Serious ill effects have not been reported following acute ingestion of large doses of estrogen containing drug products by young children. Overdosage of estrogen may cause nausea and vomiting, and withdrawal bleeding may occur in females.
Alora should not be used in individuals with any of the following conditions:
See BOX WARNING and WARNINGS and PRECAUTIONS.
Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice. The adverse reaction information from clinical trials does, however, provide a basis for identifying the adverse events that appear to be related to drug use and for approximating rates.
Incidence of adverse events > 2% of each treatment group is given in Table 5.
Table 5 Incidence of Adverse Events > 2% for Alora and Placebo Systems (data are expressed as
N and (%) of treatment group).
| Body System | Placeboa | Aloraa | Aloraa | Aloraa | Aloraa |
| 0.025 mg/day | 0.05 mg/day | 0.075 mg/day | 0.1 mg/day | ||
| Preferred Term | (N = 87) | (N = 89) | (N = 90) | (N = 89) | (N = 174) |
| Body As A Whole | |||||
| Accidental Injury | 4 (4.6) | 6 (6.7) | 8 (8.9) | 4 (4.5) | 9 (5.2) |
| Allergic Reaction | 2 (2.3) | 4 (4.5) | 4 (4.4) | 2 (2.2) | 1 (0.6) |
| Asthenia | 4 (4.6) | 7 (7.9) | 4 (4.4) | 0 (0) | 4 (2.3) |
| Cyst | 3 (3.4) | 0 (0) | 6 (6.7) | 3 (3.4) | 0 (0) |
| Flu Syndrome | 9 (10.3) | 8 (9) | 12 (13.3) | 9 (10.1) | 6 (3.4) |
| Headache | 11 (12.6) | 10 (11.2) | 8 (8.9) | 5 (5.6) | 37 (21.3) |
| Infection | 2 (2.3) | 2 (2.2) | 3 (3.3) | 3 (3.4) | 2 (1.1) |
| Infection Fungal | 1 (1.1) | 3 (3.4) | 9 (10) | 4 (4.5) | 0 (0) |
| Pain | 11 (12.6) | 9 (10.1) | 5 (5.6) | 6 (6.7) | 16 (9.2) |
| Pain Abdominal | 4 (4.6) | 7 (7.9) | 5 (5.6) | 1 (1.1) | 5 (2.9) |
| Pain Back | 5 (5.7) | 5 (5.6) | 3 (3.3) | 7 (7.9) | 11 (6.3) |
| Pain Chest | 4 (4.6) | 4 (4.5) | 2 (2.2) | 1 (1.1) | 2 (1.1) |
| Cardiovascular | |||||
| Hypertension | 3 (3.4) | 3 (3.4) | 3 (3.3) | 6 (6.7) | 0 (0) |
| Migraine | 2 (2.3) | 6 (6.7) | 2 (2.2) | 0 (0) | 2 (1.1) |
| Vasodilation | 13 (14.9) | 6 (6.7) | 2 (2.2) | 1 (1.1) | 0 (0) |
| Digestive | |||||
| Constipation | 4 (4.6) | 3 (3.4) | 6 (6.7) | 1 (1.1) | 3 (1.7) |
| Diarrhea | 2 (2.3) | 1 (1.1) | 3 (3.3) | 2 (2.2) | 5 (2.9) |
| Dyspepsia | 1 (1.1) | 8 (9) | 4 (4.4) | 3 (3.4) | 2 (1.1) |
| Flatulence | 5 (5.7) | 1 (1.1) | 2 (2.2) | 3 (3.4) | 8 (4.6) |
| Gastroenteritis | 2 (2.3) | 3 (3.4) | 4 (4.4) | 3 (3.4) | 0 (0) |
| Nausea | 3 (3.4) | 6 (6.7) | 5 (5.6) | 3 (3.4) | 7 (4) |
| Metabolic And Nutritional | |||||
| Edema Peripheral | 4 (4.6) | 3 (3.4) | 4 (4.4) | 3 (3.4) | 3 (1.7) |
| Weight Increased | 4 (4.6) | 3 (3.4) | 2 (2.2) | 4 (4.5) | 1 (0.6) |
| Musculoskeletal | |||||
| Arthralgia | 12 (13.8) | 5 (5.6) | 10 (11.1) | 11 (12.4) | 2 (1.1) |
| Bone Fracture Spontaneous | 7 (8) | 1 (1.1) | 3 (3.3) | 0 (0) | 0 (0) |
| Joint Disorder | 2 (2.3) | 4 (4.5) | 4 (4.4) | 1 (1.1) | 0 (0) |
| Myalgia | 4 (4.6) | 3 (3.4) | 2 (2.2) | 5 (5.6) | 3 (1.7) |
| Nervous | |||||
| Anxiety | 3 (3.4) | 0 (0) | 9 (10) | 2 (2.2) | 3 (1.7) |
| Depression | 8 (9.2) | 1 (1.1) | 3 (3.3) | 1 (1.1) | 6 (3.4) |
| Dizziness | 0 (0) | 1 (1.1) | 7 (7.8) | 4 (4.5) | 1 (0.6) |
| Hypesthesia | 2 (2.3) | 3 (3.4) | 3 (3.3) | 0 (0) | 0 (0) |
| Insomnia | 7 (8) | 4 (4.5) | 2 (2.2) | 1 (1.1) | 8 (4.6) |
| Respiratory | |||||
| Asthma | 1 (1.1) | 3 (3.4) | 3 (3.3) | 1 (1.1) | 2 (1.1) |
| Bronchitis | 6 (6.9) | 7 (7.9) | 4 (4.4) | 4 (4.5) | 6 (3.4) |
| Cough Increased | 2 (2.3) | 1 (1.1) | 4 (4.4) | 1 (1.1) | 6 (3.4) |
| Infection Respiratory | 23 (26.4) | 22 (24.7) | 22 (24.4) | 19 (21.3) | 28 (16.1) |
| Pharyngitis | 1 (1.1) | 4 (4.5) | 2 (2.2) | 2 (2.2) | 4 (2.3) |
| Pneumonia | 4 (4.6) | 4 (4.5) | 4 (4.4) | 1 (1.1) | 1 (0.6) |
| Sinusitis | 16 (18.4) | 9 (10.1) | 11 (12.2) | 6 (6.7) | 13 (7.5) |
| Skin | |||||
| Application Site Reaction | 51 (58.6) | 47 (52.8) | 51 (56.7) | 49 (55.1) | 10 (5.7) |
| Hirsutism | 0 (0) | 2 (2.2) | 2 (2.2) | 4 (4.5) | 1 (0.6) |
| Pruritus | 4 (4.6) | 2 (2.2) | 1 (1.1) | 6 (6.7) | 9 (5.2) |
| Rash | 5 (5.7) | 6 (6.7) | 8 (8.9) | 4 (4.5) | 5 (2.9) |
| Special Senses | |||||
| Conjunctivitis | 2 (2.3) | 2 (2.2) | 3 (3.3) | 2 (2.2) | 0 (0) |
| Otitis Media | 2 (2.3) | 3 (3.4) | 2 (2.2) | 1 (1.1) | 0 (0) |
| Urogenital | |||||
| Breast Enlargement | 3 (3.4) | 1 (1.1) | 2 (2.2) | 6 (6.7) | 4 (2.3) |
| Infection Urinary Tract | 2 (2.3) | 5 (5.6) | 4 (4.4) | 2 (2.2) | 3 (1.7) |
| Leukorrhea | 1 (1.1) | 3 (3.4) | 2 (2.2) | 4 (4.5) | 3 (1.7) |
| Neoplasm Breast | 6 (6.9) | 3 (3.4) | 5 (5.6) | 1 (1.1) | 3 (1.7) |
| Pain Breast | 7 (8) | 13 (14.6) | 16 (17.8) | 31 (34.8) | 12 (6.9) |
| Vaginitis | 6 (6.9) | 0 (0) | 3 (3.3) | 0 (0) | 14 (8) |
| Vaginal Bleedingc | 4 (12.9) | NA | 6 (8.7) | NA | 29 (33.3) |
|
a -Adverse events for the three lower Alora doses and placebo were obtained from the 2-year prevention of osteoporosis study b -Adverse events for the highest Alora doses were obtained from two 12-week studies of the treatment of menopausal symptoms c -Data reported for women with partially or fully intact uteri in the menopausal symptom study only (N = 31 for Placebo; N = 69 for Alora 0.05 mg/day and N = 87 for Alora 0.1 mg/day) NA – data not available |
|||||
The following additional adverse reactions have been reported with estrogens and/or progestin therapy:
Alora is indicated in:
The mainstays for decreasing the risk of postmenopausal osteoporosis are weight bearing exercise, adequate calcium and vitamin D intake, and, when indicated, pharmacologic therapy. Postmenopausal women require an average of 1500 mg/day of elemental calcium to remain in neutral calcium balance. Therefore, when not contraindicated, calcium supplementation may be helpful for women with suboptimal dietary intake. Vitamin D supplementation of 400-800 IU/day may also be required to ensure adequate daily intake in postmenopausal women.
The skin metabolizes estradiol only to a small extent. In contrast, orally administered estradiol is rapidly metabolized by the liver to estrone and its conjugates, giving rise to higher circulating levels of estrone than estradiol. Therefore, transdermal administration produces therapeutic plasma levels of estradiol with lower levels of estrone and estrone conjugates and requires smaller total doses than does oral therapy.
AbsorptionEstradiol is transported across intact skin and into the systemic circulation by a passive diffusion process, the rate of diffusion across the stratum corneum being the principal factor. Alora presents sufficient concentration of estradiol to the surface of the skin to maintain continuous transport over the 3 to 4 day dosing interval.
Direct measurement of total absorbed dose of estradiol through analysis of residual estradiol content of systems worn over a continuous 4-day interval during 251 separate occasions in 123 postmenopausal women demonstrated that the average daily dose absorbed from Alora was 0.003 ± 0.001 mg estradiol per cm2 active surface area. The nominal mean in vivo daily delivery rates of estradiol calculated from these data are 0.027 mg/day, 0.054 mg/day, 0.081 mg/day, and 0.11 mg/day for the 9 cm2, 18 cm2, 27 cm2, and 36 cm2 Alora, respectively.
In another study, 20 women also were treated with three consecutive doses of Alora 0.05 mg/day, Alora 0.075 mg/day and Alora 0.1 mg/day on abdominal application sites. Mean steady-state estradiol serum concentrations observed over the dosing interval are shown in Figure 1.
Figure 1:
Mean steady-state estradiol serum concentration during the third twice weekly dose of Alora
0.1 mg/day, Alora 0.075 mg/day, and Alora 0.05 mg/day in 20 postmenopausal women.
| Alora 0.1 mg/day, Alora 0.075 mg/day, and Alora 0.05 mg/day in 20 postmenopausal women - Illustration" width="570" height="374" /> |
In a single dose randomized crossover study conducted to compare the effect of site of Alora application, 31 postmenopausal women wore single Alora 0.05 mg/day for 4-day periods on the lower abdomen, upper quadrant of the buttocks, and outside aspect of the hip. The estradiol serum concentration profiles are shown in Figure 2.
Figure 2:
Mean estradiol serum concentrations during a single 4-day wearing of Alora 0.05 mg/day applied by 31 postmenopausal women to the lower abdomen, upper quadrant of the buttocks or outer
aspect of the hip.
| Alora 0.05 mg/day applied by 31 postmenopausal women to the lower abdomen, upper quadrant of the buttocks or outer aspect of the hip - Illustration" width="478" height="312" /> |
| * Cmax and Cavg statistically different from abdomen |
Table 1 provides a summary of the estradiol pharmacokinetic parameters studied during biopharmaceutic evaluation of Alora.
Table 1: Mean (SD) Pharmacokinetic Profile of Alora Over an 84-hour Dosing Interval.
| Alora (mg/day) |
Application Site | N | Dosing | Cmax (pg/ml) |
Cmin (pg/ml) |
Cavg (pg/ml) |
CL (L/hr) |
| 0.05 | Abdomen | 20 | Multiple | 92 (33) | 43 (12) | 64 (19) | 54 (18) |
| 0.075 | Abdomen | 20 | Multiple | 120 (60) | 53 (23) | 86 (40) | 53 (12) |
| 0.1 | Abdomen | 42 | Multiple | 144 (57) | 58 (20) | 98 (38) | 61 (18) |
| 0.05 | Abdomen | 31 | Single | 53 (23) | - | 41 (18) | 69 (22) |
| Buttock | 31 | Single | 67 (45) | - | 45 (21) | 66 (23) | |
| Hip* | 31 | Single | 69 (30) | - | 48 (17) | 62 (18) | |
| * Cmax and Cavg statistically different from abdomen |
Steady-state estradiol serum concentrations were measured in two well-controlled clinical trials in the treatment of menopausal symptoms of 3 month duration (Studies 1 and 2), and one trial in the prevention of postmenopausal osteoporosis of 2 year duration (Study 3). Table 2 provides a summary of these data.
Table 2: Mean (SD) steady-state estradiol serum concentrations (pg/ml) in clinical trials of 3 month (Studies 1 and 2) and 2 year (Study 3) duration.
| Alora (mg/day) |
Study 1 | Study 2 | Study 3 |
| 0.025 | - | - | 24.5 (12.4) |
| 0.05 | 46.9 (38.5) | 38.8 (38.0) | 42.6 (23.7) |
| 0.075 | - | - | 56.7 (36.8) |
| 0.1 | 99.2 (77.0) | 97.0 (87.5) | - |
In a 2-year, randomized, double-blind, placebo-controlled, prevention of postmenopausal osteoporosis study in 355 hysterectomized women, the average baseline-adjusted steady-state estradiol serum concentrations were 18.6 pg/ml (45 patients) for the 0.025 mg/day dose, 35.9 pg/ml (47 patients) for the 0.05 mg/day dose, and 50.1 pg/ml (46 patients) for the 0.075 mg/day dose. These values were linearly related and dose proportional.
DistributionNo specific investigation of the tissue distribution of estradiol absorbed from Alora in humans has been conducted. The distribution of exogenous estrogens is similar to that of endogenous estrogens. Estrogens are widely distributed in the body and are generally found in higher concentrations in the sex hormone target organs. Estrogens circulate in the blood largely bound to sex hormone binding globulin (SHBG) and albumin.
MetabolismExogenous estrogens are metabolized in the same manner as endogenous estrogens. Circulating estrogens exist in a dynamic equilibrium of metabolic interconversions. These transformations take place mainly in the liver. Estradiol is converted reversibly to estrone, and both can be converted to estriol, which is the major urinary metabolite. Estrogens also undergo enterohepatic recirculation via sulfate and glucuronide conjugation in the liver, biliary secretion of conjugates into the intestine, and hydrolysis in the gut followed by reabsorption. In postmenopausal women a significant portion of the circulating estrogens exists as sulfate conjugates, especially estrone sulfate, which serves as a circulating reservoir for the formation of more active estrogens.
ExcretionEstradiol, estrone and estriol are excreted in the urine along with glucuronide and sulfate conjugates. The apparent mean (SD) serum half-life of estradiol determined from biopharmaceutic studies conducted with Alora is 1.75 2.87 hours.
Alora (Estradiol Transdermal System, USP) 0.025 mg/day. Each 9 cm2 system contains 0.77 mg of estradiol, USP for nominal delivery of 0.025 mg of estradiol per day when dosed in a twice weekly regimen.
NDC 0023-5885-12 Patient Calendar Box of 8 Systems
Alora (Estradiol Transdermal System, USP) 0.05 mg/day. Each 18 cm2 system contains 1.5 mg of estradiol, USP for nominal delivery of 0.05 mg of estradiol per day when dosed in a twice weekly regimen.
NDC 0023-5886-15 Patient Calendar Box of 8 Systems
Alora (Estradiol Transdermal System, USP) 0.075 mg/day. Each 27 cm2 system contains 2.3 mg of estradiol, USP for nominal delivery of 0.075 mg of estradiol per day when dosed in a twice weekly regimen.
NDC 0023-5887-17 Patient Calendar Box of 8 Systems
Alora (Estradiol Transdermal System, USP) 0.1 mg/day. Each 36 cm2 system contains 3.1 mg of estradiol, USP for nominal delivery of 0.1 mg of estradiol per day when dosed in a twice weekly regimen.
NDC 0023-5888-11 Patient Calendar Box of 8 Systems
Store at 20-25°C (68-77°F).
Do not store unpouched. Apply immediately upon removal from the protective pouch.
Discard used Alora in household trash in a manner that prevents accidental application or ingestion by children, pets, or others.
Keep out of reach of children.
Distributed By: Allergan USA, Inc. Irvine, CA 92612. Revised: Nov 2017
See BOX WARNING
The use of unopposed estrogens in women who have a uterus is associated with an increased risk of endometrial cancer.
Cardiovascular DisordersEstrogen and estrogen/progestin therapies have been associated with an increased risk of cardiovascular events such as myocardial infarction and stroke, as well as venous thrombosis and pulmonary embolism (venous thromboembolism or VTE). Should any of these occur or be suspected, estrogens should be discontinued immediately.
Risk factors for arterial vascular disease (e.g., hypertension, diabetes mellitus, tobacco use, hypercholesterolemia, and obesity) and/or venous thromboembolism (e.g., personal history or family history of VTE, obesity, and systemic lupus erythematosus) should be managed appropriately.
Coronary Heart Disease And StrokeIn the Women’s Health Initiative (WHI) study an increased risk of stroke was observed in women receiving CE compared to placebo.
In the CE/MPA substudy of WHI an increased risk of coronary heart disease (CHD) events (defined as non-fatal myocardial infarction and CHD death) was observed in women receiving CE/MPA compared to women receiving placebo (37 vs. 30 per 10,000 women-years). The increase in risk was observed in Year 1 and persisted.
In the same substudy of WHI, an increased risk of stroke was observed in women receiving CE/MPA compared to women receiving placebo (29 vs. 21 per 10,000 women-years). The increase in risk was observed after the first year and persisted..
In postmenopausal women with documented heart disease (n = 2,763, average age 66.7 years) a controlled clinical trial of secondary prevention of cardiovascular disease (Heart and Estrogen/ Progestin Replacement Study; (HERS)) treatment with CE/MPA–0.625 mg/2.5 mg per day demonstrated no cardiovascular benefit. During an average follow-up of 4.1 years, treatment with CE/MPA did not reduce the overall rate of CHD events in postmenopausal women with established coronary heart disease. There were more CHD events in the CE/MPA-treated group than in the placebo group in Year 1, but not during the subsequent years. Participation in an open label extension of the original HERS trial (HERS II) was agreed to by 2,321 women. Average follow-up in HERS II was an additional 2.7 years, for a total of 6.8 years overall. Rates of CHD events were comparable among women in the CE/MPA group and the placebo group in HERS, HERS II, and overall.
Large doses of estrogen (5 mg conjugated estrogens per day), comparable to those used to treat cancer of the prostate and breast, have been shown in a large prospective clinical trial in men to increase the risks of nonfatal myocardial infarction, pulmonary embolism, and thrombophlebitis.
Venous Thromboembolism (VTE)In the Women’s Health Initiative (WHI) study, an increased risk of deep vein thrombosis was observed in women receiving CE compared to placebo.
In the CE/MPA substudy of WHI, a 2-fold greater rate of VTE, including deep venous thrombosis and pulmonary embolism, was observed in women receiving CE/MPA compared to women receiving placebo. The rate of VTE was 34 per 10,000 women-years in the CE/MPA group compared to 16 per 10,000 women-years in the placebo group. The increase in VTE risk was observed during the first year and persisted.
If feasible, estrogens should be discontinued at least 4 to 6 weeks before surgery of the type associated with an increased risk of thromboembolism, or during periods of prolonged immobilization.
Malignant Neoplasms Endometrial CancerThe use of unopposed estrogens in women with intact uteri has been associated with an increased risk of endometrial cancer. The reported endometrial cancer risk among unopposed estrogen users is about 2 to 12-fold greater than in non-users, and appears dependent on duration of treatment and on estrogen dose. Most studies show no significant increased risk associated with use of estrogens for less than 1 year. The greatest risk appears associated with prolonged use, with increased risks of 15 to 24-fold for 5 to 10 years or more, and this risk has been shown to persist for at least 8 to 15 years after estrogen therapy is discontinued.
Clinical surveillance of all women taking estrogen/progestin combinations is important. Adequate diagnostic measures, including endometrial sampling when indicated, should be undertaken to rule out malignancy in all cases of undiagnosed persistent or recurring abnormal vaginal bleeding. There is no evidence that the use of natural estrogens results in a different endometrial risk profile than synthetic estrogens of equivalent estrogen dose. Adding a progestin to estrogen therapy has been shown to reduce the risk of endometrial hyperplasia, which may be a precursor to endometrial cancer.
Breast CancerThe use of estrogens and progestins by postmenopausal women has been reported to increase the risk of breast cancer. The most important randomized clinical trial providing information about this issue is the WHI substudy of CE/MPA. The results from observational studies are generally consistent with those of the WHI clinical trial and report no significant variation in the risk of breast cancer among different estrogens or progestins, doses, or routes of administration.
The CE/MPA substudy of WHI reported an increased risk of breast cancer in women who took CE/MPA for a mean follow-up of 5.6 years. Observational studies have also reported an increased risk for estrogen/progestin combination therapy, and a smaller increased risk for estrogen alone therapy, after several years of use. In the WHI trial and from observational studies, the excess risk increased with duration of use. From observational studies, the risk appeared to return to baseline in about 5 years after stopping treatment. In addition, observational studies suggest that the risk of breast cancer was greater, and became apparent earlier, with estrogen/progestin combination therapy as compared to estrogen alone therapy.
In the CE/MPA substudy, 26% of the women reported prior use of estrogen alone and/or estrogen/progestin combination hormone therapy. After a mean follow-up of 5.6 years during the clinical trial, the overall relative risk of invasive breast cancer was 1.24 (95% confidence interval 1.01 -1.54), and the overall absolute risk was 41 vs. 33 cases per 10,000 women-years, for CE/MPA compared with placebo. Among women who reported prior use of hormone therapy, the relative risk of invasive breast cancer was 1.86, and the absolute risk was 46 vs. 25 cases per 10,000 women-years, for CE/MPA compared with placebo. Among women who reported no prior use of hormone therapy, the relative risk of invasive breast cancer was 1.09, and the absolute risk was 40 vs. 36 cases per 10,000 women-years for CE/MPA compared with placebo. In the same substudy, invasive breast cancers were larger and diagnosed at a more advanced stage in the CE/MPA group compared with the placebo group. Metastatic disease was rare with no apparent difference between the two groups. Other prognostic factors such as histologic subtype, grade and hormone receptor status did not differ between the groups.
The use of estrogen plus progestin has been reported to result in an increase in abnormal mammograms requiring further evaluation. All women should receive yearly breast examinations by a healthcare provider and perform monthly self-examinations. In addition, mammography examinations should be scheduled based on patient age, risk factors, and prior mammogram results.
DementiaIn the estrogen plus progestin WHIMS, a population of 4,532 postmenopausal women aged 65 to 79 years was randomized to CE/MPA or placebo. After an average follow-up of 4 years, 40 women being treated with CE/MPA (1.8%, n = 2,229) and 21 women in the placebo group (0.9%, n = 2,303) received diagnoses of probable dementia. The relative risk for CE/MPA versus placebo was 2.05 (95% confidence interval 1.21 -3.48), and was similar for women with and without histories of menopausal hormone use before WHIMS. The absolute risk of probable dementia for CE/MPA versus placebo was 45 vs. 22 cases per 10,000 women-years and the absolute excess risk for CE/MPA was 23 cases per 10,000 women-years. It is unknown whether these findings apply to younger postmenopausal women.
Gallbladder DiseaseA 2 to 4-fold increase in the risk of gallbladder disease requiring surgery in postmenopausal women receiving estrogens has been reported.
HypercalcemiaEstrogen administration may lead to severe hypercalcemia in patients with breast cancer and bone metastases. If hypercalcemia occurs, use of the drug should be stopped and appropriate measures should be taken to reduce the serum calcium level.
Visual AbnormalitiesRetinal vascular thrombosis has been reported in patients receiving estrogens. Discontinue medication pending examination if there is sudden partial or complete loss of vision, or a sudden onset of proptosis, diplopia, or migraine. If examination reveals papilledema or retinal vascular lesions, estrogens should be discontinued.
PRECAUTIONS General Addition Of A Progestin When A Woman Has Not Had A HysterectomyStudies of the addition of a progestin for 10 or more days of a cycle of estrogen administration, or daily with estrogen in a continuous regimen, have reported a lowered incidence of endometrial hyperplasia than would be induced by estrogen treatment alone. Endometrial hyperplasia may be a precursor to endometrial cancer.
There are, however, possible risks that may be associated with the use of progestins with estrogens compared to estrogen-alone regimens. These include:
In a small number of case reports, substantial increases in blood pressure have been attributed to idiosyncratic reactions to estrogens. In a large, randomized, placebo-controlled clinical trial, a generalized effect of estrogens on blood pressure was not seen. Blood pressure should be monitored at regular intervals with estrogen use.
HypertriglyceridemiaIn patients with pre-existing hypertriglyceridemia, estrogen therapy may be associated with elevations of plasma triglycerides leading to pancreatitis and other complications.
Impaired Liver Function And Past History Of Cholestatic JaundiceEstrogens may be poorly metabolized in patients with impaired liver function. For patients with a history of cholestatic jaundice associated with past estrogen use or with pregnancy, caution should be exercised and in the case of recurrence, medication should be discontinued.
HypothyroidismEstrogen administration leads to increased thyroid-binding globulin (TBG) levels. Patients with normal thyroid function can compensate for the increased TBG by making more thyroid hormone, thus maintaining free T4 and T3 serum concentrations in the normal range. Patients dependent on thyroid hormone replacement therapy who are also receiving estrogens may require increased doses of their thyroid replacement therapy. These patients should have their thyroid function monitored in order to maintain their free thyroid hormone levels in an acceptable range.
Fluid RetentionBecause estrogens may cause some degree of fluid retention, conditions which might be influenced by this factor, such as patients with asthma, epilepsy, migraine, and cardiac or renal dysfunction, warrant careful observation when estrogens are prescribed.
Ovarian CancerThe CE/MPA substudy of WHI reported that estrogen plus progestin increased the risk of ovarian cancer. After an average follow-up of 5.6 years, the relative risk for ovarian cancer for CE/MPA vs. placebo was 1.58 (95% confidence interval 0.77-3.24) but was not statistically significant. The absolute risk for CE/MPA vs. placebo was 4.2 vs. 2.7 cases per 10,000 women-years.
A meta-analysis of 17 prospective and 35 retrospective epidemiology studies found that women who used hormonal therapy for menopausal symptoms had an increased risk for ovarian cancer. The primary analysis, using case-control comparisons, included 12,110 cancer cases from the 17 prospective studies. The relative risks associated with current use of hormonal therapy was 1.41 (95% confidence interval [CI] 1.32 to 1.50); there was no difference in the risk estimates by duration of the exposure (less than 5 years [median of 3 years] vs. greater than 5 years [median of 10 years] of use before the cancer diagnosis). The relative risk associated with combined current and recent use (discontinued use within 5 years before cancer diagnosis) was 1.37 (95% CI 1.27-1.48) and the elevated risk was significant for both estrogen-alone and estrogen plus progestin products. The exact duration of hormone therapy use associated with an increased risk of ovarian cancer, however, is unknown.
Exacerbation Of EndometriosisEndometriosis may be exacerbated with administration of estrogens. A few cases of malignant transformation of residual endometrial implants have been reported in women treated post-hysterectomy with estrogen alone therapy. For patients known to have residual endometriosis post-hysterectomy, the addition of progestin should be considered.
HypocalcemiaEstrogens should be used with caution in individuals with severe hypocalcemia.
Exacerbation Of Other ConditionsEstrogens may cause an exacerbation of asthma, diabetes mellitus, epilepsy, migraine, porphyria, systemic lupus erythematosus, and hepatic hemangiomas and should be used with caution in women with these conditions.
Patient InformationSee text of Patient Information. Physicians are advised to discuss the PATIENT INFORMATION leaflet with patients for whom they prescribe Alora.
Laboratory TestsEstrogen administration should be guided by clinical response at the lowest dose for the treatment of vasomotor symptoms and vulvar and vaginal atrophy. Laboratory parameters may be useful in guiding dosage for the treatment of hypoestrogenism due to hypogonadism, castration and primary ovarian failure.
Carcinogenesis, Mutagenesis, Impairment Of FertilityLong-term continuous administration of natural and synthetic estrogens in certain animal species increases the frequency of carcinomas of the breast, uterus, cervix, vagina, testis, and liver.
Long-term continuous administration of estrogen, with or without progestin, in women with or without a uterus, has shown an increased risk of endometrial cancer, breast cancer, and ovarian cancer.
.
Pregnancy Category XAlora should not be used during pregnancy.
Nursing MothersEstrogen administration to nursing mothers has been shown to decrease the quantity and quality of the milk. Detectable amounts of estrogens have been identified in the milk of mothers receiving estrogen therapy. Estrogens are not indicated for the prevention of postpartum breast engorgement. Caution should be exercised when Alora is administered to a nursing woman.
Pediatric UseEstrogen replacement therapy has been used for the induction of puberty in adolescents with some forms of pubertal delay. Safety and effectiveness in pediatric patients have not otherwise been established.
Large and repeated doses of estrogen over an extended time period have been shown to accelerate epiphyseal closure, which could result in short adult stature if treatment is initiated before the completion of physiologic puberty in normally developing children. If estrogen is administered to patients whose bone growth is not complete, periodic monitoring of bone maturation and effects on epiphyseal centers is recommended during estrogen administration.
Estrogen treatment of prepubertal girls also induces premature breast development and vaginal cornification, and may induce gynecomastia.
Geriatric UseIn the Women’s Health Initiative Memory Study, including 4,532 women 65 years of age and older, followed for an average of 4 years, 82% (n = 3,729) were 65 to 74 while 18% (n = 803) were 75 and over. Most women (80%) had no prior hormone therapy use. Women treated with conjugated estrogens plus medroxyprogesterone acetate were reported to have a 2-fold increase in the risk of developing probable dementia. Alzheimer’s disease was the most common classification of probable dementia in both the conjugated estrogens plus medroxyprogesterone acetate group and the placebo group. Ninety percent of the cases of probable dementia occurred in the 54% of women that were older than 70.
With respect to efficacy in the approved indications, there have not been sufficient numbers of geriatric patients involved in studies utilizing Alora to determine whether those over 65 years of age differ from younger subjects in their response to Alora.
Alora should be administered twice weekly, as instructed. The adhesive side of the Alora system should be placed on a clean, dry area of skin. The recommended application site is the lower abdomen. In addition, the upper quadrant of the buttocks or outer aspect of the hip may be used. Alora should not be applied to the breasts. The sites of application should be rotated, with an interval of at least 1 week allowed between applications to a particular site. The area selected should not be oily, damaged, or irritated. The waistline should be avoided, since tight clothing may rub the system off. The system should be applied immediately after opening the pouch and removing the protective liner. The system should be pressed firmly in place with the palm of the hand for about 10 seconds, making sure there is good contact, especially around the edges.
In the event that a system should fall off, the same system may be reapplied. If necessary, a new system may be applied to another site. The original treatment schedule should be maintained.
Initiation Of TherapyFor treatment of moderate-to-severe vasomotor symptoms, vulvar and vaginal atrophy associated with the menopause, hypogonadism, castration, or primary ovarian failure, treatment is usually initiated with Alora 0.05 mg/day applied to the skin twice weekly. The lowest dose and regimen that will control symptoms should be chosen and medication should be discontinued as promptly as possible. Attempts to discontinue or taper medication should be made at 3-month to 6-month intervals.
For the prevention of postmenopausal osteoporosis, the minimum dose of Alora that has been studied and shown to be effective is 0.025 mg/day applied to the skin twice weekly. Bone mineral density measurements should be repeated to monitor treatment efficacy. The dosage may be increased as necessary, depending on bone mineral density and adverse events.
In women who are not currently taking oral estrogens or in women switching from topical therapy or another transdermal estradiol therapy, treatment with Alora can be initiated at once. In women who are currently taking oral estrogens, treatment with Alora should be initiated 1 week after withdrawal of oral therapy or sooner if menopausal symptoms reappear in less than 1 week.
When estrogen is prescribed for a postmenopausal woman with a uterus, progestin should also be initiated to reduce the risk of endometrial cancer. A woman without a uterus does not need progestin. Use of estrogen, alone or in combination with a progestin, should be limited to the shortest duration consistent with treatment goals and risks for the individual woman. Patients should be reevaluated periodically as clinically appropriate (e.g., 3-month to 6-month intervals) to determine if treatment is still necessary. For women who have a uterus, adequate diagnostic measures, such as endometrial sampling, when indicated, should be undertaken to rule out malignancy in cases of undiagnosed persistent or recurring abnormal vaginal bleeding.
Therapeutic RegimenAlora may be administered in a continuous regimen in patients who do not possess an intact uterus. In those patients with an intact uterus who are not using concomitant progestin therapy, Alora can be administered on a cyclic schedule (e.g., 3 weeks of therapy followed by 1 week without) for the treatment of postmenopausal symptoms. However, no studies have been conducted using this intermittent regimen for the prevention of postmenopausal osteoporosis.
In vitro and in vivo studies have shown that estrogens are metabolized partially by cytochrome P450 3A4 (CYP3A4). Therefore, inducers or inhibitors of CYP3A4 may affect estrogen drug metabolism. Inducers of CYP3A4 such as St. John’s Wort preparations (Hypericum perforatum), phenobarbital, phenytoin, carbamazepine, rifampin 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, and grapefruit juice may increase plasma concentrations of estrogens and may result in side effects.
AdhesionThe adhesion potential of Alora was evaluated in a randomized clinical trial involving 408 healthy postmenopausal women who wore placebo systems corresponding to the 18 cm2 size Alora. The placebos were applied twice weekly for 4 weeks on the lower quadrant of the abdomen. It should be noted that the lower abdomen, the upper quadrant of the buttocks or outer aspect of the hip are the approved sites of application for Alora. Subjects were instructed not to do strenuous activities, take baths, use hot tubs or swim. In 968 observations, there was a partial or complete adhesion rate of approximately 97%. The total detachment rate was approximately 3%. Adhesion potentials of the 9 cm2, 27 cm2 and 36 cm2 sizes of Alora have not been studied.
