PHARMACOKINETICS SECTION.

12.3Pharmacokinetics. AbsorptionEstradiol acetate is hydrolyzed to estradiol which is absorbed through the vaginal mucosa as evidenced by the mean time to maximum concentration (t max) for estradiol of about hour (range 0.25 to 1.5 hrs). After achieving the Cmax the estradiol concentration starts declining during the first 24 to 48 hours and then at relatively constant rate for the remainder of the 3-month dosing interval (see Figure for results from rings stored for 16 months). In vitro studies have shown that this initial release is higher as the rings age upon storage. Following administration of Femring (0.05 mg/day estradiol), average serum estradiol concentration was 40.6 pg/mL; the corresponding apparent in vivo estradiol delivery rate was 0.052 mg/day. Following administration of Femring (0.10 mg/day estradiol), average serum estradiol concentration was 76 pg/mL; apparent in vivo delivery rate was 0.097 mg/day. Results are summarized in Table below. Table 2. Summary of Mean (Percent RSD) Pharmacokinetic Parameters for FemringDose(as estradiol)Numberof subjectsCmax(pg/mL)Tmax(hour)Cavg(pg/mL)0.05 mg/dayEstradiol 251129 (25)0.9 (41)40.6 (26)Estrone 25141 (25)6.2 (84)35.9 (21)Estrone sulfate 252365 (44)9.3 (39)494.6 (48)0.10 mg/dayEstradiol 121665 (23)0.7 (90)-- Estradiol 11----76.0 (24)Estrone 11----45.7 (25) Relative Standard Deviation, 1Study 1, 2Study 2, 3Study 3, 4-- Not determined Consistent with the avoidance of first pass metabolism achieved by vaginal estradiol administration, serum estradiol concentrations were slightly higher than estrone concentrations.DistributionThe distribution of exogenous estrogens is similar to that of endogenous estrogens. Estrogens are widely distributed in the body and are generally found in higher concentrations in the sex hormone target organs. Estrogens circulate in the blood largely bound to SHBG and albumin.MetabolismExogenous estrogens are metabolized in the same manner as endogenous estrogens. Circulating estrogens exist in dynamic equilibrium of metabolic interconversions. These transformations take place mainly in the liver. Estradiol is converted reversibly to estrone, and both can be converted to estriol, which is major urinary metabolite. Estrogens also undergo enterohepatic recirculation via sulfate and glucuronide conjugation in the liver, biliary secretion of conjugates into the intestine, and hydrolysis in the intestine followed by reabsorption. In postmenopausal women, significant proportion of the circulating estrogens exist as sulfate conjugates, especially estrone sulfate, which serves as circulating reservoir for the formation of more active estrogens.ExcretionEstradiol, estrone, and estriol are excreted in the urine along with glucuronide and sulfate conjugates.The estradiol apparent elimination half-life value is 21 to 26 hours.Use in Specific PopulationsNo pharmacokinetic studies were conducted with Femring in specific populations, including women with renal or hepatic impairment.. Figure 1. Mean serum estradiol concentrations following multiple dose administration of Femring (0.05 mg/day estradiol) (second dose administered at 13 weeks) (inset: mean (+-SD) of serum concentrati.

PREGNANCY SECTION.

8.1Pregnancy Femring 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.

RECENT MAJOR CHANGES SECTION.

Warnings and Precautions, Malignant Neoplasms 5.2) 11/2017.

ADVERSE REACTIONS SECTION.

6 ADVERSE REACTIONS. The following serious adverse reactions are discussed elsewhere in the labeling:Cardiovascular Disorders see Boxed Warning, Warnings and Precautions (5.1) ]. Malignant Neoplasms see Boxed Warning, Warnings and Precautions (5.2) ]. Cardiovascular Disorders see Boxed Warning, Warnings and Precautions (5.1) ]. Malignant Neoplasms see Boxed Warning, Warnings and Precautions (5.2) ]. Most common adverse reactions (incidence 5 percent) are vaginal bleeding and breast tenderness. 6.1) To report SUSPECTED ADVERSE REACTIONS, Millicent at 1-877-810-2101 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch. 6.1Clinical Trials Experience. Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice.In 13-week clinical trial that included 225 postmenopausal women treated with Femring and 108 women treated with placebo vaginal rings, adverse reactions that occurred at rate of >= percent are summarized in Table 1. Table 1. Incidence of Adverse Reactions Occurring in >= Percent of Subjects Presented in Descending Frequency of Preferred TermAdverse EventPlacebo(n 108)Estradiol0.05 mg/day(n 113)Estradiol0.10 mg/day(n 112)n (percent)n (percent)n (percent)Headache (NOS)10 (9.3)8 (7.1)11 (9.8)Intermenstrual Bleeding2 (1.9)9 (8.0)11 (9.8)Vaginal Candidiasis3 (2.8)7 (6.2)12 (10.7)Breast Tenderness2 (1.9)7 (6.2)12 (10.7)Back Pain4 (3.7)7 (6.2)4 (3.6)Abdominal Distension3 (2.8)8 (7.1)3 (2.7)Sinusitis (NOS)2 (1.9)2 (1.8)4 (3.6)Uterine Pain1 (0.9)2 (1.8)5 (4.5)Urinary Tract Infection (NOS)2 (1.9)1 (0.9)4 (3.6)AE adverse event; NOS not otherwise specified. 6.2Postmarketing Experience. few cases of toxic shock syndrome (TSS) have been reported in women using vaginal rings. TSS is rare, but serious disease that may cause death. Warning signs of TSS include fever, nausea, vomiting, diarrhea, muscle pain, dizziness, faintness, or sunburn-rash on face and body.Cases of ring adherence to the vaginal or bladder wall, making ring removal difficult, have been reported in women using vaginal rings and may require surgical removal of the device. Women should be carefully evaluated for vaginal or bladder wall ulceration or erosion. Cases of vaginal erosion and vaginal ulceration have been reported with other estradiol vaginal rings. If an ulceration or erosion has occurred, consideration should be given to leaving the ring out and not replacing it until healing is complete to prevent the ring from adhering to the vaginal tissue.A few cases of bowel obstruction associated with vaginal ring use have been reported. Persistent abdominal complaints consistent with obstruction should be carefully evaluated.A few cases of inadvertent ring insertion into the urinary bladder, which may require surgical removal, have been reported for women using vaginal rings. Persistent unexplained urinary symptoms should be carefully evaluated.The following additional adverse reactions have been identified during post-approval use of Femring. Because these reactions are reported voluntarily from population of uncertain size, it is not always possible to reliably estimate their frequency or establish causal relationship to drug exposure.Genitourinary systemUterine cancer, vaginal hemorrhage, ovarian cyst, irregular menstruation, metrorrhagia, menorrhagia, dysmenorrhea, uterine enlargement. BreastsBreast cancer, fibrocystic breast disease, breast disorder, breast mass, breast enlargement, breast pain, nipple pain, breast discharge. CardiovascularChest pain, increased blood pressure, irregular heart rate, pulmonary embolism, cerebrovascular accident (stroke), hemiparesis, transient ischemic attack, thrombosis. GastrointestinalAbdominal pain, pancreatitis, cholecystitis, cholelithiasis, vomiting. SkinGeneralized erythema, erythema multiforme, erythema nodosum, rash, hirsutism, pruritis. Eyes Blindness, contact lens intolerance. Central Nervous SystemDizziness, headache, depression, nervousness, mood disturbances, irritability. MiscellaneousMedical device complication, back pain, angioedema, weight increased/decreased, edema, libido increased/decreased, urticaria, hypersensitivity, anaphylaxis. A few cases of toxic shock syndrome (TSS) have been reported in women using vaginal rings. TSS is rare, but serious disease that may cause death. Warning signs of TSS include fever, nausea, vomiting, diarrhea, muscle pain, dizziness, faintness, or sunburn-rash on face and body.. Cases of ring adherence to the vaginal or bladder wall, making ring removal difficult, have been reported in women using vaginal rings and may require surgical removal of the device. Women should be carefully evaluated for vaginal or bladder wall ulceration or erosion. Cases of vaginal erosion and vaginal ulceration have been reported with other estradiol vaginal rings. If an ulceration or erosion has occurred, consideration should be given to leaving the ring out and not replacing it until healing is complete to prevent the ring from adhering to the vaginal tissue.. few cases of bowel obstruction associated with vaginal ring use have been reported. Persistent abdominal complaints consistent with obstruction should be carefully evaluated.. few cases of inadvertent ring insertion into the urinary bladder, which may require surgical removal, have been reported for women using vaginal rings. Persistent unexplained urinary symptoms should be carefully evaluated.

OVERDOSAGE SECTION.

10 OVERDOSAGE. Overdosage of estrogen may cause nausea, vomiting, breast tenderness, dizziness, abdominal pain, drowsiness and fatigue, and withdrawal bleeding may occur in women. Treatment of overdose consists of discontinuation of Femring with institution of appropriate symptomatic care.

PACKAGE LABEL.PRINCIPAL DISPLAY PANEL.

NDC 72495-201-05Femring(R) (estradiol acetate vaginal ring) 0.05 mg/day Rx only label.

BOXED WARNING SECTION.

Estrogen-Alone TherapyEndometrial CancerThere is an increased risk of endometrial cancer in woman with uterus who uses unopposed estrogens. Adding progestin to estrogen therapy has been shown to reduce the risk of endometrial hyperplasia, which may be precursor to 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 [see Warnings and Precautions (5.2)]. Cardiovascular Disorders and Probable DementiaEstrogen-alone therapy should not be used for the prevention of cardiovascular disease or dementia [see Warnings and Precautions (5.1,5.3), and Clinical Studies(14.3,14.4)]. The Womens Health Initiative (WHI) estrogen-alone substudy reported increased risks of stroke and deep vein thrombosis (DVT) in postmenopausal women (50 to 79 years of age) during 7.1 years of treatment with daily oral conjugated estrogens (CE) [0.625 mg]-alone, relative to placebo[seeWarnings and Precautions (5.1), and Clinical Studies (14.3)].The WHI Memory Study (WHIMS) estrogen-alone ancillary study of the WHI reported an increased risk of developing probable dementia in postmenopausal women 65 years of age or older during 5.2 years of treatment with daily CE (0.625 mg)-alone, relative to placebo. It is unknown whether this finding applies to younger postmenopausal women [seeWarnings and Precautions (5.3),Use in Specific Populations (8.5), and Clinical Studies (14.4)].In the absence of comparable data, these risks should be assumed to be similar for other doses of CE and other dosage forms of estrogens.Estrogens with or without progestins should be prescribed at the lowest effective doses and for the shortest duration consistent with treatment goals and risks for the individual woman.Estrogen Plus Progestin TherapyCardiovascular Disorders and Probable DementiaEstrogen plus progestin therapy should not be used for the prevention of cardiovascular disease or dementia [see Warnings and Precautions (5.1, 5.3) and Clinical Studies (14.3, 14.4)]. The WHI estrogen plus progestin substudy reported increased risks of DVT, pulmonary embolism (PE), stroke and myocardial infarction (MI) in postmenopausal women (50 to 79 years of age) during 5.6 years of treatment with daily oral CE (0.625 mg) combined with medroxyprogesterone acetate (MPA) [2.5 mg], relative to placebo [seeWarnings and Precautions (5.1), and Clinical Studies (14.3)]. The WHIMS estrogen plus progestin ancillary study of the WHI reported increased risk of developing probable dementia in postmenopausal women 65 years of age or older during years of treatment with daily CE (0.625 mg) combined with MPA (2.5 mg), relative to placebo. It is unknown whether this finding applies to younger postmenopausal women [seeWarnings and Precautions (5.3), Use in Specific Populations (8.5) and Clinical Studies (14.4)].Breast CancerThe WHI estrogen plus progestin substudy also demonstrated an increased risk of invasive breast cancer [seeWarnings and Precautions (5.3), and Clinical Studies (14.3)].In the absence of comparable data, these risks should be assumed to be similar for other doses of CE and MPA and other combinations and dosage forms of estrogens and progestins.Estrogens with or without progestins should be prescribed at the lowest effective doses and for the shortest duration consistent with treatment goals and risks for the individual woman.. WARNING: ENDOMETRIAL CANCER, CARDIOVASCULAR DISORDERS, BREAST CANCER, AND PROBABLE DEMENTIASee full prescribing information for complete boxed warning.Estrogen-Alone TherapyThere is an increased risk of endometrial cancer in woman with uterus who uses unopposed estrogens (5.2)Estrogen-alone therapy should not be used for the prevention of cardiovascular disease or dementia (5.1, 5.3)The Womens Health Initiative (WHI) estrogen-alone substudy reported increased risks of stroke and deep vein thrombosis (DVT) (5.1)The WHI Memory Study (WHIMS) estrogen-alone ancillary study of WHI reported an increased risk of probable dementia in postmenopausal women 65 years of age and older (5.3)Estrogen Plus Progestin TherapyEstrogen plus progestin therapy should not be used for the prevention of cardiovascular disease or dementia (5.1, 5.3)The WHI estrogen plus progestin substudy reported increased risks of stroke, DVT, pulmonary embolism (PE), and myocardial infarction (MI) (5.1)The WHI estrogen plus progestin substudy reported an increased risk of invasive breast cancer (5.2)The WHIMS estrogen plus progestin ancillary study of WHI reported an increased risk of probable dementia in postmenopausal women 65 years of age and older (5.3). There is an increased risk of endometrial cancer in woman with uterus who uses unopposed estrogens (5.2). Estrogen-alone therapy should not be used for the prevention of cardiovascular disease or dementia (5.1, 5.3). The Womens Health Initiative (WHI) estrogen-alone substudy reported increased risks of stroke and deep vein thrombosis (DVT) (5.1). The WHI Memory Study (WHIMS) estrogen-alone ancillary study of WHI reported an increased risk of probable dementia in postmenopausal women 65 years of age and older (5.3). Estrogen plus progestin therapy should not be used for the prevention of cardiovascular disease or dementia (5.1, 5.3). The WHI estrogen plus progestin substudy reported increased risks of stroke, DVT, pulmonary embolism (PE), and myocardial infarction (MI) (5.1). The WHI estrogen plus progestin substudy reported an increased risk of invasive breast cancer (5.2). The WHIMS estrogen plus progestin ancillary study of WHI reported an increased risk of probable dementia in postmenopausal women 65 years of age and older (5.3).

CARCINOGENESIS & MUTAGENESIS & IMPAIRMENT OF FERTILITY SECTION.

13.1Carcinogenesis, Mutagenesis, Impairment of Fertility. 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.Estradiol acetate was assayed for mutation in four histidine-requiring strains of Salmonella typhimurium and in one tryptophan-requiring strain of Escherichia coli. Estradiol acetate did not induce mutations in any of the bacterial strains tested under the conditions employed.

CLINICAL PHARMACOLOGY SECTION.

12 CLINICAL PHARMACOLOGY. 12.1Mechanism of Action. Endogenous estrogens are largely responsible for the development and maintenance of the female reproductive system and secondary sexual characteristics. Although circulating estrogens exist in 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, which is 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 negative feedback mechanism. Estrogens act to reduce the elevated levels of these hormones seen in postmenopausal women.. 12.2Pharmacodynamics. There are no pharmacodynamic data for Femring.. 12.3Pharmacokinetics. AbsorptionEstradiol acetate is hydrolyzed to estradiol which is absorbed through the vaginal mucosa as evidenced by the mean time to maximum concentration (t max) for estradiol of about hour (range 0.25 to 1.5 hrs). After achieving the Cmax the estradiol concentration starts declining during the first 24 to 48 hours and then at relatively constant rate for the remainder of the 3-month dosing interval (see Figure for results from rings stored for 16 months). In vitro studies have shown that this initial release is higher as the rings age upon storage. Following administration of Femring (0.05 mg/day estradiol), average serum estradiol concentration was 40.6 pg/mL; the corresponding apparent in vivo estradiol delivery rate was 0.052 mg/day. Following administration of Femring (0.10 mg/day estradiol), average serum estradiol concentration was 76 pg/mL; apparent in vivo delivery rate was 0.097 mg/day. Results are summarized in Table below. Table 2. Summary of Mean (Percent RSD) Pharmacokinetic Parameters for FemringDose(as estradiol)Numberof subjectsCmax(pg/mL)Tmax(hour)Cavg(pg/mL)0.05 mg/dayEstradiol 251129 (25)0.9 (41)40.6 (26)Estrone 25141 (25)6.2 (84)35.9 (21)Estrone sulfate 252365 (44)9.3 (39)494.6 (48)0.10 mg/dayEstradiol 121665 (23)0.7 (90)-- Estradiol 11----76.0 (24)Estrone 11----45.7 (25) Relative Standard Deviation, 1Study 1, 2Study 2, 3Study 3, 4-- Not determined Consistent with the avoidance of first pass metabolism achieved by vaginal estradiol administration, serum estradiol concentrations were slightly higher than estrone concentrations.DistributionThe distribution of exogenous estrogens is similar to that of endogenous estrogens. Estrogens are widely distributed in the body and are generally found in higher concentrations in the sex hormone target organs. Estrogens circulate in the blood largely bound to SHBG and albumin.MetabolismExogenous estrogens are metabolized in the same manner as endogenous estrogens. Circulating estrogens exist in dynamic equilibrium of metabolic interconversions. These transformations take place mainly in the liver. Estradiol is converted reversibly to estrone, and both can be converted to estriol, which is major urinary metabolite. Estrogens also undergo enterohepatic recirculation via sulfate and glucuronide conjugation in the liver, biliary secretion of conjugates into the intestine, and hydrolysis in the intestine followed by reabsorption. In postmenopausal women, significant proportion of the circulating estrogens exist as sulfate conjugates, especially estrone sulfate, which serves as circulating reservoir for the formation of more active estrogens.ExcretionEstradiol, estrone, and estriol are excreted in the urine along with glucuronide and sulfate conjugates.The estradiol apparent elimination half-life value is 21 to 26 hours.Use in Specific PopulationsNo pharmacokinetic studies were conducted with Femring in specific populations, including women with renal or hepatic impairment.. Figure 1. Mean serum estradiol concentrations following multiple dose administration of Femring (0.05 mg/day estradiol) (second dose administered at 13 weeks) (inset: mean (+-SD) of serum concentrati.

CLINICAL STUDIES SECTION.

14 CLINICAL STUDIES. 14.1Effects on Vasomotor Symptoms. 13-week double-blind, placebo-controlled clinical trial was conducted to evaluate the efficacy of doses of the vaginal ring in the treatment of moderate to severe vasomotor symptoms in 333 postmenopausal women between 29 and 85 years of age (mean age 51.7 years, 77 percent were Caucasian) who had at least moderate to severe hot flushes daily or at least 56 moderate to severe hot flushes per week before randomization. Patients were randomized to receive either placebo, Femring 0.05 mg/day or Femring 0.10 mg/day. Femring 0.05 mg/day and Femring 0.10 mg/day were shown to be statistically better than placebo at weeks and 12 for relief of both the frequency and severity of moderate to severe vasomotor symptoms. Frequency results are shown in Table 3. Severity results are shown in Table 4. Table 3. Mean Change from Baseline in the Number of Moderate to Severe Vasomotor Symptoms per Week ITT Population, LOCFVisitPlacebo(n 105)Estradiol0.05 mg/day(n 111)Estradiol0.10 mg/day(n 109)Baseline [1] Mean (SD)83.62 (60.42)73.83 (24.53)75.11 (25.44)Week 4Mean (SD)51.14 (51.19)21.59 (27.76)11.37 (19.43)Mean Change from Baseline (SD)-32.48 (46.25)-52.24 (32.92)-63.75 (26.68)p value vs. Placebo (95 percent CI) [2]-<0.001 (-30.7, -8.8)<0.001 (-42.2, -20.3)Week 12Mean (SD)42.21 (41.13)15.48 (25.42)8.25 (16.58)Mean Change from Baseline (SD)-41.41 (65.61)-58.36 (31.36)-66.87 (27.44)p value vs. Placebo (95 percent CI) [2]-0.006 (-30.5, -3.4)<0.001 (-39.1, -11.8)Denotes statistical significance at the 0.050 level. [1] The baseline number of moderate to severe vasomotor symptoms (MSVS) is the weekly average number of MSVS during the two weeks between screening and randomization. [2] values and confidence intervals are from two-way ANOVA with factors for treatment and study center for the difference between treatment groups in the mean change from baseline. Confidence intervals are adjusted for multiple comparisons within each timepoint using Dunnetts method. ITT intent to treat; LOCF last observation carried forward; CI confidence interval Table 4. Mean Change from Baseline in the Severity of Moderate to Severe Vasomotor Symptoms per Week ITT Population, LOCFVisitPlacebo(n 105)Estradiol0.05 mg/day(n 111)Estradiol0.10 mg/day(n 109)Baseline [1] Mean (SD)2.51 (0.26)2.46 (0.23)2.48 (0.24)Week 4Mean (SD)2.23 (0.71)1.67 (1.07)1.15 (1.14)Mean Change from Baseline (SD)-0.28 (0.69)- 0.79 (1.08)-1.33 (1.10)p value vs. Placebo (95 percent CI) [2]-<0.001 (-0.8, -0.2)<0.001 (-1.3, -0.8)Week 12Mean (SD)2.00 (0.96)1.41 (1.17)0.92 (1.09)Mean Change from Baseline (SD)-0.51 (0.94)-1.06 (1.16)-1.56 (1.06)p value vs. Placebo (95 percent CI) [2]-<0.001 (-0.9, -0.2)<0.001 (-1.4, -0.7)Denotes statistical significance at the 0.050 level. [1] The baseline severity of moderate to severe vasomotor symptoms (MSVS) is the average severity of MSVS during the two weeks between screening and randomization. [2] values and confidence intervals are from two-way ANOVA with factors for treatment and study center for the difference between treatment groups in the mean change from baseline. Confidence intervals are adjusted for multiple comparisons within each timepoint using Dunnetts method. ITT intent to treat; LOCF last observation carried forward; CI confidence interval 14.2Effects on Vulvar and Vaginal Atrophy. In the same 13-week clinical trial, vaginal superficial cells increased by mean of 16.0 percent and 18.9 percent for Femring 0.05 mg/day and Femring 0.10 mg/day, respectively, as compared to 1.11 percent for placebo at week 13. corresponding reduction in parabasal cells was observed at week 13. Vaginal pH decreased for Femring 0.05 mg/day and Femring 0.10 mg/day by mean of 0.73 and 0.60, respectively, compared to mean decrease of 0.25 in the placebo group.. 14.3Womens Health Initiative Studies. 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. 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 cause. These substudies did not evaluate the effects of CE-alone or CE plus MPA on menopausal symptoms.WHI Estrogen-Alone SubstudyThe WHI estrogen-alone substudy was stopped early because an increased risk of stroke was observed, and it was deemed that no further information would be obtained regarding the risks and benefits of estrogen-alone in predetermined primary endpoints.Results of the estrogen-alone substudy, which included 10,739 women (average 63 years of age, range 50 to 79; 75.3 percent White, 15.1 percent Black, 6.1 percent Hispanic, 3.6 percent Other), after an average follow-up of 7.1 years, are presented in Table 5. Table 5. Relative and Absolute Risk Seen in the Estrogen-Alone Substudy of WHI EventRelative Risk CE vs. Placebo (95 percent nCI b) CE = 5,310 Placebo = 5,429 Absolute Risk per 10,000 Women-YearsCHD events 0.95 (0.78-1.16)5457Non-fatal MIc0.91 (0.73-1.14)4043CHD deathc1.01 (0.71-1.43)1616All strokes 1.33 (1.05-1.68)4533Ischemicstrokec1.55 (1.19-2.01)3825Deep vein thrombosis c,d 1.47 (1.06-2.06)2315Pulmonary embolism 1.37 (0.90-2.07)1410Invasive breast cancer 0.80 (0.62-1.04)2834Colorectal cancer 1.08 (0.75-1.55)1716Hip fracture 0.65 (0.45-0.94)1219Vertebral fractures c,d 0.64 (0.44-0.93)1118Lower arm/wrist fractures c,d 0.58 (0.47-0.72)3559Total fractures c,d 0.71 (0.64-0.80)144197Deaths due to other causes e,f 1.08 (0.88-1.32)5350Overall Mortality c,d 1.04 (0.88-1.22)7975Global Index 1.02 (0.92-1.13)206201aAdapted from numerous WHI publications. WHI publications can be viewed at www.nhlbi.nih.gov/whi. bNominal confidence intervals unadjusted for multiple looks and multiple comparisons. cResults are based on centrally adjudicated data for an average follow-up of 7.1 years. dNot included in global index. eResults are based on an average follow-up of 6.8 years. fAll deaths, except from breast or colorectal cancer, definite or probable CHD, PE or cerebrovascular disease. gA subset of the events was combined in global index defined as the earliest occurrence of CHD events, invasive breast cancer, stroke, PE, colorectal cancer, hip fracture, or death due to other causes. For those outcomes included in the WHI global index that reached statistical significance, the absolute excess risk per 10,000 women-years in the group treated with CE-alone were 12 more strokes, while the absolute risk reduction per 10,000 women-years was fewer hip fractures. The absolute excess risk of events included in the global index was non-significant events per 10,000 women-years. There was no difference between the groups in terms of all-cause mortality No overall difference for primary CHD events (nonfatal MI, silent MI and CHD death) and invasive breast cancer incidence in women receiving CE-alone compared with placebo was reported in final centrally adjudicated results from the estrogen-alone substudy, after an average follow-up of 7.1 years. See Table 5.Centrally adjudicated results for stroke events from the estrogen-alone substudy, after an average follow-up of 7.1 years, reported no significant difference in distribution of stroke subtype or severity, including fatal strokes, in women receiving CE-alone compared to placebo. Estrogen-alone therapy increased the risk of ischemic stroke, and this excess was present in all subgroups of women examined. 10 See Table 5. Timing of the initiation of estrogen-alone therapy relative to the start of menopause may affect the overall risk benefit profile. The WHI estrogen-alone substudy stratified by age, showed in women 50 to 59 years of age, non-significant trend toward reduced risk for CHD hazard ratio HR 0.63 (95 percent CI 0.36-1.09)] and overall mortality [HR 0.71 (95 percent CI 0.46-1.11)]. WHI Estrogen Plus Progestin SubstudyThe WHI estrogen plus progestin substudy was stopped early. According to the predefined stopping rule, after an average follow-up of 5.6 years of treatment, the increased risk of breast cancer and cardiovascular events exceeded the specified benefits included in the global index. The absolute excess risk of events included in the global index was 19 per 10,000 women-years.For those outcomes included in the WHI global index that reached statistical significance after 5.6 years of follow-up, the absolute excess risks per 10,000 women-years in the group treated with CE plus MPA were more CHD events, more strokes, 10 more PEs, and more invasive breast cancers, while the absolute risk reductions per 10,000 women-years were fewer colorectal cancers and fewer hip fractures.Results of the CE plus MPA substudy, which included 16,608 women (average 63 years of age, range 50 to 79; 83.9 percent White, 6.8 percent Black, 5.4 percent Hispanic, 3.9 percent Other) are presented in Table 6. These results reflect centrally adjudicated data after an average follow-up of 5.6 years. Table 6. Relative and Absolute Risk Seen in the Estrogen Plus Progestin Substudy of WHI at an Average of 5.6 Years a,b EventRelative Risk CE/MPA vs. Placebo (95% nCI c) CE/MPA = 8,506 Placebo = 8,102 Absolute Risk per 10,000 Women-YearsCHD events1.23 (0.99-1.53)4134Non-fatal MI1.28 (1.00-1.63)3125CHD death1.10 (0.70-1.75)88All strokes1.31 (1.03-1.68)3325Ischemic stroke1.44 (1.09-1.90)2618Deep vein thrombosis 1.95 (1.43-2.67)2613Pulmonary embolism2.13 (1.45-3.11)188Invasive breast cancer 1.24 (1.01-1.54)4133Colorectal cancer0.61 (0.42-0.87)1016Endometrial cancer 0.81 (0.48-1.36)67Cervical cancer 1.44 (0.47-4.42)21Hip fracture0.67 (0.47-0.96)1116Vertebral fractures 0.65 (0.46-0.92)1117Lower arm/wrist fractures 0.71 (0.59-0.85)4462Total fractures 0.76 (0.69-0.83)152199Overall Mortality c,f 1.00 (0.83-1.19)5252Global Index 1.13 (1.02-1.25)184165aAdapted from numerous WHI publications. WHI publications can be viewed at www.nhlbi.nih.gov/whi. bResults are based on centrally adjudicated data. cNominal confidence intervals unadjusted for multiple looks and multiple comparisons. dNot included in global index. eIncludes metastatic and non-metastatic breast cancer with the exception of in situ cancer. fAll deaths, except from breast or colorectal cancer, definite or probable CHD, PE or cerebrovascular disease. gA subset of the events was combined in global index defined as the earliest occurrence of CHD events, invasive breast cancer, stroke, PE, colorectal cancer, hip fracture, or death due to other causes. Timing of initiation of estrogen plus progestin therapy relative to the start of menopause may affect the overall risk benefit profile. The WHI estrogen plus progestin substudy stratified by age showed in women 50 to 59 years of age non-significant trend toward reduced risk for overall mortality [HR 0.69 (95 percent CI, 0.44-1.07)]. 14.4Womens Health Initiative Memory Study. The WHIMS estrogen-alone ancillary study of WHI enrolled 2,947 predominantly healthy hysterectomized postmenopausal women 65 to 79 years of age and older (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 Alzheimers 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 group 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 of WHI 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 of age, and 18 percent were 75 years of age and older) to evaluate the effects of 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 years, 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 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 the treatment group and the placebo group was AD. Since the substudy 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) ].

CONTRAINDICATIONS SECTION.

4 CONTRAINDICATIONS. Femring is contraindicated in women with any of the following conditions:Undiagnosed abnormal genital bleedingKnown, suspected, or history of breast cancerKnown or suspected estrogen-dependent neoplasiaActive DVT, PE, or history of these conditionsActive arterial thromboembolic disease (for example, stroke and MI), or history of these conditionsKnown anaphylactic reaction or angioedema to FemringKnown liver impairment or diseaseKnown protein C, protein S, or antithrombin deficiency, or other known thrombophilic disordersKnown or suspected pregnancy. Undiagnosed abnormal genital bleeding. Known, suspected, or history of breast cancer. Known or suspected estrogen-dependent neoplasia. Active DVT, PE, or history of these conditions. Active arterial thromboembolic disease (for example, stroke and MI), or history of these conditions. Known anaphylactic reaction or angioedema to Femring. 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 4, 5.2) Known or suspected estrogen-dependent neoplasia 4, 5.2) Active DVT, PE, or history of these conditions 4, 5.1) Active arterial thromboembolic disease (for example, stroke and MI), or history of these conditions 4, 5.1) Known anaphylactic reaction or angioedema to Femring 4) Known liver impairment or disease 4, 5.10) Known protein C, protein S, or antithrombin deficiency, or other known thrombophilic disorders 4) Known or suspected pregnancy 4, 8.1) Undiagnosed abnormal genital bleeding 4) Known, suspected, or history of breast cancer 4, 5.2) Known or suspected estrogen-dependent neoplasia 4, 5.2) Active DVT, PE, or history of these conditions 4, 5.1) Active arterial thromboembolic disease (for example, stroke and MI), or history of these conditions 4, 5.1) Known anaphylactic reaction or angioedema to Femring 4) Known liver impairment or disease 4, 5.10) Known protein C, protein S, or antithrombin deficiency, or other known thrombophilic disorders 4) Known or suspected pregnancy 4, 8.1).

DESCRIPTION SECTION.

11 DESCRIPTION. Femring (estradiol acetate vaginal ring) is an off-white, soft, flexible ring with central core containing estradiol acetate.Femring is made of cured silicone elastomer composed of dimethyl polysiloxane silanol, silica (diatomaceous earth), normal propyl orthosilicate, stannous octoate; barium sulfate and estradiol acetate. The rings have the following dimensions: outer diameter 56 mm, cross-sectional diameter 7.6 mm, core diameter mm.Femring is available in two strengths: Femring 0.05 mg/day has central core that contains 12.4 mg of estradiol acetate, which releases at rate equivalent to 0.05 mg of estradiol per day for months. Femring 0.10 mg/day has central core that contains 24.8 mg of estradiol acetate, which releases at rate equivalent to 0.10 mg of estradiol per day for months.Estradiol acetate is chemically described as estra-1,3,5(10)-triene-3,17-diol-3-acetate. The molecular formula of estradiol acetate is 20H 26O and the molecular weight of estradiol acetate is 314.42. The Structural formula of Estradiol acetate is chemically described as estra-1,3,5(10)-triene-3,17b-diol-3-acetate.

DOSAGE & ADMINISTRATION SECTION.

2 DOSAGE AND ADMINISTRATION. Generally, when estrogen is prescribed for postmenopausal woman with uterus, progestin should also be considered to reduce the risk of endometrial cancer.A woman without uterus does not need progestin. In some cases, however, hysterectomized women with history of endometriosis may need progestin s ee Warnings and Precautions 5.2 5.14 )] Use of estrogen-alone, or in combination with 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.. One ring inserted into the vagina for months. Patients should be started at the lowest dose. 2.1, 2.2) One ring inserted into the vagina for months. Patients should be started at the lowest dose. 2.1, 2.2) 2.1Treatment of Moderate to Severe Vasomotor Symptoms due to Menopause. Start therapy with 0.05 mg/day. Dosage adjustment should be guided by the clinical response.Therapy should be started at the lowest effective dose and the shortest duration consistent with treatment goals. Attempts to taper or discontinue the medication should be made at to month intervals.. 2.2Treatment of Moderate to Severe Vulvar and Vaginal Atrophy due to Menopause.. Start therapy with 0.05 mg/day. Dosage adjustment should be guided by the clinical response.Therapy should be started at the lowest effective dose and the shortest duration consistent with treatment goals. Attempts to taper or discontinue the medication should be made at to month intervals.

DOSAGE FORMS & STRENGTHS SECTION.

3 DOSAGE FORMS AND STRENGTHS. The following two strengths of Femring are available:Femring (0.05 mg/day): Each off-white, soft, flexible ring has central core that contains 12.4 mg of estradiol acetate, which releases at rate equivalent to 0.05 mg of estradiol per day for months.Femring (0.10 mg/day): Each off-white, soft, flexible ring has central core that contains 24.8 mg of estradiol acetate, which releases at rate equivalent to 0.10 mg of estradiol per day for months.. Femring (0.05 mg/day): Each off-white, soft, flexible ring has central core that contains 12.4 mg of estradiol acetate, which releases at rate equivalent to 0.05 mg of estradiol per day for months. 3) Femring (0.10 mg/day): Each off-white, soft, flexible ring has central core that contains 24.8 mg of estradiol acetate, which releases at rate equivalent to 0.10 mg of estradiol per day for months. 3) Femring (0.05 mg/day): Each off-white, soft, flexible ring has central core that contains 12.4 mg of estradiol acetate, which releases at rate equivalent to 0.05 mg of estradiol per day for months. 3) Femring (0.10 mg/day): Each off-white, soft, flexible ring has central core that contains 24.8 mg of estradiol acetate, which releases at rate equivalent to 0.10 mg of estradiol per day for months. 3).

PEDIATRIC USE SECTION.

8.4Pediatric Use. Femring is not indicated in children. Clinical studies have not been conducted in the pediatric population.

DRUG INTERACTIONS SECTION.

7 DRUG INTERACTIONS. No drug interaction studies have been conducted for Femring.. Inducers and/or inhibitors of CYP3A4 may affect estrogen drug metabolism 7.1) Inducers and/or inhibitors of CYP3A4 may affect estrogen drug metabolism 7.1) 7.1Metabolic Interactions. 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. Johns wort Hypericum perforatum) preparations, phenobarbital, carbamazepine and rifampin may decrease the plasma concentration of estrogens, possibly resulting in 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 the plasma concentration of estrogens and may result in side effects.

GERIATRIC USE SECTION.

8.5Geriatric Use. There have not been sufficient numbers of geriatric women involved in clinical studies utilizing Femring to determine whether those over 65 years of age differ from younger subjects in their response to Femring.The Womens Health Initiative StudiesIn the WHI estrogen-alone substudy (daily CE [0.625 mg]-alone versus placebo), there was higher relative risk of stroke in women greater than 65 years of age see Clinical Studies (14.2) . In the WHI estrogen plus progestin substudy (daily CE [0.625 mg] plus MPA [2.5 mg] versus placebo), there was higher relative risk of nonfatal stroke and invasive breast cancer in women greater than 65 years of age see Clinical Studies (14.2) ]. The Womens Health Initiative Memory StudyIn the WHIMS ancillary studies of postmenopausal women 65 to 79 years of age, there was an increased risk of developing probable dementia in women receiving estrogen-alone or estrogen plus progestin when compared to placebo see Warnings and Precautions (5.3) and Clinical Studies (14.4) ]. Since both ancillary studies were 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 Clinical Studies (14.4) ].

HOW SUPPLIED SECTION.

16 HOW SUPPLIED/STORAGE AND HANDLING. 16.1How Supplied. Each Femring (estradiol acetate vaginal ring) is individually packaged in pouch consisting of one side medical grade paper and the other side polyester/polyethylene laminate.N 72495-201-05 Femring 0.05 mg/day (estradiol acetate vaginal ring) is available in single units. 72495-202-10 Femring 0.10 mg/day (estradiol acetate vaginal ring) is available in single units. 16.2Storage and Handling. Store at 25o (77o F); excursions permitted to 15 to 30o (59 to 86o F) [see USP Controlled Room Temperature].Do not store unpouched. Insert immediately upon removal from the protective pouch.

INDICATIONS & USAGE SECTION.

1 INDICATIONS AND USAGE. Femring is an estrogen 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 Moderate to Severe Vasomotor Symptoms due to Menopause 1.1) Treatment of Moderate to Severe Vulvar and Vaginal Atrophy due to Menopause 1.2) 1.1 Treatment of Moderate to Severe Vasomotor Symptoms due to Menopause.. 1.2Treatment of Moderate to Severe Vulvar and Vaginal Atrophy due to Menopause.

INFORMATION FOR PATIENTS SECTION.

17 PATIENT COUNSELING INFORMATION. See FDA-approved patient labeling Patient Information and Instructions for Use). 17.1Vaginal Bleeding. Inform postmenopausal women of the importance of reporting abnormal vaginal bleeding to their healthcare provider as soon as possible see Warnings and Precautions (5.2) ]. 17.2Possible Serious Adverse Reactions with Estrogen-Alone Therapy. Inform postmenopausal women of possible serious adverse reactions of estrogen-alone therapy including Cardiovascular Disorders, Malignant Neoplasms, and Probable Dementia see Warnings and Precautions 5.1 5.2 5.3 )]. 17.3Possible Less Serious but Common Adverse Reactions with Estrogen-Alone Therapy. Inform postmenopausal women of possible less serious but common adverse reactions of estrogen-alone therapy such as headache, breast pain and tenderness, nausea and vomiting.Contact with blood may cause discoloration of Femring during use. This does not affect the release of the drug. Inform postmenopausal women of the importance of reporting abnormal vaginal bleeding to their healthcare provider as soon as possible.

LABORATORY TESTS SECTION.

5.17Laboratory Tests. 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 vulvar and vaginal atrophy due to menopause.

MECHANISM OF ACTION SECTION.

12.1Mechanism of Action. Endogenous estrogens are largely responsible for the development and maintenance of the female reproductive system and secondary sexual characteristics. Although circulating estrogens exist in 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, which is 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 negative feedback mechanism. Estrogens act to reduce the elevated levels of these hormones seen in postmenopausal women.

NONCLINICAL TOXICOLOGY SECTION.

13 NONCLINICAL TOXICOLOGY. 13.1Carcinogenesis, Mutagenesis, Impairment of Fertility. 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.Estradiol acetate was assayed for mutation in four histidine-requiring strains of Salmonella typhimurium and in one tryptophan-requiring strain of Escherichia coli. Estradiol acetate did not induce mutations in any of the bacterial strains tested under the conditions employed.

NURSING MOTHERS SECTION.

8.3Nursing Mothers. Femring 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 women receiving estrogen-alone therapy. Caution should be exercised when Femring is administered to nursing woman.

PHARMACODYNAMICS SECTION.

12.2Pharmacodynamics. There are no pharmacodynamic data for Femring.

REFERENCES SECTION.

15 REFERENCES. Rossouw JE, et al. Postmenopausal Hormone Therapy and Risk of Cardiovascular Disease by Age and Years Since Menopause. JAMA. 2007;297:1465-1477. Hsia J, et al. Conjugated Equine Estrogens and Coronary Heart Disease. Arch Int Med. 2006;166:357-365. Curb JD, et al. Venous Thrombosis and Conjugated Equine Estrogen in Women Without Uterus. Arch Int Med. 2006;166:772-780. Cushman M, et al. Estrogen Plus Progestin and Risk of Venous Thrombosis. JAMA. 2004;292:1573-1580. Stefanick ML, et al. Effects of Conjugated Equine Estrogens on Breast Cancer and Mammography Screening in Postmenopausal Women With Hysterectomy. JAMA. 2006;295:1647-1657. Chlebowski RT, et al. Influence of Estrogen Plus Progestin on Breast Cancer and Mammography in Healthy Postmenopausal Women. JAMA. 2003;289:3234-3253. Anderson GL, et al. Effects of Estrogen Plus Progestin on Gynecologic Cancers and Associated Diagnostic Procedures. JAMA. 2003;290:1739-1748. Shumaker SA, et al. Conjugated Equine Estrogens and Incidence of Probable Dementia and Mild Cognitive Impairment in Postmenopausal Women. JAMA. 2004;291:2947-2958. Jackson RD, et al. Effects of Conjugated Equine Estrogen on Risk of Fractures and BMD in Postmenopausal Women With Hysterectomy: Results From the Womens Health Initiative Randomized Trial. Bone Miner Res. 2006;21:817-828. Hendrix SL, et al. Effects of Conjugated Equine Estrogen on Stroke in the Womens Health Initiative. Circulation. 2006;113:2425-2434. Rossouw JE, et al. Postmenopausal Hormone Therapy and Risk of Cardiovascular Disease by Age and Years Since Menopause. JAMA. 2007;297:1465-1477. Hsia J, et al. Conjugated Equine Estrogens and Coronary Heart Disease. Arch Int Med. 2006;166:357-365. Curb JD, et al. Venous Thrombosis and Conjugated Equine Estrogen in Women Without Uterus. Arch Int Med. 2006;166:772-780. Cushman M, et al. Estrogen Plus Progestin and Risk of Venous Thrombosis. JAMA. 2004;292:1573-1580. Stefanick ML, et al. Effects of Conjugated Equine Estrogens on Breast Cancer and Mammography Screening in Postmenopausal Women With Hysterectomy. JAMA. 2006;295:1647-1657. Chlebowski RT, et al. Influence of Estrogen Plus Progestin on Breast Cancer and Mammography in Healthy Postmenopausal Women. JAMA. 2003;289:3234-3253. Anderson GL, et al. Effects of Estrogen Plus Progestin on Gynecologic Cancers and Associated Diagnostic Procedures. JAMA. 2003;290:1739-1748. Shumaker SA, et al. Conjugated Equine Estrogens and Incidence of Probable Dementia and Mild Cognitive Impairment in Postmenopausal Women. JAMA. 2004;291:2947-2958. Jackson RD, et al. Effects of Conjugated Equine Estrogen on Risk of Fractures and BMD in Postmenopausal Women With Hysterectomy: Results From the Womens Health Initiative Randomized Trial. Bone Miner Res. 2006;21:817-828. Hendrix SL, et al. Effects of Conjugated Equine Estrogen on Stroke in the Womens Health Initiative. Circulation. 2006;113:2425-2434.

SPL PATIENT PACKAGE INSERT SECTION.

Patient InformationFemring (fem-ring) (estradiol acetate vaginal ring)Read this Patient Information before you start using Femring and each time you get refill. There may be new information. This information does not take the place of talking to your healthcare provider about your menopausal symptoms or your treatment.What is the most important information should know about Femring (an estrogen hormone)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 Femring. Vaginal bleeding after menopause may be warning sign of cancer of the uterus (womb). Your healthcare provider should check any unusual vaginal bleeding to find out the cause.Do not use estrogen-alone to prevent heart disease, heart attacks, strokes or dementia (decline in brain function).Using estrogen-alone may increase your chances of getting strokes or blood clots.Using estrogen-alone may increase your chance of getting dementia, based on study of women 65 years of age or older.Do not use estrogens with progestins to prevent heart disease, heart attacks, strokes or dementia.Using estrogens with progestins may increase your chances of getting heart attacks, strokes, breast cancer, or blood clots.Using estrogens with progestins may increase your chance of getting dementia, based on study of women 65 years of age or older.You and your healthcare provider should talk regularly about whether you still need treatment with Femring.What is FemringFemring is prescription vaginal ring that contains estradiol (an estrogen hormone). Femring should be removed after 90 days of continuous use. If you and your healthcare provider decide you should continue using Femring, new ring can be inserted in your vagina.What is Femring used forFemring is used after menopause to:reduce moderate to severe hot flushesEstrogens are hormones made by womans ovaries. The ovaries normally stop making estrogens when 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 estrogen levels begin dropping, some women get very uncomfortable symptoms, such as feelings of warmth in the face, neck, and chest, or sudden intense episodes 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 moderate to severe menopausal changes in and around the vaginaYou and your healthcare provider should talk regularly about whether you still need treatment with Femring to control these problems. If you use Femring only to treat your menopausal changes in and around your vagina, talk with your healthcare provider about whether topical vaginal product would be better for you.You and your healthcare provider should talk regularly about whether you still need treatment with Femring.Who should not use FemringDo not start using Femring if you:have unusual vaginal bleedingVaginal bleeding after menopause may be warning sign of cancer of the uterus (womb). Your healthcare provider should check any unusual vaginal bleeding to find out the cause.currently have or have had certain cancersEstrogens may increase the chances of getting certain types of cancers, including cancer of the breast and uterus. If you have or have had cancer, talk with your healthcare provider about whether you should use Femring.had stroke or heart attack currently have or have had blood clotscurrently have or have had liver problemshave been diagnosed with bleeding disorderare allergic to Femring or any of its ingredientsSee the list of ingredients in Femring at the end of this leaflet. think you may be pregnant Femring is not for pregnant women. If you think you may be pregnant, you should have pregnancy test and know the results. Do not use Femring if the test is positive and talk to your healthcare provider. What should tell my healthcare provider before use FemringBefore you use Femring, tell your healthcare provider if you:have any unusual vaginal bleeding Vaginal bleeding after menopause may be warning sign of cancer of the uterus (womb). Your healthcare provider should check any unusual vaginal bleeding to find out the cause. have any problems with your vagina or cervix (lower end of your womb)Your healthcare provider may need to check you more carefully if your cervix, bladder, or rectum have fallen out of their normal position and into the vagina or through the opening of the vagina. This may make it more difficult for you to keep Femring in place in your vagina. have any other medical conditionsYour healthcare provider may need to check you more carefully if you have certain conditions such as asthma (wheezing), epilepsy (seizures), diabetes, migraine, endometriosis, lupus, angioedema (swelling of face and tongue) or problems with your heart, liver, thyroid, kidneys, or have high calcium levels in your blood. are going to have surgery or will be on bed restYour healthcare provider will let you know if you need to stop using Femring. are breastfeeding The hormones in Femring can pass into your breast milk. Tell your healthcare provider about all the medicines you take, including prescription and nonprescription medicines, vitamins and herbal supplements. Some medicines may affect how Femring works. Femring may also affect how your other medicines work. Keep list of your medicines and show it to your healthcare provider and pharmacist when you get new medicine. How should use FemringFor detailed instructions, see the step-by-step instructions for using Femring at the end of this Patient Information.Use Femring exactly as your healthcare provider tells you to use it.Femring is inserted into your vagina by you.Femring should stay in your vagina for 90 days.After 90 days Femring should be removed. If you and your healthcare provider decide you should continue using Femring, new Femring can be inserted.You and your healthcare provider should talk regularly (every to months) about the dose of medicine you are using and whether you still need treatment with Femring.What are the possible problems you may have when using Femringtoxic shock syndrome (TSS)Toxic shock syndrome is rare but serious illness caused by bacterial infection that may cause death. Remove your Femring immediately and call your healthcare provider right away if you have any of the following symptoms: fever nausea or vomiting diarrhea muscle pain dizziness feel faint sunburn rash on your face or body attachment to your vaginal wallContact your healthcare provider right away if you have difficulty removing Femring. accidental placement in your bladderWhat are the possible side effects of FemringSide 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 attackstrokeblood clotsdementiabreast cancercancer of the lining of the uterus (womb)cancer of the ovaryhigh blood pressurehigh blood sugargallbladder diseaseliver problemschanges in your thyroid hormone levelsenlargement of benign tumors of the uterus (fibroids)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 lumpsunusual vaginal bleedingchanges in vision or speechsudden new severe headachessevere pains in your chest or legs with or without shortness of breath, weakness and fatigueLess serious, but common side effects include:headachebreast tenderness or painirregular vaginal bleeding or spottingstomach or abdominal cramps, bloatingnausea and vomitinghair lossfluid retentionvaginal yeast infectionreactions from inserting Femring such as burning, irritation, and itchingThese are not all the possible side effects of Femring. For more information, ask your healthcare provider or pharmacist. Tell your healthcare provider if you have any side effects that bother you or does not go away.You may report side effects to Millicent at 1-877-810-2101 or to FDA at 1-800-FDA-1088.What can do to lower my chances of serious side effect with FemringTalk with your healthcare provider regularly about whether you should continue using Femring.If you have uterus, talk with your healthcare provider about whether the addition of progestin is right for you. The addition of progestin is generally recommended for woman with uterus to reduce the chance of getting cancer of the uterus (womb). See your healthcare provider right away if you develop vaginal bleeding while using Femring.Have 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 (breast x-ray), 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 chance for getting heart disease.Ask your healthcare provider for ways of lowering your chances for getting heart disease.How should store FemringStore at room temperature 68o to 77o (20o to 25o C).KEEP FEMRING and all other medicines out of the reach of children. General information about safe and effective use of Femring.Medicines are sometimes prescribed for conditions that are not mentioned in patient information leaflets. Do not use Femring for conditions for which it was not prescribed. Do not give Femring to other people, even if they have the same symptoms you have. It may harm them.Contact with blood may cause discoloration of Femring during use. This does not affect the way in which Femring releases medicine to control your menopausal symptoms. Call your health care provider right away if you have unusual vaginal bleeding.This leaflet summarizes the most important information about Femring. If you would like more information, talk with your healthcare provider or pharmacist. You can ask for information about Femring that is written for health professionals. You can get more information by calling the toll free number 1-877-810-2101.What are the ingredients in FemringActive ingredient: estradiol Inactive ingredients: cured silicone elastomer composed of dimethyl polysiloxane silanol, silica (diatomaceous earth), normal propyl orthosilicate, stannous octoate; and barium sulfate. There are no coloring agents in Femring. 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 Femring. Vaginal bleeding after menopause may be warning sign of cancer of the uterus (womb). Your healthcare provider should check any unusual vaginal bleeding to find out the cause.. Do not use estrogen-alone to prevent heart disease, heart attacks, strokes or dementia (decline in brain function).. Using estrogen-alone may increase your chances of getting strokes or blood clots.. Using estrogen-alone may increase your chance of getting dementia, based on study of women 65 years of age or older.. Do not use estrogens with progestins to prevent heart disease, heart attacks, strokes or dementia.. Using estrogens with progestins may increase your chances of getting heart attacks, strokes, breast cancer, or blood clots.. Using estrogens with progestins may increase your chance of getting dementia, based on study of women 65 years of age or older.. You and your healthcare provider should talk regularly about whether you still need treatment with Femring.. reduce moderate to severe hot flushes. treat moderate to severe menopausal changes in and around the vagina. have unusual vaginal bleeding. currently have or have had certain cancers. had stroke or heart attack currently have or have had blood clots. currently have or have had liver problems. have been diagnosed with bleeding disorder. are allergic to Femring or any of its ingredientsSee the list of ingredients in Femring at the end of this leaflet. think you may be pregnant Femring is not for pregnant women. If you think you may be pregnant, you should have pregnancy test and know the results. Do not use Femring if the test is positive and talk to your healthcare provider. have any unusual vaginal bleeding Vaginal bleeding after menopause may be warning sign of cancer of the uterus (womb). Your healthcare provider should check any unusual vaginal bleeding to find out the cause. have any problems with your vagina or cervix (lower end of your womb)Your healthcare provider may need to check you more carefully if your cervix, bladder, or rectum have fallen out of their normal position and into the vagina or through the opening of the vagina. This may make it more difficult for you to keep Femring in place in your vagina. have any other medical conditionsYour healthcare provider may need to check you more carefully if you have certain conditions such as asthma (wheezing), epilepsy (seizures), diabetes, migraine, endometriosis, lupus, angioedema (swelling of face and tongue) or problems with your heart, liver, thyroid, kidneys, or have high calcium levels in your blood. are going to have surgery or will be on bed restYour healthcare provider will let you know if you need to stop using Femring. are breastfeeding The hormones in Femring can pass into your breast milk. Use Femring exactly as your healthcare provider tells you to use it.. Femring is inserted into your vagina by you.. Femring should stay in your vagina for 90 days.. After 90 days Femring should be removed. If you and your healthcare provider decide you should continue using Femring, new Femring can be inserted.. You and your healthcare provider should talk regularly (every to months) about the dose of medicine you are using and whether you still need treatment with Femring.. toxic shock syndrome (TSS)Toxic shock syndrome is rare but serious illness caused by bacterial infection that may cause death. Remove your Femring immediately and call your healthcare provider right away if you have any of the following symptoms: fever nausea or vomiting diarrhea muscle pain dizziness feel faint sunburn rash on your face or body attachment to your vaginal wallContact your healthcare provider right away if you have difficulty removing Femring. accidental placement in your bladder. 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. changes in your thyroid hormone levels. enlargement of benign tumors of the uterus (fibroids). 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. headache. breast tenderness or pain. irregular vaginal bleeding or spotting. stomach or abdominal cramps, bloating. nausea and vomiting. hair loss. fluid retention. vaginal yeast infection. reactions from inserting Femring such as burning, irritation, and itching. Talk with your healthcare provider regularly about whether you should continue using Femring.. If you have uterus, talk with your healthcare provider about whether the addition of progestin is right for you. The addition of progestin is generally recommended for woman with uterus to reduce the chance of getting cancer of the uterus (womb). See your healthcare provider right away if you develop vaginal bleeding while using Femring.. Have 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 (breast x-ray), 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 chance for getting heart disease.. Store at room temperature 68o to 77o (20o to 25o C).

SPL UNCLASSIFIED SECTION.

1.1 Treatment of Moderate to Severe Vasomotor Symptoms due to Menopause.

STORAGE AND HANDLING SECTION.

16.2Storage and Handling. Store at 25o (77o F); excursions permitted to 15 to 30o (59 to 86o F) [see USP Controlled Room Temperature].Do not store unpouched. Insert immediately upon removal from the protective pouch.

USE IN SPECIFIC POPULATIONS SECTION.

8 USE IN SPECIFIC POPULATIONS. Nursing Mothers: Estrogen administration to nursing women 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 Womens Health Initiative Memory ancillary studies of the Womens Health Initiative 5.3, 8.5) See 17 for PATIENT COUNSELING INFORMATION and FDA-approved patient labeling.Revised 08/2018. Nursing Mothers: Estrogen administration to nursing women 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 Womens Health Initiative Memory ancillary studies of the Womens Health Initiative 5.3, 8.5) 8.1Pregnancy Femring 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. 8.3Nursing Mothers. Femring 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 women receiving estrogen-alone therapy. Caution should be exercised when Femring is administered to nursing woman.. 8.4Pediatric Use. Femring is not indicated in children. Clinical studies have not been conducted in the pediatric population.. 8.5Geriatric Use. There have not been sufficient numbers of geriatric women involved in clinical studies utilizing Femring to determine whether those over 65 years of age differ from younger subjects in their response to Femring.The Womens Health Initiative StudiesIn the WHI estrogen-alone substudy (daily CE [0.625 mg]-alone versus placebo), there was higher relative risk of stroke in women greater than 65 years of age see Clinical Studies (14.2) . In the WHI estrogen plus progestin substudy (daily CE [0.625 mg] plus MPA [2.5 mg] versus placebo), there was higher relative risk of nonfatal stroke and invasive breast cancer in women greater than 65 years of age see Clinical Studies (14.2) ]. The Womens Health Initiative Memory StudyIn the WHIMS ancillary studies of postmenopausal women 65 to 79 years of age, there was an increased risk of developing probable dementia in women receiving estrogen-alone or estrogen plus progestin when compared to placebo see Warnings and Precautions (5.3) and Clinical Studies (14.4) ]. Since both ancillary studies were 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 Clinical Studies (14.4) ]. 8.6Renal Impairment. The effect of renal impairment on the pharmacokinetics of Femring has not been studied.. 8.7Hepatic Impairment. The effect of hepatic impairment on the pharmacokinetics of Femring has not been studied.

WARNINGS AND PRECAUTIONS SECTION.

5 WARNINGS AND PRECAUTIONS. Femring is used only in the vagina, however, the risks associated with oral estrogens should be taken into account.. 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, 5.9, 5.10) Monitor thyroid function in women on thyroid replacement therapy 5.11, 5.18) 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, 5.9, 5.10) Monitor thyroid function in women on thyroid replacement therapy 5.11, 5.18) 5.1Cardiovascular Disorders. 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 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 history or family history of VTE, obesity, and systemic lupus erythematosus) should be managed appropriately.StrokeIn the WHI estrogen-alone substudy, statistically significant increased risk of stroke was reported in women 50 to 79 years of age receiving daily CE (0.625 mg)-alone compared to women in the same age group receiving placebo (45 versus 33 per 10,000 women-years). The increase in risk was demonstrated in year and persisted see Clinical Studies (14.3) ]. Should stroke occur or be suspected, estrogen-alone therapy should be discontinued immediately. Subgroup analyses of women 50 to 59 years of age suggest no increased risk of stroke for those women receiving CE (0.625 mg)-alone versus those receiving placebo (18 versus 21 per 10,000 women-years). In the WHI estrogen plus progestin substudy, statistically significant increased risk of stroke was reported in women 50 to 79 years of age receiving daily CE (0.625 mg) plus MPA (2.5 mg) compared to women in the same age group receiving placebo (33 versus 25 per 10,000 women-years) see Clinical Studies (14.3) ]. The increase in risk was demonstrated after the first year and persisted. Should stroke occur or be suspected, estrogen plus progestin therapy should be discontinued immediately. Coronary Heart DiseaseIn the WHI estrogen-alone substudy, no overall effect on coronary heart disease (CHD) events (defined as nonfatal MI, silent MI, or CHD death) was reported in women receiving estrogen-alone compared to placebo [ see Clinical Studies (14.3) . Subgroup analyses of women 50 to 59 years of age suggest statistically non-significant reduction in CHD events (CE [0.625 mg]-alone compared to placebo) in women with less than 10 years since menopause (8 versus 16 per 10,000 woman-years). In the WHI estrogen plus progestin substudy, there was statistically non-significant increased risk of CHD events reported in women receiving daily CE (0.625 mg) plus MPA (2.5 mg) compared to women receiving placebo (41 versus 34 per 10,000 women-years). An increase in relative risk was demonstrated in year 1, and trend toward decreasing relative risk was reported in years through [ see Clinical Studies (14.3) ]. In postmenopausal women with documented heart disease (n 2,763, average 66.7 years of age), in controlled clinical trial of secondary prevention of cardiovascular disease (Heart and Estrogen/Progestin Replacement Study; HERS) treatment with daily CE (0.625 mg) plus MPA (2.5 mg) demonstrated no cardiovascular benefit. During an average follow-up of 4.1 years, treatment with CE plus MPA did not reduce the overall rate of CHD events in postmenopausal women with established CHD. There were more CHD events in the CE plus MPA-treated group than in the placebo group in year 1, but not during the subsequent years. Two thousand, three hundred and twenty-one (2,321) women from the original HERS trial agreed to participate in an open label extension of HERS, HERS II. Average follow-up in HERS II was an additional 2.7 years, for total of 6.8 years overall. Rates of CHD events were comparable among women in the CE plus MPA group and the placebo group in HERS, HERS II, and overall.Venous ThromboembolismIn the WHI estrogen-alone substudy, the risk of VTE (DVT and PE), was increased for women receiving daily CE (0.625 mg)-alone compared to placebo (30 versus 22 per 10,000 women-years), although only the increased risk of DVT reached statistical significance (23 versus 15 per 10,000 women-years). The increase in VTE risk was demonstrated during the first years [ see Clinical Studies (14.3) ]. Should VTE occur or be suspected, estrogen-alone therapy should be discontinued immediately. In the WHI estrogen plus progestin substudy, statistically significant 2-fold greater rate of VTE was reported in women receiving daily CE (0.625 mg) plus MPA (2.5 mg) compared to women receiving placebo (35 versus 17 per 10,000 women-years). Statistically significant increases in risk for both DVT (26 versus 13 per 10,000 women-years) and PE (18 versus per 10,000 women-years) were also demonstrated. The increase in VTE risk was demonstrated during the first year and persisted [ see Clinical Studies (14.3) ]. Should VTE occur or be suspected, estrogen plus progestin therapy should be discontinued immediately. If feasible, estrogens should be discontinued at least to weeks before surgery of the type associated with an increased risk of thromboembolism, or during periods of prolonged immobilization.. 5.2Malignant Neoplasms. Endometrial CancerAn increased risk of endometrial cancer has been reported with the use of unopposed estrogen therapy in woman with uterus. The reported endometrial cancer risk among unopposed estrogen users is about to 12 times greater than in non-users, and appears dependent on duration of treatment and on estrogen dose. Most studies show no significant increased risk associated with use of estrogens for less than year. The greatest risk appears associated with prolonged use, with increased risks of 15- to 24-fold for to 10 years or more. This risk has been shown to persist for at least to 15 years after estrogen therapy is discontinued.An increased risk of endometrial cancer has been reported with the use of unopposed estrogen therapy in woman with uterus. The reported endometrial cancer risk among unopposed estrogen users is about to 12 times greater than in non-users, and appears dependent on duration of treatment and on estrogen dose. Most studies show no significant increased risk associated with use of estrogens for less than year. The greatest risk appears associated with prolonged use, with increased risks of 15- to 24-fold for to 10 years or more. This risk has been shown to persist for at least to 15 years after estrogen therapy is discontinued.Clinical surveillance of all women using estrogen-alone or estrogen plus progestin therapy is important. 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. Clinical surveillance of all women using estrogen-alone or estrogen plus progestin therapy is important. 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.There is no evidence that the use of natural estrogens results in different endometrial risk profile than synthetic estrogens of equivalent estrogen dose. Adding progestin to estrogen therapy in postmenopausal women has been shown to reduce the risk of endometrial hyperplasia, which may be precursor to endometrial cancer.There is no evidence that the use of natural estrogens results in different endometrial risk profile than synthetic estrogens of equivalent estrogen dose. Adding progestin to estrogen therapy in postmenopausal women has been shown to reduce the risk of endometrial hyperplasia, which may be precursor to endometrial cancer.Breast CancerThe most important randomized clinical trial providing information about breast cancer in estrogen-alone users is the WHI substudy of daily CE (0.625 mg)-alone. In the WHI estrogen-alone substudy, after an average follow up of 7.1 years, daily CE-alone was not associated with an increased risk of invasive breast cancer (relative risk [RR] 0.80) The most important randomized clinical trial providing information about breast cancer in estrogen-alone users is the WHI substudy of daily CE (0.625 mg)-alone. In the WHI estrogen-alone substudy, after an average follow up of 7.1 years, daily CE-alone was not associated with an increased risk of invasive breast cancer (relative risk [RR] 0.80) [ see Clinical Studies (14.3) ]. The most important randomized clinical trial providing information about breast cancer in estrogen plus progestin users is the WHI substudy of daily CE (0.625 mg) plus MPA (2.5 mg). After mean follow-up of 5.6 years, the estrogen plus progestin substudy reported an increased risk of invasive breast cancer in women who took daily CE plus MPA. In this substudy, prior use of estrogen-alone or estrogen plus progestin therapy was reported by 26 percent of the women. The relative risk of invasive breast cancer was 1.24, and the absolute risk was 41 versus 33 cases per 10,000 women-years for CE plus MPA compared with placebo. Among women who reported prior use of hormone therapy, the relative risk of invasive breast cancer was 1.86 and the absolute risk was 46 versus 25 cases per 10,000 women-years for CE plus MPA compared with placebo. Among women who reported no prior use of hormone therapy, the relative risk of invasive breast cancer was 1.09, and the absolute risk was 40 versus 36 cases per 10,000 women-years for CE plus MPA compared with placebo. In the same substudy, invasive breast cancers were larger, were more likely to be node positive, and were diagnosed at more advanced stage in the CE (0.625 mg) plus MPA (2.5 mg) group compared with the placebo group. Metastatic disease was rare with no apparent difference between the two groups. Other prognostic factors, such as histologic subtype, grade and hormone receptor status did not differ between the groups The most important randomized clinical trial providing information about breast cancer in estrogen plus progestin users is the WHI substudy of daily CE (0.625 mg) plus MPA (2.5 mg). After mean follow-up of 5.6 years, the estrogen plus progestin substudy reported an increased risk of invasive breast cancer in women who took daily CE plus MPA. In this substudy, prior use of estrogen-alone or estrogen plus progestin therapy was reported by 26 percent of the women. The relative risk of invasive breast cancer was 1.24, and the absolute risk was 41 versus 33 cases per 10,000 women-years for CE plus MPA compared with placebo. Among women who reported prior use of hormone therapy, the relative risk of invasive breast cancer was 1.86 and the absolute risk was 46 versus 25 cases per 10,000 women-years for CE plus MPA compared with placebo. Among women who reported no prior use of hormone therapy, the relative risk of invasive breast cancer was 1.09, and the absolute risk was 40 versus 36 cases per 10,000 women-years for CE plus MPA compared with placebo. In the same substudy, invasive breast cancers were larger, were more likely to be node positive, and were diagnosed at more advanced stage in the CE (0.625 mg) plus MPA (2.5 mg) group compared with the placebo group. Metastatic disease was rare with no apparent difference between the two groups. Other prognostic factors, such as histologic subtype, grade and hormone receptor status did not differ between the groups [ see Clinical Studies (14.3) ]. Consistent with the WHI clinical trial, observational studies have also reported an increased risk of breast cancer for estrogen plus progestin therapy, and smaller increased risk for estrogen-alone therapy, after several years of use. The risk increased with duration of use, and appeared to return to baseline over about years after stopping treatment (only the observational studies have substantial data on risk after stopping). Observational studies also suggest that the risk of breast cancer was greater, and became apparent earlier, with estrogen plus progestin therapy as compared to estrogen-alone therapy. However, these studies have not found significant variation in the risk of breast cancer among different estrogen plus progestin combinations, doses, or routes of administration.Consistent with the WHI clinical trial, observational studies have also reported an increased risk of breast cancer for estrogen plus progestin therapy, and smaller increased risk for estrogen-alone therapy, after several years of use. The risk increased with duration of use, and appeared to return to baseline over about years after stopping treatment (only the observational studies have substantial data on risk after stopping). Observational studies also suggest that the risk of breast cancer was greater, and became apparent earlier, with estrogen plus progestin therapy as compared to estrogen-alone therapy. However, these studies have not found significant variation in the risk of breast cancer among different estrogen plus progestin combinations, doses, or routes of administration.The use of estrogen-alone and estrogen plus progestin has been reported to result in an increase in abnormal mammograms requiring further evaluation. The use of estrogen-alone and estrogen plus progestin has been reported to result in an increase in abnormal mammograms requiring further evaluation.All women should receive yearly breast examinations by healthcare provider and perform monthly breast self-examinations. In addition, mammography examinations should be scheduled based on patient age, risk factors and prior mammogram results.All women should receive yearly breast examinations by healthcare provider and perform monthly breast self-examinations. In addition, mammography examinations should be scheduled based on patient age, risk factors and prior mammogram results.Ovarian CancerThe WHI estrogen plus progestin substudy reported statistically non-significant increased risk of ovarian cancer. After an average follow-up of 5.6 years, the relative risk for ovarian cancer for CE plus MPA versus placebo was 1.58 (95 percent CI, 0.77-3.24). The absolute risk for CE plus MPA versus placebo was versus cases per 10,000 women-years. The WHI estrogen plus progestin substudy reported statistically non-significant increased risk of ovarian cancer. After an average follow-up of 5.6 years, the relative risk for ovarian cancer for CE plus MPA versus placebo was 1.58 (95 percent CI, 0.77-3.24). The absolute risk for CE plus MPA versus placebo was versus cases per 10,000 women-years. A meta-analysis of 17 prospective and 35 retrospective epidemiology studies found that women who used hormonal therapy for menopausal symptoms had an increased risk for ovarian cancer. The primary analysis, using case-control comparisons, included 12,110 cancer cases from the 17 prospective studies. The relative risks associated with current use of hormonal therapy was 1.41 (95% confidence interval [CI] 1.32 to 1.50); there was no difference in the risk estimates by duration of the exposure (less than years [median of years] vs. greater than years [median of 10 years] of use before the cancer diagnosis). The relative risk associated with combined current and recent use (discontinued use within years before cancer diagnosis) was 1.37 (95% CI 1.27-1.48), and the elevated risk was significant for both estrogen-alone and estrogen plus progestin products. The exact duration of hormone therapy use associated with an increased risk of ovarian cancer, however, is unknown.. 5.3Probable Dementia. In the WHIMS estrogen-alone ancillary study of WHI, 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-years [ see Use in Specific Populations (8.5) and Clinical Studies (14.4) ]. In the WHIMS estrogen plus progestin ancillary study, 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 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-years [ see Use in Specific Populations (8.5) and Clinical Studies (14.4) ]. 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 substudies were conducted in women aged 65 to 79 years, it is unknown whether these findings apply to younger postmenopausal women [ see Use in Specific Populations (8.5) and Clinical Studies (14.4) ]. 5.4Gallbladder Disease. 2- to 4-fold increase in the risk of gallbladder disease requiring surgery in postmenopausal women receiving estrogens has been reported.. 5.5Hypercalcemia. Estrogen administration may lead to severe hypercalcemia in women 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.. 5.6Visual Abnormalities. Retinal vascular thrombosis has been reported in women receiving estrogens. Discontinue medication pending examination if there is sudden partial or complete loss of vision, or sudden onset of proptosis, diplopia, or migraine. If examination reveals papilledema or retinal vascular lesions, estrogens should be permanently discontinued.. 5.7Addition of Progestin When Woman Has Not Had Hysterectomy. Studies of the addition of progestin for 10 or more days of cycle of estrogen administration, or daily with estrogen in continuous regimen, have reported lowered incidence of endometrial hyperplasia than would be induced by estrogen treatment alone. Endometrial hyperplasia may be 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.. 5.8Elevated Blood Pressure. In small number of case reports, substantial increases in blood pressure have been attributed to idiosyncratic reactions to estrogens. In large, randomized, placebo-controlled clinical trial, generalized effect of estrogen therapy on blood pressure was not seen.. 5.9Hypertriglyceridemia. 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.. 5.10Hepatic Impairment and/or Past History of Cholestatic Jaundice. Estrogens may be poorly metabolized in women with impaired liver function. For women with 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.. 5.11Hypothyroidism. 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 4 and 3 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. 5.12Fluid Retention. Estrogens may cause some degree of fluid retention. Women with conditions that might be influenced by this factor, such as cardiac or renal impairment, warrant careful observation when estrogen-alone is prescribed.. 5.13Hypocalcemia. Estrogen therapy should be used with caution in women with hypoparathyroidism as estrogen-induced hypocalcemia may occur.. 5.14Exacerbation of Endometriosis. 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.. 5.15Hereditary Angioedema. Exogenous estrogens may exacerbate symptoms of angioedema in women with hereditary angioedema.. 5.16Exacerbation of Other Conditions. 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.. 5.17Laboratory Tests. 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 vulvar and vaginal atrophy due to menopause.. 5.18Drug-Laboratory Test Interactions. 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 TBG levels leading to increased circulating total thyroid hormone levels as measured by protein-bound iodine (PBI), 4 levels (by column or by radioimmunoassay) or 3 levels by radioimmunoassay. 3 resin uptake is decreased, reflecting the elevated TBG. Free 4 and free 3 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 HDL cholesterol subfraction concentrations, reduced low-density lipoprotein (LDL) cholesterol concentration, increased triglycerides levels. Impaired glucose tolerance.. 5.19Vaginal Use and Expulsion. Femring may not be suitable for women with conditions that make the vagina more susceptible to vaginal irritation or ulceration, or make expulsions more likely, such as narrow vagina, vaginal stenosis, vaginal infection, cervical prolapse, rectoceles and cystoceles. If local treatment of vaginal infection is required, Femring can remain in place during treatment.