CONJUGATED ESTROGEN TABLET

NAME OF THE MEDICINAL PRODUCT

Conjugated Estrogen Tablet USP 0.3 mg,

Conjugated Estrogen Tablet USP 0.45 mg,

Conjugated Estrogen Tablet USP 0.625mg

QUALITATIVE AND QUANTITATIVE COMPOSITION
Each tablet contains 0.625 mg conjugated estrogens.
Excipients with known effect:
Each tablet contains lactose monohydrate 54.1 mg and sucrose 45 mg.

PHARMACEUTICAL FORM
Coated Tablet. Maroon oval biconvex sugar-coated tablet marked with “ 0.625” in white ink.

CLINICAL PARTICULARS

Therapeutic indications
− Hormone replacement therapy for estrogen deficiency symptoms in postmenopausal women.

− Prevention of osteoporosis in postmenopausal women at high risk of future fractures who are intolerant of, or contraindicated for, other medicinal products approved for the prevention of osteoporosis.

Posology and method of administration

Adults:
Conjugated estrogen is an estrogen only HRT.

Treatment of Postmenopausal Symptoms
Conjugated estrogen 0.3-1.25mg daily is the usual starting dose for women without a uterus. Continuous administration is recommended.

For initiation and continuation of treatment of postmenopausal symptoms, the lowest effective dose for the shortest duration
should be used. Treatment to control menopausal symptoms should be initiated with Conjugated estrogen 0.3mg. If symptoms are not adequately controlled, higher doses of Conjugated estrogen may be prescribed. Once treatment is established the lowest effective dose necessary for the relief of symptoms should be used. Patients should be re-evaluated periodically to determine if treatment for symptoms is still necessary.

Prevention of postmenopausal osteoporosis:
When prescribing solely for the prevention of postmenopausal osteoporosis, therapy should only be considered for women at significant risk of osteoporosis and non-estrogen medications should be carefully considered.

The minimum effective dose is 0.625mg daily for most patients.

Starting or Changing Treatment
In women who are not taking hormone replacement therapy or women who switch from a continuous combined hormone replacement therapy product, treatment may be started on any convenient day. In women transferring from a sequential hormone replacement therapy regimen, treatment should begin the day following completion of the prior regimen.

Concomitant progestogen use for women with a uterus
In women with a uterus, where the addition of a progestogen is necessary it should be added for at least 12-14 days every 28 day cycle to reduce the risk to the endometrium.

Unless there is a previous diagnosis of endometriosis, it is not recommended to add a progestogen in hysterectomised women.

The benefits of the lower risk of endometrial hyperplasia and endometrial cancer due to adding progestogen should be weighed against the increased risk of breast cancer.

Forgotten tablet
If a tablet is forgotten, it should be taken as soon as the patient remembers, therapy should then be continued as before. If more than one tablet has been forgotten only the most recent tablet should be taken, the patient should not take double the usual dose to make up for missed tablets.

Missed pills may cause breakthrough bleeding in women with a uterus.

Elderly
There are no special dosage requirements for elderly patients, but as with all medicines, the lowest effective dose should be used.

Paediatric population
Safety and effectiveness in pediatric patients have not been established. Estrogen treatment of prepubertal girls induces premature breast development and vaginal cornification, and may induce uterine bleeding.
Since large and repeated doses of estrogen over an extended time period have been shown to accelerate epiphyseal closure, hormonal therapy should not be started before epiphyseal closure has occurred in order not to compromise final growth.

Method of administration
For Oral administration

Tablets should be taken whole; do not divide, crush, chew, or dissolve tablets in mouth.

CONTRAINDICATION
1. Known, suspected or history of breast cancer
2. Known or suspected estrogen-dependent malignant tumours (e.g. endometrial cancer)
3. Undiagnosed genital bleeding
4. Untreated endometrial hyperplasia
5. Previous or current venous thromboembolism (e.g. deep vein thrombosis, pulmonary embolism)

  1. Known thrombophilic disorders (e.g. protein C, protein S, or antithrombin deficiency)
    7. Active or recent arterial thromboembolic
    disease (e.g. angina, myocardial infarction)
    8. Acute liver disease or history of liver disease where the liver function tests have failed to return to normal
    9. Hypersensitivity to the active substance or to any of the excipients.
    10. Porphyria

 

SPECIAL PRECAUTIONS & WARNINGS

For the treatment of postmenopausal symptoms, HRT should only be initiated for symptoms that adversely affect quality of life. In all cases, a careful appraisal of the risks and benefits should be undertaken at least annually and HRT should only be continued as long as the benefit outweighs the risk.

Evidence regarding the risks associated with HRT in the treatment of premature menopause is limited. Due to the low level of absolute risk in younger women, however, the balance of benefits and risks for these women may be more favourable than in older women.

  1. Medical examination/Follow up
    Before initiating or reinstituting HRT, a complete personal and family medical history should be taken. Physical (including pelvic and breast) examination should be guided by this and by the contraindications and warnings for use. During treatment, periodic check-ups are recommended of a frequency and nature adapted to the individual women. Women should be advised what changes in their breasts should be reported to their doctor or nurse. Investigations, including appropriate imaging tools, e.g. mammography, should be carried out in accordance with currently accepted screening practices, modified to the clinical needs of the individual.
  2. Conditions that need supervision
    If any of the following conditions are present, have occurred previously, and/or have been aggravated during pregnancy or previous hormone treatment, the patient should be closely supervised. It should be taken into account that these conditions may recur or be aggravated during treatment with Conjugated estrogen, in particular:
    − Leiomyoma (uterine fibroids) or endometriosis
    − Risk factors for thromboembolic disorders
    − Risk factors for estrogen dependent tumours (e.g. first degree heredity for breast cancer)
    − Hypertension
    − Liver disorders (e.g. liver adenoma)
    − Diabetes mellitus with or without vascular involvement
    − Cholelithiasis
    − Migraine or (severe) headaches
    − Systemic lupus erythematosus (SLE)
    − A history of endometrial hyperplasia (see below)
    − Epilepsy
    − Asthma
    − Otosclerosis
  3. Reasons for immediate withdrawal of therapy

Therapy should be discontinued if a contra-indication is discovered and in the following situations:
− Jaundice or deterioration in liver function
− Significant increase in blood pressure
− New onset of migraine-type headache
− Pregnancy

  1. Endometrial Hyperplasia and Carcinoma

In women with an intact uterus the risk of endometrial hyperplasia and carcinoma is increased when estrogens are administered alone for prolonged periods. The reported increase in endometrial cancer risk among estrogen-only users varies from 2-to 12-fold greater compared with non-users, depending on the duration of treatment and estrogen dose. After stopping treatment risk may remain elevated for at least 10 years.
The addition of a progestogen for at least 12 days per month/28 day cycle or continuous combined estrogen-progestogen therapy in non-hysterectomised women prevents the excess risk associated with estrogen-only HRT.
For oral doses of conjugated equine estrogens >0.625 mg the endometrial safety of added progestogens has not been demonstrated. The reduction in risk to the endometrium should be weighed against the increase in the risk of breast cancer of added progestogen.
Breakthrough bleeding and spotting may occur during the first months of treatment. If break-through bleeding or spotting appears after some time on therapy, or continues after treatment has been discontinued, the reason should be investigated, which may include endometrial biopsy to exclude endometrial malignancy.
Unopposed estrogen stimulation may lead to pre-malignant or malignant transformation in the residual foci of endometriosis. Therefore, the addition of progestogens to estrogen replacement therapy should be considered in women who have undergone hysterectomy because of endometriosis, if they are known to have residual endometriosis (but see above).

  1. Breast Cancer
    The overall evidence suggests an increased risk of breast cancer in women taking combined estrogen-progestogen and possibly also estrogen-only HRT, that is dependent on the duration of taking HRT.
    The Women’s Health Initiative trial (WHI) found no increase in the risk of breast cancer in hysterectomised women using estrogen-only HRT. Observational studies have mostly reported a small increase in risk of having breast cancer diagnosed that is substantially lower than that found in users of estrogen-progestogen combinations.
    For all HRT, an excess risk becomes apparent within a few years of use and increases with the duration of intake but returns to baseline within a few (at most five) years after stopping treatment.
    HRT, especially estrogen-progestogen combined treatment, increases the density of mammographic images which may adversely affect the radiological detection of breast cancer.
  2. Ovarian Cancer
    Ovarian cancer is much rarer than breast cancer.
    Epidemiological evidence from a large meta-analysis suggests a slightly increased risk in women taking estrogen-only or combined estrogen-progestogen HRT, which becomes apparent within 5 years of use and diminishes over time after stopping.
    Some other studies, including the WHI trial, suggest that the use of combined HRTs may be associated with a similar or slightly smaller risk.
  3. Venous thromboembolism
    Hormone replacement therapy (HRT) is associated with a 1.3-3 fold risk of developing venous thromboembolism (VTE) i.e. deep vein thrombosis or pulmonary embolism. The occurrence of such an event is more likely in the first year of HRT than later.
    Patients with a history of VTE or known thrombophilic states have an increased risk of VTE. HRT may add to this risk. HRT is therefore contraindicated in these patients. Personal or strong family history of thromboembolism or recurrent spontaneous abortion should be investigated in order to exclude a thrombophilic predisposition.
    Generally recognised risk factors for VTE include, use of estrogens, older age, major surgery, prolonged immobilisation, obesity (Body Mass Index >30kg/m2), pregnancy/postpartum period, systemic lupus erythematosus (SLE) and cancer. There is no consensus about the possible role of varicose veins in VTE.
    As in all postoperative patients scrupulous attention should be given to prophylactic measures to prevent VTE following surgery. If prolonged immobilisation is liable to follow elective surgery, particularly abdominal or orthopaedic surgery to the lower limbs temporarily stopping HRT 4 to 6 weeks earlier is recommended. Treatment should not be restarted until the woman is completely mobilised.
    In women with no personal history of VTE but with a first degree relative with a history of thrombosis at young age, screening may be offered after careful counselling regarding its limitations (only a proportion of thrombophilic defects are identified by screening). If a thrombophilic defect is identified which segregates with thrombosis in family members or if the defect is ‘severe’ (e.g., antithrombin, protein S, or protein C deficiencies or a combination of defects) HRT is contraindicated.
    Women already on chronic anticoagulant treatment require careful consideration of the benefit-risk of use of HRT.
    If VTE develops after initiating therapy, the drug should be discontinued. Patients should be told to contact their doctors immediately when they are aware of potential thromboembolic symptoms (e.g. painful swelling of a leg, sudden pain in the chest, dyspnoea).
  4. Coronary Artery Disease (CAD)
    There is no evidence from randomised controlled trials of protection against myocardial infarction in women with or without existing CAD who received combined estrogen-progestogen or estrogen-only HRT. Randomised controlled data found no increased risk of CAD in hysterectomised women using estrogen-only therapy.
    9. Ischaemic Stroke

Combined estrogen-progestogen and estrogen-only therapy are associated with an up to 1.5-fold increase in risk of ischaemic stroke. The relative risk does not change with age or time since menopause. However, as the baseline risk of stroke is strongly age-dependent, the overall risk of stroke in women who use HRT will increase with age.
In the WHI estrogen-alone substudy, a statistically significant increased risk of stroke was reported in women 50 to 79 years of age receiving daily CE (0.625 mg) compared to women receiving placebo (45 versus 33 per 10,000 women-years). The increase in risk was demonstrated in year one and persisted. Subgroup analyses of women 50 to 59 years of age suggest no increased risk of stroke for those women receiving CE (0.625 mg) versus those receiving placebo (18 versus 21 per 10,000 women-years).

Other Conditions

  1. Estrogens may cause fluid retention and therefore patients with cardiac or renal dysfunction should be carefully observed.
  2. The use of estrogen may influence the laboratory results of certain endocrine tests and liver enzymes.

Estrogens increase thyroid binding globulin (TBG), leading to increased circulating total thyroid hormone, as measured by protein-bound iodine (PBI), T4 levels (by column or by radio-immunoassay) or T3 levels (by radio-immunoassay). T3 resin uptake is decreased, reflecting the elevated TBG. Free T4 and free T3 concentrations are unaltered.

Other binding proteins may be elevated in serum, i.e. corticoid binding globulin (CBG), sex-hormone-binding globulin (SHBG) leading to increased circulating corticosteroids and sex steroids, respectively. Free or biologically active hormone concentrations are unchanged. Other plasma proteins may be increased (angiotensinogen/renin substrate, alpha-I-antitrypsin, ceruloplasmin).

Some patients dependent on thyroid hormone replacement therapy may require increased doses in order to maintain their free thyroid hormone levels in an acceptable range. Therefore, patients should have their thyroid function monitored more frequently when commencing concurrent treatment in order to maintain their free thyroid hormone levels in an acceptable range.

  1. A worsening of glucose tolerance may occur in patients taking estrogens and therefore diabetic patients should be carefully observed while receiving hormone replacement therapy.
  2. There is an increase in the risk of gallbladder disease in women receiving HRT (see Conditions that need supervision).

14.Women with pre-existing hypertriglyceridemia should be followed closely during estrogen replacement or hormone replacement therapy, since rare cases of large increases of plasma triglycerides leading to pancreatitis have been reported with estrogen therapy in this condition.

15.Estrogens should be used with caution in individuals with severe hypocalcaemia.

16.HRT use does not improve cognitive function. There is some evidence from the WHI trial of increased risk of probable dementia in women who start using continuous combined or estrogen-only HRT after the age of 65.

  1. Exogenous estrogens may induce or exacerbate symptoms of angioedema, particularly in women with hereditary angioedema.
  2. Laboratory monitoring

Estrogen administration should be guided by clinical response rather than by hormone levels (e.g., estradiol, FSH).

  1. This product contains lactose monohydrate and sucrose. Patients with rare hereditary problems of galactose intolerance, fructose intolerance, the Lapp lactase deficiency, glucose-galactose malabsorption or sucrase-isomaltase insufficiency should not take this medicine

Interaction with other medicinal products and other forms of interaction

The metabolism of estrogens may be increased by concomitant use of substances known to induce drug-metabolising enzymes, specifically cytochrome P450 3A4 (CYP3A4) enzymes. Therefore, inducers or inhibitors of CYP3A4 may affect estrogen drug metabolism. Inducers of CYP3A4, such as St. John’s wort (Hypericum perforatum) preparations, phenobarbital, phenytoin, carbamazepine, rifampicin, rifabutin, nevirapine, efavirenz and dexamethasone , may reduce plasma concentrations of estrogens, possibly resulting in a decrease in therapeutic effects and/or changes in the uterine bleeding profile. Inhibitors of CYP3A4, such as cimetidine, erythromycin, clarithromycin, ketoconazole, itraconazole, ritonavir, nelfinavir and grapefruit juice, may increase plasma concentrations of estrogens and may result in side effects.

Interference with Laboratory and Other Diagnostic Tests

Laboratory test interactions

Increased platelet count decreased levels of antithrombin III, and increased plasminogen antigen and activity.

Estrogens increase thyroid-binding globulin (TBG) leading to increased circulating total thyroid hormone, as measured by protein-bound iodine (PBI), T4 levels by column or by radioimmunoassay or T3 levels by radioimmunoassay. T3 resin uptake is decreased, reflecting the elevated TBG. Free T4 and free T3 concentrations are unaltered.

Other binding proteins may be elevated in serum, i.e., corticosteroid binding globulin (CBG), sex hormone-binding globulin (SHBG) leading to increased circulating corticosteroid and sex steroids, respectively. Free or biologically active hormone concentrations may be decreased.

Increased plasma HDL and HDL2 cholesterol subfraction concentrations, reduced LDL cholesterol concentrations, increased triglyceride levels.

Impaired glucose tolerance.

The response to metyrapone may be reduced.

Fertility, pregnancy and lactation

Pregnancy

Conjugated estrogen is not indicated during pregnancy.

For women with a uterus

If pregnancy occurs during medication with Conjugated estrogen treatment should be withdrawn immediately. The results of most epidemiological studies to date relevant to inadvertent foetal exposure to estrogens indicate no teratogenic or foetotoxic effects.

Breast-feeding

Conjugated estrogen is not indicated during lactation.

Effects on ability to drive and use machines
No studies on the effect of ability to drive or use machines have been performed

System Organ Class Common ADRs

(>1/100, < 1/10)

Uncommon ADRs

(>1/1000, <1/100)

Rare ADRs

(>1/10000, <1/1000)

Very Rare ADRs (<1/10000), isolated reports
Infections and infestations Vaginitis, including vaginal candidiasis
Neoplasms benign and malignant (including cysts and polyps) Fibrocystic breast changes; Ovarian cancer; Growth potentiation of benign meningioma Enlargement of hepatic haemangiomas
Immune system disorders Hypersensitivity Anaphylactic/ anaphylactoid reactions, including urticaria and angioedema
Metabolism and nutrition disorders Glucose intolerance Exacerbation of porphyria; Hypocalcaemia
Psychiatric disorders Depression Changes in libido; Mood disturbances; Irritability
Nervous system disorders Dizziness; Headache; Migraine; Anxiety Stroke; Exacerbation of epilepsy Exacerbation of chorea
Eye disorders Intolerance to contact lenses Retinal vascular thrombosis
Cardiac disorders Myocardial infarction
Vascular disorders Venous thrombosis; Pulmonary embolism Superficial thrombophlebitis
Respiratory, thoracic and mediastinal disorders Exacerbation of asthma
Gastrointestinal disorders Nausea; Bloating; Abdominal pain Vomiting; Pancreatitis; Ischaemic colitis
Hepatobiliary disorders Gallbladder disease Cholestatic jaundice
Skin and subcutaneous tissue disorders Alopecia Chloasma/melasma; Hirsutism; Pruritus; Rash
Musculoskeletal, connective tissue and bone disorders Arthralgias; Leg cramps
Reproductive system & breast disorders Abnormal uterine bleeding (Breakthrough bleeding/spotting); Breast pain, tenderness, enlargement, discharge; Leucorrhoea Change in menstrual flow; Change in cervical ectropion and secretion Dysmenorrhoea /pelvic pain; Galactorrhoea; Increased size of uterine leiomyomata
General disorders and administration site conditions Oedema
Investigations Changes in weight (increase or decrease); Increased triglycerides Increases in blood pressure

UNDESIRABLE EFFECTS
Adverse drug reactions (ADRs)

The adverse reactions listed in the table are based on post-marketing spontaneous (reporting rate), clinical trials and class-effects.

Breast Cancer
• An up to 2-fold increased risk of having breast cancer diagnosed is reported in women taking combined estrogen-progestogen therapy for more than 5 years.
• Any increased risk in users of estrogen-only therapy is substantially lower than that seen in users of estrogen-progestogen combinations.
• The level of risk is dependent on the duration of use.
• Results of the largest randomised placebo-controlled trial (WHI-study) and largest epidemiological study (MWS) are presented.

Million Women study– Estimated additional risk of breast cancer after 5 years’ use

ge range

(years)

Additional cases per 1000 never-users of HRT over a 5 year period* Risk ratio & 95%CI# Additional cases per 1000 HRT users over 5 years

(95%CI)

Estrogen only HRT
50-65 9-12 1.2 1-2 (0-3)
Combined estrogen-progestogen
50-65 9-12 1.7 6 (5-7)
#Overall risk ratio. The risk ratio is not constant but will increase with increasing duration on use

Note: Since the background incidence of breast cancer differs by EU country, the number of additional cases of breast cancer will also change proportionately.

 

US WHI studies – additional risk of breast cancer after 5 years’ use

Age range

(yrs)

Incidence per 1000 women in placebo arm over 5 years Risk ratio & 95%CI Additional cases per 1000 HRT users over 5 years (95%CI)
CEE estrogen-only
50-79 21 0.8 (0.7 – 1.0) -4 (-6 – 0)**
CEE+MPA estrogen & progestogen‡
50-79 17 1.2 (1.0 – 1.5) +4 (0 – 9)

When the analysis was restricted to women who had not used HRT prior to the study there was no increased risk apparent during the first 5 years of treatment: after 5 years the risk was higher than in non-users.
*Taken from baseline incidence rates in developed countries
**WHI study in women with no uterus, which did not show an increase in risk of breast cancer

Endometrial Cancer

Postmenopausal women with a uterus
The endometrial cancer risk is about 5 in every 1000 women with a uterus not using HRT.
In women with a uterus, use of estrogen-only HRT is not recommended because it increases the risk of endometrial cancer.
Depending on the duration of estrogen-only use and estrogen dose, the increase in risk of endometrial cancer in epidemiology studies varied from between 5 and 55 extra cases diagnosed in every 1000 women between the ages of 50 and 65.
Adding a progestogen to estrogen-only therapy for at least 12 days per cycle can prevent this increased risk. In the Million Women Study the use of five years of combined (sequential or continuous) HRT did not increase risk of endometrial cancer (RR of 1.0 (0.8-1.2)).

Ovarian cancer
Use of estrogen-only and combined estrogen-progestogen HRT has been associated with a slightly increased risk of having ovarian cancer diagnosed
A meta-analysis from 52 epidemiological studies reported an increased risk of ovarian cancer in women currently using HRT compared to women who have never used HRT (RR 1.43, 95% CI 1.31-1.56). For women aged 50 to 54 years taking 5 years of HRT, this results in about 1 extra case per 2000 users. In women aged 50 to 54 who are not taking HRT, about 2 women in 2000 will be diagnosed with ovarian cancer over a 5-year period.

Risk of venous thromboembolism

Age range (years) Incidence per 1000 women in placebo arm over 5 years Risk ratio and 95%CI Additional cases per 1000 HRT users
Oral estrogen-only*
50-59 7 1.2 (0.6-2.4) 1 (-3 – 10)
Oral combined estrogen-progestogen
50-59 4 2.3 (1.2 – 4.3) 5 (1 – 13)

HRT is associated with a 1.3-3-fold increased relative risk of developing venous thromboembolism (VTE), i.e. deep vein thrombosis or pulmonary embolism. The occurrence of such an event is more likely in the first year of using HT. Results of thWHI studies are presented:

 

*Study in women with no uterus

Risk of coronary artery disease
• The risk of coronary artery disease is slightly increased in users of combined estrogen-progestogen HRT over the age of 60.

Risk of ischaemic stroke
• The use of estrogen-only and estrogen + progestogen therapy is associated with an up to 1.5 fold increased relative risk of ischaemic stroke. The risk of haemorrhagic stroke is not increased during use of HRT.
• This relative risk is not dependent on age or on duration of use, but as the baseline risk is strongly age-dependent, the overall risk of stroke in women who use HRT will increase with age,

WHI studies combined – Additional risk of ischaemic stroke* over 5 years’ use

Age range (years) Incidence per 1000 women in placebo arm over 5 years Risk ratio and 95%CI Additional cases per 1000 HRT users over 5 years
50-59 8 1.3 (1.1 1.6) 3 (1-5)

*no differentiation was made between ischaemic and haemorrhagic stroke.

Other adverse reactions reported in association with estrogen/progestogen treatment including Conjugated estrogen:
• Estrogen-dependent neoplasms benign and malignant, e.g. endometrial hyperplasia, endometrial cancer.
• Venous thromboembolism, i.e. deep leg or pelvic venous thrombosis and pulmonary embolism, is more frequent among hormone replacement therapy users than among non-users..
• Myocardial infarction.
• Gallbladder disease.

Skin and subcutaneous disorders: erythema multiforme, erythema nodosum, vascular purpura
• Probable dementia over the age of 65.
• Exacerbation of otosclerosis.
• Gynecomastia in males.

Reporting of suspected adverse reactions
Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product.

Healthcare professionals are asked to report any suspected adverse reactions via the Yellow Card Scheme at www.mhra.gov.uk/yellowcard.

Overdose
Symptoms of overdosage of estrogen-containing products in adults and children may include nausea, vomiting, breast tenderness, dizziness, abdominal pain, drowsiness/ fatigue and withdrawal bleeding may occur in females. There is no specific antidote, and further treatment should be symptomatic.

 Pharmacological properties

Pharmacodynamic properties

ATC Code: G03C A57

Conjugated Estrogens
The active ingredients are primarily the sulfate esters of estrone, equilin sulfates, 17α-estradiol and 17β-estradiol. These substitute for the loss of estrogen production in menopausal women, and alleviate menopausal symptoms. Estrogens prevent bone loss following menopause or ovariectomy.

Mechanism of Action
Endogenous estrogens are largely responsible for the development and maintenance of the female reproductive system and secondary sexual characteristics. Although circulating estrogens exist in a dynamic equilibrium of metabolic interconversions, estradiol is the principal intracellular human estrogen and is substantially more potent than its metabolites, estrone and estriol, at the receptor level.

The primary source of estrogen in normally cycling adult women is the ovarian follicle, which secretes 70 to 500 mcg of estradiol daily, depending on the phase of the menstrual cycle. After menopause, most endogenous estrogen is produced by conversion of androstenedione, which is secreted by the adrenal cortex, to estrone in the peripheral tissues. Thus, estrone and the sulfate-conjugated form, estrone sulfate, are the most abundant circulating estrogens in postmenopausal women.

Estrogens act through binding to nuclear receptors in estrogen-responsive tissues. To date, two estrogen receptors have been identified. These vary in proportion from tissue to tissue. Circulating estrogens modulate the pituitary secretion of the gonadotropins, luteinizing hormone (LH) and follicle stimulating hormone (FSH), through a negative feedback mechanism. Estrogens act to reduce the elevated levels of these gonadotropins seen in postmenopausal women.

Effects on estrogen-deficiency (vasomotor) symptoms

In the first year of the Health and Osteoporosis, Progestin and Estrogen (HOPE) Study, a total of 2,805 postmenopausal women (average age 53.3 ± 4.9 years) were randomly assigned to one of eight treatment groups, receiving either placebo or conjugated estrogens, with or without medroxyprogesterone acetate. Efficacy for vasomotor symptoms was assessed during the first 12 weeks of treatment in a subset of symptomatic women (n = 241) who had at least seven moderate-to-severe hot flushes daily, or at least 50

moderate-to-severe hot flushes during the week before randomization. With conjugated estrogen (0.3 mg, 0.45 mg, and 0.625 mg tablets), the decrease of both the frequency and severity of moderate-to-severe vasomotor symptoms was shown to be statistically improved compared with placebo at weeks 4 and 12.

Table 1 shows the observed mean number of hot flushes in the CE 0.3 mg, 0.45 mg, and 0.625 mg and placebo treatment groups over the initial 12-week period.
Standard errors based on assumption of equal variances.

TABLE 1. SUMMARY TABULATION OF THE NUMBER OF HOT FLUSHES PER DAY– MEAN VALUES AND COMPARISONS BETWEEN THE CE TREATMENT GROUPS AND THE PLACEBO GROUP: PATIENTS WITH AT LEAST 7 MODERATE TO SEVERE FLUSHES PER DAY OR AT LEAST 50 PER WEEK AT BASELINE, EFFICACY EVALUABLE (EE) POPULATION
Treatment

(No. of Patients)

————— No. of Hot Flushes/Day ——————
Time Period

(week)

Baseline

Mean ± SD

Observed

Mean ± SD

Mean

Change ± SEa

p-Values vs. Placeboa
0.625 mg CE
4 (n=27) 12.29 ± 3.89 1.95 ± 2.77 -10.34 ± 0.90 <0.001
12 (n=26) 12.03 ± 3.73 0.45 ± 0.95 -11.58 ± 0.88 <0.001
0.45 mg CE
4 (n=32) 12.25 ± 5.04 5.04 ± 5.31 -7.21 ± 0.83 <0.001
12 (n=30) 12.49 ± 5.11 2.33 ± 3.39 -10.16 ± 0.82 <0.001
0.3 mg CE
4 (n=30) 13.77 ± 4.78 4.65 ± 3.71 -9.12 ± 0.85 <0.001
12 (n=29) 13.83 ± 4.86 2.20 ± 2.73 -11.63 ± 0.83 <0.001
Placebo
4 (n=28) 11.69 ± 3.87 7.89 ± 5.28 -3.80 ± 0.88
12 (n=25) 11.61 ± 3.79 5.27 ± 4.97 -6.34 ± 0.89

Prevention of osteoporosis

At present there is no established screening programme for determining women at risk of developing osteoporotic fracture. Epidemiological studies suggest a number of individual risk factors which contribute to the development of postmenopausal osteoporosis. These include: early menopause; family history of osteoporosis; thin, small frame; cigarette use; recent prolonged systemic corticosteroid use.

Estrogen deficiency at menopause is associated with an increasing bone turnover and decline in bone mass. The effect of estrogens on the bone mineral density is dose-dependent. Protection appears to be effective for as long as treatment is continued. After discontinuation of HRT, bone mass is lost at a rate similar to that in untreated women.

Evidence from the WHI trial and meta-analysed trials shows that current use of HRT, alone or in combination with a progestogen – given to predominantly healthy women – reduces the risk of hip, vertebral and other osteoporotic fractures. HRT may also help prevent fractures in women with low bone density and/or established osteoporosis, but the evidence for that is limited.

Effect on bone mineral density

Health and Osteoporosis, Progestin and Estrogen (HOPE) Study

The HOPE study was a double-blind, randomized, placebo/active-drug-controlled, multicenter study of healthy postmenopausal women with an intact uterus. Subjects (mean age 53.3 ± 4.9 years) were 2.3 ± 0.9 years on average since menopause and took one 600 mg tablet of elemental calcium (Caltrate™) daily. Subjects were not given Vitamin D supplements. They were treated with conjugated estrogen 0.625 mg, 0.45 mg, 0.3 mg, or placebo. Prevention of bone loss was assessed by measurement of bone mineral density (BMD), primarily at the anteroposterior lumbar spine (L2 to L4). Secondarily, BMD measurements of the total body, femoral neck, and trochanter were also analyzed. Serum osteocalcin, urinary calcium, and N telopeptide were used as bone turnover markers (BTM) at cycles 6, 13, 19, and 26.
Intent-to-treat subjects
All active treatment groups showed significant differences from placebo in each of the four BMD endpoints at cycles 6, 13, 19, and 26. The percent changes from baseline to final evaluation are shown in Table 2.

TABLE 2. PERCENT CHANGE IN BONE MINERAL DENSITY: COMPARISON BETWEEN CE AND PLACEBO GROUPS IN THE INTENT-TO-TREAT POPULATION, LOCF.
Region Evaluated Treatment Groupa No. of Subjects Baseline (g/cm2)

Mean ± SD

Change from Baseline (%)

Adjusted Mean ± SE

p-Value vs Placebo
L2 to L4 BMD
0.625 83 1.17 ± 0.15 2.32 ± 0.35 <0.001
0.45 91 1.13 ± 0.15 2.08 ± 0.34 <0.001
0.3 87 1.14 ± 0.15 1.24 ± 0.34 <0.001
Placebo 85 1.14 ± 0.14 -2.46 ± 0.35
Total body BMD
0.625 84 1.15 ± 0.08 0.66 ± 0.17 <0.001
0.45 91 1.14 ± 0.08 0.71 ± 0.16 <0.001
0.3 87 1.14 ± 0.07 0.37 ± 0.16 <0.001
Placebo 85 1.13 ± 0.08 -1.52 ± 0.16
Femoral neck BMD
0.625 84 0.91 ± 0.14 1.74 ± 0.43 <0.001
0.45 91 0.89 ± 0.13 1.95 ± 0.41 <0.001
0.3 87 0.86 ± 0.11 0.57 ± 0.42 <0.001
Placebo 85 0.88 ± 0.14 -1.81 ± 0.43
Femoral trochanter BMD
0.625 84 0.78 ± 0.13 3.78 ± 0.57 <0.001
0.45 91 0.76 ± 0.12 3.46 ± 0.54 <0.001
0.3 87 0.75 ± 0.10 3.19 ± 0.55 0.003
Placebo 85 0.75 ± 0.12 0.93 ± 0.56

The bone turnover markers serum osteocalcin and urinary N-telopeptide significantly decreased (p < 0.001) in all active-treatment groups at cycles 6, 13, 19, and 26 compared with the placebo group. Larger mean decreases from baseline were seen with the active groups than with the placebo group. Significant differences from placebo were seen less frequently in urine calcium.

WHI Estrogen-Alone Substudy

Timing of the initiation of estrogen therapy relative to the start of menopause may affect the overall risk benefit profile. The WHI estrogen-alone substudy stratified by age showed in women 50-59 years of age, a non-significant trend towards reduced risk for CHD and overall mortality compared with placebo in women who initiated hormone therapy closer to menopause than those initiating therapy more distant from menopause.

Table 3 describes the primary results of the Estrogen-alone substudy stratified by age at baseline.

TABLE 3. WOMEN’S HEALTH INITIATIVE ESTROGEN-ALONE SUBSTUDY RESULTS STRATIFIED BY AGE AT BASELINE
AGE
Endpoint 50-59 years 60-69 years 70-79 years
CE

(N=1637)

Placebo

(N=1673)

CE

(N=2387)

Placebo

(N=2465)

CE

(N=1286)

Placebo

(N=1291)

CHDa,b
Number of cases 21 34 96 106 84 77
Absolute risk (N) c 17 27 58 62 98 88
Hazard ratio

(95% CI)

0.63 (0.36-1.09) 0.94 (0.71-1.24) 1.13 (0.82-1.54)
Strokeb
Number of cases 18 21 84 54 66 52
Absolute risk (N)c 15 17 51 31 76 59
Hazard ratio

(95% CI)

0.89 (0.47-1.69) 1.62 (1.15-2.27) 1.21 (0.84-1.75)
DVTb
Number of cases 16 10 39 29 30 20
Absolute risk (N)c 13 8 23 17 34 22
Hazard ratiod

(95% CI)

1.64 (0.74-3.60) 3.02 (1.51-6.06) 4.54 (2.22-9.31)
VTE b [16]
Number of cases 20 15 54 43 37 28
Absolute risk (N)c 16 12 32 25 42 31
Hazard ratio d

(95% CI)

1.37 (0.70-2.68) 2.82 (1.59-5.01) 3.77 (2.07-6.89)
Pulmonary Embolism b
Number of cases 12 8 28 17 12 14
Absolute risk (N)c 10 6 17 10 14 16
Hazard ratiod

(95% CI)

1.54 (0.63-3.77) 2.80 (1.28-6.16) 2.36 (0.96-5.80)
Invasive Breast Cancer
Number of cases 25 35 42 60 27 29
Absolute risk (N)c 21 29 26 36 32 34
Hazard ratio

(95% CI)

0.72 (0.43-1.21) 0.72 (0.49-1.07) 0.94 (0.56-1.60)
Colorectal Cancer
Number of cases 8 14 26 31 27 13
Absolute risk (N)c 7 12 16 19 32 15
Hazard ratio

(95% CI)

0.59 (0.25-1.41) 0.88 (0.52-1.48) 2.09 (1.08-4.04)
Hip Fractureb
Number of cases 5 1 9 20 32 52
Absolute risk (N)c 4 1 5 12 37 58
Hazard ratio

(95% CI)

5.02 (0.59-43.02) 0.47 (0.22-1.04) 0.64 (0.41-0.99)
Total Fracturesb
Number of cases 153 173 220 348 167 240
Absolute risk (N)c 126 139 132 201 191 269
Hazard ratio

(95% CI)

0.90 (0.72-1.12) 0.63 (0.53-0.75) 0.70 (0.57-0.85)
Overall Mortalityb
Number of cases 34 48 129 131 134 113
Absolute risk (N)c 28 38 77 75 153 127
Hazard ratio

(95% CI)

0.71 (0.46-1.11) 1.02 (0.80-1.30) 1.20 (0.93-1.55)

 

Conjugated estrogen 0.625mg
Drug

PK Parameter

Arithmetic Mean

(%CV)

Cmax

(ng/mL)

tmax

(h)

t1/2

(h)

AUC

(pg.h/mL)*

total estrone 7.3 (41) 7.3 (51) 15.0 (25) 134 (42)
baseline-adjusted total estrone 7.1 (41) 7.3 (25) 13.6 (27) 122 (39)
total equilin 5.0 (42) 6.2 (26) 10.1 (27) 65 (45)

a CHD defined as myocardial infarction or coronary death

a Based on adjudicated data over a mean duration of therapy of 7.1 years

  1. Absolute risk is per 10,000 person-years.
  2. VTE hazard ratios compared with women aged 50-59 taking placebo

 Pharmacokinetic properties

Absorption

Conjugated estrogens are soluble in water and are well absorbed from the gastrointestinal tract after release from the drug formulation. Conjugated estrogen tablets release conjugated estrogens slowly over several hours. Maximum plasma concentrations are achieved approximately 6-10 hours following administration. The estrogens are generally eliminated in near-parallel fashion, with half-lives ranging from 10-20 hours, when corrected for endogenous concentrations as needed.

The pharmacodynamic profile of unconjugated and conjugated estrogens following a dose of 2 x 0.625mg is provided in Table 1.

Conjugated estrogen 0.625mg
Drug

PK Parameter

Arithmetic Mean

(%CV)

Cmax

(pg/mL)

tmax

(h)

t1/2

(h)

AUC

(pg.h/mL)*

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