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Home , Conjugated estrogens, Esterified estrogens, Estradiol acetate, Estropipate

Detail-Document #251109 −This Detail-Document accompanies the related article published in−

PHARMACIST’S LETTER / PRESCRIBER’S LETTER November 2009 ~ Volume 25 ~ Number 251109

Converting Between Products

The following dose comparisons of estrogen products are approximations based on average blood levels of resulting from administration of each product, as well as information from current literature on biologically equivalent doses. Ultra-low doses result in estradiol levels of <20 pg/mL (73.5 pmol/L), low doses result in estradiol levels of around 20 pg/mL, standard doses result in estradiol levels of around 30 to 40 pg/L (110 to 147 pmol/L), and high doses result in estradiol levels of more than 40 pg/mL. Blood levels of hormones are less variable for topical products than for oral products in individual patients, although there’s still a lot of variability in general between patients. Guidelines and product labeling recommend using the lowest effective dose for the shortest duration of time consistent with treatment goals for postmenopausal symptoms. Estrogen therapy should always be tailored for each individual patient. Product labeling should be consulted for specific indications and doses of each product.

Product Ultra-low Low Standard High Dose Dose Dose Dose Oral Conjugated Premarin NA 0.3 mg1 0.625 mg2,9,22 0.9 mg18 0.45 mg2 (U.S. only) (U.S. only) 1.25 mg2 Synthetic C.E.S. NA 0.3 mg23 0.625 mg22,23 0.9 mg23 ( only) 1.25 mg23 Cenestin NA 0.3 mg19 0.625 mg19,22 0.9 mg19 (U.S. only) 0.45 mg19 1.25 mg19 Enjuvia NA 0.3 mg20 0.625 mg20,22 0.9 mg20 (U.S. only) 0.45 mg20 1.25 mg20 PMS-Conjugated NA 0.3 mg24 0.625 mg22,24 0.9 mg24 Estrogens 1.25 mg24 (Canada only)

Esterified estrogens Menest NA 0.3 mg2,21 0.625 mg2,21,22 1.25 mg2,21 (U.S. only) 2.5 mg21 Ogen NA NA 0.625 mg 2.5 mgb (0.75 mg estropipate)10,22 (3 mg estropipate) 1.25 mg (1.5 mg estropipate)10 17beta-estradiol Estrace NA 0.5 mg1 1 mg10,22 NA 2 mg2 Femtrace NA 0.45 mg1,16 0.9 mg16,22 1.8 mg16 (U.S. only)

More. . . Copyright © 2009 by Therapeutic Research Center Pharmacist’s Letter / Prescriber’s Letter ~ P.O. Box 8190, Stockton, CA 95208 ~ Phone: 209-472-2240 ~ Fax: 209-472-2249 www.pharmacistsletter.com ~ www.prescribersletter.com (Detail-Document #251109: Page 2 of 3)

Product Ultra-low Low Standard High Dose Dose Dose Dose Topical/ Estradiol Patches (Doses indicate patch release rate of estrogen. See product labeling for frequency of patch application.) Alora NA 0.025 mg/day10,11 0.05 mg/day9,11,22 0.075 mg/day10,11 (U.S. only) 0.1 mg/day10,11 Climara NA 0.025 mg/day12,29 0.0375 mg/dayb 0.06 mg/dayb (0.0375 and 0.06 mg/day 0.05 mg/day9,12,22,26 0.075 mg/dayb,29 are U.S. only) 0.1 mg/day12,26 Estraderm NA 0.025 mg/day27 0.05 mg/day13,22,27 0.1 mg/day13,27 (Canada only) Estradot NA 25 mcg/day17 37.5 mcg/day17 75 mcg/day17 (Canada only) 50 mcg/day17,22 100 mcg/day17 Menostara 14 mcg/day1 NA NA NA (U.S. only) Oesclim NA 25 mcg/day25 50 mcg/day22,25 NA (Canada only) Vivelle NA NA 0.05 mg/day15,22 0.1 mg/day15 (U.S. only) Vivelle-Dot NA 0.025 mg/dayb 0.0375 mg/day14 0.075 mg/day14 (U.S. only) 0.05 mg/day14,22 0.1 mg/day14

Gels/pumps/sprays Divigel 0.25 gm3 0.5 gm3 1 gm3 NA (U.S. only) Elestrin gel 1 actuation4 NA 2 actuations4 NA (U.S. only)

Evamist spray NA 1 spray5 2-3 sprays5 NA (U.S. only) EstroGel pump NA NA 1 actuation6 2 actuations30 4 actuations30 Estrasorb emulsion NA NA NA 2 pouches7 (U.S. only) Vaginal Estradiol (Femring is the only product with systemic effects. Vaginal products with only local effects are not included in this chart.) Femring NA NA 0.05 mg/day8 0.1 mg/day8 (U.S. only) a. Menostar is only indicated for prevention of postmenopausal .28 b. Estimated estradiol level based on the assumption of a linear relationship between dose and estradiol levels.

Users of this document are cautioned to use their own professional judgment and consult any other necessary or appropriate sources prior to making clinical judgments based on the content of this document. Our editors have researched the information with input from experts, government agencies, and national organizations. Information and Internet links in this article were current as of the date of publication.

More. . . Copyright © 2009 by Therapeutic Research Center Pharmacist’s Letter / Prescriber’s Letter ~ P.O. Box 8190, Stockton, CA 95208 Phone: 209-472-2240 ~ Fax: 209-472-2249 www.pharmacistsletter.com ~ www.prescribersletter.com

(Detail-Document #251109: Page 3 of 3)

Project Leader in preparation of this Detail- 15. Product information for Vivelle. Novartis. East Document: Stacy A. Hester, R.Ph., BCPS, Hanover, NJ 07936. June 2004. 16. Product information for Femtrace. Warner Chilcott. Assistant Editor Rockaway, NJ 07866. November 2007. 17. Product monograph for Estradot. Novartis References Pharmaceuticals Canada. Dorval, Quebec H9S 1. Reid RL, Blake J, Abramson B, et al. 1A9. February 2009. and osteoporosis update 2009. J Obstet and 18. Product information for Premarin. . Gynaecol Can 2009;31:S1-S48. Philadelphia, PA 19101. March 2008. 2. Furness S, Roberts H, Marjoribanks J, et al. 19. Product information for Cenestin. Duramed. in postmenopausal women and Pomona, NY 10970. September 2004. risk of . Cochrane 20. Product information for Enjuvia. Duramed. Database Syst Rev 2009;2:CD000402. Pomona, NY 10970. April 2007. 3. Product information for Divigel. Upsher-Smith. 21. Product information for Menest. Monarch. Bristol, Minneapolis, MN 55447. June 2007. TN 37620. July 2004. 4. Product information for Elestrin. Kenwood 22. North American Menopause Society. Menopause Therapeutics. Fairfield, NJ 07004. December practice: a clinician's guide. Section G. Hormonal 2006. drugs. October 2007 (Edition 3). 5. Product information for Evamist. Ther-Rx. St. http://www.menopause.org/Portals/0/Content/PDF/ Louis, MO 63044. April 2008. G.pdf. (Accessed May 10, 2009). 6. Product information for Estrogel. ASCEND. 23. eCPS [Internet]. Ottawa (ON): Canadian Herndon, VA 20170. January 2008. Pharmacists Association. c2009. C.E.S. prodcuct 7. Product information for Estrasorb. Novavax. monograph (June 2009). http://www.e-cps.ca. Columbia, MD 21046. October 2003. (Accessed October 21, 2009). 8. Product information for Femring. Warner Chilcott. 24. Product monograph for PMS-Conjugated Rockaway, NJ 07866. February 2007. Estrogens. Montreal, Quebec H4P 2T4. February 9. Grady D. Clinical Practice. Management of 2004. menopausal symptoms. N Engl J Med 25. Product monograph for Oesclim. Triton Pharma. 2006;355;2338-47. Concord, Ontario L4K 3T8. September 2008. 10. Boothby LA, Doering PL, Kipersztok S. 26. Product monograph for Climara. Bayer. Toronto, Bioidentical hormone therapy: a review. ON M9W 1G6. March 2007. Menopause 2004;11:356-67. 27. Product monograph for Estraderm. Novartis 11. Product information for Alora. Watson. Corona, Canada. Dorval, Quebec H9S 1A9. January 2009. CA 92880. May 2005. 28. Product monograph for Menostar. Bayer. Wayne, 12. Product information for Climara. Bayer. Wayne, NJ 07470. June 2009. NJ 07470. January 2008. 29. Personal communication. Z. Farrell. Medical and 13. Product information for Estraderm. Novartis. East Scientific Affairs. Bayer. Toronto, ON M9W 1G6. Hanover, NJ 07936. June 2004. October 20, 2009. 14. Product information for Vivelle-Dot. Novartis. East 30. Product monograph for EstroGel. Schering-Plough Hanover, NJ 07936. June 2004. Canada. Kirkland, QC. H9H 4M7. February 2009.

Cite this Detail-Document as follows: Converting between estrogen products. Pharmacist’s Letter/Prescriber’s Letter 2009;25(11):251109.

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