Parenteral estrogens as first-line (mono)therapy?

[noahware]

I know high-dose oral DES had lots of problems and fell out of favor decades ago, mainly because of oral delivery and too-high dosing. What about the use of transdermal estrogen? I have heard about patches used by men who have already undergone prior ADT, as second line therapy or for QoL improvement, but know very little about the potential as first-line initial systemic treatment. (Apparently some use of this "newer" estrogen monotherapy in Europe already exists.)

Any thoughts, experiences or studies anyone would care to share?

[Tall_Allen]

Several men on this forum use it. If you are interested, you might PM Richard Wassersug.

[noahware in reply to Tall_Allen]

Thanks, I was just looking at some of his posts from a few years back... he certainly seems like the guy to talk to.

I know one touted advantage (in addition to QoL) is lower cost... but if insurance won't cover it as first-line treatment, then I guess it might not be as affordable out-of-pocket as the pricier treatments that are effectively "free" via full coverage.

[Tall_Allen in reply to noahware]

You can have transdermal creams or patches made up by a compounding pharmacy. It is less expensive that way.

[cesces]

I think if you are doing adt, you can't not take estrogen patches, just for side effect issues.

And as I understand it, it is a treatment all on its own.

[noahware in reply to cesces]

I wasn't aware of that. I knew some men on ADT used them, but maybe that is when they are on ADT vaca?

But in any case, thanks, I am thinking of it all on its own as monotherapy for primary treatment (of asymptomatic Gleason 3+4 w/ a few spinal mets).

[GP24 in reply to cesces]

You can use these patches at a lower dose to mitigate the side effects of Lupron and at a higher dose to replace Lupron.

The lower dose is one 100 μg patch (or lower) every three to four days. This will mitigate several side effects combined, hot flashes, bone loss, mood swings and more.

The higher dose, which is used in the Patch trial in the UK, is three 100 μg patches at once changed every three to four days.

[pjoshea13 in reply to GP24]

I believe that Dr. Myers used the Vivelle-Dot 0.025 mg estradiol patch.

Essentially, while on classic ADT, E2 should not fall below 12 pg/mL. Bone loss is rapid. A good target for E2 IMO is 20 pg/mL.

-Patrick

[GP24 in reply to pjoshea13]

As far as I know, a 25 μg estradiol patch is the lowest dose you can get. A healthy man has an estrogen level up to 40 pg/mL. When I took bicalutamide, my estrogen level was higher and I did not notice any problems with that. Therefore I think you can increase the estrogen level above 12 pg/ml. If your side effects are already gone with 12 pg/ml you do not need to increase the level of cause. A high estrogen level and a low testosterone level will cause breast enlargement. I took Tamoxifen to avoid that.

[Wassersug]

I see my name mentioned in this thread (Thanks Tall Allen).

I have used transdermal estradiol for ADT for years, following a protocol similar to the PATCH study in the UK, which is now part of the grand STAMPEDE trial (see cinicaltrials.gov).

Initially I used the actual patches, but soon found the gel (Estrogel) easier to manage.

The case for using transdermal estradiol for ADT is mentioned in th ADT book, but not endorsed there as it is an off label use and it was important to all of us who contributed to the book that we stayed with evidence-based treatments.

If folks would like more information, they are invited (as Tall Allen says) to PM me directly.

Richard W.

[noahware in reply to Wassersug]

Thanks!

I will be in touch.

[petercraig2]

Hello,

I have been using 100mg estrogen x4 patches changing x2 daily for about 2 1/2 years and very successful.

Initially I didn't like the documented cardiac risks, anecdotal descriptions of 'night sweats, rigid dosage regime of standard ADT and so went for patches.

Following surgery my PSA climbed to 24 and is now <.008 which is below measurement at my lab. Estradiol is pretty steady at 1414, and Testosterone is <.1 with no side affects apart for gynecomastia which I can live with. My biggest complaint this that as an 'Off Label' therapy the provincial health plan here does not cover the cost.

It may not be for everyone but is worth a try for anyone with no downside risks that I am aware of.

Best of luck

Peter

[noahware in reply to petercraig2]

Thanks for sharing!

[MateoBeach]

The PATCH trial using estradiol patches as mono therapy for ADT altered their dosing for more consistent castrate levels of Testosterone, which is how you can monitor and adjust it individually. The trial went to 4 of the 0.10 mg estradiol per 24 hrs in the biweekly formulation. (Like DOTT a d Vivelle dot). So 4 are worn at one time and one is changed out daily on a rotating basis (keep a diagram with dates!)

I used this for ADT adjuvant to RT. It was very satisfactory for me. However the onset was slow: after one month I was still not quite below 20 on my T level.

So I had my MO give me a single injection of Degarelix at half the usual first dose , 120 mg. This drives T to castrate level within one day. Then the patches can take over. I decided this is a good way to get it started. Regular T and PSA levels should be followed along with other monitoring. Some would also check LH and FSH levels.