estrogens, conjugated Nursing Considerations & Management

Drug Name

Generic Name :estrogens, conjugated

Brand Name: 

• Oral, topical vaginal cream: C.E.S. (CAN), Premarin
• Parenteral: Premarin Intravenous
• Synthetic: Cenestin

Classification: Hormone, Estrogen

Pregnancy Category X

Dosage & Route

Dosages

• Oral drug should be given cyclically (3 wk on/1 wk off) except in selected cases of carcinoma and prevention of postpartum breast engorgement.

ADULTS

• Moderate to severe vasomotor symptoms associated with menopause: 0.625 mg/day PO. If patient has not menstruated in 2 mo, start at any time. If patient is menstruating, start therapy on day 5 of bleeding; 0.625–1.25 mg (Cenestin).
• Atrophic vaginitis, kraurosis vulvae associated with menopause: 0.3–1.25 mg/day PO or more if needed. 0.5–2 g vaginal cream daily intravaginally or topically, depending on severity of condition. Taper or discontinue at 3- to 6-mo intervals.
• Female hypogonadism: 0.3–0.625 mg/day PO for 20 days followed by 10 days of rest. If bleeding does not appear at the end of this time, repeat course. If bleeding does occur before the end of the 10-day rest, begin a 20-day 2.5–7.5 mg estrogen cyclic regimen with oral progestin given during the last 5 days of therapy. If bleeding occurs before this cycle is finished, restart course on day 5 of bleeding.
• Female castration, primary ovarian failure: 1.25 mg/day PO. Adjust dosage by patient response to lowest effective dose.
• Prostatic cancer (inoperable): 1.25–2.5 mg tid PO. Judge effectiveness by phosphatase determinations and by symptomatic improvement.
• Osteoporosis: 0.625 mg/day PO given continuously or cyclically (25 days on/5 days off).
• Breast cancer (inoperable, progressing): 10 mg tid PO for at least 3 mo.
• Abnormal uterine bleeding due to hormonal imbalance: 25 mg IV or IM. Repeat in 6–12 hr as needed. IV route provides a more rapid response.

PEDIATRIC PATIENTS

• Not recommended due to effect on the growth of the long bones.

Therapeutic actions

• Estrogens modulate pituitary secretion of gonadotropins, leutinising hormones and follicle-stimulating hormones through -ve feedback mechanism, thus reducing elevated levels of hormones in postmenopausal women during oestrogen replacement therapy

Indications

Oral

• Palliation of moderate to severe vasomotor symptoms, atrophic vaginitis, or kraurosis vulvae associated with menopause
• Treatment of female hypogonadism; female castration; primary ovarian failure
• Osteoporosis: To retard progression
• Palliation of inoperable prostatic cancer
• Palliation of metastatic breast cancer
• Cenestin: Treatment of moderate to severe vasomotor symptoms associated with menopause
• Unlabeled use: Postcoital contraceptive

Parenteral

• Treatment of uterine bleeding due to hormonal imbalance in the absence of organic pathology

Vaginal cream

• Treatment of atrophic vaginitis and kraurosis vulvae associated with menopause

Adverse effects

• Abnormal bleeding; vomiting, nausea; tender breasts, wt gain, fluid retention; headache, depression. Males: Gynaecomastia, impotence.
• Potentially Fatal: Unopposed replacement therapy in postmenopausal women associated with increased risk of endometrial and breast cancer.

Contraindications

• Severe liver impairment; breast carcinoma; thromboembolic disorders; CV disease; undiagnosed vag bleeding; estrogen-dependent neoplasms; hypersensitivity; pregnancy.

Nursing considerations

Assessment

• History: Allergy to estrogens; breast cancer, estrogen-dependent neoplasm; undiagnosed abnormal genital bleeding; active or previous thrombophlebitis or thromboembolic disorders; pregnancy; lactation; metabolic bone disease; renal insufficiency; CHF
• Physical: Skin color, lesions, edema; breast examination; injection site; orientation, affect, reflexes; P, auscultation, BP, peripheral perfusion; R, adventitious sounds; bowel sounds, liver evaluation, abdominal examination; pelvic examination; serum calcium, phosphorus; LFTs, renal function tests; Pap smear; glucose tolerance test

Interventions

• BLACK BOX WARNING: Arrange for pretreatment and periodic (at least annual) history and physical, which should include BP, breasts, abdomen, pelvic organs, and a Pap smear; increased risk of endometrial cancer.
• BLACK BOX WARNING: Do not use to prevent CV events or dementia; may increase risk; including thrombophlebitis, pulmonary embolism, CVA, MI.
• BLACK BOX WARNING: Caution patient of the risks involved with estrogen use, the need to prevent pregnancy during treatment, for frequent medical follow-up, and periodic rests from drug treatment.
• WARNING: Give cyclically for short term only when treating postmenopausal conditions because of the risk of endometrial neoplasm; taper to the lowest effective dose, and provide a drug-free week each month.
• Refrigerate unreconstituted parenteral solution; use reconstituted solution within a few hours.
• Refrigerated reconstituted solution is stable for 60 days; do not use solution if darkened or precipitates have formed.
• WARNING: Arrange for the concomitant use of progestin therapy during long-term estrogen therapy in women with a uterus; this will mimic normal physiologic cycling and allow for cyclic uterine bleeding, which may decrease the risk of endometrial cancer. Women without a uterus do not need progestin.

Teaching points

• Use this drug cyclically or short term; prepare a calendar of drug days, rest days, and drug-free periods.
• Use vaginal cream properly.
• Potentially serious side effects can occur: Cancers, blood clots, liver problems; it is very important that you have periodic medical examinations throughout therapy.
• This drug cannot be given to pregnant women because of serious toxic effects to the baby.
• You may experience these side effects: Nausea, vomiting, bloating; headache, dizziness, mental depression (use caution if driving or performing tasks that require alertness); sensitivity to sunlight (use a sunscreen and wear protective clothing); rash, loss of scalp hair, darkening of the skin on the face; changes in menstrual patterns.
• Report pain in the groin or calves of the legs, chest pain or sudden shortness of breath, abnormal vaginal bleeding, lumps in the breast, sudden severe headache, dizziness or fainting, changes in vision or speech, weakness or numbness in the arm or leg, severe abdominal pain, yellowing of the skin or eyes, severe mental depression, pain at injection site.