At a glance......
- 1 Types of Estrogen Hormone
- 2 Mechanism of Action
- 3 Indications of Estrogen Hormone
- 4 Contraindications of Estrogen Hormone
- 5 Dosage of Estrogen Hormone
- 6 Side Effects of Estrogen Hormone
- 7 Drug Interactions
- 7.1 Levels of estrogen
- 7.2 Estrogen sources and uses
- 7.3 Estrogen therapy
- 7.4 Transitioning to female
- 7.5 Birth control
- 8 Monitoring
User Review( votes)
Low Estrogen Symptoms/Estrogen Hormone is a steroid hormone associated with the female reproductive organs and is responsible for the development of female sexual characteristics. Estrogen or estradiol is the most common form of estrogen hormone for FDA-approved treatment as hormone replacement therapy (HRT) in the management of symptoms associated with menopause. Furthermore, this activity will highlight the mechanism of action, adverse event profile, off-label uses, administration and dosing, monitoring, and relevant interactions pertinent for members of the interprofessional team.
Types of Estrogen Hormone
There are different types of estrogen:
- Estrone – This type of estrogen is present in the body after menopause. It is a weaker form of estrogen and one that the body can convert to other forms of estrogen, as necessary.
- Estradiol – Both males and females produce estradiol, and it is the most common type of estrogen in females during their reproductive years. Too much estradiol may result in acne, loss of sex drive, osteoporosis, and depression. Very high levels can increase the risk of uterine and breast cancer. However, low levels can result in weight gain and cardiovascular disease.
- Estriol – levels of estriol rise during pregnancy, as it helps the uterus grow and prepares the body for delivery. Estriol levels peak just before birth.
Normal estrogen levels in women
According to Mayo Medical Laboratories, the following estrone and estradiol levels are considered normal for women:
|Prepubescent female||Undetectable–29 pg/mL||Undetectable–20 pg/ml|
|Pubescent female||10–200 pg/mL||Undetectable–350 pg/ml|
|Premenopausal adult female||17–200 pg/mL||15–350 pg/ml|
|Postmenopausal adult female||7–40 pg/mL||<10 pg/ml|
In premenopausal girls and women, estradiol levels vary widely throughout the menstrual cycle.
Normal estrogen levels in men
According to Mayo Medical Laboratories, the following estrone and estradiol levels are considered normal for men
|Prepubescent male||Undetectable–16 pg/ml||Undetectable–13 pg/ml|
|Pubescent male||Undetectable–60 pg/ml||Undetectable–40 pg/ml|
|Adult male||10–60 pg/ml||10–40 pg/ml|
Mechanism of Action
Estrogen enters the systemic circulation as a free hormone or protein-bound, either as sex hormone-binding globulin (SHBG) or albumin. Non-protein-bound estrogen has the property to diffuse into cells freely with no regulation. The initiation of cellular physiological response to estrogen begins in the cell cytoplasm with the binding of estrogen to either alpha-estrogen receptor or beta-estrogen receptor. The activated estrogen-estrogen receptor complex then crosses into the nucleus of cells to induce transcription of DNA by binding to nucleotide sequences known as estrogen response elements (ERE) to enact a physiological response. Estrogen hormone levels in the body are regulated by the negative feedback effect of estrogen on the hypothalamus and pituitary gland. An example of negative feedback can be observed during the menstrual cycle. Estrogen metabolic activity primarily takes place within the liver hepatocytes CYP3A4 and excreted from the body in the urine.[rx][rx][rx]
The effects of estrogen on various systems of the body are described below
Breast – Estrogen is responsible for the development of mammary gland tissue and parenchymal and stromal changes in breast tissue at puberty in females. Estrogen is also responsible for the development of mammary ducts during puberty, and during pregnancy, functions to secrete breast milk in postpartum lactation.
Uterus – In the uterus, estrogen helps to proliferate endometrial cells in the follicular phase of the menstrual cycle, thickening the endometrial lining in preparation for pregnancy.
Contraception – Ethinyl estradiol, an ingredient of OCPs, functions to suppress the hypothalamus release of gonadotropin-releasing hormone (GnRH) and pituitary release of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) in preventing ovulation during the menstrual cycle.
Vagina – Estrogen supports the proliferation of epithelial mucosa cells of the vagina and the vulva. In the absence of estrogen, the vaginal and vulvar mucosal epithelium becomes thin and presents with symptoms of dryness known as vulvovaginal atrophy.[rx]
Cardiovascular – Estrogen affects plasma lipids by increasing high-density lipoproteins (HDL) and triglyceride levels while decreasing low-density lipoproteins (LDL) and total plasma cholesterol and reduce the risk of coronary artery disease in early use in postmenopausal women.[rx]
Indications of Estrogen Hormone
Estrogen is a steroid hormone associated with the female reproductive organs and is responsible for the development of female sexual characteristics. Estrogen is often referred to in the following structures as either estrone, estradiol, and estriol.
- According to early studies, estrogen as hormone replacement therapy for postmenopausal women showed promising benefits of decreased risk of osteoporosis, coronary arterial disease, and mortality.[rx] Later studies conducted by the Women’s Health Initiative concluded that risk was greater than the benefit of hormone replacement therapy in postmenopausal women.
- The Women’s Health Initiative ended clinical studies prematurely because of participants in the study developed an increased risk of breast cancer and coronary artery disease.[rx] Newer studies contradict the finding of the Women’s Health Initiative, with evidence of the improved quality of life and reduced risk of coronary artery disease and osteoporosis in women when women start estrogen hormone replacement therapy at the onset of menopause.[rx]
- The FDA approves of estrogen for hormone replacement therapy in the treatment of symptoms of menopause. Synthetic estrogen is also available for clinical use with the purpose of having increase absorption and effectiveness by alteration of the estrogen chemical structure for topical or oral administration. Synthetic steroid estrogens include Ethinyl estradiol, estradiol valerate, estropipate, conjugate esterified estrogen, and quinestrol. Ethinyl estradiol is a commonly used synthetic estrogen to prevent pregnancy as a component of the oral contraceptive pill approved by the FDA.[rx] Some nonsteroidal synthetic estrogens include dienestrol, diethylstilbestrol, benzestrol, methestrol, and hexestrol.
- Conjugated estrogen therapy is indicated in the treatment of moderate to severe vasomotor symptoms due to menopause.
- Conjugated estrogen therapy is indicated in the treatment of moderate to severe symptoms of vulvar and vaginal atrophy due to menopause. When prescribing solely for the treatment of symptoms of vulvar and vaginal atrophy, topical vaginal products should be considered.
- Conjugated estrogen therapy is indicated in the treatment of hypoestrogenism due to hypogonadism, castration or primary ovarian failure.
- Conjugated estrogen therapy is indicated in the treatment of breast cancer (for palliation only) in appropriately selected women and men with metastatic disease.
- Conjugated estrogen therapy is indicated in the treatment of advanced androgen-dependent carcinoma of the prostate (for palliation only).
- The FDA approves of estrogen for hormone replacement therapy in the treatment of symptoms of menopause. Synthetic estrogen is also available for clinical use with the purpose of having increase absorption and effectiveness by alteration of the estrogen chemical structure for topical or oral administration.
Clinically, the use of estrogen includes the following FDA-approved indications
Primary ovarian insufficiency
Symptoms associated with menopause including vulvovaginal atrophy, dyspareunia, hot flashes and night sweats, and prevention of osteoporosis
Oral contraceptive pill (OCP) to prevent pregnancy
Moderate acne vulgaris
Prostate cancer with advanced forms of metastasis
Estrogen/synthetic estrogen has the following non-FDA-approved indication for polycystic ovarian syndrome for the relief of symptoms of hyperandrogenism and amenorrhea.[rx]
Contraindications of Estrogen Hormone
The following are contraindications for the use of natural estrogen and synthetic estrogen derivatives:
Estrogen hormone receptor sensitive malignancies including breast cancer, ovarian cancer, and endometrial cancers
Coronary arterial disease
History of thromboembolism or thrombophlebitis
History of hypercoagulable disease (Factor V Leiden syndrome, Protein C or Protein S deficiencies and metastatic disease)
History of ischemic stroke
History of dementia or neurocognitive disorders
History of tobacco use
Estradiol use in pregnancy is classified as pregnancy risk factor category X, and the use of esterified estrogens are contraindicated for use during pregnancy
Dosage of Estrogen Hormone
Estrogen hormone therapy may be prescribed in the following combinations as either estrogen-only medication or estrogen and hormone combination medication to treat symptoms of menopause, prevention of osteoporosis, prevention of pregnancy, hypoestrogenism, and metastatic breast and advance prostate cancers.
Available Estrogen Preparations
Estrogen: Conjugated may be prescribed in the dosage of 0.3-mg, 0.625-mg, 0.9-mg, and 1.25-mg tablets
Estradiol may be prescribed in the dosage of 0.5-mg, 1-mg, and 2-mg tablets
Norethindrone/Ethinyl estradiol 1.5 mg/30 mcg tablets for oral contraception
Combination estrogen-etonogestrel/ethinyl estradiol hormone vaginal ring for contraception: 0.12 mg/0.015 mg per day.
Estradiol only vaginal ring for vulvovaginal atrophy: 7.5 mcg per day
Estradiol valerate administered as an intramuscular injection in the dosage of 10 mg per mL, 20 mg per mL, and 40 mg per mL for vasomotor symptoms of menopause, vulvovaginal atrophy, and hypoestrogenism. Recommendations for advanced prostate cancer palliative treatment is more than 30-mg intramuscular injection.
Estradiol cypionate administered as an intramuscular injection in the dosage of 5 mg per mL for treatment of moderate-to-severe symptoms of menopause.
Available as a topical cream, topical spray, vaginal cream, vaginal tablet insert, and transdermal patch
Estradiol topical gel (0.006%): 0.52 mg per pump
Estradiol topical spray applied to the inner surface of the forearm: 1.53 mg per actuation
Estradiol hemihydrate tablet for vaginal insert may be prescribed at the following dosage: 10-mcg, 25-mcg tablet
Estrogen, conjugated vaginal cream: 0.625 mg per gram applied intravaginally
Estradiol transdermal patches may be prescribed at the following dosage: 0.025 mg, 0.05 mg, 0.075 mg, or 0.1 mg per day.
Estrogen Treatment: Pills
- What are they? Oral medication is the most common form of ERT. Examples are conjugated Estrogens (Premarin), estradiol (Estrace), and Estratab. Follow your doctor’s instructions for dosing. Most estrogen pills are taken once a day without food. Some have more complicated dosing schedules.
- Pros. Like other types of estrogen therapy, estrogen pills can reduce or resolve troublesome symptoms of menopause. They can also lower the risk of osteoporosis. While there are newer ways of getting ERT, oral estrogen medicines are the best-studied type of estrogen therapy.
- Cons. The risks of this type of estrogen therapy have been well-publicized. On its own, estrogen causes a slight increase in the risk of strokes, blood clots, and other problems. When combined with the hormone progestin, the risks of breast cancer and heart attack may rise as well. Oral estrogen-like any estrogen therapy — can also cause side effects. These include painful and swollen breasts, vaginal discharge, headache, and nausea.
Because oral estrogen can be hard on the liver, people with liver damage should not take it. Instead, they should choose a different way of getting estrogen.
Estrogen Treatment: Skin Patches
What are they?
- Skin patches are another type of ERT – Examples are Alora, Climara, Estraderm, and Vivelle-Dot. Combination estrogen and progestin patches — like Climara Pro and Combipatch — are also available. Menostar has a lower dose of estrogen than other patches, and it’s only used for reducing the risk of osteoporosis. It doesn’t help with other menopause symptoms.
Usually, you would wear the patch on your lower stomach, beneath the waistline. You would then change the patch once or twice a week, according to the instructions.
- Pros – In addition to offering the same benefits as an oral therapy, this type of estrogen treatment has several additional advantages. For one, the patch is convenient. You can stick it on and not worry about having to take a pill each day. While estrogen pills can be dangerous for people with liver problems, patches are OK, because the estrogen bypasses the liver and goes directly into the blood. A 2007 study also showed that the patch does not pose a risk of blood clots in postmenopausal women like oral estrogen does, though more studies are needed before making definitive conclusions on whether patches are safer than pills. Right now, all estrogens carry the same black-box warning with respect to clot formation.
- Cons – While some experts believe that estrogen patches may be safer than oral estrogen in other ways, it’s too early to know. So, for now, assume that estrogen patches pose most of the same risks a very small increase in the risk of serious problems, like cancer and stroke. They also have many similar although perhaps milder — side effects. These include painful and swollen breasts, vaginal discharge, headache, and nausea. The patch itself might irritate the skin where you apply it.
Estrogen patches should not be exposed to high heat or direct sunlight. Heat can make some patches release the estrogen too quickly, giving you too high a dose at first and then too low a dose later. So don’t use tanning beds or saunas while you’re wearing an estrogen patch.
Estrogen Treatment: Topical Creams, Gels, and Sprays
What are they?
- Estrogen gels (like Estrogen and Divigell) – creams (like Estrasorb), and sprays (like Evamist) offer another way of getting estrogen into your system. As with patches, this type of estrogen treatment is absorbed through the skin directly into the bloodstream. The specifics on how to apply these creams vary, although they’re usually used once a day. Estrogel is applied on one arm, from the wrist to the shoulder. Estrasorb is applied to the legs. Evamist is applied to the arm.
- Pros – Because estrogen creams are absorbed through the skin and go directly into the bloodstream, they’re safer than oral estrogen for people who have liver and cholesterol problems.
- Cons – Estrogen gels, creams, and sprays have not been well-studied. While they could be safer than oral estrogen, experts aren’t sure. So assume that they pose the same slight risk of serious conditions, like cancer and stroke.
One potential problem with using this type of estrogen treatment is that the gel, cream or spray can rub or wash off before it’s been fully absorbed. Make sure you let the topical dry before you put on clothes. Always apply it after you bathe or shower.
Side Effects of Estrogen Hormone
- Natural estrogen and synthetic estrogen may cause the following common adverse effects: breast tenderness, nausea, vomiting, bloating, stomach cramps, headaches, weight gain, hyperpigmentation of the skin, hair loss, vaginal itching, abnormal uterine bleeding also known as breakthrough bleeding, and anaphylaxis.
- Weight gain may be a reported adverse effect of the oral contraceptive pill (OCP) containing Ethinyl estradiol, but studies conducted on short-term and long-term use of OCPs resulted in no weight gain association.[rx][rx]
- More severe side effects of estrogen include hypertension, cerebrovascular accident, myocardial infarction, venous thromboembolism, pulmonary embolism, exacerbation of epilepsy, irritability, exacerbation of asthma, galactorrhea and nipple discharge, hypocalcemia, gallbladder disease, hepatic hemangioma and adenoma, pancreatitis, breast hypertrophy, endometrial hyperplasia, vaginitis, vulvovaginal candidiasis (intravaginal preparations), enlargement of uterine fibroids, and risk of cervical cancer and breast cancer.
Tell your doctor right away if you have any serious side effects, including mental, mood changes (such as depression, memory loss), breast lumps, unusual vaginal bleeding (such as spotting, breakthrough bleeding, prolonged, recurrent bleeding), increased or new vaginal irritation, itching, odor, discharge, severe stomach, abdominal pain, persistent nausea, vomiting, yellowing eyes, skin, dark urine, swelling hands, ankles, feet, increased thirst, urination.
The use of estrogen without progestins increased the risk of endometrial cancer. The use of estrogen with and without progestins resulted in an increased risk of myocardial infarction, stroke, pulmonary emboli, and deep vein thrombosis in postmenopausal women (50 to 79 years old) and an increased risk of invasive breast cancer in postmenopausal women (50 to 79 years old) with oral conjugated estrogens with medroxyprogesterone by studies established by the Women’s Health Initiative. The use of oral conjugated estrogens plus medroxyprogesterone acetate increased the risk of developing dementia in postmenopausal women older than 65 years of age have been established by the Women’s Health Initiative Memory Study.[rx][rx]
US Preventive Services Task Force (USPSTF) Score: D
Using estrogen-alone or combined estrogen and progestin use to prevent a chronic condition in postmenopausal women with or without a uterus is not recommended by the US Preventive Services Task Force (USPSTF).[rx]
Drug interactions may change how your medications work or increase your risk for serious side effects. This document does not contain all possible drug interactions. Keep a list of all the products you use (including prescription/nonprescription drugs and herbal products) and share it with your doctor and pharmacist. Do not start, stop, or change the dosage of any medicines without your doctor’s approval.
Some products that may interact with this drug include: aromatase inhibitors (such as anastrozole, exemestane, letrozole), fulvestrant, ospemifene, raloxifene, tamoxifen, toremifene, tranexamic acid.
This medication may interfere with certain laboratory tests (including metyrapone test), possibly causing false test results. Make sure laboratory personnel and all your doctors know you use this drug.
Why is estrogen important?
Estrogen helps bring about the physical changes that turn a girl into a woman. This time of life is called puberty. These changes include:
- Growth of the breasts
- Growth of pubic and underarm hair
- Start of menstrual cycles
Estrogen helps control the menstrual cycle and is important for childbearing.
Estrogen also has other functions
- Keeps cholesterol in control
- Protects bone health for both women and men
- Affects your brain (including mood), bones, heart, skin, and other tissues
How does estrogen work?
The ovaries, which produce a woman’s eggs, are the main source of estrogen from your body. Your adrenal glands, located at the top of each kidney, make small amounts of this hormone, so does fat tissue. Estrogen moves through your blood and acts everywhere in your body.
What can go wrong with estrogen levels?
- For many reasons, your body can make too little or too much estrogen. Or, you can take in too much estrogen, such as through birth control pills or estrogen replacement therapy. You might want to keep track of your symptoms (changes you feel) by writing them down each day. Bring this symptom journal to your doctor.
Estrogen and your menstrual cycle
- Your estrogen levels change throughout the month. They are highest in the middle of your menstrual cycle and lowest during your period. Estrogen levels drop at menopause.
- How do you know what your estrogen level is? You will need to give a blood or urine sample to test your estrogen. Ask your doctor what your test results mean.
The most common reason for low estrogen in women is menopause or surgical removal of the ovaries. Symptoms of low estrogen include:
- Menstrual periods that are less frequent or that stop
- Hot flashes (suddenly feeling very warm) and/or night sweats
- Trouble sleeping
- Dryness and thinning of the vagina
- Low sexual desire
- Mood swings
- Dry skin
Some women get menstrual migraines, a bad headache right before their menstrual period, because of the drop in estrogen.
Men – Low estrogen in men can cause excess belly fat and low sexual desire.
High Estrogen in Women
Excess estrogen can lead to these problems, among others:
- Weight gain, mainly in your waist, hips, and thighs
- Menstrual problems, such as light or heavy bleeding
- Worsening of premenstrual syndrome
- Fibrocystic breasts (non-cancerous breast lumps)
- Fibroids (noncancerous tumors) in the uterus
- Loss of sex drive
- Feeling depressed or anxious
- swelling and tenderness in your breasts
- fibrocystic lumps in your breasts
- decreased sex drive
- irregular menstrual periods
- increased symptoms of premenstrual syndrome (PMS)
- mood swings
- anxiety and panic attacks
- weight gain
- hair loss
- cold hands or feet
- trouble sleeping
- sleepiness or fatigue
- memory problems
Men. High estrogen in men can cause
- Infertility – Estrogen is partly responsible for creating healthy sperm. When estrogen levels are high, sperm levels may fall and lead to fertility issues.
- Gynecomastia – Estrogen may stimulate breast tissue growth. Men with too much estrogen may develop gynecomastia, a condition which leads to larger breasts.
- Erectile dysfunction (ED) – Men with high levels of estrogen may have difficulty getting or maintaining an erection.
- Enlarged breasts (gynecomastia)
- Poor erections
Levels of estrogen
Estrogen levels vary among individuals. They also fluctuate during the menstrual cycle and over a female’s lifetime. This fluctuation can sometimes produce effects such as mood changes before menstruation or hot flashes in menopause.
Factors that can affect estrogen levels include
- pregnancy, the end of pregnancy, and breastfeeding
- older age
- overweight and obesity
- extreme dieting or anorexia nervosa
- strenuous exercise or training
- the use of certain medications, including steroids, ampicillin, estrogen-containing drugs, phenothiazines, and tetracyclines
- some congenital conditions, such as Turner’s syndrome
- high blood pressure
- primary ovarian insufficiency
- an underactive pituitary gland
- polycystic ovary syndrome (PCOS)
- tumors of the ovaries or adrenal glands
An imbalance of estrogen leads to:
- irregular or no menstruation
- light or heavy bleeding during menstruation
- more severe premenstrual or menopausal symptoms
- hot flashes, night sweats, or both
- noncancerous lumps in the breast and uterus
- mood changes and sleeping problems
- weight gain, mainly in the hips, thighs, and waist
- low sexual desire
- vaginal dryness and vaginal atrophy
- mood swings
- feelings of depression and anxiety
- dry skin
- erectile dysfunction
- larger breasts, known as gynecomastia
Males with low estrogen levels may have excess belly fat and low libido.
If a person has low levels of estrogen, a doctor may prescribe supplements or medication.
Estrogen products include
- synthetic estrogen
- bioidentical estrogen
- Premarin, which contains estrogens from the urine of pregnant mares
- Estrogen therapy can help manage menopause symptoms as part of hormone therapy, which people usually refer to as hormone replacement therapy.
- The treatment may consist solely of estrogen (estrogen replacement therapy, or ERT), or it may involve a combination of estrogen and progestin, a synthetic form of progesterone.
- Hormone treatment is available as a pill, nasal spray, patch, skin gel, injection, vaginal cream, or ring.
It can help manage
- hot flashes
- vaginal dryness
- painful intercourse
- mood changes
- sleep disorders
- decreased sexual desire
It may also help reduce the risk of osteoporosis, which increases when people enter menopause.
Side effects include
- breast soreness
- leg cramps
- vaginal bleeding
- fluid retention, leading to swelling
Some types of hormone therapy can also increase the risk of a stroke, blood clots, and uterine and breast cancer. A doctor can advise a person on whether estrogen therapy is suitable for them.
In addition to menopause, estrogen therapy can also help resolve
- primary ovarian insufficiency
- other ovarian issues
- some types of acne
- some cases of prostate cancer
- delayed puberty[rx], for example, in Turner’s syndrome
High levels of estrogen can increase the risk and progression of some types of breast cancer. Some hormone treatments block the action[rx] of estrogen as a way of slowing or stopping cancer development. Hormonal therapy is not for everyone. A family history of breast cancer or thyroid issues may contradict using hormones. People who are unsure can speak to a doctor.
Transitioning to female
A doctor can prescribe estrogen[rx] as part of the therapy for a person assigned male at birth who wishes to transition to a female. The person may also need anti-androgenic treatment.
- Estrogen can help a person develop female secondary sexual characteristics, such as breasts, and reduce male pattern hair formation.
- Estrogen therapy will be part of a broader treatment approach. A healthcare professional can advise the individual on the best course of treatment.
Birth control pills contain either synthetic estrogen and progestin or progestin-only.
- Some types prevent pregnancy by stopping ovulation, and they do this by ensuring that hormone levels do not fluctuate throughout the month.
- They also make the mucus in the cervix thick so that any sperm cannot reach the egg. Other uses include decreasing premenstrual symptoms and reducing the severity of hormone-related acne.
Birth control pills may increase the risk of
- heart attack
- blood clots
- pulmonary embolism
- nausea and vomiting
- irregular bleeding
- weight changes
- breast tenderness and swelling
Oral birth control presents more risk for women who smoke or are over the age of 35 years. Long-term use may also lead to a higher risk of breast cancer.
Food sources of estrogen
Some foods contain phytoestrogens, which are plant-based substances that resemble estrogen. Some studies suggest that these may affect levels[rx] of estrogen in the body. However, there is not enough evidence to confirm this.
Foods that contain phytoestrogens include
- cruciferous vegetables
- soy and some foods containing soy protein
- seeds and grains
Some people believe that foods containing phytoestrogens can help manage hot flashes and other effects of menopause, but this does not have scientific backing. In addition, eating whole soy foods, for example, is unlikely to have the same effect as taking extracts from soy as a supplement.
Some herbs and supplements contain phytoestrogens, which act in a similar way to estrogen. These may help regulate estrogen and treat symptoms of menopause.
- black cohosh
- red clover
- soy isoflavones
However, it is unclear exactly how these compounds affect estrogen and estrogen-related activity in the body, and there is not enough evidence to confirm that they are safe and effective, especially in the long term. Researchers have called for further studies.
In addition, the Food and Drug Administration (FDA) does not regulate herbal and nonmedicinal supplements. As a result, it is not possible to know exactly what a product contains.
Prior to the initiation of the use of estrogen, screening should be conduct towards the patient’s risk of breast cancer, endometrial cancer, the risk of cardiovascular disease including stroke, venous thrombosis, and myocardial infarction. Patients should also be screened for hypertension before starting estrogen therapy, and patients should be continued to be monitored for the development of hypertension while taking estrogen. Routine women’s wellness exams including mammography and pap smear should be continued during the use of hormone replacement therapy with estrogen. Smoking cessation should be encouraged before the start and duration of use of OCPs due to tobacco use having an increased risk of venous thrombosis.[rx]
The Endocrine Society recommends monitoring patients’ improvement of postmenopausal symptoms while taking estrogen as hormone replacement therapy at the following intervals: first 1 to 3 months of the start of therapy, then re-evaluated at 6 to 12 months of therapy, then annually after the first year.[rx]