Estradiol is a hormone made naturally in the human body by the ovaries. It is incredibly important in the regulation of the menstrual cycle, cardiovascular system, neurologic system, skeletal system, vascular system, and many more. Estradiol is the most potent and most abundant estrogen (E2) during a woman's reproductive years. There are four different kinds of estrogen: estrone (E1), estradiol (E2), estriol (E3), and estetrol (E4).
When women enter menopause, estrogen synthesis significantly decreases due to lower-functioning ovaries. The decrease in estrogen is the reason most women have post-menopausal symptoms. Post-menopausal symptoms include, but are not limited to, hot flashes, vaginal dryness, vaginal itchiness, dysuria, and dyspareunia. These symptoms can be very discomforting to patients and can affect the quality of life, sleep, mood, interpersonal relationships, daily activities, and sexual function. When the ovaries no longer synthesize estradiol, it can then get synthesized by several extragonadal sites. These sites include but are not limited to, adipose tissue, bones, brain, and smooth muscle cells in vascular endothelium.
Before women enter menopause, estradiol protects women from cardiovascular disease due to increased regulation of cholesterol and triglyceride metabolism, thus decreasing the risk for atherosclerotic heart disease. To combat these symptoms, estradiol can be taken supplementally for the management and treatment of postmenopausal symptoms and for women who have had hysterectomies, salpingo-oophorectomy, or unilateral salpingo-oophorectomy. Estrogen is also useful in female patients with hypoestrogenism due to castration, hypogonadism, or primary ovarian failure such as Turner syndrome.
The majority of studies find that postmenopausal symptoms experience significant improvement with the use of estradiol hormone replacement therapy (HRT). Also, research has shown that estradiol can decrease stress by reducing the release of cortisol in response to a physical stressor. Estradiol increases the amount of corticosteroid-binding globulin (CBG), thus reducing the free cortisol levels circulating in the body, responding to stress. Less cortisol can act on the body, including areas in the brain that are integral in the stress response.
Estrogen formulations have also served as an off label treatment option for male-to-female transgender patients. However, the levels of blood estrogen levels are closely monitored to avoid complications of the treatment.
Estrogen has a significant role in bone health. Women in postmenopausal age develop osteoporosis due to decreased levels of estrogen. Estrogen derived formulations such as raloxifene have received approval for osteoporosis prevention and treatment in a selected patient population.
Estrone is converted to estradiol in the granulosa cells of the ovary by the enzyme 17-beta-hydroxysteroid dehydrogenase (17-beta-HSD). The aromatization of testosterone synthesizes estradiol. Estradiol is a steroid hormone and, therefore, can easily cross the cell membrane. Estrone binds to its specific intracellular receptor and regulates DNA transcription for protein formation. Estrone exerts its effects on the menstrual cycle, breasts, ovaries, brain, musculoskeletal system, cardiovascular system, and more. Estrone is thought to affect the gene transcription of other genes that do not have estrogen-responsive elements.
Hormone replacement therapy (HRT) is normally used for a short period in post-menopausal women. The routes of admission can be transdermal (cream and patches), intramuscular, or oral. Estradiol therapy usually comes in two forms: as a vaginal cream or as a capsule. Studies have found that the use of estradiol vaginal cream twice a week has significantly reduced vaginal dryness and dyspareunia compared to placebo pills. However, there was no significant improvement between estradiol vaginal cream and placebo therapy in vaginal irritation, itchiness, and dysuria.
There is still research being done to determine the efficacy of vaginal estradiol capsules. Capsules currently undergoing clinical trials hope to relieve post-menopausal symptoms with very little systemic estradiol exposure. The capsules are expected to be less messy and more patient-friendly than creams and tablets.
In one clinical trial, capsules improved vaginal dryness and dyspareunia. Also, capsules increased the percent of superficial and intermediate cells in the vagina, thus improving vaginal physiology.
Sustained-release estradiol vaginal rings are becoming more popular in research. Rings can be effective for up to 90 days and can be easily inserted and removed by patients. The ring may be beneficial to women who choose not to apply vaginal estrogen creams.
Adverse effects are generally uncommon; however, there have been reports of the following:
Cardiovascular: edema, hypertension, thrombophlebitis, retinal thrombosis.
Central Nervous System: headache, depression, pain, dizziness anxiety, migraine, nipple pain
Respiratory: nasopharyngitis, flu-like symptoms, sinusitis, upper respiratory tract infection, headache, bronchitis, sinus congestion, pharyngitis, asthma exacerbation, cough
Dermatologic: skin rash, pruritus, erythema multiforme, erythema nodosum, urticaria
Skeletal: arthralgia, weakness, back and neck pain, limb pain, myalgia, leg cramps
Endocrine: weight gain or loss, hot flash, libido changes, hirsutism, menstrual changes, porphyria exacerbation, fluid retention, hypocalcemia, elevated triglycerides, galactorrhea
Gastrointestinal: Abdominal pain, constipation, heartburn, flatulence, bloating, nausea, vomiting, diarrhea, pancreatitis, gastroenteritis, carbohydrate intolerance
Hypersensitivity: anaphylaxis, angioedema, hypersensitivity reactions
Hepatic: Hepatic hemangioma exacerbation, jaundice
Ophthalmic: conjunctivitis, steepening of the cornea, contact lens intolerance
Infections: fungal and other infections
Otic: Otitis media
The United States Food and Drug Administration (FDA) Boxed Warnings:
Women who take estrogen plus progestin therapy are at increased risk for breast cancer.
Women with increased exposure to estrogen are at risk for endometrial cancer. Estrogen stimulates endometrial growth, which results in endometrial hyperplasia, which could result in endometrial cancer.
Other risk factors to increased exposure to estrogen HRT are cerebrovascular events, coronary artery disease, and venous thromboembolism. There have also been reports of ovarian cancer with estrogen use.
Women who are at increased risk of breast cancer or endometrial cancer should not begin Estradiol therapy.
Overweight women with exposure to increased levels of estradiol in their lifetime should not add supplemental estradiol to their post-menopause regimen. Adipose tissue carries an increased level of estrogen. Therefore overweight women are at risk of increased exposure compared to average-weight and underweight women.
Women who have angioedema or anaphylactic reaction to estradiol or its components, abnormal genital bleeding, blood clotting disorders such as deep venous thrombosis or pulmonary thromboembolism, cardiovascular disease (stroke or myocardial infarction), protein C or S or antithrombin deficiency as well as thrombophilic disorders, or pregnancy are listed as a contraindication to estradiol treatment.
Estradiol HRT can increase a patient's risk of cardiovascular disease, DVT, and stroke and, therefore, is not a viable option in at-risk patients.
Women who are at risk can consider other alternatives such as laser therapy, lubricants, dilators, and even physical therapy to strengthen pelvic floor muscles if patients are complaining of dyspareunia.
There is not much monitoring for estradiol therapy for women who choose to use vaginal creams or capsules. However, women who choose to use the high-dose estradiol vaginal ring should understand the risks due to increased estradiol in the systemic circulation.
If a woman is at risk for developing endometrial cancer, and she chooses to undergo estradiol HRT, she should continually undergo endometrial monitoring.
Levels of estrogen are monitored in transgender patients and maintained according to Endocrine Society guidelines.
There have not been any published reports of Estradiol toxicity in humans. However, one study measured estradiol toxicity in amphibians' embryos. Research determined that estradiol toxicity occurred when the amount of estradiol severely outnumbered estradiol receptors; this was an incredibly high number that would be highly unlikely in a human population. Estradiol excess may lead to side effects and complications noted in the adverse effect section.
Educating women about the physiology behind post-menopausal symptoms is essential so that they can understand the changes that occur with decreased estrogen. Many women are embarrassed and shy to talk about this topic. Primary care physicians and obstetricians-gynecologists should ask and encourage women to talk about their symptoms. Providers will better be able to offer advice, tips, and education, as indicated.
When initiating or considering initiating estradiol therapy, an interprofessional healthcare team approach is the optimal path to follow. The family clinician and gynecologist should coordinate their efforts. A pharmacist should review the patient's medication record, verify that dosing is appropriate, and counsel the patient regarding potential adverse effects so that they can report these to the prescriber should they present. Nursing must also assist the team by counseling the patient so they are aware of possible adverse events. They can also monitor the patient on follow-up visits, as well as determine how effectively the patient responds to treatment. This interprofessional team paradigm optimizes treatment and avoids adverse events, thereby improving patient outcomes. [Level 5]
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