Let's talk about the route someone can get estrogen. We just talked about endogenous estrogen,
now we're talking about if we're giving you exogenous or estrogen as a medication. You can take it
orally, transdermally, intravaginally (yeah that's kind of personal), or you can give it IV or IM
but they rarely do that. So, oral, transdermal, and intravaginal are going to be the most used
routes. So let's break these down a little bit more. Now you can give it as an emulsion. You take
it every morning, you put it on the tops of your thighs and the backs of your calves. It's kind
of odd, isn't it? But it's very specific, you put it on the tops of your thighs and the back of your
calves. Now if you have a spray, you put it on your inner forearm and you have to let it dry for
2 minutes. So it's really important that the patient be patient when they're using a spray because
they've got to put it on their inner forearm and wait a full 2 minutes for it to dry before they
get dressed. Now if you have a gel, they put it on 1 arm from shoulder to wrist. Okay, it's very
specific. You don't just put this wherever you feel like it, but they've done research and proven
these are the most effective places to put it. Now patches need to go on intact skin. Okay, that
applies to any type of patch. Right? Any type of medication we're delivering through a transdermal
patch needs to go on intact skin and you don't want to put it on your breast or your waistline.
So the 2 places you don't put it are your breast or your waistline. Okay, so let's roll through
that again. Got some pretty weird places. Emulsion: Thighs and backs of calves. Spray: Inner
forearm. Gel: Arm from shoulder to wrist. Patches: Not on the breast and not on the waistline.
Now tablets, you take 1 tablet daily for the first 2 weeks and then you can take 1 biweekly,
every other week. Creams go on a much more personal spot, they go very high into the vagina
and you put them in at bedtime. Vaginal rings go in the vagina but they also stay in place for
3 months. Now, a lot of women for convenience prefer to have something that they can just have in
place for 3 months. So, you really want to have a conversation with your patients about what seems
to be the most appropriate route for them to remember to do this consistently. Some people
don't want to be bothered with the forearm, the hip, the waist, the thigh, all that kind of stuff
and they just want to go straight for a vaginal ring. But involve the patient in decision-making.
Help them determine what is most comfortable for them and their preference. Now there are
some adverse effects of taking estrogen as an exogenous estrogen or as a medication. Nausea is the
most common effect and this may involve the healthcare provider and the nurse and the patient having
lots of conversation until they can find adjustments for this effect. Now there's also an increased
risk for endometrial carcinoma if you use estrogen for a long time without progestin. So a lot of
times you recommend that these be used together to decrease that risk for endometrial carcinoma.
Now if a woman is pregnant and they're exposed a high-dose exposure to a maturing male fetus, that
can impact the fetus' development of testicles. So just like testosterone, you don't want a female
fetus to be exposed to testosterone, you don't want a male fetus to be exposed to estrogen,
can really kind of wreak havoc in their development. So, we're thinking about, ooohhh, things
that we want to avoid and estrogen. Nausea is uncomfortable, it's not going to really cause
significant harm but nobody wants to be nauseated. So work with your patients in problem solving
kind of walking through that. Now you want to make sure that estrogen you consider giving
with progestin to decrease the risk of endometrial carcinoma and you want to be absolutely
sure that a pregnant woman is not exposed to estrogen if they have a male fetus. So, remember
all the different routes and ways that we give estrogen, there's risk for exposing someone else
to it so you want to be ultra careful with not exposing someone else. Now, when it comes to estrogen
in women of age or of experience, people who are older than 65 years, they have an increased
risk for a DVT. Now DVT stands for deep vein thrombosis and those usually start in the calf.
This means they are big clot that starts deep in the veins and that's what deep vein thrombosis
means. Now when you have a DVT, that little clot can break off and travel through the rest of
your body which can end up being a heart attack or a stroke. So, estrogen particularly for women who
are older, older than 65 years of age, increases their risk for dementia and for DVT and stroke.
So we found in some of the earlier studies once they divided people out by age groups, we found that
the older women receiving estrogen are the ones that had these risk factors. Now, there is an
increased risk of endometrial cancer if you don't have progestin with estrogen that's why
combination therapy that includes estrogen and progestin will not increase the risk. So you want to
have that conversation with your patients when you're educating them about the options.