Estradiol benzoate/progesterone

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Estradiol benzoate/progesterone
Estradiol benzoate.svg
Progesterone.svg
Estradiol benzoate (top) and
progesterone (bottom)
Combination of
Estradiol benzoate Estrogen
Progesterone Progestogen
Clinical data
Trade names Clinomin Forte, Duogynon, Lutrogen, Sistocyclin, Vermagest, others
Other namesEB/P4
Routes of
administration 		Intramuscular injection (oil solution, aqueous suspension)
ATC code
Identifiers
CAS Number
PubChem CID
ChemSpider
UNII

Estradiol benzoate/progesterone (EB/P4), sold under the brand names Duogynon and Sistocyclin among others, is a combination medication of estradiol benzoate (EB), an estrogen, and progesterone (P4), a progestogen. [1] [2] [3] It has been formulated both as short-acting oil solutions and long-acting microcrystalline aqueous suspensions and is given by injection into muscle either once or continuously at regular intervals. [4] [5]

Contents

EB/P4 was one of the first combined estrogen and progestogen medications to be introduced for medical use. [6] It was first marketed in Germany as an oil solution in 1950. [6] Microcrystalline EB/P4 in aqueous suspension was developed and marketed under the brand name Sistocyclin several years later. [6] EB/P4 was eventually superseded by longer-acting parenteral estrogen–progestogen combinations as well as by oral estrogen–progestogen combinations. [6]

Medical uses

EB/P4 has been used to treat menstrual disorders such as secondary amenorrhea and menstrual irregularity, [4] [5] as a form of emergency contraception within 48 hours of sexual intercourse, [7] [8] and as a test for pregnancy. [4] [5] In the form of a microcrystalline aqueous suspension, EB/P4 has particularly been used to treat functional uterine bleeding. [9] [10]

EB/P4 has been studied in the treatment of breast cancer in women and found to be effective. [11] [12] [13]

Available forms

EB/P4 is or has been available for use by intramuscular injection both in the form of short-acting oil solutions (e.g., Duogynon, Lutrogen) and long-acting microcrystalline aqueous suspensions (e.g., Clinomin Forte, Sistocyclin). [4] [5] [14] These are provided as ampoules, with the oil-solution ampoules containing 2–3 mg EB and 12.5–50 mg progesterone and the aqueous-suspension ampoules containing 10 mg EB and 200 mg progesterone. [4] The crystal sizes in microcrystalline EB/P4 in aqueous suspension (Sistocyclin) are 0.01 to 0.02 mm for EB crystals and 0.02 to 0.1 mm for P4 crystals. [15] [16] [17] An oil-solution ampoule containing 30 mg EB and 30 mg P4 (brand name Vermagest) is used as an injectable emergency contraceptive. [18] [7] [8] Clinomin Forte is an aqueous suspension of EB/P4 that additionally contains lidocaine and remains available today. [19]

Side effects

Pharmacology

Pharmacodynamics

EB is an estrogen, or an agonist of the estrogen receptors, the biological target of estrogens like endogenous estradiol. [20] It is an estradiol ester and prodrug of estradiol with a longer duration of action than estradiol when administered by intramuscular injection in oil solution or aqueous suspension. [20] P4 is a progestogen, or an agonist of the progesterone receptors, the biological target of progestogens like endogenous progesterone. [20]

The full endometrial transformation dosage of EB/P4 in oil solution is 1 to 2 mg EB and 20 to 25 mg P4 by intramuscular injection daily for 10 to 14 days, whereas the full endometrial transformation dosage of EB/P4 in microcrystalline aqueous suspension is a single intramuscular injection of 10 mg EB and 200 mg P4. [6] For comparison, the full endometrial transformation dosage of estradiol valerate and hydroxyprogesterone caproate in oil solution (brand name Gravibinon) is a single intramuscular injection of 10 mg estradiol valerate and 250 to 375 mg hydroxyprogesterone caproate. [6] Endometrial transformation normally occurs during the luteal phase of the menstrual cycle; it is induced by endogenous progesterone following adequate priming by endogenous estradiol. [21]

The decidua (pregnancy-type endometrium) induction dosage of EB/P4 in oil solution is 2 to 5 mg EB and 20 to 100 mg P4 by intramuscular injection daily for 5 to 7 weeks, whereas the decidua induction dosage of EB/P4 in microcrystalline aqueous suspension is 10 to 20 mg EB and 200 to 250 mg P4 in microcrystalline aqueous suspension by intramuscular injection once per week for about 6 weeks. [6] For comparison, the decidua induction dosage of estradiol valerate and hydroxyprogesterone caproate in oil solution is about the same as that of microcrystalline EB/P4 in aqueous suspension. [6] The decidua induction dosages of estrogen and progestogen combinations are pseudopregnancy dosages. [6]

Pharmacokinetics

EB/P4 is administered by intramuscular injection a single time or continuously at regular intervals, depending on the indication. [4] [5] [22] Amorphous EB/P4 in oil solution (e.g., Duogynon, Lutrogen) is reported to have a duration of action of 2 days in terms of the progestogen component, and hence is a short-acting preparation, whereas microcrystalline EB/P4 in aqueous suspension (e.g., Sistocyclin) has a duration of 10 to 12 days, and hence is a long-acting preparation. [22] [5] A study found that a single intramuscular injection of 10 mg microcrystalline EB in aqueous suspension with a 0.05 mm crystal size (similar to that in Sistocyclin) resulted in a maximal 7-fold increase in estradiol excretion on the 2nd day after injection and maintained elevated estradiol excretion for 17 days. [16] [17]

Potencies and durations of natural estrogens by intramuscular injection
EstrogenFormDose (mg)Duration by dose (mg)
EPDCICD
Estradiol Aq. soln. ?–<1 d
Oil soln.40–60–1–2 ≈ 1–2 d
Aq. susp. ?3.50.5–2 ≈ 2–7 d; 3.5 ≈ >5 d
Microsph. ?–1 ≈ 30 d
Estradiol benzoate Oil soln.25–35–1.66 ≈ 2–3 d; 5 ≈ 3–6 d
Aq. susp.20–10 ≈ 16–21 d
Emulsion ?–10 ≈ 14–21 d
Estradiol dipropionate Oil soln.25–30–5 ≈ 5–8 d
Estradiol valerate Oil soln.20–3055 ≈ 7–8 d; 10 ≈ 10–14 d;
40 ≈ 14–21 d; 100 ≈ 21–28 d
Estradiol benz. butyrate Oil soln. ?1010 ≈ 21 d
Estradiol cypionate Oil soln.20–30–5 ≈ 11–14 d
Aq. susp. ?55 ≈ 14–24 d
Estradiol enanthate Oil soln. ?5–1010 ≈ 20–30 d
Estradiol dienanthate Oil soln. ?–7.5 ≈ >40 d
Estradiol undecylate Oil soln. ?–10–20 ≈ 40–60 d;
25–50 ≈ 60–120 d
Polyestradiol phosphate Aq. soln.40–60–40 ≈ 30 d; 80 ≈ 60 d;
160 ≈ 120 d
Estrone Oil soln. ?–1–2 ≈ 2–3 d
Aq. susp. ?–0.1–2 ≈ 2–7 d
Estriol Oil soln. ?–1–2 ≈ 1–4 d
Polyestriol phosphate Aq. soln. ?–50 ≈ 30 d; 80 ≈ 60 d
Notes and sources
Notes: All aqueous suspensions are of microcrystalline particle size. Estradiol production during the menstrual cycle is 30–640 µg/d (6.4–8.6 mg total per month or cycle). The vaginal epithelium maturation dosage of estradiol benzoate or estradiol valerate has been reported as 5 to 7 mg/week. An effective ovulation-inhibiting dose of estradiol undecylate is 20–30 mg/month. Sources: See template.
Parenteral potencies and durations of progestogens [lower-alpha 1] [lower-alpha 2]
CompoundFormDose for specific uses (mg) [lower-alpha 3] DOA [lower-alpha 4]
TFD [lower-alpha 5] POICD [lower-alpha 6] CICD [lower-alpha 7]
Algestone acetophenide Oil soln.-–75–15014–32 d
Gestonorone caproate Oil soln.25–50––8–13 d
Hydroxyprogest. acetate [lower-alpha 8] Aq. susp.350––9–16 d
Hydroxyprogest. caproate Oil soln.250–500 [lower-alpha 9] –250–5005–21 d
Medroxyprog. acetate Aq. susp.50–1001502514–50+ d
Megestrol acetate Aq. susp.-–25>14 d
Norethisterone enanthate Oil soln.100–2002005011–52 d
Progesterone Oil soln.200 [lower-alpha 9] ––2–6 d
Aq. soln. ?––1–2 d
Aq. susp.50–200––7–14 d
Notes and sources:
  1. ↑ Sources: [23] [24] [25] [26] [27] [28] [29] [30] [31] [32] [33] [34] [35] [36] [37] [38] [39] [40] [41] [42]
  2. ↑ All given by intramuscular or subcutaneous injection.
  3. ↑ Progesterone production during the luteal phase is ~25 (15–50) mg/day. The OID of OHPC is 250 to 500 mg/month.
  4. ↑ Duration of action in days.
  5. ↑ Usually given for 14 days.
  6. ↑ Usually dosed every two to three months.
  7. ↑ Usually dosed once monthly.
  8. ↑ Never marketed or approved by this route.
  9. 1 2 In divided doses (2 × 125 or 250 mg for OHPC, 10 × 20 mg for P4).

History

EB/P4 in oil solution for use by intramuscular injection was first marketed in Germany in 1950. [6] It was one of the first combined estrogen and progestogen medications to be introduced for medical use. [6] To achieve a longer duration of action, microcrystalline EB/P4 with defined crystal sizes in aqueous suspension was developed, studied in 1954, [43] and marketed under the brand name Sistocyclin shortly thereafter in the 1950s. [11] [9] [10] [5] [14] Formulations containing a combination of EB or estradiol valerate (an estradiol ester with a longer duration than EB) and the longer-acting synthetic progestogen hydroxyprogesterone caproate in oil solution (brand names Primosiston, Gravibinon) were introduced in 1955 and eventually superseded EB/P4. [6] Oral estrogen–progestogen combinations, such as mestranol/noretynodrel (brand name Enovid), were also introduced in the 1950s, and soon replaced EB/P4 for menstrual and other indications as well. [6]

Society and culture

Brand names

EB/P4 has been marketed under a large number of brand names including Component E-C, Component E-S, Di Pro Oleosum, Duogynon, Duogynon ampule, Duogynon forte, Duogynon simplex, Duoton Fort T P, Emmenovis, Estroprogyn, Gestrygen, Implus-C, Implus S, Jephagynon, Klimovan, Limovanil, Lutofolone, Menovis, Menstrogen Forte, Mestrolar, Metrigen Fuerte, Nomestrol, Phenokinon-F, Pro-Estramon-S, Prodiol, Proger F, Progestediol, Sistocyclin, Synovex C, Synovex S, and Tonevex S. [1] [2] [3] [44]

Availability

EB/P4 was originally developed and marketed in Europe. [4] [5] Today, it is available in a number of places in the world including various Latin American countries, Egypt, Italy, Lebanon, Taiwan, Thailand, Turkey, Malaysia, and Ethiopia. [1] [2] [3] EB/P4 is available specifically as an injectable emergency contraceptive in El Salvador, Honduras, and Nicaragua. [18] [7] [8]

EB/P4 in oil solution remains widely available throughout the world. [1] [2] [45] [46] Conversely, Sistocyclin, or microcrystalline EB/P4 in aqueous suspension, is no longer marketed. [1] [2] [45] [46] However, individual formulations of microcrystalline EB in aqueous suspension (brand name Agofollin Depot) [47] and microcrystalline P4 in aqueous suspension (brand name Agolutin Depot) [48] remain available in some countries, including the Czech Republic and Slovakia. [1] [2] [45] [46]

Veterinary uses

EB/P4 is used in veterinary medicine under the brand names Component E-C, Component E-S, Synovex C, and Synovex S, among others. [1] [2]

See also

Related Research Articles

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Estrone/progesterone/testosterone (E1/P4/T), sold under the brand name Tristeron or Tristerone, is an injectable combination medication of estrone (E1), an estrogen, progesterone (P4), a progestogen, and testosterone (T), an androgen/anabolic steroid, which was used in the treatment of functional uterine bleeding in women. It contained 6 mg estrone, 50 mg progesterone, and 25 mg testosterone in microcrystalline aqueous suspension and was administered by intramuscular injection. The medication was manufactured by Wyeth and was marketed by 1951. It is no longer available.

Estradiol diundecylate/hydroxyprogesterone heptanoate/testosterone cyclohexylpropionate (EDU/OHPH/TCHP), sold under the brand name Trioestrine Retard, is an injectable combination medication of estradiol diundecylate (EDU), an estrogen, hydroxyprogesterone heptanoate (OHPH), a progestogen, and testosterone cyclohexylpropionate (TCHP), an androgen/anabolic steroid. It contained 2.25 mg EDU, 100 mg OHPH, and 67.5 mg TCHP in oil solution, was provided as ampoules, and was administered by intramuscular injection. The medication was manufactured by Roussel and Théramex and was marketed by 1953. It is no longer available.

Estradiol benzoate/progesterone/testosterone propionate (EB/P4/TP), sold under the brand names Lukestra, Steratrin, Trihormonal, and Trinestryl, is an injectable combination medication of estradiol benzoate (EB), an estrogen, progesterone (P4), a progestogen, and testosterone propionate (TP), an androgen/anabolic steroid. It contained 1 to 3 mg EB, 20 to 25 mg P4, and 25 mg TP, was provided in the form of ampoules, and was administered by intramuscular injection. The medication was introduced by 1949 and was marketed in the United States, the United Kingdom, and Germany among other places. It is no longer available.

References

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  30. ↑ Henzl MR, Edwards JA (10 November 1999). "Pharmacology of Progestins: 17α-Hydroxyprogesterone Derivatives and Progestins of the First and Second Generation". In Sitruk-Ware R, Mishell DR (eds.). Progestins and Antiprogestins in Clinical Practice. Taylor & Francis. pp. 101–132. ISBN   978-0-8247-8291-7.
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  36. ↑ Becker H, Düsterberg B, Klosterhalfen H (1980). "[Bioavailability of cyproterone acetate after oral and intramuscular application in men (author's transl)]" [Bioavailability of Cyproterone Acetate after Oral and Intramuscular Application in Men]. Urologia Internationalis. 35 (6): 381–5. doi:10.1159/000280353. PMID   6452729.
  37. ↑ Moltz L, Haase F, Schwartz U, Hammerstein J (May 1983). "[Treatment of virilized women with intramuscular administration of cyproterone acetate]" [Efficacy of Intra muscularly Applied Cyproterone Acetate in Hyperandrogenism]. Geburtshilfe Und Frauenheilkunde. 43 (5): 281–7. doi:10.1055/s-2008-1036893. PMID   6223851.
  38. ↑ Wright JC, Burgess DJ (29 January 2012). Long Acting Injections and Implants. Springer Science & Business Media. pp. 114–. ISBN   978-1-4614-0554-2.
  39. ↑ Chu YH, Li Q, Zhao ZF (April 1986). "Pharmacokinetics of megestrol acetate in women receiving IM injection of estradiol-megestrol long-acting injectable contraceptive". The Chinese Journal of Clinical Pharmacology. The results showed that after injection the concentration of plasma MA increased rapidly. The meantime of peak plasma MA level was 3rd day, there was a linear relationship between log of plasma MA concentration and time (day) after administration in all subjects, elimination phase half-life t1/2β = 14.35 ± 9.1 days.
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