Ethinylestradiol

Ethinylestradiol
Clinical data
Pronunciation /ˌɛθɪnɪlˌiːstrəˈdaɪ.əl/
Trade names Estinyl, others
AHFS/Drugs.com International Drug Names
MedlinePlus a604032
Pregnancy
category
Routes of
administration		 • By mouth (tablet)
• Transdermal (patch)
• Vaginal (ring)
ATC code
Legal status
Legal status
  • In general: ℞ (Prescription only)
Pharmacokinetic data
Bioavailability 38–48%[1][2]
Protein binding 97–98% (to albumin;[3] does not bind to SHBG)[4]
Metabolism Liver (primarily CYP3A4)[5]
Biological half-life 7–36 hours[6][1][5][7]
Excretion Feces: 62%[6]
Urine: 38%[6]
Identifiers
Synonyms 17α-Ethynylestradiol; 17α-Ethynylestra-1,3,5(10)-triene-3,17β-diol; NSC-10973[8]
CAS Number
PubChem CID
IUPHAR/BPS
DrugBank
ChemSpider
UNII
KEGG
ChEBI
ChEMBL
ECHA InfoCard 100.000.311
Chemical and physical data
Formula C20H24O2
Molar mass 296.403 g/mol
3D model (JSmol)
 NYesY (what is this?)  (verify)

Ethinylestradiol (EE) is an orally active estrogen and a synthetic derivative of estradiol, a steroid hormone and the major endogenous estrogen in humans.[8] EE is used as a medication and is a component of almost all formulations of combined birth control pills, being nearly the exclusive estrogen used for this purpose.[9]

EE was patented in 1935 and came into medical use in 1943.[10][11] It started being used in oral contraceptives in 1964.[12]

Medical uses

Under the brand name Estinyl, EE was formerly used for hormone replacement therapy in menopause and the treatment of female hypogonadism, loss of menstruation, dysmenorrhea, acne, prostate cancer, and breast cancer.[13] However, in more recent times, EE is mainly used in COCs. In contraception, due to concerns of unopposed estrogen action and the possible increased risk of endometrial cancer that accompanies this, EE is formulated in combination with progestins. EE is little used in menopausal hormone replacement therapy.[14]

EE has been used at very high dosages (1–2 mg/day) in the treatment of prostate cancer.[15]

Contraindications

EE should be avoided in women with a history of or known susceptibility to thrombosis (blood clots), particularly venous thromboembolism (VTE).

Due to risk of cholestatic hepatotoxicity, it is widely considered that COCs containing EE should be avoided in women with a history of cholestasis of pregnancy, hepatic tumors, active hepatitis, and familial defects in biliary excretion.[16]

Side effects

Side effects of EE are the same as for other estrogens and include breast tenderness, headache, fluid retention (bloating), nausea, dizziness, and weight gain.[6][16] The estrogen component of oral contraceptives, which is almost always EE, can cause breast tenderness and fullness.[17]

Rare reactions

Venous thromboembolism

EE carries a greater risk of blood clot formation and VTE than does natural estradiol, which is thought to be due to different degrees of hepatic metabolism between the two drugs (see below).

The original formulations of COCs contained as much as 150 μg EE.[18] However, it was soon found that EE is associated with incidence of VTE and that the risk is dose-dependent.[18] Subsequently, the dosage of EE was greatly reduced, and is now generally between 25 and 35 μg,[18] in some cases less than 20 μg,[18] and not more than 50 μg.[19][20][17] These lower dosages have a significantly reduced risk of VTE with no loss of contraceptive effectiveness.[18] According to a bulletin posted by the U.S. FDA, the rate of deep vein thrombosis in women taking COCs containing 20 to 40 μg EE is 4 per 10,000, which is approximately equivalent to the rate of 3 per 10,000 in women not taking a COC.[21] No study has shown a further reduced risk of VTE below an EE dosage of 30 or 35 μg.[18]

Cholestatic hepatotoxicity

EE has, albeit rarely (at the low dosages that are now used in COCs), been associated with cholestatic hepatotoxicity similarly to 17α-alkylated anabolic-androgenic steroids and 17α-ethynylated 19-nortestosterone progestins.[22][23] Glucuronide metabolites of EE, via effects on the ABCB11 (BSEP) and MRP2 (ABCC2) proteins and consequent changes in bile flow and bile salt excretion, appear to be responsible for the cholestasis.[24] High concentrations of estradiol, via its metabolite estradiol D-glucuronide, are also implicated in cholestasis, for instance in cholestasis of pregnancy.[23] However, the incidence and severity of cholestatic hepatotoxicity appear to be much greater with EE than with estradiol, which is due to its 17α-ethynyl substitution and consequent reduced metabolism.[16]

Endometrial cancer

The high doses of EE that were used in early COCs were associated with a significantly increased risk of endometrial cancer in certain preparations, for instance those containing the progestogen dimethisterone.[25] Unopposed estrogens like EE have carcinogenic effects in the endometrium and progestogens protect against these effects, but dimethisterone is a relatively weak progestogen and was unable to adequately antagonize the endometrial carcinogenic effects of EE, in turn resulting in the increased risk of endometrial cancer.[25] COCs containing dimethisterone have since been discontinued (with more potent progestogens used instead) and doses of EE in COCs in general have been dramatically reduced, abrogating the risk.[25] In turn, most studies of modern COCs have found a decreased risk of endometrial cancer.[26]

Interactions

Inducers of certain cytochrome P450 enzymes such as CYP3A4 can decrease circulating concentrations of EE.[16] Examples include anticonvulsants like phenytoin, primidone, ethosuximide, phenobarbital, and carbamazepine, azole antifungals like fluconazole, and rifamycin antibiotics like rifampin (rifampicin).[16] Conversely, inhibitors of CYP3A4 and certain other cytochrome P450 enzymes may increase circulating levels of EE.[16] An example is troleandomycin, which is a potent and highly selective inhibitor of CYP3A4.[16]

Paracetamol has been found to competitively inhibit the sulfation of EE, with pretreatment of 1 g paracetamol significantly increasing the AUC levels of EE (by 22%) and decreasing the AUC levels of EE sulfate in women.[16] The same has been found for ascorbic acid (vitamin C) and EE, although the significance of the interaction has been regarded as dubious.[16]

Unlike the case of estradiol, there is probably no pharmacokinetic interaction between smoking (which potently induces certain cytochrome P450 enzymes and markedly increases the 2-hydroxylation of estradiol) and EE.[16] This suggests that estradiol and EE are metabolized by different cytochrome P450 enzymes.[16] There is however still an increased risk of cardiovascular complications with smoking and EE, similarly to the case of smoking and other estrogens.[16]

The 19-nortestosterone progestins, gestodene and, to a lesser extent, desogestrel, have been found to inhibit cytochrome P450 enzymes and to progressively inhibit the metabolism and increase the concentrations of EE.[16]

EE has been found to significantly increase (by 38%) the AUC of omeprazole (which is metabolized by CYP2C19).[16]

Pharmacology

EE is an estrogen similarly to natural estrogens like estradiol and conjugated equine estrogens and synthetic estrogens like diethylstilbestrol. It binds to and activates both isoforms of the estrogen receptor, ERα and ERβ.[14] In one study, EE was found to have 233% and 37.8% of the affinity of estradiol for the ERα and ERβ, respectively.[27] EE also appears to signal through the GPER membrane estrogen receptor, similarly to estradiol.[28][29][30] Estrogens have antigonadotropic effects through activation of the ERα.[31] As a contraceptive, EE acts in concert with a progestin to inhibit the mid-cycle surge in luteinizing hormone (LH) and follicle-stimulating hormone (FSH), thereby inhibiting folliculogenesis and preventing ovulation and the possibility of pregnancy.[32][33]

Orally, EE is about 100 times as potent by weight as natural estrogens like micronized estradiol and conjugated equine estrogens.[34][35][36] In contrast, the potencies of EE and natural estrogens are similar when they are administered intravenously, due to the bypassing of first-pass metabolism.[18] Relative to its prodrug mestranol, EE is about 1.7 times as potent by weight orally.[35]

Differences from estradiol

As can be seen in the table below, EE shows strong and disproportionate effects on hepatic protein production relative to estradiol.[37] The liver as well as the uterus express 17β-hydroxysteroid dehydrogenase (17β-HSD), and this enzyme serves to inactivate estradiol and effectively suppress its potency in these tissues (analogously but in the opposite manner to potentiation of testosterone by 5α-reductase into the more potent dihydrotestosterone in so-called androgenic tissues like the skin, hair follicles, and prostate gland)[38] by reversibly converting it into the far less potent estrogen estrone (which has approximately 4% of the estrogenic activity of estradiol, most of which is actually due to conversion into estradiol).[37] In contrast to estradiol, the 17α-ethynyl group of EE prevents oxidation of the C17β position of EE by 17β-HSD, and for this reason, EE is not inactivated in these tissues and has much stronger relative estrogenic activity in them.[37][39][7] This is the mechanism of the disproportionately strong effects of EE on hepatic protein production,[37][39] which results in a greatly increased magnitude of effect on VTE risk relative to estradiol.[40]

On the other hand, due to the loss of inactivation of EE by 17β-HSD in the endometrium (uterus), EE is relatively more active than estradiol in the endometrium and, for this reason, is associated with a significantly lower incidence of vaginal bleeding and spotting in comparison.[37] This is particularly so in the case of combined estrogen and progestogen therapy (as in COCs or menopausal HRT), as progestogens induce the expression of 17β-HSD in the endometrium.[37] The reduced vaginal bleeding and spotting with EE is one of the main reasons that it is used in COCs instead of estradiol,[2] in spite of its potentially inferior safety profile (related to its adverse effects on hepatic protein synthesis and VTE incidence).[41]

EE has been found to have similar effects on hepatic protein production and VTE risk regardless of whether the route of administration is oral, transdermal, or vaginal, indicating that oral versus non-oral routes do not reduce the hepatic actions of EE relative to non-hepatic actions.[39] In contrast, at typical menopausal dosages, whereas oral estradiol shows significant effects on hepatic protein production, transdermal estradiol shows little or no such effects.[37]

Relative oral potency (by weight) of EE and various other estrogens[37]
Estrogen Hot flashes FSH HDL cholesterol SHBG CBG Angiotensinogen
Estradiol 100 100 100 100 100 100
Estriol 30 30 20 ? ? ?
Estrone sulfate ? 90 50 90 70 150
CEEs 120 110 150 300 150 500
Equilin sulfate ? ? 600 750 600 750
Ethinylestradiol 12,000 12,000 40,000 50,000 60,000 35,000
Diethylstilbestrol ? 340 ? 2,560 2,450 1,950
Hot flashes = clinical relief of hot flashes; FSH = suppression of FSH levels; HDL cholesterol, SHBG, CBG,
and angiotensinogen = increase in the serum levels of these hepatic proteins.

Pharmacokinetics

Absorption

The oral bioavailability of EE is between 38 and 48%, with a wide range of 20% to 65% (mean 45%) that is due to high interindividual variability.[6] Although relatively low, the oral bioavailability of EE is considerably higher than that of estradiol (5%).[1][6] Following a single 20 μg dose of EE in combination with 1 mg norethisterone in postmenopausal women, EE concentrations have been found to reach a maximum of 50 pg/mL within an average of 1.5 hours.[37] Following the first dose, mean levels of EE in general further increase by about 50% until steady-state concentrations are reached;[37] steady-state is reached after one week of daily administration.[14] For comparison, the mean peak levels of estradiol achieved with 2 mg micronized estradiol or estradiol valerate are 40 pg/mL following the first dose and 80 pg/mL after three weeks of administration.[37] These concentrations of estradiol are in the same range as the concentrations of EE that are produced by an oral dose of EE that is 100 times lower by weight, which is in accordance with the approximately 100-fold increased oral potency of EE relative to estradiol.[34][37] In accordance with the high interindividual variability in the oral bioavailability of EE, there is a large degree of interindividual variation in EE levels.[37]

Distribution

Unlike estradiol, which binds with high affinity to sex hormone-binding globulin (SHBG), EE has no affinity for this protein and is instead bound almost exclusively to albumin (97–98%).[3][37][6][42] As estradiol that is bound to SHBG is considered to be hormonally inactive,[43] the lack of binding of EE to SHBG may be involved in its increased comparative potency.

Metabolism

Due to high first-pass metabolism in the intestines and liver, only 1% of an oral dose of an EE appears in the circulation as EE itself.[37] During first-pass metabolism, EE is extensively conjugated via sulfation into the hormonally inert EE sulfate, and levels of EE sulfate in circulation are between 6- and 22-fold higher than those of EE.[37] For comparison, with oral administration of 2 mg micronized estradiol, levels of estrone and estrone sulfate are 4- to 6-fold and 200-fold higher than those of estradiol, respectively.[37] In contrast to estradiol, EE, due to steric hindrance by its C17α ethynyl group, is not metabolized or inactivated by 17β-HSD,[7] and this is the primary factor responsible for the dramatically increased potency of oral EE relative to oral estradiol.[37] Due to the formation of EE sulfate, enterohepatic circulation is involved in the pharmacokinetics of EE similarly to estradiol, although to a lesser extent.[37]

Aside from sulfate conjugation, EE is mainly metabolized by hydroxylation into catechol estrogens.[37] This is mainly by 2-hydroxylation into 2-hydroxy-EE, which is catalyzed primarily by CYP3A4.[6] Hydroxylation of EE at the C4, C6α, and C16β positions into 4-, 6α-, and 16β-hydroxy-EE has also been reported, but appears to contribute to its metabolism to only a small extent.[6] 2- and 4-methoxy-EE are also formed via transformation by catechol O-methyltransferase of 2- and 4-hydroxy-EE.[37] Unlike the case of estradiol, 16α-hydroxylation does not occur with EE, owing to steric hindrance by its ethynyl group at C17α.[6][37] The ethynylation of EE is largely irreversible, and so EE is not metabolized into estradiol, unlike estradiol esters.[37] A review found that the range of the reported terminal half-life of EE in the literature was 13.1 to 27.0 hours.[1] Another review reported a terminal half-life of EE of 10–20 hours.[6] However, the terminal half-life of EE has also been reported by other sources to be as short as 7 hours[7] and as long as 36 hours.[5]

Unlike the case of estradiol, in which there is a rapid rise in its levels and which remain elevated in a plateau-like curve for many hours, levels of EE fall rapidly after peaking.[37] This is thought to be because estrone and estrone sulfate can be reversibly converted back into estradiol and serve as a hormonally inert reservoir for estradiol, whereas the EE sulfate reservoir for EE is much smaller in comparison.[37]

EE, following oxidative formation of a very reactive metabolite, irreversibly inhibits cytochrome P450 enzymes involved in its metabolism, and this may also play a role in the increased potency of EE relative to estradiol.[37] Indeed, EE is said to have a marked effect on hepatic metabolism, and this is one of the reasons, among others, that natural estrogens like estradiol may be preferable.[42]

Elimination

EE is eliminated 62% in the feces and 38% in the urine.[6]

Chemistry

EE is an estrane steroid and a derivative of estradiol with an ethynyl substitution at the C17α position. It is also known as 17α-ethynylestradiol or as 17α-ethynylestra-1,3,5(10)-triene-3,17β-diol. The 17α-ethynylation of EE is analogous to the 17α-substitution of testosterone derivatives such as 17α-ethynylated progestins like ethisterone (17α-ethynyltestosterone) and norethisterone (17α-ethynyl-19-nortestosterone) and 17α-alkylated anabolic-androgenic steroids like methyltestosterone (17α-methyltestosterone).

Derivatives

A number of derivatives of EE exist. These include mestranol (EE 3-methyl ether), quinestrol (EE 3-cyclopentyl ether), ethinylestradiol sulfonate (EE 3-isopropylsulfonate), and moxestrol (11β-methoxy-EE). The former three are prodrugs of EE, while the latter is not.

Analogues

A few 17α-substituted analogues of EE exist. Examples include methylestradiol, ethinylestriol, and nilestriol (ethinylestriol 3-cyclopentyl ether).

History

EE was the first orally active synthetic estrogen and was described in 1938 by Hans Herloff Inhoffen and Walter Hohlweg of Schering AG in Berlin.[44][45][46][47][48] It was approved by the FDA in the U.S. on June 25, 1943 and marketed by Schering under the brand name Estinyl.[11] The FDA withdrew approval of Estinyl effective June 4, 2004 at the request of Schering, which had discontinued marketing it.[49]

EE was first used in COCs, as an alternative to mestranol, in 1964, and shortly thereafter superseded mestranol in COCs.[12]

Society and culture

Generic name

Ethinylestradiol is the English generic name and its INN, USAN, BAN, and JAN.[50][8][51][52] It has also been spelled as ethynylestradiol, ethynyloestradiol, and ethinyloestradiol (all having the same pronunciation), and the latter was formerly its BAN but was eventually changed.[50][8][52] In addition, a space is often included in the name of EE such that it is written as ethinyl estradiol (as well as variations thereof), and this is its USP name.[50][52] The generic name of EE in French and its DCF are éthinylestradiol, in Spanish is etinilestradiol, in Italian and its DCIT are etinilestradiolo, and in Latin is ethinylestradiolum.[50][52]

The name of the drug is often abbreviated as EE or as EE2 in the medical literature.

Brand names

EE has been marketed as a standalone oral drug under the brand names Esteed, Estinyl, Feminone, Lynoral, Menolyn, Novestrol, Palonyl, Spanestrin, and Ylestrol among others, although most or all of these formulations are now discontinued.[53][54][52] It is marketed under a very large number of brand names throughout the world in combination with progestins for use as an oral contraceptive.[50] In addition, EE is marketed in the U.S. in combination with norelgestromin under the brand names Ortho Evra and Xulane as a contraceptive patch, in combination with etonogestrel under the brand name NuvaRing as a contraceptive vaginal ring, and in combination with norethisterone acetate under the brand name FemHRT in oral hormone replacement therapy for the treatment of menopausal symptoms.[55]

See also

References

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  2. 1 2 Fruzzetti F, Trémollieres F, Bitzer J (2012). "An overview of the development of combined oral contraceptives containing estradiol: focus on estradiol valerate/dienogest". Gynecological Endocrinology : the Official Journal of the International Society of Gynecological Endocrinology. 28 (5): 400–8. PMC 3399636 Freely accessible. PMID 22468839. doi:10.3109/09513590.2012.662547.
  3. 1 2 Facts and Comparisons (Firm); Ovid Technologies, Inc (2005). Drug Facts and Comparisons 2005: Pocket Version. Facts and Comparisons. p. 121. ISBN 978-1-57439-179-4.
  4. ↑ Micromedex (1 January 2003). USP DI 2003: Drug Information for Healthcare Professionals. Thomson Micromedex. pp. 1253, 1258, 1266. ISBN 978-1-56363-429-1.
  5. 1 2 3 Claude L Hughes; Michael D. Waters (23 March 2016). Translational Toxicology: Defining a New Therapeutic Discipline. Humana Press. pp. 73–. ISBN 978-3-319-27449-2.
  6. 1 2 3 4 5 6 7 8 9 10 11 12 Stanczyk FZ, Archer DF, Bhavnani BR (2013). "Ethinyl estradiol and 17β-estradiol in combined oral contraceptives: pharmacokinetics, pharmacodynamics and risk assessment". Contraception. 87 (6): 706–27. PMID 23375353. doi:10.1016/j.contraception.2012.12.011.
  7. 1 2 3 4 Shellenberger, T. E. (1986). "Pharmacology of estrogens". The Climacteric in Perspective: 393–410. doi:10.1007/978-94-009-4145-8_36. Ethinyl estradiol is a synthetic and comparatively potent estrogen. As a result of the alkylation in 17-C position it is not a substrate for 17β dehydrogenase, an enzyme which transforms natural estradiol-17β to the less potent estrone in target organs.
  8. 1 2 3 4 J. Elks (14 November 2014). The Dictionary of Drugs: Chemical Data: Chemical Data, Structures and Bibliographies. Springer. pp. 522–. ISBN 978-1-4757-2085-3.
  9. ↑ Evans G, Sutton EL. "Oral contraception". Med Clin North Am. 99: 479–503. PMID 25841596. doi:10.1016/j.mcna.2015.01.004.
  10. ↑ Fischer, Janos; Ganellin, C. Robin (2006). Analogue-based Drug Discovery. John Wiley & Sons. p. 482. ISBN 9783527607495.
  11. 1 2 FDA (2007). "Approval history: Estinyl (ethinyl estradiol) NDA 005292". search: Estinyl
  12. 1 2 J.G. Gruhn; R.R. Kazer (11 November 2013). Hormonal Regulation of the Menstrual Cycle: The Evolution of Concepts. Springer Science & Business Media. pp. 185–. ISBN 978-1-4899-3496-3. In 1964, ethinyl estradiol was introduced as an alternative to mestranol as the estrogenic component, [...]
  13. ↑ RxList.com - Estinyl (ethynyl estradiol)
  14. 1 2 3 Michael Oettel; Ekkehard Schillinger (6 December 2012). Estrogens and Antiestrogens II: Pharmacology and Clinical Application of Estrogens and Antiestrogen. Springer Science & Business Media. pp. 248, 369. ISBN 978-3-642-60107-1. The binding affinity of EE2 for the estrogen receptor is similar to that of estradiol. [...] During daily intake, the EE2 levels increase up to a steady state which is reached after about 1 week.
  15. ↑ R. S. Satoskar; S. D. Bhandarkar &nirmala N. Rege (1973). Pharmacology and Pharmacotherapeutics. Popular Prakashan. pp. 934–. ISBN 978-81-7991-527-1.
  16. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Jeffrey K. Aronson (21 February 2009). Meyler's Side Effects of Endocrine and Metabolic Drugs. Elsevier. pp. 177, 219, 223, 224, 230, 232, 239, 242. ISBN 978-0-08-093292-7.
  17. 1 2 Kenneth L. Becker (2001). Principles and Practice of Endocrinology and Metabolism. Lippincott Williams & Wilkins. pp. 1024, 1035. ISBN 978-0-7817-1750-2. Low-dose COCs contain <50 μg of estrogen and are the primary choice for oral contraception. COCs containing ≥50 μg of estrogen should no longer be routinely used for contraception. [...] The estrogen component of COCs can cause breast fullness and tenderness.
  18. 1 2 3 4 5 6 7 Tommaso Falcone; William W. Hurd (2007). Clinical Reproductive Medicine and Surgery. Elsevier Health Sciences. pp. 388–. ISBN 0-323-03309-1.
  19. ↑ Committee on the Relationship Between Oral Contraceptives and BreastCancer (1 January 1991). Oral Contraceptives and Breast Cancer. National Academies. pp. 143–. NAP:13774. Following a recommendation by its Fertility and Maternal Health Drugs Advisory Committee, the Food and Drug Administration (FDA) recently ordered the removal from the market of all oral contraceptives with [ethinylestradiol] contents greater than 50 μg.
  20. ↑ Multigenerational Reproductive Toxicology Study of Ethinyl Estradiol (CAS No. 57636) in SpragueDawley Rats (Feed Studies). DIANE Publishing. pp. 27–. ISBN 978-1-4379-4231-6. Oral contraceptive formulations containing greater than 50 ug ethinyl estradiol were removed from the United States market in 1989, and currently marketed formulations generally contain between 20 and 35 μg ethinyl estradiol.
  21. ↑ Daniel Jeffrey Wallace; Bevra Hahn (2007). Dubois' Lupus Erythematosus. Lippincott Williams & Wilkins. pp. 1252–. ISBN 978-0-7817-9394-0.
  22. ↑ Michael Trauner; Peter L. M. Jansen (2004). Molecular Pathogenesis of Cholestasis. Springer Science & Business Media. pp. 260–. ISBN 978-0-306-48240-3.
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  24. ↑ Peter J. O'Brien; William Robert Bruce (2010). Endogenous Toxins: Diet, Genetics, Disease and Treatment. John Wiley & Sons. pp. 302–. ISBN 978-3-527-32363-0.
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  26. ↑ Earl A. Surwit; David Alberts (6 December 2012). Endometrial Cancer. Springer Science & Business Media. pp. 11–. ISBN 978-1-4613-0867-6.
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  29. ↑ Prossnitz ER, Barton M (2011). "The G-protein-coupled estrogen receptor GPER in health and disease". Nat Rev Endocrinol. 7 (12): 715–26. PMC 3474542 Freely accessible. PMID 21844907. doi:10.1038/nrendo.2011.122. Further research showed that the therapeutic effect of ethynylestradiol in established EAE was mediated via GPER, but not via ERα, and possibly involved production of the anti-inflammatory cytokine Il‑10.115
  30. ↑ Prossnitz ER, Barton M (2014). "Estrogen biology: new insights into GPER function and clinical opportunities". Mol. Cell. Endocrinol. 389 (1–2): 71–83. PMC 4040308 Freely accessible. PMID 24530924. doi:10.1016/j.mce.2014.02.002. In addition, the therapeutic effect of ethinyl estradiol in established disease was demonstrated to require expression of GPER but not ERα, and was associated with the production of the anti-inflammatory cytokine IL-10 (Yates et al., 2010).
  31. ↑ Quaynor SD, Stradtman EW, Kim HG, Shen Y, Chorich LP, Schreihofer DA, Layman LC (July 2013). "Delayed puberty and estrogen resistance in a woman with estrogen receptor α variant". The New England Journal of Medicine. 369 (2): 164–71. PMC 3823379 Freely accessible. PMID 23841731. doi:10.1056/NEJMoa1303611.
  32. ↑ Charles R. Craig; Robert E. Stitzel (2004). Modern Pharmacology with Clinical Applications. Lippincott Williams & Wilkins. pp. 708–. ISBN 978-0-7817-3762-3.
  33. ↑ Gautam Allahbadia; Rina Agrawal (2007). Polycystic Ovary Syndrome. Anshan. pp. 257–. ISBN 978-1-904798-74-3.
  34. 1 2 Victor Gomel; Malcolm G. Munro; Timothy C. Rowe (1990). Gynecology: a practical approach. Williams & Wilkins. p. 132,134. ISBN 978-0-683-03631-2. The synthetic estrogen, ethinyl estradiol, more commonly used in oral contraceptives, has a biological activity 100 times that of the native and conjugated substances.
  35. 1 2 Donna Shoupe (7 November 2007). The Handbook of Contraception: A Guide for Practical Management. Springer Science & Business Media. pp. 23–. ISBN 978-1-59745-150-5. EE2 has about 100 times the potency of an equivalent weight of conjugated equine estrogen or estrone sulfate for stimulating synthesis of hepatic proteins. [...] EE2 is about 1.7 times as potent as the same weight of mestranol.
  36. ↑ Nathaniel McConaghy (21 November 2013). Sexual Behavior: Problems and Management. Springer Science & Business Media. pp. 177–. ISBN 978-1-4899-1133-9. Meyer et al. found that ethinyl estradiol was 75 to 100 times more potent than conjugated estrogen on the basis of the doses required to lower testosterone to the adult female range, 0.1 mg of the former and 7.5 to 10 mg of the latter being necessary.
  37. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 Kuhl H (2005). "Pharmacology of estrogens and progestogens: influence of different routes of administration". Climacteric. 8 Suppl 1: 3–63. PMID 16112947. doi:10.1080/13697130500148875.
  38. ↑ Jerome F. Strauss, III; Robert L. Barbieri (13 September 2013). Yen and Jaffe's Reproductive Endocrinology. Elsevier Health Sciences. pp. 83–. ISBN 978-1-4557-2758-2.
  39. 1 2 3 Rogerio A. Lobo (5 June 2007). Treatment of the Postmenopausal Woman: Basic and Clinical Aspects. Academic Press. pp. 177, 770–771. ISBN 978-0-08-055309-2.
  40. ↑ Donna Shoupe (10 February 2011). Contraception. John Wiley & Sons. pp. 79–. ISBN 978-1-4443-4263-5.
  41. ↑ Sitruk-Ware R, Nath A (2011). "Metabolic effects of contraceptive steroids". Rev Endocr Metab Disord. 12 (2): 63–75. PMID 21538049. doi:10.1007/s11154-011-9182-4.
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