Estring is a brand name for a vaginal ring that releases estradiol, a form of estrogen. It is prescribed to women experiencing vaginal and urinary symptoms of menopause, such as vaginal dryness, burning, itching, painful urination, and frequent urges to urinate. These symptoms arise from the body's decreased estrogen production during menopause. While Estring can effectively alleviate these issues, it's crucial to understand its potential side effects and risks.
What is Estring?
Estring is a hormone replacement therapy (HRT) that contains estradiol. Estradiol is a naturally occurring estrogen in women, primarily produced by the ovarian follicles during their reproductive years. After menopause, the body mainly produces estrogen by transforming androstenedione (from the adrenal cortex) into estrone. Estring is designed to deliver estradiol directly to the vagina, helping to restore estrogen levels in the vaginal tissues and alleviate menopausal symptoms.
How Estring Works
Estrogen works by binding to receptors in the body, including ERα and ERβ, which then enter the nucleus of the target cell and activate certain genes. This process causes the body to produce proteins that express the effects of estradiol. Estrogen has a range of effects, including reducing hot flashes, chills, mood swings, and sleep problems.
How to Use Estring
Estring is a vaginal ring inserted high into the vagina as directed by a healthcare provider. The ring is typically left in place for 90 days, after which it is removed and replaced with a new ring if continued treatment is necessary.
- Insertion: Wash and dry your hands before handling the ring. Insert the ring high into the vagina as directed.
- Duration: The ring is usually left in place for 90 days. Do not leave a ring in place for longer than 90 days.
- Positioning: If the ring is put in properly, it should not be felt during daily activities or sexual intercourse. If discomfort is experienced, it may mean the ring is not inserted high enough.
- Falling Out: If the ring falls out of the vagina, rinse it with lukewarm water and reinsert it.
- Removal: The ring is removed by hooking a finger through it and gently pulling it out. Contact a doctor if there is trouble removing the ring.
- Disposal: Discard the used ring in the trash.
It may take 2 to 3 weeks to experience the full benefits of Estring.
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Common Side Effects
Like all medications, Estring can cause side effects. Common side effects may include:
- Nausea and vomiting
- Bloating
- Increased vaginal discharge
- Breast tenderness
- Headache
- Weight changes
- Hair loss
- Stomach cramps, bloating, nausea, vomiting, or diarrhea
- Itching, irritation, or burning sensation in the vagina
These side effects are usually mild and temporary. However, it's important to be aware of more serious potential side effects.
Serious Side Effects
While rare, Estring can cause serious side effects that require immediate medical attention. These include:
- Blood Clots: Estrogens can increase the risk of blood clots, leading to heart attack, stroke, or blood clots in the lungs or legs (deep vein thrombosis). Symptoms of blood clots include chest pain or pressure, fast or abnormal heartbeat, trouble breathing, pain in your back, jaw, throat, or arm, sweating, upset stomach, vomiting, or dizziness, sudden weakness on one side of your body, sudden and severe headache, slurred speech or trouble understanding speech, pain, swelling, or tenderness in your arm or leg, vision loss, bulging eyes, double vision.
- Endometrial Cancer: Estrogens can increase the risk of cancer of the uterus (endometrial cancer). Taking a progestin as directed by a doctor can help decrease this risk. Report any unusual vaginal bleeding to your doctor immediately.
- Breast Cancer: Estrogens, taken with or without a progestin, may increase the risk of breast cancer. Regular breast exams and mammograms are crucial. Call your healthcare provider right away if you have any of the following symptoms: New lump in your breast or armpit; Changes in the size, shape, texture, or temperature of your breast; Nipple changes.
- Ovarian Cancer: Estrogens may increase the risk for cancer in your ovaries (ovarian cancer). Call your healthcare provider right away if you have any of the following symptoms: Unusual vaginal discharge; Belly or back pain; Need to pee more often or urgently.
- Toxic Shock Syndrome (TSS): Vaginal rings have rarely caused a very serious (possibly fatal) bacterial infection (toxic shock syndrome-TSS). Remove your estradiol vaginal ring and call your healthcare provider right away if you have any of the following serious symptoms: Fever; Nausea, vomiting, or diarrhea; Dizziness or fainting; Muscle pain; A rash on your face and body that looks like a sunburn.
- Gallbladder Problems: Using vaginal estradiol may cause gallbladder problems, including cholecystitis and cholelithiasis (also known as gallstones). Call your healthcare provider right away if you have any of the following symptoms: Your skin or the whites of your eyes turning yellowish in color (also called jaundice); Fever; Pain in your upper stomach area; Stool (poop) that is clay-colored.
- Memory Problems: Using vaginal estradiol may increase your risk for memory problems (dementia), especially if you are 65 or older.
- Increased Blood Pressure (Hypertension): Vaginal estradiol may increase your blood pressure or worsen it if you have a history of high blood pressure. Increases in blood pressure may not be noticeable but look out for any of the following symptoms of severely high blood pressure: Sudden severe headache; Chest pain; Dizziness or confusion; Trouble breathing; Nausea or vomiting; Blurry or other changes to vision; Anxiety; Buzzing in the ears; Nosebleed; Feeling of skipped heart beats.
- Fluid Retention (Edema): Vaginal estradiol can cause fluid retention, also called edema. Fluid retention can cause serious issues in people with certain conditions, such as heart failure or kidney disease. Call your healthcare provider right away if you have any of the following symptoms: Chest pain; Irregular heartbeat; Shortness of breath; Stretched or shiny skin; Swollen body parts, such as the belly or ankles.
- Severe Allergic Reactions: Vaginal estradiol may cause allergic reactions, which can be serious. Stop using vaginal estradiol and get help right away if you have any of the following symptoms of a serious allergic reaction: Breathing problems or wheezing; Racing heart; Fever or general ill feeling; Swollen lymph nodes; Swelling of the face, lips, mouth, tongue, or throat (angioedema); Trouble swallowing or throat tightness; Itching, skin rash, or pale red bumps on the skin called hives; Nausea or vomiting; Dizziness, feeling lightheaded, or fainting; Stomach cramps; Joint pain.
- Vaginal Sores: Sometimes using a vaginal estradiol ring can cause some of the lining of the vagina to get very thin, or for sores to develop. This can be very painful. Remove your estradiol vaginal ring and call your healthcare provider right away if you have any of the following symptoms of vaginal thinning or sores: Pain or soreness of the vagina; Vaginal bleeding; Swelling, redness, or scapes in the vagina.
Estradiol Overdose
The amount of estradiol that is considered safe for rats to consume orally over a 90-day period is 0.003mg/kg/day. The highest dose of estradiol that has been found to be toxic to humans is 21mg/kg/21 days. Symptoms of estradiol overdose may include nausea, vomiting, abdominal pain, breast tenderness, blood clots, or vaginal bleeding. If an overdose occurs, it is recommended to cease using estradiol and provide supportive care.
Contraindications
Estring is not suitable for everyone. Contraindications include:
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- Allergies to estradiol or any other ingredients in the product
- Current or history of blood clots
- Known or suspected breast cancer
- Estrogen-dependent cancer (e.g., ovarian or endometrial cancer)
- History of stroke or heart attack
- Undiagnosed abnormal vaginal bleeding
- Known thrombophilia (e.g., protein C, protein S, or antithrombin deficiency)
- Liver problems
- Pregnancy
Warnings and Precautions
Before using Estring, inform your doctor about:
- Any allergies
- Current and past medical conditions, especially:
- Unusual vaginal bleeding or spotting after menopause
- Cancer
- Heart problems
- Stroke
- Blood clots
- High blood pressure
- Liver problems
- Asthma
- Diabetes
- Seizures
- Migraines
- Endometriosis
- Systemic lupus erythematosus
- Porphyria
- Thyroid or parathyroid problems
- Kidney problems
- High blood calcium levels
- Hereditary angioedema
- Smoking
- Gallbladder problems with estrogen use or during pregnancy
- Any upcoming surgeries or periods of prolonged immobility
- All medications and supplements you are taking
Drug Interactions
Estring can interact with certain medications, affecting how they work or increasing the risk of side effects. These include:
- St. John’s wort
- Phenobarbital or carbamazepine
- Rifampin
- Erythromycin or clarithromycin
- Ketoconazole or itraconazole
- Ritonavir
Always inform your doctor about all medications and supplements you are taking.
Food Interactions
Do not eat or drink things with grapefruit or grapefruit juice in them while using vaginal estradiol. This could increase the estradiol levels in your blood and may cause serious side effects. Limit the amount of alcohol you drink while using vaginal estradiol. There may be increased risk for liver damage if you drink significant amounts of alcohol while using vaginal estradiol.
Estring and Weight Changes
Weight changes are listed as a potential side effect of Estring. However, it's important to note that weight changes during menopause can be influenced by various factors, including hormonal changes, aging, lifestyle, and diet. Some women may experience weight gain, while others may lose weight.
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- Hormonal Changes: Menopause is associated with a decline in estrogen levels, which can affect metabolism and body composition, potentially leading to weight gain.
- Lifestyle Factors: Reduced physical activity and changes in dietary habits can also contribute to weight changes during menopause.
- Estring and Fluid Retention: Estrogen can cause fluid retention (edema), which might be perceived as weight gain.
If you experience significant weight changes while using Estring, discuss them with your doctor to determine the underlying cause and appropriate management strategies.
Patient Reviews and Experiences
Patient reviews of Estring are mixed, with some women reporting significant benefits and others experiencing side effects or difficulties with the ring.
- Positive Experiences: Many women report improved vaginal tone and lubrication, reduced pain during sex, and relief from postmenopausal urethral atrophy.
- Negative Experiences: Some women have reported difficulties with ring insertion and removal, bacterial infections, increased vaginal discharge, and concerns about the cost of the medication. Some women have reported weight gain while using Estring.
Dosage and Administration
The encouraged measure of Estring is subject to the determined condition, for example, Premature Menopause, Pharmaceutical Preparations and Postmenopause. The amount of dosage is contingent on the technique of administration enumerated in the table beneath.
Alternative Treatments
If Estring is not suitable or if side effects are intolerable, alternative treatments for vaginal and urinary symptoms of menopause include:
- Other vaginal estrogen products (creams, tablets, inserts)
- Non-hormonal lubricants and moisturizers
- Systemic hormone therapy (oral or transdermal estrogen)
- Lifestyle modifications (e.g., Kegel exercises for urinary symptoms)