Adverse Effects - The Estrogens

Adverse Effects

Adverse effects of variable severity have been reported with the therapeutic use of estrogens. Many other effects reported in con-junction with hormonal contraceptives may be related to their estrogen content. These are discussed below.

A. Uterine Bleeding

Estrogen therapy is a major cause of postmenopausal uterine bleeding. Unfortunately, vaginal bleeding at this time of life may also be due to carcinoma of the endometrium. To avoid confusion, patients should be treated with the smallest amount of estrogen possible. It should be given cyclically so that bleeding, if it occurs, will be more likely to occur during the withdrawal period. As noted above, endometrial hyperplasia can be prevented by admin-istration of a progestational agent with estrogen in each cycle.

B. Cancer

The relation of estrogen therapy to cancer continues to be the sub-ject of active investigation. Although no adverse effect of short-term estrogen therapy on the incidence of breast cancer has been dem-onstrated, a small increase in the incidence of this tumor may occur with prolonged therapy. Although the risk factor is small (1.25), the impact may be great since this tumor occurs in 10% of women, and addition of progesterone does not confer a protective effect. Studies indicate that following unilateral excision of breast cancer, women receiving tamoxifen (an estrogen partial agonist, ) show a 35% decrease in contralateral breast cancer compared with con-trols. These studies also demonstrate that tamoxifen is well toler-ated by most patients, produces estrogen-like alterations in plasma lipid levels, and stabilizes bone mineral loss. Studies bearing on the possible efficacy of tamoxifen in postmenopausal women at high risk for breast cancer are under way. A recent study shows that postmenopausal hormone replacement therapy with estrogens plus progestins was associated with greater breast epithelial cell prolif-eration and breast epithelial cell density than estrogens alone or no replacement therapy. Furthermore, with estrogens plus progestins, breast proliferation was localized to the terminal duct-lobular unit of the breast, which is the main site of development of breast can-cer. Thus, further studies are needed to conclusively assess the pos-sible association between progestins and breast cancer risk.

Many studies show an increased risk of endometrial carcinoma in patients taking estrogens alone. The risk seems to vary with the dose and duration of treatment: 15 times greater in patients taking large doses of estrogen for 5 or more years, in contrast with two to four times greater in patients receiving lower doses for short peri-ods. However, as noted above, the concomitant use of a progestin prevents this increased risk and may in fact reduce the incidence of endometrial cancer to less than that in the general population.

There have been a number of reports of adenocarcinoma of the vagina in young women whose mothers were treated with large doses of diethylstilbestrol early in pregnancy. These cancers are most common in young women (ages 14–44). The incidence is less than 1 per 1000 women exposed—too low to establish a cause-and-effect relationship with certainty. However, the risks for infer-tility, ectopic pregnancy, and premature delivery are also increased. It is now recognized that there is no indication for the use of dieth-ylstilbestrol during pregnancy, and it should be avoided. It is not known whether other estrogens have a similar effect or whether the observed phenomena are peculiar to diethylstilbestrol. This agent should be used only in the treatment of cancer (eg, of the prostate) or as a “morning after” contraceptive .

C. Other Effects

Nausea and breast tenderness are common and can be minimized by using the smallest effective dose of estrogen. Hyperpigmentation also occurs. Estrogen therapy is associated with an increase in frequency of migraine headaches as well as cholestasis, gallbladder disease, and hypertension.

Contraindications

Estrogens should not be used in patients with estrogen-dependent neoplasms such as carcinoma of the endometrium or in those with—or at high risk for—carcinoma of the breast. They should be avoided in patients with undiagnosed genital bleeding, liver disease, or a history of thromboembolic disorder. In addition, the use of estrogens should be avoided by heavy smokers.