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Prescriber's Guide - ESTRIOL/VITAMIN D3 Vaginal Cream
Prescriber's Guide

ESTRIOL/VITAMIN D3

VAGINAL CREAM

ESTRIOL/VITAMIN D3 Vaginal Cream
WHAT IS THIS MEDICATION?

Estriol used individually or in combination with Vitamin D3 has been studied for treatment in women with stress and urgency urinary incontinence.1,2

HOW ARE THE INGREDIENTS COMPOUNDED?

Estriol and Vitamin D3 may be compounded individually or combined. Generally, this combination is commonly compounded at the following strength: Estriol/Vitamin D3 0.5mg/12,500U/ml in an allergen free cream base.

HOW DO THE INGREDIENTS WORK IN THE HUMAN BODY?
Estriol

Unlike other estrogens, estriol is short acting since it has only a short retention time in the nuclei of endometrial cells. It substitutes for the loss of estrogen production in menopausal women and helps to alleviate menopausal symptoms.9,10

In cases of postmenopausal women with atrophy of the lower urogenital tract, estriol induces the normalization of the urogenital epithelium and helps to restore the normal microflora and the physiological pH in the vagina. As a result, it increases the resistance of the urogenital epithelial cells to infection and inflammation reducing vaginal complaints such as dyspareunia, dryness, itching, vaginal and urinary infections, micturition complaints and mild urinary incontinence.8-17

Vitamin D3

Low levels of Vitamin D3 have been associated with pelvic floor disorders among women.5,6,7 Vitamin D receptors are present in the bladder and striated muscle of the pelvic floor musculature.3,4 Skeletal muscle control and strength is vital for voluntary control of the urethral sphincter and pelvic floor muscle and likely a significant factor in achieving continence.

WHAT CONDITIONS HAVE THESE INGREDIENTS BEEN STUDIED FOR?

Estriol has been studied for use in women with:

  • Urge Urinary Incontinence1
  • Stage I, II, III Stress Urinary Incontinence1,2

Estriol/Vitamin D3 has been studied for use in women with:

  • Stage 1 & II Stress Urinary Incontinence2
WHAT ARE THE RESULTS OF THE CLINICAL STUDIES?
Urge & Stage I, II, & III Stress Urinary Incontinence

In an open, prospective, multicenter, controlled study1, 629 women suffering from stress and urgency urinary incontinence were treated with vaginal estriol at a dose of 10 mg daily for 3 weeks, and 10mg twice weekly for another 3 weeks. Of the 629 women who started the study, 552 were available for follow-up after 6-weeks of treatment.

Subjective improvements in symptoms of stress urinary incontinence (SUI) were 82% for grade 1, 77% for grade 2, and 69% for grade 3.

Voluntary urinary control and symptoms of urgency were improved in more than 80% of patients, and frequency was

reduced in almost 50% of women. Compared with conditions at the outset of the study, after 6 weeks, vaginal lubrication was normalized in 77%, and intercourse was no longer painful for 88% of women.

Stage I & II Stress Urinary Incontinence

In a combination use study of 60 postmenopausal women with stage I and II stress urinary incontinence2, estriol 0.5mg was co-administered with vitamin D3 12,500 IU intravaginally 3 times a week for 6 weeks after subjects failed a 6-week treatment of estriol 0.5 mg + Pelvic Floor Muscle Training (PFMT).
The results of the study showed complete remission of urinary incontinence in 1/3 of the women and another 1/3 of the women studied showed a 75% improvement in urinary retention

AT WHICH DOSES HAVE THE INGREDIENTS BE STUDIED AND HOW SHOULD THEY BE USED?
  • Estriol and Vitamin D3 should be used intravaginally
  • For Urge & Stage I, II, & III Stress Urinary Incontinence Estriol has been studied at doses of 10 mg daily for 3 weeks, followed by 10mg twice weekly for another 3 weeks
  • For Stage I & II Stress Urinary Incontinence, Estriol/Vitamin D3 has been studied at doses of 0.5mg/12,500U three times a weekly for 6 weeks
WHAT SIDE EFFECTS CAN BE CAUSED BY THE INGREDIENTS?

From literature and safety surveillance monitoring, the following adverse reactions have been reported with estriol use.

  • Fluid Retention
  • Nausea
  • Breast discomfort and pain
  • Postmenopausal spotting
  • Cervical Discharge
  • Application site irritation and pruritis
  • Flu like symptoms
WHAT PRECAUTIONS SHOULD BE KEPT IN MIND WHEN PRESCRIBING THIS MEDICATION?
Estriol

Use of exogenous estrogen is contraindicated in women with a known or suspected history of breast cancer; although recent trials8 indicate benefits for vaginal atrophy in hormone receptor positive breast cancer undergoing aromatase inhibitor therapy.

Vitamin D3

Vitamin D3 should be use cautiously in patients with arrhythmic, electrolyte imbalance, hypercalcemia, renal dysfunction and hepatobiliary dysfunction.

IS THESE INGREDIENTS SAFE DURING PREGNANCY AND BREASTFEEDING?
Pregnancy

This medicine is contraindicated during pregnancy.
If pregnancy occurs during medication with Estriol, treatment should be withdrawn immediately. The results of most epidemiological studies to date relevant to inadvertent fetal exposure to estrogens indicate no teratogenic or fetotoxic effects.

Breastfeeding

Estriol is excreted in breast milk and may decrease milk production, therefore, use of estriol is not recommended during breastfeeding

WHEN SHOULD THESE INGREDIENTS NOT BE PRESCRIBED?
  • Pregnancy
  • Known, past or suspected breast cancer
  • Known or suspected estrogen-dependent malignant tumors (e.g. endometrial cancer)
  • Undiagnosed genital bleeding
  • Untreated endometrial hyperplasia
  • Previous or current venous thromboembolism (deep venous thrombosis, pulmonary embolism)
  • Known thrombophilic disorders (e.g. protein C, protein S, or antithrombin deficiency, see section 4.4 Special warnings and precautions for use)
  • Active or recent arterial thromboembolic disease (e.g. angina, myocardial infarction)
  • Acute liver disease, or a history of liver disease as long as liver function tests failed to return to normal
  • Hypersensitivity to the active substances or to any of the excipients
  • Porphyria
WILL THE INGREDIENTS INTERACT WITH OTHER DRUGS, AND IF SO HOW?
Estriol
  • The metabolism of estrogens may be increased by concomitant use of substances known to induce drug-metabolizing enzymes, specifically cytochrome P450 enzymes, such as anticonvulsants (e.g. hydantoins (phenytoin), barbiturates (phenobarbital), carbamazepine), anti-infectives (e.g. griseofulvin, rifamycins (rifampicin, rifabutin), and antiretroviral agents (nevirapine, efavirenz)).
  • Ritonavir and nelfinavir, although known as strong inhibitors, by contrast exhibit inducing properties when used concomitantly with steroid hormones.
  • Herbal preparations containing St John’s wort (Hypericum Perforatum) may induce the metabolism of estrogens.
  • Clinically, an increased metabolism of estrogens may lead to decreased effect and changes in the uterine bleeding profile.
  • Estriol may possibly increase the pharmacological effects of corticosteroids, succinylcholine, theophyllines and troleandomycin.
Vitamin D3

Use Vitamin D3 cautiously in patients taking:

  • Erdafitinib
  • Paricalcitol
  • Calcifediol
  • Calcitriol
  • Dihydrotachysterol
  • Doxercalciferol
HOW DO THESE INGREDINTS MOVE THROUGH THE HUMAN BODY?
Estriol

Absorption. Intravaginal administration of estriol ensures optimal availability at the site of action. Estriol is also absorbed into the general circulation, as is shown by a sharp rise in the plasma levels of unconjugated estriol.

Distribution. Peak plasma levels are reached 1-2 hours after application. After vaginal application of 0.5 mg estriol, Cmax is approximately 100 pg/ml, Cmin is approximately 25 pg/ml and Caverage is approximately 70 pg/ml. After 3 weeks of daily administration of 0.5 mg vaginal estriol, Caverage has decreased to 40 pg/ml.

Metabolism. Nearly all (90%) estriol is bound to albumin in the plasma and in contrast with other estrogens, hardly any estriol is bound to sex hormone-binding globulin (SHBG). The metabolism of estriol consists principally of conjugation and deconjugation during the enterohepatic circulation.

Elimination. Estriol, being a metabolic end product, is mainly excreted via the urine in the conjugated form. Only a small part (±2 %) is excreted via the feces, mainly as unconjugated estriol.

Vitamin D3

Absorption. Previous studies have indicated that Vitamin D3 is absorbed efficiently through the dermal route.
Metabolism. Vitamin D3, or Cholecalciferol is converted in the liver to calcifediol (25-hydroxycholecalciferol), which is then converted to calcitriol in the kidney, the biologically active form of Vitamin D3 and released for use in the blood stream.
Elimination. Calcitriol (1,25-dihydroxyvitamin D3), the active form of vitamin D, has a half-life of about 15 hours, while calcidiol (25-hydroxyvitamin D3) has a half-life of about 15 days. The products of vitamin D metabolism are excreted through the bile into the feces, and very little is eliminated through the urine.

WHAT CAN HAPPEN IF TOO MUCH OF THIS MEDICATION IS TAKEN?
Estriol

The acute toxicity of estriol in animals is very low. Overdosage with Estriol cream after vaginal administration is unlikely. However, in cases where large quantities are ingested, nausea, vomiting and withdrawal bleeding in females may occur. No specific antidote is known. Symptomatic treatment can be given if necessary.

Vitamin D3

Vitamin D toxicity is rare. Vitamin D overdose causes hypercalcemia, which is a strong indication of vitamin D toxicity – this can be noted with an increase in urination and thirst. If hypercalcemia is not treated, it results in excess deposits of calcium in soft tissues and organs such as the kidneys, liver, and heart, resulting in pain and organ damage.

The main symptoms of vitamin D overdose which are those of hypercalcemia including anorexia, nausea, and vomiting. These may be followed by polyuria, polydipsia, weakness, insomnia, nervousness, pruritus and ultimately kidney failure. Furthermore, proteinuria, urinary casts, azotemia, and metastatic calcification (especially in the kidneys) may develop. Other symptoms of vitamin D toxicity include abnormal bone growth and formation, diarrhea, irritability, weight loss, and severe depression

HOW IS THIS MEDICATION STORED?

Store at room temperature.

REFERENCES
  1. Tan EM, Peltonen J. Endothelial cell growth factor and heparin regulate collagen gene expression in keloid fibroblasts. Biochem J. 1991;278 ( Pt 3)(Pt 3):863-869. doi:10.1042/bj2780863
  2. Willital GH, Heine H. Efficacy of Contractubex gel in the treatment of fresh scars after thoracic surgery in children and adolescents. Int J Clin Pharmacol Res. 1994;14(5-6):193-202.
  3. Beuth, J & Hunzelmann, N & Leendert, R & Basten, R & Noehle, M & Schneider, B. (2006). Safety and Efficacy of Local Administration of Contractubex® to Hypertrophic Scars in Comparison to Corticosteroid Treatment. Results of a Multicenter, Comparative Epidemiological Cohort Study in Germany. In vivo (Athens, Greece). 20. 277-83.
  1. Ocampo-Candiani J, Vázquez-Martínez OT, Iglesias Benavides JL, Buske K, Lehn A, Acker C. The prophylactic use of a topical scar gel containing extract of Allium cepae, allantoin, and heparin improves symptoms and appearance of cesarean-section scars compared with untreated scars. J Drugs Dermatol. 2014;13(2):176-182.
  2. Chadzyńska M. Leczenie bliznowców pooparzeniowych maścia Contractubex compositum firmy Merz [Treatment of post-burn keloid with Contractubex compositum ointment (Merz)]. Przegl Dermatol. 1987;74(1):55-61.
  3. Heparin. In: Drugs and Lactation Database (LactMed). Bethesda (MD): National Library of Medicine (US); 2006.
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This prescriber’s guide does not provide medical or legal advice. All content found on this prescriber’s guide, including: text, images, audio, or other formats were created for informational purposes only. Viewing this prescriber’s guide, receipt of information contained in this guide, or the transmission of this information from our pharmacy does not constitute a pharmacist-patient relationship.

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