The Cenestin-Enjuvia discontinuation quandary

With the recent reports that these two HRTS have been taken off the market, we've had an influx of women joining our discussion group asking what they can take to replace them.

That's not an easy question to answer. In part, the answer depends upon just why each woman chose that HRT and continued to take it. So let's look at some of the ways we might end up with this particular blend of conjugated estrogens and consider where we might go from there.

The first one they tried

For women who took one of those brands simply because that's the first one their doctors gave them and it seemed to work okay, this presents an important opportunity to actively choose and try out other hrts. We've put up a simple framework and supporting aids for working through this process based upon each woman's own priorities, not whichever drug rep most recently pitched their product to our doctor. If we work though the selection process, choosing an HRT that meets our own preferences and lifestyle, our doctors should honor that request. And because we've done our homework beforehand, we're prepared to state just why we're making that request, which factors are important to us. We may not have success with our first try or our first try may need a bit of tweaking, but we have to start somewhere. The good news is that this process is easier moving from the stability of a good solid HRT foundation than if we've just had surgery or have been in a state of hormonal uproar.

Alternative to Premarin

If a woman chose this HRT as an alternative to the Premarin that their doctors were urging on them, no, there is not another alternative. There is no other vegetable-source HRT on the market that provides conjugated estrogens. If your doctor is Premarin-or-nothing and will not countenance your using a different type of HRT, the other option is to find a more reasonable doctor who is willing to let you make the critical decisions about your own body and health. Or take Premarin. Even though Premarin is likely to provide for a somewhat different experience, it may work acceptably if one of the others previously did. That assumes, of course, that one is not a vegan or does not have ethical objections to its manufacture.

Tried everything

If women came to this HRT after hopping from one brand and type to another, taking each one at one dose for a short period of time and then, because that one didn't fit, moving on to another, it may be time to reflect upon that process. It often happens that the first dose of an HRT we take doesn't thrill us, but if it does demonstrably deliver to our bodies, we can often tweak the dose or application mode to provide a better fit. When we instead simply jump to another HRT and then another, we pile up the stress of all of those imbalances on top of an already stressful lack of estrogen, leaving us in a deeper and deeper hole we've got to dig back out of.

We've written elsewhere about the process of choosing and tuning an HRT, and while it's not instant gratification, we're all capable of the self-observation skills to carry this out. This may be a good time to revisit this basic selection process, think about which formerly-tried HRT really seemed as though it might have been a good fit for our lifestyle, and revisit it for another attempt. It's very important to remember that if we did this hopping in the first few months after a hyst, we were adding the hugely stressful burden of the menopausal transition to all of the things going on in our bodies, and in a changed setting, months or years later, our overall response might be changed as well.

Prefer oral

If a woman came to this HRT simply because they wanted an oral HRT, a pill they could pop and not worry about it, then reviewing the list of HRTS available in the US (this issue does not affect those using UK HRTs since there was not a non-Premarin conjugated estrogen sold in this market) will show you your options. While this delivery has been less popular in recent years because of its greater risks for cardiovascular disease and cancer, it remains a valid choice for women who are willing to accept that risk profile or who have found that most transdermal deliveries don't work effectively for their bodies.

Uncomfortable with estradiol

While the majority of women today use estradiol HRTs, that contain this active form of estrogen, there is a body of women who find this much activity in a dose excessively stimulating. While we can speculate about genetic variants in metabolism, we don't really have any good explanation why this affects some women but not most others. Nonetheless, after giving more than one estradiol at more than one dose a try, these women just can't settle in. In the end, an HRT that is more estrone-based (the less active, storage form of estrogen) seems to be more comfortable for them.

Unfortunately, there are not a lot of options for these women. Some of the estrone options will be sold as "piperazine estrone sulfate" (formerly known as estropipate), sold as brand names Ortho-Est and Ogen, or "esterified estrogens", sold as the brand name Menest. It's not clear how many of these remain on the market, but women are successful in finding them from time to time. Probably the best tactic, since this availability is not something your doctor will be able to advise you on, is to call around to pharmacies to see if any of them carry or can order it, and if you find one, then ask your doctor to prescribe it for you.

The other option for an estrone-based HRT would be to have one compounded. While compounding pharmacies can make up all-estrone or an estrone-estradiol blend of any proportion for use by a variety of routes (oral, transdermal, transbuccal), women should be aware that the typical "bioidentical" prescription is a generic blend that is more appropriate for a woman in natural perimenopause and contains mostly estriol, a weak estrogen breakdown product effective only in urogenital tissues, plus a small amount of estradiol. This particular type of HRT is not likely to meet a woman's needs in surgical menopause. Instead, one needs to have a doctor prescribe either all estrone or a proportional estradiol/estrone blend to come closer to replicating something more like the conjugated estrogens that have been discontinued. Compounding pharmacies cannot make up a conjugated estrogen blend to match the discontinued HRTs because they do not have access to the components.

Prefer a synthetic estrogen

There are many factors that go into selection of HRTs, and some women may for one reason or another choose a non-human-identical estrogen. There is not another synthetic estrogen blend on the market, however. The most popular synthetics that are not Premarin are ethinylestradiol, a potent synthetic used in oral contraceptives, and tibolone, sold as Livial or Tibofem, that is a synthetic steroid drug with some estrogenic, progestogenic and androgenic activity. It is unlikely that either of these will provide for the same experience as the conjugated estrogens.

How to switch

Once you've made your choice, have your new HRT and are about to run out of the last of your Enjuvia or Cenestin, you might be wondering what the best tactic is for changing over. Luckily, it's pretty easy:

  1. Take your last conjugated estrogen pill.
  2. Wait 24 hours.
  3. Begin your new HRT.

It's as easy as that.

Now, because the conjugated estrogens aren't actually human-identical estrogens, it may take your body a while to fully metabolise them, especially if you've been taking them for years. So you may find that after a few days to a few weeks or even possibly a month or two, your new hrt, even if it felt great at the beginning, now doesn't feel as though it's quite such a good fit. Don't panic! This doesn't mean it's stopped working. It just means that you were still cruising on some leftover conjugated estrogens and now they're gone so they're not contributing to your total coverage any longer. And that means that you need to make a small bump in the dose of your new HRT. In this context, "small" generally seems to mean no more than about 10-15% of your dose, not doubling it. Too big a jump is not only uncomfortable in itself, but it risks taking us right past our best dose and into the risky and unpleasant territory of excess. So this is a case where being gentle with ourselves really pays off better in the long run.

One other question we often see has to do with how much of a dose we will need of our new HRT. In general, wherever we were in the range of available doses of our old HRT (highest, lowest, middle), that's where we start in the range of doses of our new HRT. That's just a guess and it won't be perfect, but a guess is as good as we can get when changing from one type of HRT to another. So we start there and then tune. If in doubt, it's almost always better to underestimate than overestimate, just because it's easier to identify and quicker and safer to play catch-up from.

The bottom line

Cenestin and Enjuvia are gone. There is no secret illegal internet pharmacy that can provide non-counterfeit versions of it. There is no immediate replacement that we can expect to work exactly the same way. This means that, one way or another, you're changing HRT.

In order to best do this, you need to identify your own situation and goals, pick a new option, and test it, including tweaking it if needed.

We can help you with this. Here are the links again for some of the specific resources we can provide:

And of course you're always welcome to come to our discussion group to talk through your own process. We can't tell you what will work best for your own body, but we can help you and keep you company as you explore the various options you have.