CONJUGATED ESTROGENS 
Pronounciation
Trade Name(s)
- Premarin Intravenous
Reconstitute with 5 mL SWFI, directing the flow of diluent gently against the side of the vial. Agitate gently. Do not shake violently. Do not use if discolored or if precipitate is present. Dilution in an IV infusion is not recommended.
Before reconstitution, store in refrigerator at 2° to 8° C (36° to 46° F). Use immediately after reconstitution.
Manufacturer lists as incompatible with ascorbic acid, protein hydrolysate, or any solution with an acid pH.
According to the manufacturer, infusion with other agents is not generally recommended. May be given at Y-tube if compatible solutions are infusing (NS, dextrose, and invert sugar solutions). According to one source, it is compatible at the Y-site with heparin, hydrocortisone sodium succinate, and potassium chloride (KCl).
Administer slowly. Too-rapid injection may cause flushing. Must be given direct IV or through IV tubing close to needle site. Infusion solution must be compatible.
A mixture of conjugated estrogens obtained exclusively from natural sources. Administration provides a rapid and temporary increase in estrogen levels. Acts at several points on the clotting cascade, enhancing coagulability of the blood, especially in the capillary beds. Promptly corrects bleeding due to estrogen deficiency. Widely distributed in the body. Metabolized primarily in the liver and excreted in the urine. Secreted in breast milk.
Treatment of abnormal uterine bleeding due to hormonal imbalance in the absence of organic pathology. Indicated for short-term use only to provide a rapid and temporary increase in estrogen levels.
Uremic bleeding.
Known, suspected, or history of breast cancer, active deep venous thrombosis, or pulmonary embolism.
■ A history of or active arterial thromboembolic disease (e.g., stroke, MI).
■ Known or suspected estrogen-dependent neoplasia, pregnancy, undiagnosed abnormal genital bleeding, liver dysfunction or disease.
■ Hypersensitivity to this product or its ingredients (e.g., known anaphylactic reaction and angioedema).
■ Known protein C, protein S, or antithrombin deficiency, or other known thrombophilic disorders.
■ Other specific contraindications for estrogens must be considered.
IV therapy with conjugated estrogens is indicated for short-term use. However, warnings and precautions associated with oral therapy should be considered (e.g., changes in vaginal bleeding, headache, hypersensitivity reactions, skin reactions, and many more); see Precautions and prescribing information.
■ Estrogen administration should be guided by clinical response rather than laboratory monitoring. Prescribe with or without progestins at the lowest effective doses and for the shortest duration consistent with treatment goals and risks for the individual woman.
■ Estrogens with or without progestins should not be used for the prevention of cardiovascular disease or dementia.
■ Even though bleeding is controlled, the etiology of the bleeding must be determined and definitive therapy instituted.
■ Hypersensitivity reactions, including anaphylaxis and angioedema, have been reported. Do not rechallenge patients who have had an anaphylactic reaction with or without angioedema.
■ May cause fluid retention. Use with caution in patients with cardiac or renal dysfunction.
■ Use with caution in asthma, diabetes, endometriosis, epilepsy, hepatic hemangiomas, hepatic or gallbladder disease, hypercalcemia or hypocalcemia, hypercholesterolemia, hypertension, hypoparathyroidism, migraines, obesity, porphyria, systemic lupus erythematosus, tobacco use, or venous thromboembolism (VTE); may exacerbate condition.
■ May lead to severe hypercalcemia in patients with breast cancer and bone metastases.
■ In women with pre-existing hypertriglyceridemia, estrogen therapy may be associated with further elevations of triglycerides, leading to pancreatitis. Consider discontinuation of treatment if pancreatitis occurs.
■ Consider the addition of progestin in women known to have residual endometriosis posthysterectomy.
■ May induce or exacerbate symptoms of angioedema, particularly in women with hereditary angioedema.
■ Retinal vascular thrombosis has been reported in patients receiving estrogen therapy. Discontinue therapy and obtain ophthalmologic exam if visual disturbances occur.
■ Patients dependent on thyroid hormone replacement therapy (e.g., levothyroxine [Synthroid]) who are also receiving estrogen may require dose adjustment of thyroid replacement medication.
■ Estrogen-alone therapy may increase the risk of deep venous thrombosis, stroke, endometrial cancer, and dementia in postmenopausal women.
■ Estrogen plus progestin therapy may increase the risk of deep venous thrombosis, MI, pulmonary embolism, stroke, invasive breast cancer, and dementia in postmenopausal women.
■ Follow immediately with oral estrogens as recommended for dysfunctional uterine bleeding.
Monitor VS; may cause a temporary BP elevation.
■ Due to the risk of endometrial cancer, adequate diagnostic measures, including directed or random endometrial sampling when indicated, should be undertaken to rule out malignancy in postmenopausal women with undiagnosed persistent or recurring abnormal genital bleeding.
■ Monitor thyroid function in order to maintain free thyroid hormone levels in an acceptable range.
■ Monitor for S/S of hypersensitivity reactions (e.g., anaphylaxis, angioedema, bronchospasm, rash, urticaria).
Review Patient Information leaflet. Review health history and disease states with physician before beginning treatment with conjugated estrogens.
■ Review possible side effects with physician and report any side effects promptly.
■ Use effective contraception if indicated.
Avoid pregnancy.
■ Use caution during breast-feeding. Detectable amounts have been found in breast milk and may decrease quantity and quality of milk.
■ Safety for use in pediatric patients not established. Extended use may accelerate epiphyseal closure, which could result in short adult stature.
Differences in response compared to younger adults not identified.
May decrease effects of oral antidiabetics.
■ Barbiturates (e.g., phenobarbital), carbamazepine, phenytoin, rifampin, and St. John’s wort increase metabolism and decrease serum levels and effects.
■ Plasma concentrations may be increased with coadministration of clarithromycin, erythromycin, itraconazole, ketoconazole, ritonavir, and grapefruit juice.
■ May decrease metabolism and increase serum levels of cyclosporine. May increase risk of cyclosporine toxicity.
■ Increased risk of hepatotoxicity with other hepatotoxic agents (e.g., dantrolene).
■ May increase blood glucose levels and serum lipids.
■ May reduce response to metyrapone test.
■ May alter numerous coagulation tests, glucose tolerance, and thyroid and other protein-binding tests.
Rare when used as directed; flushing, nausea, vomiting. IV therapy with conjugated estrogens is indicated for short-term use. However, the numerous adverse reactions associated with oral therapy should be considered (e.g., changes in vaginal bleeding, headache, hypersensitivity reactions, skin reactions, and many more); see Precautions and prescribing information.
Anaphylaxis within minutes to hours of infusion; angioedema involving the face, tongue, larynx, hands, and feet.
No toxicity has been reported throughout years of clinical use. Discontinue if jaundice occurs. Discontinue immediately if DVT, MI, PE, stroke, or VTE occurs or is suspected. Discontinue if hypercalcemia occurs, and institute appropriate measures to reduce the serum calcium level. Permanently discontinue if examination reveals papilledema or retinal vascular lesions.