Estrogen (Vaginal)

Overview

Estrogen is administered to patients experiencing menopause, as a way of returning hormone levels to normal and in an effort to reduce or eliminate symptoms associated with the condition. While estrogen is a natural sex hormone produced in the ovaries, it's also essential to the functioning of other systems throughout the body. In cases where treatment is intended specifically to alleviate symptoms related only to the vagina, medical treatments applied directly to the vagina should be considered first. Only in cases where that type of treatment fails should estrogen be considered as an alternative.

While estrogen medication is used to treat the symptoms of menopause, it can also be used to prevent osteoporosis. Bone loss may be better treated by other medications, but, depending on the patient's symptoms or other circumstances, the doctor may prefer to prescribe estrogen supplements. Additionally, it can help raise the estrogen levels in women who have experienced ovarian failure or other conditions that result in poor estrogen production.

Women can receive estrogen treatments in fighting certain types of cancer. Breast cancer has been treated successfully with estrogen therapy and, in some cases, the treatment may be applied to other cancers. The determination will be made by the doctor and patient in a consultation about the patient's condition.

Conditions Treated

    • Menopause
    • Osteoporosis
    • Ovarian failure
    • Prostate cancer
    • Breast cancer

Type Of Medicine

    • Hormone supplement

Side Effects

    • Vaginal yeast infection
    • Variation in vaginal discharges
    • Discharge from nipples that may be clear or bloody
    • Decrease in urination
    • Unexplained imperfections or dimples in breast skin
    • Increased heart beat
    • Fever
    • Skin outbreaks that include itching, rashes, or hives
    • Hoarse voice
    • Inverted nipples
    • General irritation
    • Joint pain that may be accompanied by swelling or stiffness
    • Unexplained lump under the arm or in the breast
    • Rattling or noisy breathing
    • Pelvic pain, or a feeling of pressure
    • Swelling, redness, or pain in the limbs
    • Continuous scaling or crusting on the nipples
    • Redness of the skin
    • Swelling or redness of the breasts
    • Sores on the breasts that do not heal or may recur
    • Unexplained swelling of the face, lips, eyelids, hands, fingers, lower legs, or feet
    • Tightness or pressure in the chest
    • Difficulty breathing or swallowing
    • Vaginal bleeding
    • Back pain
    • Frequent headaches
    • Soreness or itching sensation of the genital area, which may include the vagina
    • An odorless or mild-smelling discharge from the vagina that appears thick and white
    • Unexplained weight gain
    • Body pain or aches
    • Chills
    • Persistent cough
    • Diarrhea
    • Congested ears
    • Loss of voice
    • Nasal congestion
    • Runny nose
    • Sneezing
    • Sore throat
    • Feelings of sadness or an empty feeling
    • unexplained irritability
    • Loss of appetite
    • Tiredness
    • Difficulty concentrating
    • Sleep difficulties
    • Welts

The genitourinary side effect most commonly experienced in 29% of patients is breast pain. Also common, but not as prevalent or likely as breast pain, is the development of vulvovaginal pruritus and leucorrhea. Patients may also experience vaginal discomfort, which can lead to vaginal hemorrhage or discharge and the onset of menopausal symptoms. Patients may also notice breakthrough bleeding or some unexplained spotting. Other common side effects related to the genitalia or urinary tract include breast swelling, menorrhagia, metrorrhagia, and endometrial hyperplasia. Less commonly experienced are problems with urination and Galactorrhea (a milky white excretion from the nipples that is not breast milk).

The gastrointestinal side effect most commonly experienced was abdominal pain, which was reported by 16% of patients. Other related side effects, developing in up to 10% of cases, were flatulence, diarrhea, and nausea. In rare cases, making up less than 1% of reports, the nausea was accompanied by vomiting.

There were only a handful of musculoskeletal side effects reported by patients. Most common reports were those of back pain and arthralgia. These symptoms were reported by 11% of patients. Less than 10% of patients reported also experiencing leg cramping.

Varicose veins and cardiac symptoms, such as heart palpitations, made up the bulk of cardiovascular complaints from patients while taking estrogen supplements. Other side effects that were rarely experienced with a less than 1% rate of frequency were hot flushes, hypertension, and venous thromboembolic disease. Arterial hypertension was reported in extremely rare instances.

The majority of side effects related to the nervous system consisted of reports of headaches, which occurred in 18% of patients. Far less commonly experienced, patients also reported migraines, episodes of vertigo, and an aggravation of epilepsy. Paresthesia and dizziness were also reported, but with an undefined degree of frequency.

Oncologic symptoms were rare, but conditions of benign breast neoplasm or an increased volume of uterine leiomyoma were reported. Side effects not defined in reports included endometrial cancer and breast cancer.

Estrogen therapy also resulted in some psychiatric side effects with patients most commonly reporting feelings of depression. Less commonly reported in less than 1% of cases were sleeping difficulties, nervousness, anxiety, and mood swings. A few patients also experienced a noticeable change in libido while taking estrogen therapy treatments.

In regards to dermatologic side effects of estrogen supplements, patients most often reported pruritus, a severe itching of the skin. In less common instances, patients developed rashes, acne, and skin discoloration. Patients also reported developing urticaria, erythematous, alopecia, hyperhidrosis, night sweats, contact dermatitis, and eczema, though the frequency of occurrences has not been determined.

There were rare side effects related to vision reported. In up to 1% of cases, vision abnormal NOS was reported, while undocumented reports of visual disturbances and an unexplained intolerance to contact lenses were also experienced.

Hepatic side effects have been observed in rare cases with less than 0.1% of patients developing liver function test abnormalities while receiving estrogen supplement therapy. There were also instances of cholestatic jaundice, though the frequency of occurrences was unreported.

The metabolic system was also affected in rare cases, resulting in those patients developing an intolerance to glucose. Some individuals also had problems with fluid retention during the course of estrogen treatments.

Hypersensitivity side effects were observed primarily in patients with a history of allergies. Anaphylactic reactions were reported in very rare instances.

Side effects related to the immune system were more commonly reported. In 17% of cases, patients developed upper respiratory tract infections while receiving estrogen therapy treatments. Other common immunological side effects observed in up to 10% of patients were vulvovaginal mycotic infections, pharyngitis, rhinitis, sinusitis, and moniliasis genital. In very rare circumstances, female patients developed vaginitis or vaginal candidosis.

General side effects, which have not been categorized elsewhere, included pain in 11% of cases and edema in under 10% of patients. Uncommon general side effects were asthenia and weight gain. Skin irritation was also reported in up to 10% of patients.

Additional side effects of estrogen therapy can include drug ineffectiveness, blood estrogen increase, fatigue, or an exacerbation of hereditary angioedema.

Patients should notify their doctor when experiencing any side effects resulting from estrogen supplements. In cases where the condition is severe or persistent, the doctor may be able to prescribe other medications to control those side effects or suggest lifestyle changes to lessen the impact of the symptoms. In some cases, it may be necessary to alter the dosage of estrogen supplements or consider alternative treatments if side effects continue to affect the patient.

Dosage

Estrogen is applied vaginally, so the patient must be certain to wash her hands, before applying the solution. Additionally, the patient should be certain not to touch her face, while administering treatment, because the solution may cause eye irritation. If she notices a stinging in the eyes, she should immediately rinse her eyes under cold water and check with her doctor.

While it can take up to four months to see results, the patient should be diligent in using only as much of the drug as prescribed by her doctor, as well as not exceeding the recommended duration of treatment. Typically, the doctor will adjust dosages over the first two months of treatment and periodically, throughout the full course of treatment. Where the vaginal insert of a ring is used, the device should be replaced every three months.

In applying vaginal creams or suppositories, the medication should come with a plastic applicator, which will have dosages marked on it. If the patient's dosage isn't on the applicator, she should first speak with the prescribing doctor to obtain further instructions. Where the suppository is used, simply insert it into the applicator. In using the cream, the applicator should be screwed onto the tube and the medication squeezed into the applicator up to the predetermined dosage size. Next, unscrew the applicator and put the cap back on the medication tube.

The medication can then be administered either by laying down with knees slightly bent or by standing up with one foot propped on a chair. The patient should then insert the applicator into the vagina, holding it with one hand. She should continue to slide it until it becomes slightly uncomfortable. As the patient slowly pushes on the plunger, the medication will be dispersed and the applicator can be withdrawn.

Afterwards, it's important to care for the applicator, so it can be saved to administer future dosages. Separate the plunger from the applicator and wash both pieces with warm, soapy water. The patient should be careful not to use hot or boiling water, as this may damage the device. Next, rinse both parts of the applicator and allow to dry. Later, after the individual pieces have thoroughly dried, the patient can reassemble the applicator.

In applying the vaginal ring or insert, the patient may either lie down or apply the device in a standing position with one foot propped up on a chair. Using her forefinger and middle finger, the patient should squeeze the sides of the ring together, so that it becomes compressed. She should then use her free hand to part the labia, so the ring can be slid into place. It should be placed in the upper third portion of the vagina, just before it becomes uncomfortable. While it's not necessary to be precise with placement, the patient should feel comfortable. Feelings of pain or discomfort are indications that the insert should be placed higher in the vagina.

In removing the vaginal insert, the patient should be in a standing position and prop a foot up on a chair. This will enable her to reach high enough into her vagina to hook a finger around the lip of the ring or insert. She can then slowly pull the insert out. To dispose of a ring or insert, wrap it up and dispose of it in the trash. Do not flush it down the toilet.

In treating inflammation of the vagina or a genital skin condition, the vaginal cream should be administered in dosages of two to four grams, administered once per day over a 1 to 2 week period. Subsequently, the dosage should be reduced by half over the next four weeks. After the fourth week, doctors are urged to reduce their patients' dosages to one gram, administered just three times per week. This can be continued for three weeks with a one week break to follow. If needed, the one gram dose can then be resumed for another three weeks.

In administering a ring or insert, the device can contain 2 to 24.8 milligrams of estrogen, which should last the patient for the three month period. The insert will release the medication at a rate of 7.5 to 100 micrograms (mcg) for each 24 hour period.

It's possible that the patient may forget to administer a dose in cases where the vaginal cream is prescribed. If this is the case, she may administer it upon remembering. However, if it's close to the time for her next scheduled dosage, she should skip the missed dose entirely and pick up with her normal schedule with the next dose. To reduce incidences of missed doses, the patient should establish a set schedule with specified times for administering the doses. This can also help prevent double dosing.

Since doses are administered on a daily basis, it's recommended that the patient only make up for a missed dose if there are still more than 12 hours until her next scheduled dose. If there's less time, the patient should wait until her next scheduled dose.

Major Drug Interactions:

Combining any medications can result in adverse reactions, so it's especially important for patients to share their drug use history with their doctor. This includes any medications they are currently taking, as well as those drugs they may have taken in the past. The patient should tell their doctor about nonprescription drug use, as well as those medications prescribed by other physicians and healthcare providers. Additionally, the doctor should be made aware of vitamins, herbal supplements, over the counter medicines that the patient has been taking. The patient should also be urged to discuss recreational drug and alcohol use because mixing substance abuse with estrogen therapy can have unexpected negative effects on the patient.

Here is a list of medications commonly known to interact negatively with estrogen therapy treatments. If the patient is specifically taking any of these drugs, she should notify the physician before beginning estrogen therapy.

    • Ambien (zolpidem)
    • Aspirin Low Strength (aspirin)
    • Calcium 600 D (calcium / vitamin D)
    • Cymbalta (duloxetine)
    • Fish Oil (omega-3 polyunsaturated fatty acids)
    • Flexeril (cyclobenzaprine)
    • Klonopin (clonazepam)
    • Lexapro (escitalopram)
    • Lyrica (pregabalin)
    • Nexium (esomeprazole)
    • Norco (acetaminophen / hydrocodone)
    • Singulair (montelukast)
    • Synthroid (levothyroxine)
    • Topamax (topiramate)
    • Vitamin B12 (cyanocobalamin)
    • Vitamin C (ascorbic acid)
    • Vitamin D3 (cholecalciferol)
    • Xanax (alprazolam)
    • Zoloft (sertraline)
    • Zyrtec (cetirizine)

When the patient feels it's necessary to alter the dosage of any medications, stop taking a medication, or begin a new medication, he or she should first discuss it with their doctor. The physician can advise the patient on the best procedure for altering medications, so the effectiveness of the estrogen therapy won't be compromised. Additionally, the patient's caregiver may be able to offer guidance to minimize the likelihood of experiencing negative reactions. Even a change that seems insignificant can cause adverse and severe reactions, so it's important to consult a physician beforehand.

Warnings

Another important part of beginning estrogen treatment or any new drug therapy is discussing the patient's medical history. Health conditions from which the patient currently suffers, as well as other conditions experienced in the past, can contribute to the estrogen treatment's effectiveness or can negatively interact with the supplement. In order to avoid severe complications, the patient should disclose any health conditions to the prescribing doctor.

Additionally, the patient should tell the physician if they have any allergies. In some cases, allergies can pose a risk to the patient, if a new drug treatment contains ingredients that could cause a reaction. The patient's doctor will be able to determine if estrogen therapy is a safe course of treatment.

The following medical conditions have been known to cause complications when estrogen therapy has been administered. Patients should notify their doctor, before beginning treatment, if they have, or have had, any of the following conditions:

    • Abnormal Vaginal Bleeding
    • Carcinomas (Estrogenic)
    • Hypercalcemia In Breast Cancer
    • Hypertension
    • Thromboembolism/Cardiovascular
    • Hepatic Neoplasms
    • Angioedema
    • Gallbladder Disease
    • Hypercalcemia
    • Hyperlipidemia
    • Liver Disease
    • Melasma
    • Depression
    • Fluid Retention
    • Glucose Intolerance
    • Retinal Thrombosis
    • Thyroid Function Tests

Patients should not smoke tobacco products while submitting to estrogen therapy. When combined, estrogen and smoking increase the likelihood that the patient will suffer high blood pressure, stroke, blood clotting, and heart attacks. These risks are especially likely to develop in women over the age of 35.

Similarly, the patient should notify their doctor if they have recently had surgery or will be undergoing surgery. Any situation that will cause the patient to sit or lay for extended periods of time should be discussed with the doctor prescribing estrogen therapy. These activities have a tendency to increase the risk of developing blood clots. For this reason, the doctor may advise the patient to stop taking estrogen medication or may suggest special instructions to minimize the risk of developing clots.

Additionally, it's important for women to notify their doctor if they're pregnant or planning to get pregnant. Estrogen therapy has been linked to urogenital abnormalities, which develop later in the lives of affected offspring. Female children have developed vaginal adenosis, squamous cell dysplasia of the uterine cervix, and vaginal cancer later in life, while urogenital abnormalities and testicular cancer affected male offspring.

There is insignificant data on the effects of estrogen on children who are breastfed. While it's not known how much estrogen is excreted in breast milk, the American Academy of Pediatrics reports estrogen therapy is compatible with breastfeeding. There have been reports that estrogen therapy inhibits the mother's ability to generate sufficient quantities of milk and that breast milk is weaker while taking the estrogen supplements. Additionally, estrogen should not be used as a method for preventing postpartum breast engorgement and manufacturers warn that caution should be taken in administering the hormone therapy to women who are nursing.

Storage

As with any medication, estrogen creams, suppositories, rings, and inserts should always be kept in their original packaging and the lid should be tightly closed. It's important to keep this drug out of the reach of children, even when the cap contains a childproof locking mechanism. Even small children can sometimes open medication bottles. Medication bottles should be kept in a location out of the sight and reach of children and pets to avoid accidental poisoning.

Additionally, estrogen can be kept at room temperature but should be stored in a location free from moisture or excessive heat. Estrogen supplements should not be stored in bathrooms or in kitchens, where extreme conditions may affect the medication. Instead, patients should be advised to store the medication in an area away from direct sunlight and in a secure location.

When the patient has finished treatment or the prescribing doctor advises that the medication is no longer required, the patient should contact his or her caregiver to determine the best method for disposing of any leftover supply. It's important to ensure the drug is disposed of in a manner that will prevent children, animals, or other adults from consuming the drug.

Most caregivers advise against flushing any type of medicine down the toilet. Instead, most communities have a medication take-back program. The patient should contact their caregiver to learn if their community participates in such a program. A local pharmacist or caregiver may also have information on drug disposal policies for the city in which the patient lives.

Summary

Estrogen can help alleviate the symptoms of menopause, resupply the body with a hormone deficiency, and even fight certain types of cancer, but individuals should only begin this treatment under the supervision of a physician. A trained caregiver can best determine the appropriate dosage size to correct the condition for which the patient is seeking treatment without complicating other conditions the individual may be experiencing. Combined with lifestyle changes and other medications, the use of estrogen supplements can restore hormone balances to the body without causing severe or frequent side effects. For this reason, it's important that the patient shares all of the relevant details about her lifestyle, including other medical conditions, medication and substance use, and the development of any new symptoms or allergies.

While submitting to estrogen therapy treatments, patients should maintain regular contact with their caregiver. By continuing to return for follow-up visits and recommended testing procedures, the patient can ensure the best possible results from treatment. Regular visits will help the physician determine how well the estrogen supplements are interacting with the body and whether a dosage change is required.

Estrogen drug therapy can be an ideal treatment for a number of conditions from alleviating the symptoms of menopause to treating cancer in both men and women. In some cases, the dosage depends on the severity of the condition, so a consultation with a trained caregiver is necessary. In the event of an overdose, patients should immediately contact emergency services. If they can't reach their city's emergency personnel for any reason, they should contact their local poison control center.

Patients suffering from estrogen deficiencies or menopausal symptoms should contact their doctor for a consultation. Beginning treatment as soon as possible will help restore the body and help patients better cope with their condition. Through the use of estrogen hormone supplements and recommended lifestyle changes, doctors can help patients achieve a more normal balance and reduce the risks of developing related medical conditions in the future.