1.1 Treatment of Moderate to Severe Vasomotor Symptoms Due to Menopause

Estradiol transdermal system (twice-weekly) is indicated for the treatment of moderate to severe vasomotor symptoms due to menopause.

1.2 Prevention of Postmenopausal Osteoporosis

Estradiol transdermal system (twice-weekly) is indicated for the prevention of postmenopausal osteoporosis. When prescribing solely for the prevention of postmenopausal osteoporosis, therapy should only be considered for women at significant risk of osteoporosis and non-estrogen medications should be carefully considered.

2.1 Treatment of Moderate to Severe Vasomotor Symptoms

Start therapy with estradiol transdermal system (twice-weekly) 0.0375 mg per day applied to the skin twice weekly. Dosage adjustment should be guided by the clinical response.

Therapy should be started at the lowest effective dose and the shortest duration consistent with the treatment goals. Attempts to taper or discontinue the medication should be made at 3 to 6 month intervals.

2.2 Prevention of Postmenopausal Osteoporosis

Start therapy with estradiol transdermal system (twice-weekly) 0.025 mg per day applied to the skin twice weekly. The dose may be adjusted as necessary.

2.3 Patch Application Instructions

The adhesive side of estradiol transdermal system (twice-weekly) should be placed on a clean, dry area on the lower abdomen (below the umbilicus) or buttocks. Estradiol transdermal system (twice-weekly) should not be applied to the breasts.

Estradiol transdermal system (twice-weekly) should be replaced twice weekly (every 3 to 4 days).

The sites of application must be rotated, with an interval of at least 1 week allowed between applications to a particular site.

The area selected should not be oily, damaged, or irritated. The waistline should be avoided, since tight clothing may rub the system off. The system should be applied immediately after opening the pouch and removing the protective liner. The system should be pressed firmly in place with the palm of the hand for about 10 seconds, making sure there is good contact with the skin, especially around the edges. In the event that a system should fall off, the same system may be reapplied. If the same system cannot be reapplied, a new system should be applied to another location. If a woman has forgotten to apply a patch, she should apply a new patch as soon as possible. In either case, the original treatment schedule should be continued. The interruption of treatment in women taking estradiol transdermal system (twice-weekly) might increase the likelihood of breakthrough bleeding, spotting and recurrence of symptoms.

5.1 Cardiovascular 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.

5.2 Malignant Neoplasms

5.3 Probable Dementia

In the WHIMS estrogen-alone ancillary study of WHI, a population of 2,947 hysterectomized women 65 to 79 years of age was randomized to daily CE (0.625 mg)-alone or placebo.

After an average follow-up of 5.2 years, 28 women in the estrogen-alone group and 19 women in the placebo group were diagnosed with probable dementia. The relative risk of probable dementia for CE-alone versus placebo was 1.49 (95 percent CI, 0.83 to 2.66). The absolute risk of probable dementia for CE-alone versus placebo was 37 versus 25 cases per 10,000 women-years8 [see Use in Specific Populations (8.5), and Clinical Studies (14.4)].

In the WHIMS estrogen plus progestin ancillary study of WHI, a population of 4,532 postmenopausal women 65 to 79 years of age was randomized to daily CE (0.625 mg) plus MPA (2.5 mg) or placebo.

After an average follow-up of 4 years, 40 women in the CE plus MPA group and 21 women in the placebo group were diagnosed with probable dementia. The relative risk of probable dementia for CE plus MPA versus placebo was 2.05 (95 percent CI, 1.21 to 3.48). The absolute risk of probable dementia for CE plus MPA versus placebo was 45 versus 22 cases per 10,000 women-years8 [see Use in Specific Populations (8.5), and Clinical Studies (14.4)].

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 to 2.60). Since both ancillary studies were conducted in women 65 to 79 years of age, it is unknown whether these findings apply to younger postmenopausal women8 [see Use in Specific Populations (8.5), and Clinical Studies (14.4)].

5.4 Gallbladder Disease

A 2- to 4-fold increase in the risk of gallbladder disease requiring surgery in postmenopausal women receiving estrogens has been reported.

5.5 Hypercalcemia

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.

5.6 Visual Abnormalities

Retinal vascular thrombosis has been reported in patients receiving estrogens. Discontinue medication pending examination if there is sudden partial or complete loss of vision, or a sudden onset of proptosis, diplopia, or migraine. If examination reveals papilledema or retinal vascular lesions, estrogens should be permanently discontinued.

5.7 Addition of a Progestin When a Woman Has Not Had a Hysterectomy

Studies of the addition of a progestin for 10 or more days of a cycle of estrogen administration, or daily with estrogen in a continuous regimen, have reported a lowered incidence of endometrial hyperplasia than would be induced by estrogen treatment alone. Endometrial hyperplasia may be a precursor to endometrial cancer.

There are, however, possible risks that may be associated with the use of progestins with estrogens compared to estrogen-alone regimens. These include an increased risk of breast cancer.

5.8 Elevated Blood Pressure

In a small number of case reports, substantial increases in blood pressure have been attributed to idiosyncratic reactions to estrogens. In a large, randomized, placebo-controlled clinical trial, a generalized effect of estrogens on blood pressure was not seen.

5.9 Hypertriglyceridemia

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.

5.10 Hepatic Impairment and/or Past History of Cholestatic Jaundice

Estrogens may be poorly metabolized in patients with impaired liver function. For women with a history of cholestatic jaundice associated with past estrogen use or with pregnancy, caution should be exercised and in the case of recurrence, medication should be discontinued.

5.11 Hypothyroidism

Estrogen administration leads to increased thyroid-binding globulin (TBG) levels. Women with normal thyroid function can compensate for the increased TBG by making more thyroid hormone, thus maintaining free T4 and T3 serum concentrations in the normal range. Women dependent on thyroid hormone replacement therapy who are also receiving estrogens may require increased doses of their thyroid replacement therapy. These women should have their thyroid function monitored in order to maintain their free thyroid hormone levels in an acceptable range.

5.12 Fluid Retention

Estrogens may cause some degree of fluid retention. Women with conditions that might be influenced by this factor, such as cardiac or renal dysfunction, warrant careful observation when estrogen is prescribed.

5.13 Hypocalcemia

Estrogen therapy should be used with caution in women with hypoparathyroidism as estrogen-induced hypocalcemia may occur.

5.14 Exacerbation of Endometriosis

A few cases of malignant transformation of residual endometrial implants have been reported in women treated post-hysterectomy with estrogen-alone therapy. For women known to have residual endometriosis post-hysterectomy, the addition of progestin should be considered.

5.15 Severe Anaphylactic/Anaphylactoid Reactions and Angioedema

Cases of anaphylactic/anaphylactoid reactions, which developed anytime during the course of estradiol transdermal system (twice-weekly) treatment and required emergency medical management, have been reported in the postmarketing setting. Involvement of skin (hives, pruritus, swollen lips-tongue-face) and either respiratory tract (respiratory compromise) or gastrointestinal tract (abdominal pain, vomiting) has been noted.

Angioedema involving eye/eyelid, face, larynx, pharynx, tongue and extremity (hands, legs, ankles, and fingers) with or without urticaria requiring medical intervention has occurred in the postmarketing experience of using estradiol transdermal system (twice-weekly). If angioedema involves the tongue, glottis, or larynx, airway obstruction may occur. Patients who develop angioedema anytime during the course of treatment with estradiol transdermal system (twice-weekly) should not receive it again.

Exogenous estrogens may exacerbate symptoms of angioedema in women with hereditary angioedema.

5.16 Exacerbation of Other Conditions

Estrogen therapy may cause an exacerbation of asthma, diabetes mellitus, epilepsy, migraines, porphyria, systemic lupus erythematosus, and hepatic hemangiomas and should be used with caution in women with these conditions.

5.17 Laboratory 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.

5.18 Drug-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 anti factor Xa and antithrombin III; decreased antithrombin III activity; increased levels of fibrinogen and fibrinogen activity; increased plasminogen antigen and activity.

Increased thyroid-binding globulin (TBG) leading to increased circulating total thyroid hormone levels, as measured by protein-bound iodine (PBI), T4 levels (by column or by radioimmunoassay) or T3 levels by radioimmunoassay. T3 resin uptake is decreased, reflecting the elevated TBG. Free T4 and free T3 concentrations are unaltered. Women on thyroid replacement therapy may require higher doses of thyroid hormone.

Other binding proteins may be elevated in serum, for example, corticosteroid-binding globulin (CBG), sex hormone-binding globulin (SHBG), leading to increased total circulating corticosteroids and sex steroids, respectively. Free hormone concentrations, such as testosterone and estradiol, may be decreased. Other plasma proteins may be increased (angiotensinogen/renin substrate, alpha-1-antitrypsin, ceruloplasmin).

Increased plasma high-density lipoprotein (HDL) and HDL2 cholesterol subfraction concentrations, reduced low-density lipoprotein (LDL) cholesterol concentration, increased triglycerides levels.

Impaired glucose tolerance.

6.1 Clinical Trials Experience

Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice.

There were no clinical trials conducted with estradiol transdermal system (twice-weekly). Estradiol transdermal system (twice-weekly) is bioequivalent to Vivelle®. The following adverse reactions are reported with Vivelle therapy:

During the clinical pharmacology studies with estradiol transdermal system (twice-weekly), 35 percent or less of subjects experienced barely perceptible erythema. No transdermal systems were removed due to irritation. Three subjects (2.2 percent) reported mild discomfort while wearing estradiol transdermal system (twice-weekly) (N = 136).

6.2 Postmarketing Experience

The following additional adverse reactions have been identified during post-approval use of estradiol transdermal system (twice-weekly). Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure.

Breast: Breast enlargement

Cardiovascular: Palpitations, angina unstable

Gastrointestinal: Hemorrhage, diarrhea

Skin: Application site reactions, erythema, rash, hyperhidrosis, pruritus, urticaria

Central Nervous System: Dizziness, paresthesia, migraine, mood swings, emotional disorder, irritability, nervousness

Miscellaneous: Portal vein thrombosis, dyspnea, malaise, fatigue, peripheral edema, muscle spasms, paresthesia oral, swollen tongue, lip swelling, pharyngeal edema

7.1 Metabolic 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. John’s wort (Hypericum perforatum) preparations, phenobarbital, carbamazepine and rifampin may reduce plasma concentrations of estrogens, possibly resulting in a decrease in therapeutic effects and/or changes in the uterine bleeding profile. Inhibitors of CYP3A4 such as erythromycin, clarithromycin, ketoconazole, itraconazole, ritonavir, and grapefruit juice may increase plasma concentrations of estrogens and may result in side effects.

8.1 Pregnancy

Estradiol transdermal system (twice-weekly) 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.

8.3 Nursing Mothers

Estradiol transdermal system (twice-weekly) 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 therapy. Caution should be exercised when estradiol transdermal system (twice-weekly) is administered to a nursing woman.

8.4 Pediatric Use

Estradiol transdermal system (twice-weekly) is not indicated in children. Clinical studies have not been conducted in the pediatric population.

8.5 Geriatric Use

There have not been sufficient numbers of geriatric women involved in clinical studies utilizing estradiol transdermal system (twice-weekly) to determine whether those over 65 years of age differ from younger subjects in their response to estradiol transdermal system (twice-weekly).

8.6 Renal Impairment

The effect of renal impairment on the pharmacokinetics of estradiol transdermal system (twice-weekly) has not been studied.

8.7 Hepatic Impairment

The effect of hepatic impairment on the pharmacokinetics of estradiol transdermal system (twice-weekly) has not been studied.

12.1 Mechanism 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 a dynamic equilibrium of metabolic interconversions, estradiol is the principal intracellular human estrogen and is substantially more potent than its metabolites, estrone and estriol, at the receptor level.

The primary source of estrogen in normally cycling adult women is the ovarian follicle, which secretes 70 to 500 mcg of estradiol daily, depending on the phase of the menstrual cycle. After menopause, most endogenous estrogen is produced by conversion of androstenedione, secreted by the adrenal cortex, to estrone in the peripheral tissues. Thus, estrone and the sulfate conjugated form, estrone sulfate, are the most abundant circulating estrogens in postmenopausal women.

Estrogens act through binding to nuclear receptors in estrogen responsive tissues. To date, two estrogen receptors have been identified. These vary in proportion from tissue to tissue.

Circulating estrogens modulate the pituitary secretion of the gonadotropins, luteinizing hormone (LH) and follicle stimulating hormone (FSH) through a negative feedback mechanism. Estrogens act to reduce the elevated concentrations of these hormones seen in postmenopausal women.

12.2 Pharmacodynamics

There are no pharmacodynamic data for estradiol transdermal system (twice-weekly).

12.3 Pharmacokinetics

Absorption

In a single-dose, two way-crossover clinical study conducted in 96 healthy, non-smoking postmenopausal women under fed condition, estradiol transdermal system (twice-weekly) (0.1 mg per day) was bioequivalent to Vivelle (0.1 mg per day) based on estradiol exposure (AUC0-84) and estradiol peak concentration (Cmax) following a single-dose on the lower abdomen for 84 hours.

Estradiol pharmacokinetics were characterized in a separate open-label, single-center, randomized, single-dose, three-way crossover study conducted in 36 healthy, non-smoking postmenopausal women (aged 40 to 65 years). Estradiol transdermal system (twice-weekly) delivering nominal estradiol of approximately 0.025 mg, 0.05 mg, and 0.1 mg per day were applied to the lower abdomen under fed state in a crossover fashion for 84 hours. The mean estradiol pharmacokinetics parameters are summarized in Table 2. AUC and Cmax are dose proportional from 0.025 mg to 0.1 mg per day.

Table 2: Mean (SD) Serum Pharmacokinetic Parameters of Baseline-Uncorrected Estradiol following a Single Dose of Estradiol Transdermal System (Twice-Weekly) (N = 36)

* Median (minimum-maximum)
Parameter	0.1 mg/day	0.05 mg/day	0.025 mg/day
AUC84 (pg•hr/mL)	5875 (1857)	3057 (980)	1763 (600)
AUC120 (pg•hr/mL)	6252 (1938)	3320 (1038)	1979 (648)
Cmax (pg/mL)	117 (39.3)	56.6 (17.6)	30.3 (11.1)
Tmax (hr)*	24.0 (8-60)	24.0 (8-60)	36.0 (8-84)

Figure 1 illustrates the mean baseline-uncorrected estradiol serum concentrations of estradiol transdermal system (twice-weekly) at three different strengths.

Figure 1: Mean Baseline-Uncorrected Estradiol Serum Concentration-Time Profiles Following a Single Dose of Estradiol Transdermal System (Twice-Weekly) 0.1 mg per day (Treatment A), 0.05 mg per day (Treatment B), and 0.025 mg per day (Treatment C) (N = 36)

  

13.1 Carcinogenesis, 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.

14.1 Effects on Vasomotor Symptoms

There have been no efficacy and safety trials conducted with estradiol transdermal system (twice-weekly). In a pharmacokinetic study, estradiol transdermal system (twice-weekly) was shown to be bioequivalent to Vivelle.

In two controlled clinical trials with Vivelle, in a total of 356 subjects, the 0.075 and 0.1 mg doses were superior to placebo in relieving vasomotor symptoms at Weeks 4, 8 and 12 of treatment. In these studies, the 0.0375 and 0.05 mg doses did not differ from placebo at Week 4, therefore, a third 12-week placebo-controlled study in 255 subjects was performed with Vivelle to establish the efficacy of the lowest dose of 0.0375 mg. The baseline mean daily number of hot flushes in these 255 subjects was 11.5. Results at Weeks 4, 8, and 12 of treatment are shown in Figure 2.

Figure 2: Mean (SD) Change from Baseline in Mean Daily Number of Hot Flushes for Vivelle 0.0375 mg versus Placebo in a 12-Week Trial.

The 0.0375 mg dose was superior to placebo in reducing both the frequency and severity of vasomotor symptoms at Weeks 4, 8 and 12 of treatment.

14.2 Effects on Bone Mineral Density

There have been no bone efficacy and safety trials conducted with estradiol transdermal system (twice-weekly). In a pharmacokinetic study, estradiol transdermal system (twice-weekly) was shown to be bioequivalent to Vivelle.

Efficacy and safety of Vivelle in the prevention of postmenopausal osteoporosis have been studied in a 2-year double-blind, randomized, placebo-controlled, parallel group study. A total of 261 hysterectomized (161) and non-hysterectomized (100), surgically or naturally menopausal women (within 5 years of menopause), with no evidence of osteoporosis (lumbar spine bone mineral density within 2 standard deviations of average peak bone mass, i.e., ≥ 0.0827 g/cm2) were enrolled in this study; 194 patients were randomized to one of the four doses of Vivelle (0.1, 0.05, 0.0375, or 0.025 mg/day) and 67 patients to placebo. Over 2 years, study systems were applied to the buttock or the abdomen twice a week. Non-hysterectomized women received oral medroxyprogesterone acetate (2.5 mg/day) throughout the study.

The study population comprised naturally (82 percent) or surgically (18 percent) menopausal, hysterectomized (61 percent) or non-hysterectomized (39 percent) women with a mean age of 52.0 years (range 27 to 62 years); the mean duration of menopause was 31.7 months (range 2 to 72 months). Two hundred thirty-two (89 percent) randomized subjects (173 on active drug, 59 on placebo) contributed data to the analysis of percent change from baseline in bone mineral density (BMD) of the AP lumbar spine, the primary efficacy variable. Patients were given supplemental dietary calcium (100 mg elemental calcium/day) but no supplemental vitamin D. There was an increase in BMD of the AP lumbar spine in all Vivelle dose groups; in contrast to this, a decrease in AP lumbar spine BMD was observed in placebo patients. All Vivelle doses were significantly superior to placebo (p < 0.05) at all time points with the exception of Vivelle 0.05 mg/day at 6 months. The highest dose of Vivelle was superior to the three lower doses. There were no statistically significant differences in pairwise comparisons among the three lower doses (See Figure 3).

Figure 3: Bone Mineral Density – AP Lumbar Spine Least Squares Means of Percentage Change from Baseline All Randomized Patients with at Least One Post-baseline Assessment Available with Last Post-baseline Observation Carried Forward

Analysis of percent change from baseline in femoral neck BMD, a secondary efficacy outcome variable, showed qualitatively similar results; all doses of Vivelle were significantly superior to placebo (p < 0.05) at 24 months. The highest Vivelle dose was superior to placebo at all time points. A mixture of significant and non-significant results were obtained for the lower dose groups at earlier time points. The highest Vivelle dose was superior to the three lower doses, and there were no significant differences among the three lower doses at this skeletal site (see Figure 4).

Figure 4: Bone Mineral Density – Femoral Neck Least Squares Means of Percentage Change from Baseline All Randomized Patients with at Least One Post-baseline Assessment Available with Last Post-baseline Observation Carried Forward

14.3 Women’s 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. A “global index” included the earliest occurrence of CHD, invasive breast cancer, stroke, PE, endometrial cancer (only in the CE plus MPA substudy), colorectal cancer, hip fracture, or death due to other cause. These substudies did not evaluate the effects of CE-alone or CE plus MPA on menopausal symptoms.

14.4 Women’s 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 (45 percent were 65 to 69 years of age, 36 percent were 70 to 74 years of age, and 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 to 2.66). The absolute risk of probable dementia for CE-alone versus placebo was 37 versus 25 cases per 10,000 women-years. Probable dementia as defined in this study included Alzheimer’s disease (AD), vascular dementia (VaD) and mixed type (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 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 daily CE (0.625 mg) plus MPA (2.5 mg) on the incidence of probable dementia (primary outcome) compared to placebo.

After an average follow-up of 4 years, the relative risk of probable dementia for CE plus MPA versus placebo was 2.05 (95 percent CI, 1.21 to 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 type (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)].

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 to 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)].

16.1 How Supplied

Estradiol Transdermal System, USP (Twice-Weekly) is available as 0.025 mg/day, 0.0375 mg/day, 0.05 mg/day, 0.075 mg/day or 0.1 mg/day of estradiol. Each strength is supplied in a Patient Calendar Pack containing 8 individually packaged systems.

The 0.025 mg per day is available as a 2.5 cm2 system containing estradiol, USP hemihydrate equivalent to 0.41 mg of estradiol, for nominal* delivery of 0.025 mg of estradiol per day. Each rectangular patch with rounded corners consists of an opaque, white to cream adhesive layer, matte film backing randomly printed with “Estradiol 0.025 mg/day” in brown ink, and a clear release liner. The patch is contained in a square, flat, notched, pouch. The pouch is imprinted with the lot number and expiration date. They are available as follows:

NDC 0378-4619-26
carton containing 8 systems

The 0.0375 mg per day is available as a 3.75 cm2 system containing estradiol, USP hemihydrate equivalent to 0.62 mg of estradiol for nominal* delivery of 0.0375 mg of estradiol per day. Each rectangular patch with rounded corners consists of an opaque, white to cream adhesive layer, matte film backing randomly printed with “Estradiol 0.0375 mg/day” in brown ink, and a clear release liner. The patch is contained in a square, flat, notched, pouch. The pouch is imprinted with the lot number and expiration date. They are available as follows:

NDC 0378-4620-26
carton containing 8 systems

The 0.05 mg per day is available as a 5.0 cm2 system containing estradiol, USP hemihydrate equivalent to 0.82 mg of estradiol for nominal* delivery of 0.05 mg of estradiol per day. Each rectangular patch with rounded corners consists of an opaque, white to cream adhesive layer, matte film backing randomly printed with “Estradiol 0.05 mg/day” in brown ink, and a clear release liner. The patch is contained in a square, flat, notched, pouch. The pouch is imprinted with the lot number and expiration date. They are available as follows:

NDC 0378-4621-26
carton containing 8 systems

The 0.075 mg per day is available as a 7.5 cm2 system containing estradiol, USP hemihydrate equivalent to 1.23 mg of estradiol for nominal* delivery of 0.075 mg of estradiol per day. Each rectangular patch with rounded corners consists of an opaque, white to cream adhesive layer, matte film backing randomly printed with “Estradiol 0.075 mg/day” in brown ink, and a clear release liner. The patch is contained in a square, flat, notched, pouch. The pouch is imprinted with the lot number and expiration date. They are available as follows:

NDC 0378-4622-26
carton containing 8 systems

The 0.1 mg per day is available as a 10.0 cm2 system containing estradiol, USP hemihydrate equivalent to 1.64 mg of estradiol for nominal* delivery of 0.1 mg of estradiol per day. Each rectangular patch with rounded corners consists of an opaque, white to cream adhesive layer, matte film backing randomly printed with “Estradiol 0.1 mg/day” in brown ink, and a clear release liner. The patch is contained in a square, flat, notched, pouch. The pouch is imprinted with the lot number and expiration date. They are available as follows:

NDC 0378-4623-26
carton containing 8 systems

[*see DESCRIPTION]

16.2 Storage and Handling

Store at room temperature 20° to 25°C (68° to 77°F). [See USP Controlled Room Temperature.]

Do not store unpouched. Apply immediately upon removal from the protective pouch.

Used transdermal systems still contain active hormone. To discard, fold the sticky side of the transdermal system together, place it in a sturdy child-proof container, and place this container in the trash. Used transdermal systems should not be flushed in the toilet.

17.1 Vaginal Bleeding

Inform postmenopausal women of the importance of reporting unusual vaginal bleeding to their healthcare providers as soon as possible [see Warnings and Precautions (5.2)].

17.2 Possible 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)].

17.3 Possible Less Serious but Common Adverse Reactions with Estrogen-Alone Therapy

Inform postmenopausal women of less serious but common adverse reactions of estrogen-alone therapy such as headache, breast pain and tenderness, nausea and vomiting.

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