk of diseases of the heart and blood vessels. FDA is currently 
evaluating the committee's report.
  The agency also is evaluating the situation with generic conjugated 
estrogens. In February 1990, FDA proposed withdrawing approval of these 
products' marketing applications. Though generic conjugated estrogens are 
similar to Premarin, they are not identical, and their differences may
affect their safety and effectiveness. For example, they might be less
effective or ineffective in preventing osteoporosis.

How to Take Estrogens 
  As with all drugs, patients should take estrogens exactly as directed and 
should never give their medication to someone else. They should use the 
lowest dose needed, for the shortest time possible, and only for the
prescribed treatment. 
  Oral estrogens are given once daily, whereas patches are changed twice
weekly. When the physician deems it desirable to simulate the menstrual 
cycle, doses continue for three weeks, followed by a week without treatment.
Taking oral estrogens at the same time each day establishes a routine and 
provides the greatest benefit with the least chance of side effects.
  If nausea is a problem, taking the tablet with food or immediately after a
meal may help. This symptom usually disappears with continued use.
  When using the estrogen stick-on patch: 
* Read directions carefully.
* Wash and dry hands before and after handling. 
* Apply patch to the abdomen on a clean, dry, non-oily, hairless area free
of cuts and irritation. 
* Press firmly about 10 seconds, particularly around the edges. 
* To avoid irritation, apply each dose to a different area, allowing at 
least a week to pass before an area is used again.
* Reapply a loosened patch or discard it and apply a new patch. 
* Never apply a patch to the breasts or to an area such as the waist where
clothing might rub it loose.
  Clinical data support only cyclic short-term use of vaginal estrogen
cream. To apply:
* Puncture dispensing end of tube with plastic spike on cap.
* Screw nozzle end of applicator to end of tube.
* Squeeze cream into applicator barrel until it reaches prescribed dosage,
usually full or half full 
* Unscrew applicator from tube. 
* Lie on back with knees drawn up and then gently insert applicator deeply
into vagina and press plunger downward to its original position.
  To clean the applicator, pull the plunger from the barrel and wash it with
mild soap and warm water. Do not boil or use hot water. 

Missed Doses
  Take a missed tablet as soon as possible, but skip it if it's almost time 
for the next one; this applies to patches, too. Never double an oral dose,
and wear only one patch at a time.

Relief of Symptoms
  The body readily absorbs estrogens into the bloodstream through the skin, 
vagina or intestines. Thus, therapy usually begins relieving menopausal 
symptoms such as hot flashes within a day or two. These problems may recur
during the week off the drug, but they usually don't reach pre-treatment
intensity.

Side Effects and Risks
  While estrogens have important uses, they also have serious risks.
  Estrogens cause the uterine lining, or endometrium, to thicken in 
preparation for possible pregnancy. In the absence of a fertilized egg, 
female hormones called progestins cause the lining to shed, as menstruation.
Therapy with estrogens alone can cause endometrial hyperplasia (overgrowth),
a precursor to cancer in certain women. 
  In some studies, estrogen treatment of menopausal symptoms for longer than
a year has increased the risk of endometrial hyperplasia/cancer. The
greatest risk is with higher than usual dosages and with treatment that 
lasts five years or more. As a protective measure, some physicians may add
10 to 14 days dosage with a progestin to the monthly regimen. Women on this 
regimen will have cyclic bleeding similar to menstruation and even may
experience premenstrual-like symptoms. Women who have had the uterus
surgically removed have no risk of endometrial cancer.
  There are concerns about the long-term effects of progestins, particularly
the possibility that they may raise harmful LDL (low-density lipoprotein) 
cholesterol while lowering beneficial HDL (high-density lipoprotein)
cholesterol.
  Large doses of estrogens, such as a 30-milligram (mg) daily dose to treat 
breast cancer, are linked to increased risk of heart attack and blood-clot
conditions. (By comparison, the usual daily dosage for menopausal symptoms
is 0.01 to 0.05 mg of ethinyl estradiol or 0.3 to 1.25 mg of conjugated 
estrogens.) 
  Cigarette smoking may increase the risk of serious blood clots in women 
taking estrogens, the risk increasing with the patient's age and amount 
smoked. Smoking also may make estrogens less effective. 
  Breast cancer has been reported in men on estrogens; men receiving this 
drug should see their doctors at least annually.
  It's unknown whether estrogen use increases a woman's risk of breast
cancer. Like all women, those taking estrogens should have annual medical 
checkups that include breast examination and should practice breast 
self-examination. 
  People taking estrogens should get emergency medical help if any of the 
following symptoms of blood clots occurs: 
* sudden or severe headache 
* sudden loss of coordination 
* sudden loss or change of vision 
* pains in the chest, groin or leg, especially in the calf
* sudden, unexplained shortness of breath 
* sudden slurring of speech 
* weakness or numbness in an arm or leg 
  Check with the doctor as soon as possible if any of the following estrogen
side effects occurs:
* swollen feet and lower legs 
* rapid weight gain 
* breast pain 
* increased breast size 
* blood-filled skin sores 
* changes in vaginal bleeding 
* confusion 
* general feeling of illness
* joint or muscle aches 
* breast lumps or discharge from nipples
* mental depression 
* persistent nausea or vomiting 
* pains in the stomach, side or abdomen 
* sores in the mouth or nose or on lower legs, thighs, forearms, genitals,
soles, or palms 
* uncontrolled jerky muscle movement
* unusual tiredness 
* yellow eyes or skin 
  Estrogens may foster bleeding or overgrowth of the gums. Regular cleaning 
by a dental professional and plaque control by the patient will minimize
problems. 
  Side effects requiring medical care only if severe or bothersome include
mild acne, stomach bloating, appetite loss, problems wearing contact lenses 
due to dry eyes, and migraine headaches. Exposure to the sun can cause
brown, blotchy skin spots, so it's wise to use a sunscreen. 
  Some patients may have other side effects. Patients who develop new health
problems or have questions should check with the doctor.
  Estrogens may affect certain diagnostic laboratory tests, such as the 
glucose tolerance test, so it's important that patients using estrogens tell
the doctor or laboratory personnel performing the procedure.

Before Taking This Medicine 
  Before deciding to use estrogen, it's best to talk to the doctor about the
good it will do and the risks it poses. 
  To keep risks as low as possible, patients should tell the doctor:
* if they might be pregnant. Estrogen therapy during pregnancy has been 
associated with an increased risk of birth defects, such as defects in the
reproductive organs. Breast-feeding mothers shouldn't take estrogen because 
it passes into the breast milk, and its effect on infants is unknown. 
* if they follow a special diet or ever had an unusual or allergic response 
to estrogen or to foods, dyes or preservatives. 
* if they have a family history of bone disease, cancer (especially breast
cancer in mother, sister or aunt), endometriosis (in which endometrial
tissue becomes implanted elsewhere), epilepsy, fibroids, gallbladder
disease, heart or circulatory disease, stroke, kidney disease, liver
disease, migraine headaches, or excess calcium in the blood.
* if they smoke or take other prescription or over-the-counter medicine.
Estrogens may alter the effect of some other drugs, including drugs to
prevent blood clots, diabetes drugs, calcium supplements, and a breast
cancer drug called tamoxifen. 

Proper Storage
* Store estrogens away from humidity, heat, and direct light, which can 
destroy the drug's effectiveness. Humidity from steamy baths and showers
make the bathroom medicine cabinet a poor place to store drugs. 
* Keep estrogens out of the reach of children. Caps that are child-resistant
aren't necessarily child-proof. 
* Discard estrogens when they're no longer needed or when the expiration
date is past. Be sure to dispose of the drug (including used patches) out of
the reach of children. n

Dixie Farley

Types of Estrogen 

chlorotrianisene
diethylstilbestrol
estradiol 
conjugated estrogens
esterified estrogens
estrone 
estropipate 
ethinyl estradiol 
quinestrol