Understanding Osteoporosis Medications (cont.)
Francisco Talavera, PharmD, PhD
Estrogen is available in oral tablets or capsules or as a transdermal (skin) patch. Estrogen is used as part of hormone replacement therapy (HRT) after menopause. Following a hysterectomy (removal of the uterus), estrogen alone is used. For women with a uterus, progestin is added to estrogen to decrease the risk of endometrial (the inside lining of the uterus) cancer. Women with a personal or family history of breast cancer should not take estrogens.
Other effective preventive and treatment options for osteoporosis exist, and more are being developed to avoid increasing hormone-related risks. The duration of HRT therapy women take following menopause is currently being questioned because of the increased risk of cancer, stroke, and heart attack. Examples of oral estrogens include conjugated estrogen (Premarin) and estradiol (Estrace). Examples of oral combination products of estrogen with progestin include Premphase, Prempro, Activella, and Ortho-Prefest. Examples of skin patches include estradiol (Alora, Climara, Esclim, Estraderm, Vivelle) and combination patches containing estradiol and progestin (Climara Pro, CombiPatch).
- How estrogen works: This substance slows bone loss and prevents osteoporosis when taken after menopause.
- Who should not use these medications: Persons with the following conditions should not use estrogen:
- Allergy to estrogen
- Breast cancer
- Estrogen-dependent cancers (for example, breast cancer)
- History of blood clots or clotting disorder
- Unusual vaginal bleeding that has not been checked by a doctor
- Use: The following are general guidelines:
- The dose of estrogen used, whether alone or with a progestin, should be the lowest effective dose taken for the shortest time consistent with treatment goals.
- Oral tablets are typically taken daily; for those requiring progestin, it may be given in a combination product or at various times in the monthly cycle.
- Skin patches are applied to the abdomen, hip, or upper buttock. The replacement schedule for patches depends on which patch is used. Some are replaced weekly (Climara); others are replaced twice a week (Vivelle).
- Drug or food interactions: Estrogens may decrease the effectiveness of anticoagulants such as warfarin (Coumadin). Contact your doctor or pharmacists before taking other prescription drugs, over-the-counter drugs, or herbal products.
- Side effects: The Women's Health Initiative (WHI) study reported increased risks of heart attack, stroke, invasive breast cancer, pulmonary emboli (blood clots in the lungs), and deep vein thromboses (blood clots in the legs) in postmenopausal women (50-79 years) during 5 years of treatment with conjugated estrogens (0.625 mg) combined with medroxyprogesterone acetate> (2.5 mg) relative to placebo (sugar pills). Estrogens may cause breast tenderness, weight gain, fluid retention, gall bladder disease, and vaginal bleeding, along with increasing the risk of breast or endometrial cancers. They also increase the risk of blood clots and may increase the risk of complications from clots, such as stroke, heart attack, or thrombophlebitis. Call your doctor immediately if you experience any of the following side effects:
- Itching, hives, swelling in face or hands, breathing troubles, or other allergic reactions
- Breast lumps
- Tenderness in the upper right stomach, nausea, vomiting, fever, or pain
- Vision changes
- Severe headache
- Coughing up blood
- Chest or lower leg pain
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