Topical Estradiol Gel (Non-Vaginal/Divigel)

This treatment plan reviews the risks and benefits of the treatment we are recommending. Please make sure to read it and the manufacturer's pamphlet that comes with the medicine. The manufacturer's pamphlet contains full information on potential medication interactions, side effects, and other important information you should know about the medicine before you start.

Instructions

You have stated that you wish to obtain hormonal replacement therapy treatment with topical, non-vaginal, estradiol gel. Please follow the directions on your prescription for administration of treatment. This gel comes in packets containing doses of 0.25mg-1.25mg. Apply the entire contents of one Divigel (estradiol) unit-dose packet (0.25–1.25 grams, as prescribed) once daily to clean, dry, unbroken skin of either the right or left upper thigh, alternating sides each day. Allow the gel to dry completely before dressing. Do not apply to the face, breasts, irritated skin, or in or around the vagina. Do not wash the application site for at least one hour after application. Wash hands thoroughly after application. The application area should be approximately 5 by 7 inches (about the size of two palm prints).

For women with a uterus, concurrent progestogen therapy is recommended with the use of topical estradiol to reduce the risk of endometrial hyperplasia and endometrial cancer; this is not necessary for women without a uterus unless there is a history of endometriosis.

Allergies

This medicine, like all medications, may cause an allergic reaction if you are allergic to similar medicines or components. If you are allergic to any of the following please do not take the medicine and call or message us or see your doctor in person.

• Estrogens (Estradiol, ethinylestradiol)
  
  

Conditions

We have evaluated your health history and the specific health information you provided us, however if anything changes and you develop one of these conditions, please stop taking this medicine and call or message us immediately.

• Pregnancy
• Less than 6 weeks postpartum
• History of endometrial, uterine, or ovarian cancer
• History of breast cancer
• Heart disease/Heart attack
• Porphyria
• Abnormal vaginal bleeding
  
  

Pregnancy and Breastfeeding

Based on available data, estradiol is not considered acceptable or safe for use in pregnancy.

Estrogens may decrease the quantity and quality of human milk. According to the manufacturer, the decision to breastfeed during therapy should consider the risk of infant exposure, the benefits of breastfeeding to the infant, and the benefits of treatment to the mother. (source)

Medicines, Supplements, and Foods

We have evaluated the specific health information you provided us, however if you are taking any of the medicines, foods, or supplements listed below call or message us before you take the medicine. Some of these can cause dangerous interactions with the medicine we are prescribing you and we will help you evaluate that risk and decide on an appropriate treatment plan. Please ensure your chart is up to date with your current medications, allergies, and medical conditions so your provider can safely treat you as this list may not be all inclusive.

• Aromatase inhibitors (anastrozole, exemestane, letrozole)
• Fusilic acid
• Fezolinetant
• Fulvestrant
• Hemin
• Ospemifene
• Raloxifene
• Tamoxifen
• Toremifene
• Grapefruit
  
  

Emergency Side Effects

This medicine can cause dangerous and potentially life-threatening side effects. If any of the emergency side effects listed in the manufacturer’s pamphlet or those below happen to you please stop taking the medicine and call 911 or seek immediate medical help in person.

• Sudden onset of chest pain
• Shortness of breath
• Difficulty or painful swallowing
• Severe skin rash and/or itching
• Facial or throat swelling
• Blurred vision
• Pain, redness, or swelling in the arm or leg
  
  

Other Side Effects

This medicine can also cause other side effects including (list is not all inclusive):

• Vaginal bleeding
• Nausea
• Breast tenderness
• Change in vaginal discharge
• Clear or bloody discharge from the nipple
• Fast heartbeat
• Irritation
• Joint pain, stiffness, or swelling
• Lump in the breast or under the arm
• Pain or feeling of pressure in the pelvis
• Redness of the skin
  
  

Risks

Accurate Information

We have evaluated your health history and your specific health information you provided and determined it is safe to proceed with vaginal estrogen gel at this time. If your health history changes including diagnoses or medications please message or call us before you take the medicine to ensure it's safe to proceed. Some medications and conditions can cause dangerous interactions with the medicine we are prescribing and we will help you evaluate that risk and decide on an appropriate treatment plan.

Treatment Failure

This treatment is not guaranteed to be effective. It may not work or may only partially resolve the condition for which you are seeking treatment. If the treatment is not working, or if you are experiencing new or worsening symptoms, give us a call or message us anytime. If it is an emergency, call 911 or seek immediate medical help in person. You may need to seek alternative treatment such as those listed below or in the follow up plan.

Misdiagnosis or Delayed Diagnosis

Through telehealth, there is also a risk that we misdiagnose or fail to diagnose conditions that you may have which could affect our recommendation for treatment. This risk exists with a doctor in person as well but they may have additional resources to aid their evaluation. We use evidence-based practice and guidelines as well as clinical decision-making to minimize these risks.

Accepting or Declining Our Recommendation

We have based our recommendation on your specific case and medical guidelines, but there may be alternative treatments or strategies that may be helpful to you. Some may be more or less effective than what we provide. Some treatments may require an in-person exam or procedure which we can’t provide. Message us or talk to your doctor in person to discuss alternative treatments.

Share with Your In-Person Healthcare Team

You can access your records anytime. We strongly recommend that you update your in-person doctor, pharmacist, and the rest of your healthcare team to let them know about any new medicines you are taking or other changes in your health.

You can also ask us questions anytime and we are happy to help you share any information about your health with your in-person healthcare team.