1.1 Treatment of Moderate to Severe Vasomotor Symptoms Due to Menopause

1.2 Treatment of Moderate to Severe Symptoms of Vulvar and Vaginal Atrophy Due to Menopause

1.3 Treatment of Hypoestrogenism Due to Hypogonadism, Castration, or Primary Ovarian Failure

1.4 Prevention of Postmenopausal Osteoporosis

2.1 Treatment of Moderate to Severe Vasomotor Symptoms Due to Menopause

Start therapy with estradiol transdermal system (twice-weekly) 0.0375 mg per day applied to the skin twice weekly. Make dosage adjustments based on the clinical response. Initiate estradiol transdermal system (twice-weekly) at once in a woman not currently taking oral estrogens or in a woman switching from another estradiol transdermal therapy. In women who are currently taking oral estrogens, initiate treatment with estradiol transdermal system (twice-weekly) 1 week after withdrawal of oral hormone therapy, or sooner if menopausal symptoms reappear in less than 1 week. Attempts to taper or discontinue estradiol transdermal system (twice-weekly) at 3 to 6-month intervals.

Give estradiol transdermal system (twice-weekly) continuously in a woman who does not have an intact uterus. In a woman with an intact uterus, give estradiol transdermal system (twice-weekly) on a cyclic schedule (for example, 3 weeks on estradiol transdermal system (twice-weekly) followed by 1 week off estradiol transdermal system (twice-weekly)).

2.2 Treatment of Moderate to Severe Symptoms of Vulvar and Vaginal Atrophy Due to Menopause

Start therapy with estradiol transdermal system (twice-weekly) 0.0375 mg per day applied to the skin twice weekly. Dosage adjustment should be guided by the clinical response. Attempts to taper or discontinue estradiol transdermal system (twice-weekly) at 3 to 6-month intervals.

In women not currently taking oral estrogens or in women switching from another estradiol transdermal therapy, treatment with estradiol transdermal system (twice-weekly) may be initiated at once. In women who are currently taking oral estrogens, initiate treatment with estradiol transdermal system (twice-weekly) 1 week after withdrawal of oral hormone therapy, or sooner if menopausal symptoms reappear in less than 1 week.

Give estradiol transdermal system (twice-weekly) continuously in a woman who does not have an intact uterus. In a woman with an intact uterus, give estradiol transdermal system (twice-weekly) on a cyclic schedule (for example, 3 weeks on estradiol transdermal system (twice-weekly) followed by 1 week off estradiol transdermal system (twice-weekly)).

2.3 Hypoestrogenism Due to Hypogonadism, Castration, or Primary Ovarian Failure

2.4 Prevention of Postmenopausal Osteoporosis

Start therapy with estradiol transdermal system (twice-weekly) 0.025 mg per day applied to the skin twice weekly.

In women not currently taking oral estrogens or in women switching from another estradiol transdermal therapy, treatment with estradiol transdermal system (twice-weekly) may be initiated at once. In women who are currently taking oral estrogens, initiate treatment with estradiol transdermal system (twice-weekly) 1 week after withdrawal of oral hormone therapy, or sooner if menopausal symptoms reappear in less than 1 week.

Estradiol transdermal system (twice-weekly) may be given continuously in a woman who does not have an intact uterus. In a woman with an intact uterus, estradiol transdermal system (twice-weekly) may be given on a cyclic schedule (for example, 3 weeks on estradiol transdermal system (twice-weekly) followed by 1 week off estradiol transdermal system (twice-weekly)).

2.5 Application Instructions

Place the adhesive side of estradiol transdermal system (twice-weekly) on a clean, dry area of the trunk of the body (including the abdomen or buttocks). Do not apply estradiol transdermal system (twice-weekly) to the breasts.

Replace estradiol transdermal system (twice-weekly) twice weekly. Rotate the sites of application, with an interval of at least 1 week allowed between applications to a particular site. Select an area that is not oily, damaged, or irritated. Avoid the waistline, since tight clothing may rub the system off. Apply the system immediately after opening the pouch and removing the oversized protective liner. Press the system firmly in place with the palm of the hand for about 10 seconds, making sure there is good contact, especially around the edges.

In the event that a system falls off, reapply the same system or apply a new system to another location. In either case, continue the original treatment schedule. If a woman has forgotten to apply estradiol transdermal system (twice-weekly), have her apply a new system as soon as possible. Apply the new system on the original treatment schedule. The interruption of treatment in women taking estradiol transdermal system (twice-weekly) might increase the likelihood of breakthrough bleeding, spotting and recurrence of symptoms.

5.1 Cardiovascular Disorders

Increased risks of stroke and DVT are reported with estrogen-alone therapy. Increased risks of PE, DVT, stroke, and MI are reported with estrogen plus progestin therapy. Immediately discontinue estrogen with or without progestogen therapy if any of these occur or are suspected.

Manage appropriately any risk factors for arterial vascular disease (for example, hypertension, diabetes mellitus, tobacco use, hypercholesterolemia, and obesity) and/or venous thromboembolism (VTE) (for example, personal history or family history of VTE, obesity, and systemic lupus erythematosus).

5.2 Malignant Neoplasms

5.3 Probable Dementia

In the WHI Memory Study (WHIMS) estrogen-alone ancillary study, a population of 2,947 hysterectomized women 65 to 79 years of age was randomized to daily CE (0.625 mg)-alone or placebo.

After an average follow-up of 5.2 years, 28 women in the estrogen-alone group and 19 women in the placebo group were diagnosed with probable dementia. The relative risk of probable dementia for CE-alone versus placebo was 1.49 (95% CI, 0.83 to 2.66). The absolute risk of probable dementia for CE-alone versus placebo was 37 versus 25 cases per 10,000 women-years8   [see Use in Specific Populations (8.5), and Clinical Studies (14.4)].

In the WHIMS estrogen plus progestin ancillary study of WHI, a population of 4,532 postmenopausal women 65 to 79 years was randomized to daily CE (0.625 mg) plus MPA (2.5 mg) or placebo.

After an average follow-up of 4 years, 40 women in the CE plus MPA group and 21 women in the placebo group were diagnosed with probable dementia. The relative risk of probable dementia for CE plus MPA versus placebo was 2.05 (95% CI, 1.21 to 3.48). The absolute risk of probable dementia for CE plus MPA versus placebo was 45 versus 22 cases per 10,000 women-years8   [see Use in Specific Populations (8.5), and Clinical Studies (14.4)].

When data from the two populations in the WHIMS estrogen-alone and estrogen plus progestin ancillary studies were pooled as planned in the WHIMS protocol, the reported overall relative risk for probable dementia was 1.76 (95% CI, 1.19 to 2.60). Since both ancillary studies were conducted in women aged 65 to 79 years of age, it is unknown whether these findings apply to younger postmenopausal women8   [see Use in Specific Populations (8.5), and Clinical Studies (14.4)].

5.4 Gallbladder Disease

A 2- to 4-fold increase in the risk of gallbladder disease requiring surgery in postmenopausal women receiving estrogens has been reported.

5.5 Hypercalcemia

Estrogen administration may lead to severe hypercalcemia in women with breast cancer and bone metastases. Discontinue estrogens, including estradiol transdermal system (twice-weekly), if hypercalcemia occurs, and take appropriate measures to reduce the serum calcium level.

5.6 Visual Abnormalities

Retinal vascular thrombosis has been reported in women receiving estrogens. Discontinue estradiol transdermal (twice-weekly) pending examination if there is sudden partial or complete loss of vision, or a sudden onset of proptosis, diplopia, or migraine. Permanently discontinue estrogens, including estradiol transdermal system (twice-weekly), if examination reveals papilledema or retinal vascular lesions.

5.7 Addition of a Progestogen When a Woman Has Not Had a Hysterectomy

Studies of the addition of a progestogen for 10 or more days of a cycle of estrogen administration, or daily with estrogen in a continuous regimen, have reported a lowered incidence of endometrial hyperplasia than would be induced by estrogen treatment alone. Endometrial hyperplasia may be a precursor to endometrial cancer.

There are, however, possible risks that may be associated with the use of progestogens with estrogens compared to estrogen-alone regimens. These include an increased risk of breast cancer.

5.8 Elevated Blood Pressure

In a small number of case reports, substantial increases in blood pressure have been attributed to idiosyncratic reactions to estrogens. In a large, randomized, placebo-controlled clinical trial, a generalized effect of estrogens on blood pressure was not seen.

5.9 Exacerbation of Hypertriglyceridemia

In women with preexisting hypertriglyceridemia, estrogen therapy may be associated with elevations of plasma triglycerides leading to pancreatitis. Discontinue estradiol transdermal (twice-weekly) if pancreatitis occurs.

5.10 Hepatic Impairment and/or Past History of Cholestatic Jaundice

Estrogens may be poorly metabolized in women with hepatic impairment. Exercise caution in any woman with a history of cholestatic jaundice associated with past estrogen use or with pregnancy. In the case of recurrence of cholestatic jaundice, discontinue estradiol transdermal system (twice-weekly).

5.11 Exacerbation of Hypothyroidism

Estrogen administration leads to increased thyroid-binding globulin (TBG) levels. Women with normal thyroid function can compensate for the increased TBG by making more thyroid hormone, thus maintaining free T4 and T3 serum concentrations in the normal range. Women dependent on thyroid hormone replacement therapy who are also receiving estrogens may require increased doses of their thyroid replacement therapy. Monitor thyroid function in these women during treatment with estradiol transdermal system (twice-weekly) to maintain their free thyroid hormone levels in an acceptable range.

5.12 Fluid Retention

Estrogens may cause some degree of fluid retention. Monitor any woman with a condition(s) that might predispose her to fluid retention, such as cardiac or renal impairment. Discontinue estrogen-alone therapy, including estradiol transdermal system (twice-weekly), with evidence of medically concerning fluid retention.

5.13 Hypocalcemia

Estrogen-induced hypocalcemia may occur in women with hypoparathyroidism. Consider whether the benefits of estrogen therapy, including estradiol transdermal system (twice-weekly), outweigh the risks in such women.

5.14 Exacerbation of Endometriosis

A few cases of malignant transformation of residual endometrial implants have been reported in women treated post-hysterectomy with estrogen-alone therapy. Consider the addition of progestogen therapy for women known to have residual endometriosis post-hysterectomy.

5.15 Severe Anaphylactic/Anaphylactoid Reactions and Angioedema

A few cases of anaphylactic/anaphylactoid reactions are reported in the postmarketing use of estradiol transdermal system (twice-weekly). Involvement of skin (hives, pruritus, swollen lips-tongue-face) and either respiratory tract (respiratory compromise) or gastrointestinal tract (abdominal pain, vomiting) are noted.

Angioedema involving eye/eyelid, face, larynx, pharynx, tongue and extremity (hands, legs, ankles, and fingers) with or without urticaria requiring medical intervention are reported in the postmarketing use of estradiol transdermal system (twice-weekly). Angioedema involving the tongue, glottis, or larynx, may result in airway obstruction. Do not give estradiol transdermal system (twice-weekly) to any woman who develops angioedema during treatment with estradiol transdermal system (twice-weekly).

Exogenous estrogens may exacerbate symptoms of angioedema in women with hereditary angioedema. Consider whether the benefits of estrogen therapy outweigh the risks in such women.

5.16 Exacerbation of Other Conditions

Estrogen therapy, including estradiol transdermal system (twice-weekly), may cause an exacerbation of asthma, diabetes mellitus, epilepsy, migraines, porphyria, systemic lupus erythematosus, and hepatic hemangiomas. Consider whether the benefits of estrogen therapy outweigh the risks in such women.

5.17 Laboratory Tests

Serum follicle-stimulating hormone (FSH) and estradiol levels have not been shown to be useful in the management of moderate to severe vasomotor symptoms and moderate to severe symptoms of vulvar and vaginal atrophy.

Laboratory parameters may be useful in guiding dosage for the treatment of hypoestrogenism due to hypogonadism, castration and primary ovarian failure.

5.18 Drug-Laboratory Test Interactions

1.

Accelerated prothrombin time, partial thromboplastin time, and platelet aggregation time; increased platelet count; increased factors II, VII antigen, VIII antigen, VIII coagulant activity, IX, X, XII, VII-X complex, II-VII-X complex; and beta-thromboglobulin; decreased levels of anti-factor Xa and antithrombin III; decreased antithrombin III activity; increased levels of fibrinogen and fibrinogen activity; increased plasminogen antigen and activity.

2.

Increased thyroid-binding globulin (TBG) leading to increased circulating total thyroid hormone levels, as measured by protein-bound iodine (PBI), T4 levels (by column or by radioimmunoassay) or T3 levels by radioimmunoassay. T3 resin uptake is decreased, reflecting the elevated TBG. Free T4 and free T3 concentrations are unaltered. Women on thyroid replacement therapy may require higher doses of thyroid hormone.

3.

Other binding proteins may be elevated in serum, for example, corticosteroid-binding globulin (CBG), sex hormone-binding globulin (SHBG), leading to increased total circulating corticosteroids and sex steroids, respectively. Free hormone concentrations, such as testosterone and estradiol, may be decreased. Other plasma proteins may be increased (angiotensinogen/renin substrate, alpha-1-antitrypsin, ceruloplasmin).

4.

Increased plasma high-density lipoprotein (HDL) and HDL2 cholesterol subfraction concentrations, reduced low-density lipoprotein (LDL) cholesterol concentration, and increased triglycerides levels.

5.

Impaired glucose tolerance.

6.1 Clinical Trials Experience

Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice.

There were no clinical trials conducted with the revised formulation of estradiol transdermal system (twice-weekly). The revised formulation of estradiol transdermal system (twice-weekly) is bioequivalent to the original formulation of estradiol transdermal system (twice-weekly). The following adverse reactions have been reported with the original formulation of estradiol transdermal system (twice-weekly) therapy:

6.2 Postmarketing Experience

The following additional adverse reactions have been identified during post-approval use of estradiol transdermal system (twice-weekly). Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure.

Genitourinary System

Vaginal hemorrhage and abnormal withdrawal bleeding or flow, breakthrough bleeding, spotting, uterine leiomyomata, vaginitis, vaginal discharge, ovarian cancer, endometrial hyperplasia, dysmenorrhea.

Breast

Enlargement, pain, nipple discharge, fibrocystic breast changes, breast cancer.

Cardiovascular

Deep venous thrombosis, pulmonary embolism, thrombophlebitis.

Gastrointestinal

Nausea, vomiting, abdominal cramps, bloating, cholelithiasis, liver function tests abnormal, diarrhea.

Skin

Application site reactions include localized bleeding, bruising, burning, discomfort, dryness, eczema, edema, erythema, erythema multiforme, erythema nodosum, inflammation, irritation, pain, papules and vesicles. Other skin reactions include paresthesia, skin discoloration, skin pigmentation, urticaria, swelling, loss of scalp hair, hirsutism, pruritus, and rash.

Eyes

Intolerance to contact lenses.

Central Nervous System

Migraine, dizziness, chorea, nervousness, affect liability, irritability.

Miscellaneous

Decrease in weight, reduced carbohydrate tolerance, edema, arthralgias, leg cramps, changes in libido, purpura, hypersensitivity, anaphylactic reaction, anaphylactoid reaction, angioedema.

8.1 Pregnancy

8.2 Lactation

8.4 Pediatric Use

Estradiol transdermal system (twice-weekly) is not indicated for use in pediatric patients. Clinical studies have not been conducted in the pediatric population.

If estrogen is administered to patients whose bone growth is not complete, periodic monitoring of bone maturation and effects on epiphyseal centers is recommended during estrogen administration.

8.5 Geriatric Use

There have not been sufficient numbers of geriatric women involved in clinical studies utilizing estradiol transdermal system (twice-weekly) to determine whether those over 65 years of age differ from younger subjects in their response to estradiol transdermal system (twice-weekly).

12.1 Mechanism of Action

Endogenous estrogens are largely responsible for the development and maintenance of the female reproductive system and secondary sexual characteristics. Although circulating estrogens exist in a dynamic equilibrium of metabolic interconversions, estradiol is the principal intracellular human estrogen and is substantially more potent than its metabolites, estrone and estriol, at the receptor level.

The primary source of estrogen in normally cycling adult women is the ovarian follicle, which secretes 70 to 500 mcg of estradiol daily, depending on the phase of the menstrual cycle. After menopause, most endogenous estrogen is produced by conversion of androstenedione, secreted by the adrenal cortex, to estrone in the peripheral tissues. Thus, estrone and the sulfate conjugated form, estrone sulfate, are the most abundant circulating estrogens in postmenopausal women.

Estrogens act through binding to nuclear receptors in estrogen-responsive tissues. To date, 2 estrogen receptors have been identified. These vary in proportion from tissue to tissue.

Circulating estrogens modulate the pituitary secretion of the gonadotropins, luteinizing hormone (LH) and follicle stimulating hormone (FSH) through a negative feedback mechanism. Estrogens act to reduce the elevated levels of these hormones seen in postmenopausal women.

12.2 Pharmacodynamics

Generally, a serum estrogen concentration does not predict an individual woman’s therapeutic response to estradiol transdermal system (twice-weekly) nor her risk for adverse outcomes. Likewise, exposure comparisons across different estrogen products to infer efficacy or safety for the individual woman may not be valid.

12.3 Pharmacokinetics

Absorption

In a multiple-dose study consisting of 3 consecutive system applications of the original formulation of estradiol transdermal system (twice-weekly) which was conducted in 17 healthy, postmenopausal women, blood levels of estradiol and estrone were compared following application of these units to sites on the abdomen and buttocks in a crossover fashion. Systems that deliver nominal estradiol doses of approximately 0.0375 mg per day and 0.1 mg per day were applied to abdominal application sites while the 0.1 mg per day doses were also applied to sites on the buttocks. These systems increased estradiol levels above baseline within 4 hours and maintained respective mean levels of 25 and 79 pg/mL above baseline following application to the abdomen; slightly higher mean levels of 88 pg/mL above baseline were observed following application to the buttocks. At the same time, increases in estrone plasma concentrations averaged about 12 and 50 pg/mL, respectively, following application to the abdomen and 61 pg/mL for the buttocks. While plasma concentrations of estradiol and estrone remained slightly above baseline at 12 hours following removal of the systems in this study, results from another study show these levels to return to baseline values within 24 hours following removal of the systems.

Figure 1 illustrates the mean plasma concentrations of estradiol at steady-state during application of these patches at 4 different dosages.

Figure 1. Steady-State Estradiol Plasma Concentrations for Systems Applied to the Abdomen Nonbaseline-corrected Levels

The corresponding pharmacokinetic parameters are summarized in Table 2.

Table 2. Steady-State Estradiol Pharmacokinetic Parameters for Systems Applied to the Abdomen (mean ± standard deviation) Nonbaseline-corrected Data*

* Mean baseline estradiol concentration = 11.7 pg/mL. † Peak plasma concentration. ‡ Average plasma concentration. § Minimum plasma concentration at 84 hr. ¶ Measured over 80 hr. # Applied to the buttocks.
Dosage	Cmax†	Cavg‡	Cmin (84 hr)§
(mg/day)	(pg/mL)	(pg/mL)	(pg/mL)
0.0375	46 ± 16	34 ± 10	30 ± 10
0.05	83 ± 41	57 ± 23¶	41 ± 11¶
0.075	99 ± 35	72 ± 24	60 ± 24
0.1	133 ± 51	89 ± 38	90 ± 44
0.1#	145 ± 71	104 ± 52	85 ± 47

Estradiol transdermal system (twice-weekly), the revised formulation with smaller system sizes, was shown to be bioequivalent to the original formulation of estradiol transdermal system (twice-weekly) used in the clinical trials.

13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility

Long-term, continuous administration of natural and synthetic estrogens in certain animal species increases the frequency of carcinomas of the breast, uterus, cervix, vagina, testis, and liver.

14.1 Effects on Vasomotor Symptoms in Postmenopausal Women

In a pharmacokinetic study, the revised formulation of estradiol transdermal system (twice-weekly) was shown to be bioequivalent to the original formulation of estradiol transdermal system (twice-weekly). In 2 controlled clinical trials with the original formulation of estradiol transdermal system (twice-weekly), of 356 women, the 0.075 and 0.1 mg doses were superior to placebo in relieving vasomotor symptoms at Week 4, and maintained efficacy through Weeks 8 and 12 of treatment. In this original study, the 0.0375 and 0.05 mg doses, however, did not differ from placebo until approximately Week 6, therefore, an additional 12-week, placebo-controlled study in 255 women was performed with estradiol transdermal system (twice-weekly) to establish the efficacy of the lowest dose of 0.0375 mg. The baseline mean daily number of hot flushes in these 255 women was 11.5. Results at Weeks 4, 8, and 12 of treatment are shown in Figure 2.

The 0.0375 mg dose was superior to placebo in reducing both the frequency and severity of vasomotor symptoms at Week 4 and maintained efficacy through Weeks 8 and 12 of treatment. All doses of estradiol transdermal system (twice-weekly) (0.0375 mg, 0.05 mg, 0.075 mg, and 0.1 mg) are effective for the control of vasomotor symptoms.

14.2 Effects on Bone Mineral Density in Postmenopausal Women

Efficacy and safety of estradiol transdermal system (twice-weekly) in the prevention of postmenopausal osteoporosis have been studied in a 2-year, double-blind, randomized, placebo-controlled, parallel-group study. A total of 261 hysterectomized (161) and non-hysterectomized (100), surgically or naturally menopausal women (within 5 years of menopause), with no evidence of osteoporosis (lumbar spine bone mineral density within 2 standard deviations of average peak bone mass, i.e., at least 0.827 g/cm2) were enrolled in this study; 194 women were randomized to 1 of the 4 doses of estradiol transdermal system (twice-weekly) (0.1, 0.05, 0.0375, or 0.025 mg/day) and 67 patients to placebo. Over 2 years, study systems were applied to the buttock or the abdomen twice a week. Non-hysterectomized women received oral medroxyprogesterone acetate (2.5 mg/day) throughout the study.

Figure 2. Mean (SD) Change from Baseline in Mean Daily Number of Flushes for Estradiol Transdermal System 0.0375 mg/day (Twice-Weekly) Versus Placebo in a 12-week Trial

The study population comprised naturally (82%) or surgically (18%) menopausal, hysterectomized (61%) or non-hysterectomized (39%) women with a mean age of 52 years (range 27 to 62 years); the mean duration of menopause was 31.7 months (range 2 to 72 months). Two hundred thirty-two (89%) of randomized women (173 on active drug, 59 on placebo) contributed data to the analysis of percent change from baseline in bone mineral density (BMD) of the AP lumbar spine, the primary efficacy variable. Women were given supplemental dietary calcium (1000 mg elemental calcium/day) but no supplemental vitamin D. There was an increase in BMD of the AP lumbar spine in all estradiol transdermal system (twice-weekly) dose groups; in contrast to this, a decrease in AP lumbar spine BMD was observed in placebo patients. All estradiol transdermal system (twice-weekly) doses were significantly superior to placebo (p < 0.05) at all time points with the exception of estradiol transdermal system (twice-weekly) 0.05 mg/day at 6 months. The highest dose of estradiol transdermal system (twice-weekly) was superior to the 3 lower doses. There were no statistically significant differences in pairwise comparisons among the 3 lower doses (see Figure 3).

Figure 3. Bone Mineral Density-AP Lumbar Spine Least Squares Means of Percentage Change from Baseline All Randomized Patients with at Least One Post-baseline Assessment Available with Last Post-baseline Observation Carried Forward

Analysis of percent change from baseline in femoral neck BMD, a secondary efficacy outcome variable, showed qualitatively similar results; all doses of estradiol transdermal system (twice-weekly) were significantly superior to placebo (p < 0.05) at 24 months. The highest estradiol transdermal system (twice-weekly) dose was superior to placebo at all time points. A mixture of significant and nonsignificant results were obtained for the lower dose groups at earlier time points. The highest estradiol transdermal system (twice-weekly) dose was superior to the 3 lower doses, and there were no significant differences among the 3 lower doses at this skeletal site (see Figure 4).

Figure 4. Bone Mineral Density-Femoral Neck Least Squares Means of Percentage Change from Baseline All Randomized Patients with at Least One Post-baseline Assessment Available with Last Post-baseline Observation Carried Forward

The mean serum osteocalcin (a marker of bone formation) and urinary excretion of cross-link N-telopeptides of Type 1 collagen (a marker of bone resorption) decreased numerically in most of the active treatment groups relative to baseline. However, the decreases in both markers were inconsistent across treatment groups and the differences between active treatment groups and placebo were not statistically significant.

14.3 Women’s Health Initiative Studies

The WHI enrolled approximately 27,000 predominantly healthy postmenopausal women in two substudies to assess the risks and benefits of daily oral CE (0.625 mg)-alone or in combination with the MPA (2.5 mg) compared to placebo in the prevention of certain chronic diseases. The primary endpoint was the incidence of CHD (defined as nonfatal MI, silent MI, and CHD death), with invasive breast cancer as the primary adverse outcome. A “global index” included the earliest occurrence of CHD, invasive breast cancer, stroke, PE, endometrial cancer (only in the CE plus MPA substudy), colorectal cancer, hip fracture, or death due to other causes. These substudies did not evaluate the effects of CE-alone or CE plus MPA on menopausal symptoms.

14.4 Women’s Health Initiative Memory Study

The WHIMS estrogen-alone ancillary study of WHI enrolled 2,947 predominantly healthy hysterectomized postmenopausal women 65 to 79 years of age and older (45% were age 65 to 69 years of age; 36% were 70 to 74 years of age; 19% were 75 years of age and older) to evaluate the effects of daily CE (0.625 mg)-alone on the incidence of probable dementia (primary outcome) compared to placebo.

After an average follow-up of 5.2 years, the relative risk of probable dementia for CE-alone versus placebo was 1.49 (95% CI, 0.83 to 2.66). The absolute risk of probable dementia for CE-alone versus placebo was 37 versus 25 cases per 10,000 women-years. Probable dementia as defined in this study included Alzheimer’s disease (AD), vascular dementia (VaD), and mixed types (having features of both AD and VaD). The most common classification of probable dementia in the treatment group and the placebo group was AD. Since the ancillary study was conducted in women 65 to 79 years of age, it is unknown whether these findings apply to younger postmenopausal women [see Warnings and Precautions (5.3) and Use in Specific Populations (8.5)].

The WHIMS estrogen plus progestin ancillary study enrolled 4,532 predominantly healthy postmenopausal women 65 years of age and older (47% were age 65 to 69 years of age; 35% were 70 to 74 years of age; 18% were 75 years of age and older) to evaluate the effects of daily CE (0.625 mg) plus MPA (2.5 mg) on the incidence of probable dementia (primary outcome) compared to placebo.

After an average follow-up of 4 years, the relative risk of probable dementia for CE plus MPA was 2.05 (95% CI, 1.21 to 3.48). The absolute risk of probable dementia for CE plus MPA versus placebo was 45 versus 22 per 10,000 women-years. Probable dementia as defined in this study included AD, VaD, and mixed type (having features of both AD and VaD). The most common classification of probable dementia in the treatment group and the placebo group was AD. Since the ancillary study was conducted in women 65 to 79 years of age, it is unknown whether these findings apply to younger postmenopausal women [see Warnings and Precautions (5.3) and Use in Specific Populations (8.5)].

When data from the two populations were pooled as planned in the WHIMS protocol, the reported overall relative risk for probable dementia was 1.76 (95% CI, 1.19 to 2.60). Differences between groups became apparent in the first year of treatment. It is unknown whether these findings apply to younger postmenopausal women [see Warnings and Precautions (5.3) and Use in Specific Populations (8.5)].

16.1 How Supplied

Estradiol Transdermal System, USP (Twice-Weekly) is available as 0.025 mg/day, 0.0375 mg/day, 0.05 mg/day, 0.075 mg/day or 0.1 mg/day of estradiol. Each strength is supplied in a Patient Calendar Pack containing 8 individually packaged systems.

The 0.025 mg per day is available as a 2.5 cm2 system containing estradiol, USP hemihydrate equivalent to 0.41 mg of estradiol, for nominal* delivery of 0.025 mg of estradiol per day. Each rectangular patch with rounded corners consists of an opaque, white to cream adhesive layer, matte film backing randomly printed with “Estradiol 0.025 mg/day” in brown ink, and a clear release liner. The patch is contained in a square, flat, notched, pouch. The pouch is imprinted with the lot number and expiration date. They are available as follows:

NDC 0378-4644-26
carton containing 8 systems

The 0.0375 mg per day is available as a 3.75 cm2 system containing estradiol, USP hemihydrate equivalent to 0.62 mg of estradiol for nominal* delivery of 0.0375 mg of estradiol per day. Each rectangular patch with rounded corners consists of an opaque, white to cream adhesive layer, matte film backing randomly printed with “Estradiol 0.0375 mg/day” in brown ink, and a clear release liner. The patch is contained in a square, flat, notched, pouch. The pouch is imprinted with the lot number and expiration date. They are available as follows:

NDC 0378-4643-26
carton containing 8 systems

The 0.05 mg per day is available as a 5.0 cm2 system containing estradiol, USP hemihydrate equivalent to 0.82 mg of estradiol for nominal* delivery of 0.05 mg of estradiol per day. Each rectangular patch with rounded corners consists of an opaque, white to cream adhesive layer, matte film backing randomly printed with “Estradiol 0.05 mg/day” in brown ink, and a clear release liner. The patch is contained in a square, flat, notched, pouch. The pouch is imprinted with the lot number and expiration date. They are available as follows:

NDC 0378-4642-26
carton containing 8 systems

The 0.075 mg per day is available as a 7.5 cm2 system containing estradiol, USP hemihydrate equivalent to 1.23 mg of estradiol for nominal* delivery of 0.075 mg of estradiol per day. Each rectangular patch with rounded corners consists of an opaque, white to cream adhesive layer, matte film backing randomly printed with “Estradiol 0.075 mg/day” in brown ink, and a clear release liner. The patch is contained in a square, flat, notched, pouch. The pouch is imprinted with the lot number and expiration date. They are available as follows:

NDC 0378-4641-26
carton containing 8 systems

The 0.1 mg per day is available as a 10.0 cm2 system containing estradiol, USP hemihydrate equivalent to 1.64 mg of estradiol for nominal* delivery of 0.1 mg of estradiol per day. Each rectangular patch with rounded corners consists of an opaque, white to cream adhesive layer, matte film backing randomly printed with “Estradiol 0.1 mg/day” in brown ink, and a clear release liner. The patch is contained in a square, flat, notched, pouch. The pouch is imprinted with the lot number and expiration date. They are available as follows:

NDC 0378-4640-26
carton containing 8 systems

[*see DESCRIPTION (11)]

16.2 Storage and Handling

Store at 20° to 25°C (68° to 77°F). [See USP Controlled Room Temperature.]

Do not store unpouched. Apply immediately upon removal from the protective pouch.

Used transdermal systems still contain active hormone. To discard, fold the sticky side of the transdermal system together, place it in a sturdy child-proof container, and place this container in the trash. Used transdermal systems should not be flushed in the toilet.