Dosing and uses of Cilest, Prefest (estradiol/norgestimate)
Adult dosage forms and strengths
estradiol/norgestimate
tablet
- Pink: 1mg (15 tabs)
- White: 1mg/0.09mg (15 tabs)
Hormone Replacement Therapy
1 pink tablet PO qDay for 3 days
Followed by 1 white tab PO qDay for 3 days, then repeat
Other Indications & Uses
Treatment of moderate to severe vasomotor symptoms in menopause with an intact uterus, prevention of osteoporosis in postmenopausal women with an intact uterus, vulvar and vaginal atrophy in women with an intact uterus
Off-label: postmenopausal hypercholesterolemia
Pediatric dosage forms and strengths
Not recommended
Geriatric dosage forms and strengths
Hormone replacement therapy
1 pink tablet PO qDay for 3 days
Followed by 1 white tab PO qDay for 3 days, then repeat
Cilest, Prefest (estradiol/norgestimate) adverse (side) effects
Frequency not defined
Common
- Headache
- Breast pain
- Abdominal pain
- Back pain
- URI
- Influenza-like symptoms
Less common
- Cardiovascular disease
- Deep vein thrombosis
- Hypertension
- Breast cancer
- Endometrial neoplasia
- Gallbladder disease
Warnings
Black box warnings
Cardiovascular risks
- Estrogens with and without progestins should not be used to prevent cardiovascular disease
- Estrogens plus progestins: Women’s Health Initiative (WHI) Estrogen Plus Progestin substudy reported increased risks of myocardial infarction, stroke, invasive breast cancer, pulmonary emboli, and deep vein thrombosis (DVT) in postmenopausal women (aged 50-79 yr) during 5.6 yr of treatment with daily PO conjugated estrogens (CE 0.625 mg) combined with medroxyprogesterone acetate (MPA 2.5 mg) compared with placebo
- Estrogens alone: The estrogen alone substudy of the WHI Study reported increased risks of stroke and DVT in postmenopausal women (aged 50-79 yr) during 6.8 yr of treatment with oral conjugated estrogens (0.625 mg/day) alone compared with placebo
Dementia risks
- Estrogens with and without progestins should not be used to prevent dementia
- Women's Health Initiative Memory Study (WHIMS), a substudy of the WHI study, reported increased risk of developing probable dementia in postmenopausal women aged 65 yr or older during 4 yr of treatment w/ daily CE 0.625 mg combined with MPA 2.5 mg, compared with placebo
- Estrogens alone: A substudy of the WHIMS reported an increased risk of developing probable dementia in postmenopausal women aged 65 yr or older during 5.2 yr of treatment with conjugated estrogens 0.625 mg alone compared with placebo
- Unknown whether these findings apply to younger postmenopausal women
Dose & Duration
- In the absence of comparable data, these risks should be assumed to be similar for other doses of CE and MPA and other combinations and dosage forms of estrogens and progestins
- Because of these risks, estrogens with or without progestins should be prescribed at lowest effective dose and for shortest duration consistent with treatment goals and individual risks
Contraindications
Hypersensitivity
Pregnancy
Estrogen-dependent neoplasia
Current/history of: DVT/PE, arterial thromboembolic disease, breast cancer, liver disease/tumours
Undiagnosed abnormal vaginal bleeding
Jaundice with previous OCP use
Porphyria
History of pruritus gravidarum, pemphigoid gestationis, deterioration of otosclerosis or idiopathic jaundice during pregnancy
Untreated endometrial hyperplasia
Cautions
Bone mineral density changes, current/history of depression, DM, HTN, hyperlipidemia, hypertriglyceridemia, obesity, endometriosis, family history of breast cancer and DVT/PE, smoking, epilepsy, migraine, renal impairment, severe hypocalcemia, ovarian cancer
Discontinue if the following develop: jaundice, visual problems, 4-6 wk before major surgery, any symptoms of VTE, massive BP increases, unusually severe migraines or first-time migraines, depression
Increased risk of post-op thromboembolic complications
Conditions exacerbated by fluid retention (eg, asthma, migraine, cardiac/renal dysfunction, epilepsy)
Patients on warfarin/oral anticoagulants: Estrogens increase thromboembolic risk; increase in anticoagulant dose may be warranted
History of migraine with aura
Cholelithiasis
Risk of developing dementia
Monitor blood pressure
Pregnancy and lactation
Pregnancy category: X
Lactation: enters breast milk; use with caution
Pregnancy categories
A: Generally acceptable. Controlled studies in pregnant women show no evidence of fetal risk.
B: May be acceptable. Either animal studies show no risk but human studies not available or animal studies showed minor risks and human studies done and showed no risk.
C: Use with caution if benefits outweigh risks. Animal studies show risk and human studies not available or neither animal nor human studies done.
D: Use in LIFE-THREATENING emergencies when no safer drug available. Positive evidence of human fetal risk.
X: Do not use in pregnancy. Risks involved outweigh potential benefits. Safer alternatives exist.
NA: Information not available.
Pharmacology of Cilest, Prefest (estradiol/norgestimate)
See estradiol combos for further details
Mechanism of action
Estradiol: endogenous estrogen; reduces the release of gonadotropin-releasing hormone from hypothalamus, reduces release of LH and FSH from pituitary gland; increases synthesis of DNA, RNA, and various proteins in target tissues. Estrogen replacement reduces elevated levels of estrogen and progesterone LH and FSH in postmenopausal women
Norgestimate: Progestin; inhibits secretion of gonadotropins from pituitary gland; prevents follicular maturation and ovulation, stimulates growth of mamary tissues
