Exogenous Estrogen: Routes, Adverse Effects and Risks (Nursing)

00:00 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.

01:34 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.

01:55 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.

02:41 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.

03:20 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.

04:39 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.

05:04 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.