Wyeth Pharmaceuticals LLC, a subsidiary of Pfizer Inc.
Premarin
BrandGeneric: Estrogens, conjugated
ID: 00046110481
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TL;DR — Quick Summary
Key facts from the full medication guide below
🩺What it's for
PREMARIN is a mixture of estrogens indicated for: Treatment of Moderate to Severe Vasomotor Symptoms due to Menopause (1.1) Treatment of Moderate to Severe Vulvar and Vaginal Atrophy due to Menopause (1.2) Treatment of Hypoestrogenism due to Hypogonadism, Castration or Primary Ovarian Failure (1.3) Treatment of Breast Cancer (for Palliation Only) in Appropriately Selected Women and Men with Metastatic Disease (1.4) Treatment of Advanced Androgen-Dependent Carcinoma of the Prostate (for…
💊How to take it
Generally, when estrogen therapy is prescribed for a postmenopausal woman with a uterus, a progestin should be considered to reduce the risk of endometrial cancer [see Boxed Warning]. A woman without a uterus does not need progestin. In some cases, however, hysterectomized women with a history of endometriosis may need a progestin [see Warnings and Precautions (5.2, 5.16)].
ℹ️Common side effects
The following serious adverse reactions are discussed elsewhere in labeling: Cardiovascular Disorders [see Boxed Warning, Warnings and Precautions (5.1)] Malignant Neoplasms [see Boxed Warning, Warnings and Precautions (5.2)] Most common adverse reactions ( 5 percent) are: abdominal pain, asthenia, pain, back pain, headache, flatulence, nausea, depression, insomnia, breast pain, endometrial hyperplasia, leucorrhea, vaginal hemorrhage, and vaginitis.
⚠️Serious risks
Using estrogen-alone may increase your chance of getting cancer of the uterus (womb) Report any unusual vaginal bleeding right away while you are using PREMARIN. Vaginal bleeding after menopause may be a warning sign of cancer of the uterus (womb). Your healthcare provider should check any unusual vaginal bleeding to find the cause.
📋Interactions & cautions
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 antifactor Xa and antithrombin III, decreased antithrombin III activity; increased levels of fibrinogen and fibrinogen activity; increased plasminogen antigen and activity.
📦Storage & missed dose
Store at 20 to 25 C (68 to 77 F); excursions permitted to 15 to 30 C (59 to 86 F) [see USP Controlled Room Temperature]. Dispense in a well-closed container, as defined in the USP.
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Estrogens, conjugated (Premarin) Prices
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What is PREMARIN? PREMARIN is a medicine that contains a mixture of estrogen hormones. What is PREMARIN used for? PREMARIN is used after menopause to: Reduce moderate to severe hot flashes Estrogens are hormones made by a woman's ovaries. The ovaries normally stop making estrogens when a woman is between 45 and 55 years old. This drop in body estrogen levels causes the "change of life" or menopause (the end of monthly menstrual periods). Sometimes, both ovaries are removed during an operation before natural menopause takes place. The sudden drop in estrogen levels causes "surgical menopause." When the estrogen levels begin dropping, some women get very uncomfortable symptoms, such as feelings of warmth in the face, neck, and chest, or sudden strong feelings of heat and sweating ("hot flashes" or "hot flushes"). In some women the symptoms are mild, and they will not need to take estrogens. In other women, symptoms can be more severe. Treat menopausal changes in and around the vagina You and your healthcare provider should talk regularly about whether you still need treatment with PREMARIN to control these problems. If you use PREMARIN only to treat your menopausal changes in and around your vagina, talk with your healthcare provider about whether a topical vaginal product would be better for you. Help reduce your chances of getting osteoporosis (thin weak bones) Osteoporosis from menopause is a thinning of the bones that makes them weaker and easier to break. If you use PREMARIN only to prevent osteoporosis due to menopause, talk with your healthcare provider about whether a different treatment or medicine without estrogens might be better for you. Weight-bearing exercise, like walking or running, and taking calcium (1500 mg/day of elemental calcium) and vitamin D (400 800 IU/day) supplements may also lower your chances of getting postmenopausal osteoporosis. It is important to talk about exercise and supplements with your healthcare provider before starting them. You and your healthcare provider should talk regularly about whether you still need treatment with PREMARIN. PREMARIN is also used to: Treat certain conditions in women before menopause if their ovaries do not make enough estrogen naturally. Ease symptoms of certain cancers that have spread through the body, in men and women Who should not take PREMARIN? Do not take PREMARIN if you: Have unusual vaginal bleeding Currently have or have had certain cancers Estrogens may increase the chance of getting certain types of cancers, including cancer of the breast or uterus. If you have or have had cancer, talk with your healthcare provider about whether you should use PREMARIN. Had a stroke or heart attack Currently have or have had blood clots Currently have or have had liver problems Have been diagnosed with a bleeding disorder Are allergic to PREMARIN or any of its ingredients See the end of this leaflet for a list of ingredients in PREMARIN. Think you may be pregnant Tell your healthcare provider If you have any unusual vaginal bleeding Vaginal bleeding after menopause may be a warning sign of cancer of the uterus (womb). Your healthcare provider should check any unusual vaginal bleeding to find out the cause. About all of your medical problems Your healthcare provider may need to check you more carefully if you have certain conditions, such as asthma (wheezing), epilepsy (seizures), diabetes, migraine, endometriosis, lupus, problems with your heart, liver, thyroid, kidneys, or have high calcium levels in your blood. About all the medicines you take This includes prescription and nonprescription medicines, vitamins, and herbal supplements. Some medicines may affect how PREMARIN works. PREMARIN may also affect how your other medicines work. If you are going to have surgery or will be on bedrest You may need to stop taking PREMARIN. If you are breastfeeding The hormones in PREMARIN can pass into your milk. How should I take PREMARIN? Take one PREMARIN tablet at the same time each day If you miss a dose, take it as soon as possible. If it is almost time for your next dose, skip the missed dose and go back to your normal schedule. Do not take 2 doses at the same time. Estrogens should be used at the lowest dose possible for your treatment only as long as needed. You and your healthcare provider should talk regularly (for example, every 3 to 6 months) about the dose you are taking and whether you still need treatment with PREMARIN. If you see something that resembles a tablet in your stool, talk to your healthcare provider. Take PREMARIN with or without food. What are the possible side effects of PREMARIN? Side effects are grouped by how serious they are and how often they happen when you are treated. Serious, but less common side effects include: Heart attack Stroke Blood clots Dementia Breast cancer Cancer of the lining of the uterus (womb) Cancer of the ovary High blood pressure High blood sugar Gallbladder disease Liver problems Enlargement of benign tumors of the uterus ("fibroids") Severe allergic reactions Call your healthcare provider right away if you get any of the following warning signs or any other unusual symptoms that concern you: New breast lumps Unusual vaginal bleeding Changes in vision or speech Sudden new severe headaches Severe pains in your chest or legs with or without shortness of breath, weakness and fatigue Swollen lips, tongue and face Less serious, but common side effects include: Headache Breast pain Irregular vaginal bleeding or spotting Stomach/abdominal cramps/bloating Nausea and vomiting Hair loss Fluid retention Vaginal yeast infection These are not all the possible side effects of PREMARIN. For more information, ask your healthcare provider or pharmacist for advice about side effects. You may report side effects to FDA at 1-800-FDA-1088. What can I do to lower my chances of getting a serious side effect with PREMARIN? Talk with your healthcare provider regularly about whether you should continue taking PREMARIN If you have a uterus, talk to your healthcare provider about whether the addition of a progestin is right for you. The addition of a progestin is generally recommended for women with a uterus to reduce the chance of getting cancer of the uterus (womb). See your health care provider right away if you get vaginal bleeding while taking PREMARIN Have a pelvic exam, breast exam and mammogram (breast X-ray) every year unless your healthcare provider tells you something else. If members of your family have had breast cancer or if you have ever had breast lumps or an abnormal mammogram, you may need to have breast exams more often. If you have high blood pressure, high cholesterol (fat in the blood), diabetes, are overweight, or if you use tobacco, you may have higher chances for getting heart disease. Ask your healthcare provider for ways to lower your chances of getting heart disease. General information about the safe and effective use of PREMARIN Medicines are sometimes prescribed for conditions that are not mentioned in patient information leaflets. Do not take PREMARIN for conditions for which it was not prescribed. Do not give PREMARIN to other people, even if they have the same symptoms you have. It may harm them. Keep PREMARIN out of the reach of children This leaflet provides a summary of the most important information about PREMARIN. If you would like more information, talk with your healthcare provider or pharmacist. What are the ingredients in PREMARIN? PREMARIN contains a mixture of conjugated estrogens, which are a mixture of sodium estrone sulfate and sodium equilin sulfate and other components including sodium sulfate conjugates, 17 -dihydroequilin, 17 -estradiol, and 17 -dihydroequilin. PREMARIN 0.3 mg, 0.45 mg, 0.625 mg, 0.9 mg, and 1.25 mg tablets also contain the following inactive ingredients: calcium phosphate tribasic, hydroxypropyl cellulose, microcrystalline cellulose, powdered cellulose, hypromellose, lactose monohydrate, magnesium stearate, polyethylene glycol, sucrose and titanium dioxide. The tablets come in different strengths and each strength tablet is a different color. The color ingredients are: 0.3 mg tablet (green color): D&C Yellow No. 10 and FD&C Blue No. 2. 0.45 mg tablet (blue color): FD&C Blue No. 2. 0.625 mg tablet (maroon color): FD&C Blue No. 2 and FD&C Red No. 40. 0.9 mg tablet (white color): D&C Red No. 30 and D&C Red No. 7. 1.25 mg tablet (yellow color): black iron oxide, D&C Yellow No. 10, and FD&C Yellow No. 6. The appearance of these tablets is a trademark of Wyeth LLC. Store at Controlled Room Temperature 20 25 C (68 77 F). This product's label may have been updated. For current full prescribing information, please visit www.pfizer.com. LAB-0515-6.0 Revised February/2024
Warnings and Precautions, Malignant Neoplasms (5.2) 02/2024
PREMARIN is a mixture of estrogens indicated for: Treatment of Moderate to Severe Vasomotor Symptoms due to Menopause (1.1) Treatment of Moderate to Severe Vulvar and Vaginal Atrophy due to Menopause (1.2) Treatment of Hypoestrogenism due to Hypogonadism, Castration or Primary Ovarian Failure (1.3) Treatment of Breast Cancer (for Palliation Only) in Appropriately Selected Women and Men with Metastatic Disease (1.4) Treatment of Advanced Androgen-Dependent Carcinoma of the Prostate (for Palliation Only) (1.5) Prevention of Postmenopausal Osteoporosis (1.6)
Generally, when estrogen therapy is prescribed for a postmenopausal woman with a uterus, a progestin should be considered to reduce the risk of endometrial cancer [see Boxed Warning]. A woman without a uterus does not need progestin. In some cases, however, hysterectomized women with a history of endometriosis may need a progestin [see Warnings and Precautions (5.2, 5.16)]. Use of estrogen-alone, or in combination with a progestin, should be with the lowest effective dose and for the shortest duration consistent with treatment goals and risks for the individual woman. Postmenopausal women should be re-evaluated periodically as clinically appropriate to determine if treatment is still necessary. PREMARIN may be taken without regard to meals. Daily administration of 0.3, 0.45, 0.625, 0.9, and 1.25 mg (2.1, 2.2, 2.3, 2.5, 2.6) Cyclic administration of 0.3, 0.625, and 1.25 mg (2.1, 2.2, 2.3)
Patients should be treated with the lowest effective dose. Generally, women should be started at 0.3 mg PREMARIN daily. Subsequent dosage adjustment may be made based upon the individual patient response. This dose should be periodically reassessed by the healthcare provider. PREMARIN therapy may be given continuously, with no interruption in therapy, or in cyclical regimens (regimens such as 25 days on drug followed by 5 days off drug), as is medically appropriate on an individual basis.
Patients should be treated with the lowest effective dose. Generally, women should be started at 0.3 mg PREMARIN daily. Subsequent dosage adjustment may be made based upon the individual patient response. This dose should be periodically reassessed by the healthcare provider. PREMARIN therapy may be given continuously, with no interruption in therapy, or in cyclical regimens (regimens such as 25 days on drug followed by 5 days off drug), as is medically appropriate on an individual basis.
PREMARIN therapy should be initiated and maintained with the lowest effective dose to achieve clinical goals. Female hypogonadism: 0.3 mg or 0.625 mg daily, administered cyclically (e.g., three weeks on and one week off). Doses are adjusted depending on the severity of symptoms and responsiveness of the endometrium [see Clinical Studies (14.4) ]. Female castration or primary ovarian failure: 1.25 mg daily, cyclically. Adjust dosage, upward or downward, according to severity of symptoms and response of the patient. For maintenance, adjust dosage to lowest level that will provide effective control.
Suggested dosage is 10 mg three times daily, for a period of at least three months.
1.25 mg to 2 1.25 mg three times daily. The effectiveness of therapy can be judged by phosphatase determinations as well as by symptomatic improvement of the patient.
PREMARIN therapy may be given continuously, with no interruption in therapy, or in cyclical regimens (regimens such as 25 days on drug followed by 5 days off drug), as is medically appropriate on an individual basis. Patients should be treated with the lowest effective dose. Generally, women should be started at 0.3 mg PREMARIN daily. Subsequent dosage adjustment may be made based upon the individual clinical and bone mineral density responses. This dose should be periodically reassessed by the healthcare provider.
PREMARIN (conjugated estrogens tablets, USP) Tablet Strength Tablet Shape/Color Imprint 0.3 mg oval/green PREMARIN 0.3 0.45 mg oval/blue PREMARIN 0.45 0.625 mg oval/maroon PREMARIN 0.625 0.9 mg oval/white PREMARIN 0.9 1.25 mg oval/yellow PREMARIN 1.25 Tablets: 0.3, 0.45, 0.625, 0.9, and 1.25 mg (3)
PREMARIN therapy is contraindicated in individuals with any of the following conditions: Undiagnosed abnormal genital bleeding Known, suspected, or history of breast cancer except in appropriately selected patients being treated for metastatic disease Known or suspected estrogen-dependent neoplasia Active DVT, PE, or a history of these conditions Active arterial thromboembolic disease (for example stroke and MI), or a history of these conditions Known anaphylactic reaction or angioedema with Premarin Known liver impairment or disease Known protein C, protein S or antithrombin deficiency, or other known thrombophilic disorders. Known or suspected pregnancy Undiagnosed abnormal genital bleeding (4) Known, suspected, or history of breast cancer except in appropriately selected patients being treated for metastatic diseases (4, 5.2) Known or suspected estrogen-dependent neoplasia (4, 5.2) Active DVT, PE, or a history of these conditions (4, 5.1) Active arterial thromboembolic disease (for example, stroke and MI), or a history of these conditions (4, 5.1) Known anaphylactic reaction or angioedema with PREMARIN (5.7) Known liver impairment or disease (4, 5.12) Known protein C, protein S, or antithrombin deficiency, or other known thrombophilic disorders (4) Known or suspected pregnancy (4, 8.1)
Estrogens increase the risk of gallbladder disease (5.4) Discontinue estrogen if severe hypercalcemia, loss of vision, severe hypertriglyceridemia or cholestatic jaundice occurs (5.5, 5.6, 5.11, 5.12) Monitor thyroid function in women on thyroid replacement therapy (5.13, 5.18)
An increased risk of stroke and DVT has been reported with estrogen-alone therapy. An increased risk of PE, DVT, stroke and MI has been reported with estrogen plus progestin therapy. Should any of these events occur or be suspected, estrogen with or without progestin therapy should be discontinued immediately. Risk factors for arterial vascular disease (for example, hypertension, diabetes mellitus, tobacco use, hypercholesterolemia, and obesity) and/or venous thromboembolism (VTE) (for example, personal or family history of VTE, obesity, and systemic lupus erythematosus) should be managed appropriately.
In the WHIMS estrogen-alone ancillary study of WHI, 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 percent CI 0.83 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 (14.6)]. In the WHIMS estrogen plus progestin ancillary study of WHI, a population of 4,532 postmenopausal women 65 to 79 years of age 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 percent CI 1.21 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 (14.6)]. 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 percent CI 1.19 2.60). Since both ancillary studies were conducted in women 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 (14.6)].
A 2- to 4-fold increase in the risk of gallbladder disease requiring surgery in postmenopausal women receiving estrogens has been reported.
Estrogen administration may lead to severe hypercalcemia in patients with breast cancer and bone metastases. If hypercalcemia occurs, use of the drug should be stopped and appropriate measures taken to reduce the serum calcium level.
Retinal vascular thrombosis has been reported in patients receiving estrogens. Discontinue medication pending examination if there is sudden partial or complete loss of vision, or a sudden onset of proptosis, diplopia, or migraine. If examination reveals papilledema or retinal vascular lesions, estrogens should be permanently discontinued.
Cases of anaphylaxis, which developed within minutes to hours after taking PREMARIN and require emergency medical management, have been reported in the postmarketing setting. Skin (hives, pruritis, swollen lips-tongue-face) and either respiratory tract (respiratory compromise) or gastrointestinal tract (abdominal pain, vomiting) involvement has been noted. Angioedema involving the tongue, larynx, face, hands, and feet requiring medical intervention has occurred postmarketing in patients taking PREMARIN. If angioedema involves the tongue, glottis, or larynx, airway obstruction may occur. Patients who develop an anaphylactic reaction with or without angioedema after treatment with PREMARIN should not receive PREMARIN again.
Studies of the addition of a progestin 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 progestins with estrogens compared to estrogen-alone regimens. These include an increased risk of breast cancer.
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 estrogen therapy on blood pressure was not seen.
In women with pre-existing hypertriglyceridemia, estrogen therapy may be associated with elevations of plasma triglycerides leading to pancreatitis. Consider discontinuation of treatment if pancreatitis occurs.
Estrogens may be poorly metabolized in patients with impaired liver function. For women with a history of cholestatic jaundice associated with past estrogen use or with pregnancy, caution should be exercised, and in the case of recurrence, medication should be discontinued.
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. These women should have their thyroid function monitored in order to maintain their free thyroid hormone levels in an acceptable range.
Estrogens may cause some degree of fluid retention. Women with conditions that might be influenced by this factor, such as cardiac or renal dysfunction, warrant careful observation when estrogen alone is prescribed.
Estrogen therapy should be used with caution in individuals with hypoparathyroidism as estrogen-induced hypocalcemia may occur.
Exogenous estrogens may exacerbate symptoms of angioedema in women with hereditary angioedema.
A few cases of malignant transformation of residual endometrial implants have been reported in women treated post-hysterectomy with estrogen-alone therapy. For women known to have residual endometriosis post-hysterectomy, the addition of progestin should be considered.
Estrogen therapy may cause an exacerbation of asthma, diabetes mellitus, epilepsy, migraine, porphyria, systemic lupus erythematosus, and hepatic hemangiomas and should be used with caution in women with these conditions.
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.
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 antifactor Xa and antithrombin III, decreased antithrombin III activity; increased levels of fibrinogen and fibrinogen activity; increased plasminogen antigen and activity. Increased thyroid-binding globulin (TBG) levels 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. 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). Increased plasma high-density lipoprotein (HDL) and HDL2 cholesterol subfraction concentrations, reduced low-density lipoprotein (LDL) cholesterol concentrations, increased triglyceride levels. Impaired glucose tolerance.
The following serious adverse reactions are discussed elsewhere in labeling: Cardiovascular Disorders [see Boxed Warning, Warnings and Precautions (5.1)] Malignant Neoplasms [see Boxed Warning, Warnings and Precautions (5.2)] Most common adverse reactions ( 5 percent) are: abdominal pain, asthenia, pain, back pain, headache, flatulence, nausea, depression, insomnia, breast pain, endometrial hyperplasia, leucorrhea, vaginal hemorrhage, and vaginitis. (6.1) To report SUSPECTED ADVERSE REACTIONS, contact Pfizer Inc. at 1-800-438-1985 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch
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 clinical practice. During the first year of a 2-year clinical trial with 2,333 postmenopausal women with a uterus between 40 and 65 years of age (88 percent Caucasian), 1,012 women were treated with conjugated estrogens, and 332 were treated with placebo. Table 1 summarizes treatment-related adverse reactions that occurred at a rate of 1 percent in any treatment group. Table 1: TREATMENT RELATED ADVERSE REACTIONS AT A FREQUENCY 1 PERCENT PREMARIN 0.625 mg (n=348) PREMARIN 0.45 mg (n=338) PREMARIN 0.3 mg (n=326) Placebo (n=332) Body as a whole Abdominal pain 38 (11) 28 (8) 30 (9) 21 (6) Asthenia 16 (5) 8 (2) 14 (4) 3 (1) Back pain 18 (5) 11 (3) 13 (4) 4 (1) Chest pain 2 (1) 3 (1) 4 (1) 2 (1) Generalized edema 7 (2) 6 (2) 4 (1) 8 (2) Headache 45 (13) 47 (14) 44 (13) 46 (14) Moniliasis 5 (1) 4 (1) 4 (1) 1 (0) Pain 17 (5) 10 (3) 12 (4) 14 (4) Pelvic pain 10 (3) 9 (3) 8 (2) 4 (1) Cardiovascular system Hypertension 4 (1) 4 (1) 7 (2) 5 (2) Migraine 7 (2) 1 (0) 0 3 (1) Palpitation 3 (1) 3 (1) 3 (1) 4 (1) Vasodilatation 2 (1) 2 (1) 3 (1) 5 (2) Digestive system Constipation 7 (2) 6 (2) 4 (1) 3 (1) Diarrhea 4 (1) 5 (1) 5 (2) 8 (2) Dyspepsia 7 (2) 5 (1) 6 (2) 14 (4) Eructation 1 (0) 1 (0) 4 (1) 1 (0) Flatulence 22 (6) 18 (5) 13 (4) 8 (2) Increased appetite 4 (1) 1 (0) 1 (0) 2 (1) Nausea 16 (5) 10 (3) 15 (5) 16 (5) Metabolic and nutritional Hyperlipidemia 2 (1) 4 (1) 3 (1) 2 (1) Peripheral edema 5 (1) 2 (1) 4 (1) 3 (1) Weight gain 11 (3) 10 (3) 8 (2) 14 (4) Musculoskeletal system Arthralgia 6 (2) 3 (1) 2 (1) 5 (2) Leg cramps 10 (3) 5 (1) 9 (3) 4 (1) Myalgia 2 (1) 1 (0) 4 (1) 1 (0) Nervous system Anxiety 6 (2) 4 (1) 2 (1) 4 (1) Depression 17 (5) 15 (4) 10 (3) 17 (5) Dizziness 9 (3) 7 (2) 4 (1) 5 (2) Emotional lability 3 (1) 4 (1) 5 (2) 8 (2) Hypertonia 1 (0) 1 (0) 5 (2) 3 (1) Insomnia 16 (5) 10 (3) 13 (4) 14 (4) Nervousness 9 (3) 12 (4) 2 (1) 6 (2) Skin and appendages Acne 3 (1) 1 (0) 8 (2) 3 (1) Alopecia 6 (2) 6 (2) 5 (2) 2 (1) Hirsutism 4 (1) 2 (1) 1 (0) 0 Pruritus 11 (3) 11 (3) 10 (3) 3 (1) Rash 6 (2) 3 (1) 1 (0) 2 (1) Skin discoloration 4 (1) 2 (1) 0 1 (0) Sweating 4 (1) 1 (0) 3 (1) 4 (1) Urogenital system Breast disorder 6 (2) 3 (1) 3 (1) 6 (2) Breast enlargement 3 (1) 4 (1) 7 (2) 3 (1) Breast neoplasm 4 (1) 4 (1) 7 (2) 7 (2) Breast pain 37 (11) 39 (12) 24 (7) 26 (8) Cervix disorder 8 (2) 4 (1) 5 (2) 0 Dysmenorrhea 12 (3) 10 (3) 4 (1) 2 (1) Endometrial disorder 4 (1) 2 (1) 2 (1) 0 Endometrial hyperplasia 16 (5) 8 (2) 1 (0) 0 Leukorrhea 17 (5) 17 (5) 12 (4) 6 (2) Metrorrhagia 11 (3) 4 (1) 3 (1) 1 (0) Urinary tract infection 1 (0) 2 (1) 1 (0) 4 (1) Uterine fibroids enlarged 6 (2) 1 (0) 2 (1) 2 (1) Uterine spasm 11 (3) 5 (1) 3 (1) 2 (1) Vaginal dryness 1 (0) 2 (1) 1 (0) 6 (2) Vaginal hemorrhage 46 (13) 13 (4) 6 (2) 0 Vaginal moniliasis 14 (4) 10 (3) 12 (4) 5 (2) Vaginitis 18 (5) 7 (2) 9 (3) 1 (0)
The following additional adverse reactions have been identified during post-approval use of PREMARIN. Because these reactions are reported voluntarily from a population of uncertain size, it is not possible always to reliably estimate their frequency or establish a causal relationship to drug exposure.
Data from a single-dose drug-drug interaction study involving conjugated estrogens and medroxyprogesterone acetate indicate that the pharmacokinetic disposition of both drugs is not altered when the drugs are coadministered. No other clinical drug-drug interaction studies have been conducted with conjugated estrogens. Inducers and/or inhibitors of CYP3A4 may affect estrogen drug metabolism (7.1)
In vitro and in vivo studies have shown that estrogens are metabolized partially by cytochrome P450 3A4 (CYP3A4). Therefore, inducers or inhibitors of CYP3A4 may affect estrogen drug metabolism. Inducers of CYP3A4, such as St. John's Wort (Hypericum perforatum) preparations, phenobarbital, carbamazepine, and rifampin, may reduce plasma concentrations of estrogens, possibly resulting in a decrease in therapeutic effects and/or changes in the uterine bleeding profile. Inhibitors of CYP3A4, such as erythromycin, clarithromycin, ketoconazole, itraconazole, ritonavir and grapefruit juice, may increase plasma concentrations of estrogens and may result in side effects.
Nursing Mothers: Estrogen administration has been shown to decrease the quantity and quality of breast milk (8.3) Geriatric Use: An increased risk of probable dementia in women over 65 years of age was reported in the Women's Health Initiative Memory ancillary studies of the Women's Health Initiative (5.3, 8.5)
PREMARIN should not be used during pregnancy [see Contraindications (4)]. There appears to be little or no increased risk of birth defects in children born to women who have used estrogens and progestins as an oral contraceptive inadvertently during early pregnancy.
PREMARIN should not be used during lactation. Estrogen administration to nursing women has been shown to decrease the quantity and quality of the breast milk. Detectable amounts of estrogens have been identified in the breast milk of mothers receiving estrogen-alone therapy. Caution should be exercised when PREMARIN is administered to a nursing woman.
Estrogen therapy has been used for the induction of puberty in adolescents with some forms of pubertal delay. Safety and effectiveness in pediatric patients have not otherwise been established. Large and repeated doses of estrogen over an extended time period have been shown to accelerate epiphyseal closure, which could result in short stature if treatment is initiated before the completion of physiologic puberty in normally developing children. 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. Estrogen treatment of prepubertal girls also induces premature breast development and vaginal cornification, and may induce vaginal bleeding. In boys, estrogen treatment may modify the normal pubertal process and induce gynecomastia.
There have not been sufficient numbers of geriatric patients involved in studies utilizing PREMARIN to determine whether those over 65 years of age differ from younger subjects in their response to PREMARIN.
The effect of renal impairment on the pharmacokinetics of PREMARIN has not been studied.
The effect of hepatic impairment on the pharmacokinetics of PREMARIN has not been studied.
Overdosage of estrogen may cause nausea, vomiting, breast tenderness, abdominal pain, drowsiness and fatigue, and withdrawal bleeding may occur in women. Treatment of overdose consists of discontinuation of PREMARIN therapy with institution of appropriate symptomatic care.
PREMARIN (conjugated estrogens tablets, USP) for oral administration contains a mixture of conjugated estrogens purified from pregnant mares' urine and consists of the sodium salts of water-soluble estrogen sulfates blended to represent the average composition of material derived from pregnant mares' urine. It is a mixture of sodium estrone sulfate and sodium equilin sulfate. It contains concomitant components as sodium sulfate conjugates, 17 -dihydroequilin, 17 estradiol, and 17 -dihydroequilin. Tablets for oral administration are available in 0.3 mg, 0.45 mg, 0.625 mg, 0.9 mg, and 1.25 mg strengths of conjugated estrogens. PREMARIN 0.3 mg, 0.45 mg, 0.625 mg, 0.9 mg, and 1.25 mg tablets also contain the following inactive ingredients: calcium phosphate tribasic, carnauba wax, hydroxypropyl cellulose, hypromellose, lactose monohydrate, magnesium stearate, microcrystalline cellulose, polyethylene glycol, powdered cellulose, sucrose, and titanium dioxide. Each tablet strength contains the following colors: Tablet strength Tablet color contains 0.3 mg D&C Yellow No. 10 and FD&C Blue No. 2 0.45 mg FD&C Blue No. 2 0.625 mg FD&C Blue No. 2 and FD&C Red No. 40 0.9 mg D&C Red No. 30 and D&C Red No. 7 1.25 mg Black iron oxide, D&C Yellow No. 10 and FD&C Yellow No. 6 PREMARIN tablets comply with USP Dissolution Test criteria, as outlined below: PREMARIN 1.25 mg tablets USP Dissolution Test 4 PREMARIN 0.3 mg, 0.45 mg and 0.625 mg tablets USP Dissolution Test 5 PREMARIN 0.9 mg tablets USP Dissolution Test 6
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, two 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 FSH, through a negative feedback mechanism. Estrogens act to reduce the elevated levels of these gonadotropins seen in postmenopausal women.
There are no pharmacodynamic data for PREMARIN.
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.
In the first year of the Health and Osteoporosis, Progestin and Estrogen (HOPE) Study, a total of 2,805 postmenopausal women (average age 53.3 4.9 years) were randomly assigned to one of eight treatment groups of either placebo or conjugated estrogens, with or without medroxyprogesterone acetate. Efficacy for vasomotor symptoms was assessed during the first 12 weeks of treatment in a subset of symptomatic women (n = 241) who had at least seven moderate to severe hot flushes daily, or at least 50 moderate to severe hot flushes during the week before randomization. PREMARIN (0.3 mg, 0.45 mg, and 0.625 mg tablets) was shown to be statistically better than placebo at weeks 4 and 12 for relief of both frequency and severity of moderate to severe vasomotor symptoms. Table 3 shows the adjusted mean number of hot flushes in the PREMARIN 0.3 mg, 0.45 mg, and 0.625 mg and placebo groups during the initial 12-week period. Table 3: SUMMARY TABULATION OF THE NUMBER OF HOT FLUSHES PER DAY MEAN VALUES AND COMPARISONS BETWEEN THE ACTIVE TREATMENT GROUPS AND THE PLACEBO GROUP: PATIENTS WITH AT LEAST 7 MODERATE TO SEVERE FLUSHES PER DAY OR AT LEAST 50 PER WEEK AT BASELINE, LAST OBSERVATION CARRIED FORWARD (LOCF) Treatment (No. of Patients) ---------------No. of Hot Flushes/Day--------------- Time Period (week) Baseline Mean SD Observed Mean SD Mean Change SD p-Values vs Placebo Based on analysis of covariance with treatment as factor and baseline as covariate. 0.625 mg CE (n = 27) 4 12.29 3.89 1.95 2.77 -10.34 4.73 <0.001 12 12.29 3.89 0.75 1.82 -11.54 4.62 <0.001 0.45 mg CE (n = 32) 4 12.25 5.04 5.04 5.31 -7.21 4.75 <0.001 12 12.25 5.04 2.32 3.32 -9.93 4.64 <0.001 0.3 mg CE (n = 30) 4 13.77 4.78 4.65 3.71 -9.12 4.71 <0.001 12 13.77 4.78 2.52 3.23 -11.25 4.60 <0.001 Placebo (n = 28) 4 11.69 3.87 7.89 5.28 -3.80 4.71 - 12 11.69 3.87 5.71 5.22 -5.98 4.60 -
Results of vaginal maturation indexes at cycles 6 and 13 showed that the differences from placebo were statistically significant (p < 0.001) for all treatment groups. (conjugated estrogens alone and conjugated estrogens/medroxyprogesterone acetate treatment groups).
In clinical studies of delayed puberty due to female hypogonadism, breast development was induced by doses as low as 0.15 mg. The dosage may be gradually titrated upward at 6-to 12 month intervals as needed to achieve appropriate bone age advancement and eventual epiphyseal closure. Clinical studies suggest that doses of 0.15 mg, 0.3 mg, and 0.6 mg are associated with mean ratios of bone age advancement to chronological age progression ( BA/ CA) of 1.1, 1.5, and 2.1, respectively. (PREMARIN in the dose strength of 0.15 mg is not available commercially). Available data suggest that chronic dosing with 0.625 mg is sufficient to induce artificial cyclic menses with sequential progestin treatment and to maintain bone mineral density after skeletal maturity is achieved.
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 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.
The WHIMS estrogen-alone ancillary study of WHI enrolled 2,947 predominantly healthy hysterectomized postmenopausal women 65 to 79 years of age (45 percent were 65 to 69 years of age; 36 percent were 70 to 74 years of age; 19 percent 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 percent CI 0.83 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 groups 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 percent were 65 to 69 years of age; 35 percent were 70 to 74 years; 18 percent 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 percent CI, 1.21 3.48). The absolute risk of probable dementia for CE (0.625 mg) plus MPA (2.5 mg) versus placebo was 45 versus 22 per 10,000 women-years. Probable dementia as defined in this study included AD, VaD and mixed types (having features of both AD and VaD). The most common classification of probable dementia in both the treatment and placebo groups 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 percent CI 1.19 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)].
1 Rossouw JE, et al. Postmenopausal Hormone Therapy and Risk of Cardiovascular Disease by Age and Years Since Menopause. JAMA. 2007;297:1465 1477. 2Hsia J, et al. Conjugated Equine Estrogens and Coronary Heart Disease. Arch Int Med. 2006;166:357 365. 3Curb JD, et al. Venous Thrombosis and Conjugated Equine Estrogen in Women Without a Uterus. Arch Int Med. 2006;166:772 780. 4Cushman M, et al. Estrogen Plus Progestin and Risk of Venous Thrombosis. JAMA. 2004;292:1573 1580. 5Stefanick ML, et al. Effects of Conjugated Equine Estrogens on Breast Cancer and Mammography Screening in Postmenopausal Women With Hysterectomy. JAMA. 2006;295:1647 1657. 6Chlebowski RT, et al. Influence of Estrogen Plus Progestin on Breast Cancer and Mammography in Healthy Postmenopausal Women. JAMA. 2003;289:3234 3253. 7Anderson GL, et al. Effects of Estrogen Plus Progestin on Gynecologic Cancers and Associated Diagnostic Procedures. JAMA. 2003;290:1739 1748. 8Shumaker SA, et al. Conjugated Equine Estrogens and Incidence of Probable Dementia and Mild Cognitive Impairment in Postmenopausal Women. JAMA. 2004;291:2947 2958. 9Jackson RD, et al. Effects of Conjugated Equine Estrogen on Risk of Fractures and BMD in Postmenopausal Women With Hysterectomy: Results From the Women's Health Initiative Randomized Trial. J Bone Miner Res. 2006;21:817 828. 10Hendrix SL, et al. Effects of Conjugated Equine Estrogen on Stroke in the Women's Health Initiative. Circulation. 2006;113:2425 2434.
PREMARIN (conjugated estrogens tablets, USP) Each oval green tablet contains 0.3 mg, in bottles of 100 (NDC 0046-1100-81) and 1,000 (NDC 0046-1100-91). Each oval blue tablet contains 0.45 mg, in bottles of 100 (NDC 0046-1101-81). Each oval maroon tablet contains 0.625 mg, in bottles of 100 (NDC 0046-1102-81) and 1,000 (NDC 0046-1102-91). Each oval white tablet contains 0.9 mg, in bottles of 100 (NDC 0046-1103-81). Each oval yellow tablet contains 1.25 mg, in bottles of 100 (NDC 0046-1104-81) and 1,000 (NDC 0046-1104-91). The appearance of these tablets is a trademark of Wyeth LLC.
Store at 20 to 25 C (68 to 77 F); excursions permitted to 15 to 30 C (59 to 86 F) [see USP Controlled Room Temperature]. Dispense in a well-closed container, as defined in the USP.
See FDA-approved patient labeling (Patient Information).
Inform postmenopausal women of the importance of reporting vaginal bleeding to their healthcare provider as soon as possible [see Warnings and Precautions (5.2)].
Inform postmenopausal women of possible serious adverse reactions of estrogen therapy including Cardiovascular Disorders, Malignant Neoplasms, and Probable Dementia [see Warnings and Precautions (5.1, 5.2, 5.3)].
Inform postmenopausal women of possible less serious but common adverse reactions of estrogen therapy such as headache, breast pain and tenderness, nausea and vomiting.
PREMARIN (prem-uh-rin) (Conjugated estrogen tablets, USP) Read this PATIENT INFORMATION before you start taking PREMARIN and read what you get each time you refill your PREMARIN prescription. There may be new information. This information does not take the place of talking to your healthcare provider about your medical condition or your treatment.
NDC 0046-1101-81Pfizer PREMARIN (conjugated estrogenstablets, USP) 0.45 mg 100 TabletsRx only
NDC 0046-1102-91Pfizer PREMARIN (conjugated estrogenstablets, USP) 0.625 mg Note: Dispense in child-resistant packaging.This package not for household use. 1,000 TabletsRx only
PfizerNDC 0046-1102-91Rx only PREMARIN (conjugated estrogenstablets, USP) 0.625 mg Note: Dispense in tight (USP), child-resistant containers.This package not for household use. 1,000 Tablets
NDC 0046-1102-52 PROFESSIONALSAMPLE -NOT FOR SALE PREMARIN 0.625 mg(conjugated estrogens tablets, USP) Blister card contains five 0.625 mg tablets Rx only
NDC 0046-1104-91Pfizer PREMARIN (conjugated estrogenstablets, USP) 1.25 mg Note: Dispense in tight (USP), child-resistant containers.This package not for household use. 1,000 TabletsRx only
NDC 0046-1104-91Pfizer PREMARIN (conjugated estrogenstablets, USP) 1.25 mg Note:Dispense in tight (USP),child-resistant containers.This package not for household use. 1,000 TabletsRx only
NDC 0046-1100-91Pfizer PREMARIN (conjugated estrogenstablets, USP) 0.3 mg Note: Dispense in child-resistant packaging.This package not for household use. 1,000 TabletsRx only
PfizerNDC 0046-1100-91Rx only PREMARIN (conjugated estrogenstablets, USP) 0.3 mg Note: Dispense in tight (USP), child-resistant containers.This package not for household use. 1,000 Tablets
NDC 0046-1100-52 PROFESSIONALSAMPLE -NOT FOR SALE PREMARIN 0.3 mg(conjugated estrogens tablets, USP) Blister card contains five 0.3 mg tablets Rx only
NDC 0046-1103-81Pfizer PREMARIN (conjugated estrogenstablets, USP) 0.9 mg 100 TabletsRx only