Caution: Federal law prohibits dispensing without prescription.

PREMPRO therapy consists of a single tablet containing 0.625 mg of the conjugated estrogens found in Premarin® tablets and 2.5 mg or 5 mg of medroxyprogesterone acetate (MPA) for oral administration.

PREMPHASE therapy consists of two separate tablets, a maroon Premarin tablet containing 0.625 mg of conjugated estrogens which is taken orally on days 1 through 14 and a light-blue tablet containing 0.625 mg of the conjugated estrogens found in Premarin tablets and 5 mg of medroxyprogesterone acetate (MPA) which is taken orally on days 15 through 28.

The conjugated estrogens found in Premarin tablets are a mixture of sodium estrone sulfate and sodium equilin sulfate. They contain as concomitant components, as sodium sulfate conjugates, 17(alpha)-dihydroequilin, 17(alpha)-estradiol and 17(beta)-dihydroequilin.

Medroxyprogesterone acetate is a derivative of progesterone. It is a white to off-white, odorless, crystalline powder, stable in air, melting between 200° C and 210° C. It is freely soluble in chloroform, soluble in acetone and in dioxane, sparingly soluble in alcohol and in methanol, slightly soluble in ether, and insoluble in water. The chemical name for MPA is pregn-4-ene-3,20-dione, 17-(acetyloxy)-6-methyl-, (6(alpha))-. Its molecular formula is C ₂₄ H ₃₄ O ₄ , with a molecular weight of 386.53. Its structural formula is:

PREMPRO 2.5 mg

Each peach tablet for oral administration contains 0.625 mg conjugated estrogens, 2.5 mg of medroxyprogesterone acetate and the following inactive ingredients: calcium phosphate tribasic, calcium sulfate, carnauba wax, cellulose, glyceryl monooleate, lactose, magnesium stearate, methylcellulose, pharmaceutical glaze, polyethylene glycol, sucrose, povidone, titanium dioxide, and red ferric oxide.

PREMPRO 5.0 mg

Each light-blue tablet for oral administration contains 0.625 mg conjugated estrogens, 5 mg of medroxyprogesterone acetate and the following inactive ingredients: calcium phosphate tribasic, calcium sulfate, carnauba wax, cellulose, glyceryl monooleate, lactose, magnesium stearate, methylcellulose, pharmaceutical glaze, polyethylene glycol, sucrose, povidone, titanium dioxide, FD&C Blue No. 2.

PREMPHASE

Each maroon Premarin tablet for oral administration contains 0.625 mg of conjugated estrogens and the following inactive ingredients: calcium phosphate tribasic, calcium sulfate, carnauba wax, cellulose, glyceryl monooleate, lactose, magnesium stearate, methylcellulose, pharmaceutical glaze, polyethylene glycol, stearic acid, sucrose, titanium dioxide, FD&C Blue No.2, D&C Red No. 27, FD&C Red No. 40. These tablets comply with USP Drug Release Test 1.

Each light-blue tablet for oral administration contains 0.625 mg of conjugated estrogens and 5 mg of medroxyprogesterone acetate and the following inactive ingredients: calcium phosphate tribasic, calcium sulfate, carnauba wax, cellulose, glyceryl monooleate, lactose, magnesium stearate, methylcellulose, pharmaceutical glaze, polyethylene glycol, sucrose, povidone, titanium dioxide, FD&C Blue No.2.

Estrogens are largely responsible for the development and maintenance of the female reproductive system and secondary sexual characteristics. By a direct action, they cause growth and development of the uterus, fallopian tubes, and vagina. With other hormones, such as pituitary hormones and progesterone, they cause enlargement of the breasts through promotion of ductal growth, stromal development, and the accretion of fat. Estrogens are intricately involved with other hormones, especially progesterone, in the processes of the ovulatory menstrual cycle and pregnancy and affect the release of pituitary gonadotropins. They also contribute to the shaping of the skeleton, maintenance of tone and elasticity of urogenital structures, changes in the epiphyses of the long bones that allow for the pubertal growth spurt and its termination, and pigmentation of the nipples and genitals.

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 µg of estradiol daily, depending on the phase of the menstrual cycle. After menopause, most endogenous estrogen is produced by interconversion of androstenedione, secreted by the adrenal cortex, to estrone by peripheal tissues. Thus, estrone and the sulfate conjugated form, estrone sulfate, are the most abundant circulating estrogens in postmenopausal women.

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

The pharmacologic effects of the administered conjugated estrogens are similar to those of endogenous estrogens. In responsive tissue (female genital organs, breasts, hypothalamus, pituitary) estrogens enter the cell and are transported into the nucleus. As a result of the estrogen action, specific RNA and protein synthesis occurs.

The use of unopposed estrogen therapy has been associated with an increased risk of endometrial hyperplasia, a possible precursor of endometrial adenocarcinoma. The results of clinical studies indicate that the addition of a progestin to an estrogen replacement regimen for more than 10 days per cycle reduces the incidence of endometrial hyperplasia and the attendant risk of adenocarcinoma in women with intact uteri. The addition of a progestin to an estrogen replacement regimen has not been shown to interfere with the efficacy of estrogen replacement therapy for its approved indications.

Androgenic and anabolic effects of medroxyprogesterone acetate (MPA) have been noted, but the drug is apparently devoid of significant estrogenic activity. Parenterally administered MPA inhibits gonadotropin production, which in turn prevents follicular maturation and ovulation, although available data indicate that this does not occur when the usually recommended oral dosage is given as single daily doses. MPA may achieve its beneficial effect on the endometrium in part by decreasing nuclear estradiol receptors and suppression of epithelial DNA synthesis in endometrial tissue.

PHARMACOKINETICS

Absorption

Conjugated estrogens are soluble in water and are well absorbed from the gastrointestinal tract after release from the drug formulation. However, PREMPRO and PREMPHASE contain a formulation of MPA that is immediately released and a modified-release formulation of conjugated estrogens that slowly releases estrogens over several hours. Maximum plasma concentrations of the various conjugated and unconjugated estrogens are attained within 4 to 10 hours after dose administration. MPA is well absorbed from the gastrointestinal tract, and maximum MPA plasma concentrations are attained within 2 to 4 hours after dose administration. Table 1 summarizes the mean pharmacokinetic parameters for unconjugated and conjugated estrogens, and medroxyprogesterone acetate following administration of 0.625 mg/2.5 mg and 0.625 mg/5mg tablets to healthy postmenopausal women.

Food-Effect:   Single dose studies in healthy, postmenopausal women were conducted to investigate any potential drug interaction when PREMPRO or PREMPHASE is administered with a high fat breakfast. Administration with food decreased the C _max of total estrone by 18 to 34% and increased total equilin C _max by 38% compared to the fasting state, with no other effect on the rate or extent of absorption of other conjugated or unconjugated estrogens. Administration with food approximately doubles MPA C _max and increases MPA AUC by approximately 20 to 30%.

Dose Proportionality:   The C _max and AUC values for MPA observed in two separate pharmacokinetic studies conducted with PREMPRO or PREMPHASE 2 × 0.625 mg/2.5 mg and 2 × 0.625 mg/5mg tablets exhibited nonlinear dose proportionality; doubling the MPA dose from 2 × 2.5 to 2 × 5.0 mg increased the mean C _max and AUC by 3.2 and 2.8 folds, respectively. The apparent clearance (CI/F) of MPA obtained with 2 × 0.625 mg/5 mg tablets was lower than that observed with 2 × 0.625 mg/2.5 mg tablets.

Distribution

The conjugated estrogens bind mainly to albumin, but the unconjugated estrogens bind to both albumin and sex-hormone-binding globulin (SHBG). MPA is approximately 90% bound to plasma proteins but does not bind to SHBG.

Metabolism

Metabolism and inactivation of estrogens occur primarily in the liver. Some estrogens are excreted into the bile; however, they are reabsorbed from the intestine and returned to the liver through the portal venous system. Metabolism and elimination of MPA occurs primarily in the liver via hydroxylation, with subsequent conjugation and elimination in the urine.

Excretion

Water-soluble estrogen conjugates are strongly acidic and are ionized in body fluids, which favor excretion through the kidneys since tubular reabsorption is minimal. The apparent terminal-phase disposition half-life (t _1/2 ) of the various estrogens is prolonged by the slow absorption from PREMPRO and PREMPHASE and ranges from 10 to 24 hours. Most metabolites of MPA are excreted as glucuronide conjugates with only minor amounts excreted as sulfates. MPA has a t _1/2 ranging from 38 to 46 hours.

Drug-Interactions

Coadministration of conjugated estrogens with MPA does not affect the pharmacokinetic profile of MPA. Similarly, MPA does not affect the pharmacokinetic profile of the conjugated or unconjugated estrogens.

CLINICAL STUDIES

In a 1-year clinical trial of 1376 women randomized to PREMPRO 0.625 mg/2.5 mg (Regimen A, n=340), PREMPRO 0.625 mg/5 mg (Regimen B, n=338), PREMPHASE 0.625 mg/5 mg (Regimen C, n=351), or Premarin 0.625 mg alone (n=347), results of evaluable biopsies at 12 months (n=279 for Regimen A, 274 for Regimen B, 277 for Regimen C, and 283 for Premarin alone) showed a reduced risk of endometrial hyperplasia in the two PREMPRO treatment groups (less than 1%) and in the PREMPHASE treatment group (less than 1%; 1% when focal hyperplasia was included) compared to the Premarin group (8%; 20% when focal hyperplasia was included). See Table 2.

In this clinical trial the incidence of amenorrhea increased over time in both PREMPRO groups. Seventeen percent of the patients randomized to Regimen A experienced amenorrhea during the entire 13 cycles of the study, and 15 percent of the patients on Regimen B experienced amenorrhea during the entire 13 cycles of the study. The following two figures describe cumulative amenorrhea which is defined as amenorrhea continuing from a given cycle to the end of the study.

Information Regarding Lipid Effects

The results of a clinical trial conducted in a 97% Caucasian population at low risk for cardiovascular disease, showed that the increases in HDL-C and HDL ₂ -C subfraction were significantly less for PREMPRO and PREMPHASE than Premarin alone, but decreases in LDL-C were comparable with Premarin alone. Compared with Premarin, total Cholesterol concentrations were significantly lower after 1 year of treatment than at baseline among patients receiving PREMPRO or PREMPHASE.

The following table summarizes mean percent changes from baseline lipid parameter values after 1 year of treatment with the combined regimens.

For information regarding cardiovascular effects in the general population as well as in women with documented coronary heart disease, see PRECAUTIONS , General-- Cardiovascular Risk .

PREMPRO or PREMPHASE therapy is indicated in women with an intact uterus for the:

1. Treatment of moderate to severe vasomotor symptoms associated with the menopause. There is no adequate evidence that estrogens are effective for nervous symptoms or depression which might occur during menopause and they should not be used to treat these conditions.
2. Treatment of vulvar and vaginal atrophy.
3. Prevention of osteoporosis.

Since estrogen administration is associated with risks as well as benefits, selection of patients ideally should be based on prospective identification of risk factors for developing osteoporosis. Unfortunately, there is no certain way to identify those women who will develop osteoporotic fractures. Most prospective studies of efficacy for this indication have been carried out in white menopausal women, without stratification by other risk factors, and tend to show a universally salutary effect on bone. Thus, patient selection must be individualized based on the balance of risks and benefits.

Estrogen replacement therapy reduces bone resorption and retards or halts postmenopausal bone loss. Case-control studies have shown an approximately 60% reduction in hip and wrist fractures in women whose estrogen replacement was begun within a few years of menopause. Studies also suggest that estrogen reduces the rate of vertebral fractures. Even when started as late as 6 years after menopause, estrogen may prevent further loss of bone mass for as long as the treatment is continued. When estrogen therapy is discontinued, bone mass declines at a rate comparable to that in the immediate postmenopausal period. There is no evidence that estrogen replacement therapy restores bone mass to premenopausal levels.

At skeletal maturity there are sex and race differences in both the total amount of bone present and its density, in favor of men and blacks. Thus, women are at higher risk than men because they start with less bone mass and, for several years following natural or induced menopause, the rate of bone mass decline is accelerated. White and Asian women are at higher risk than black women.

Early menopause is one of the strongest predictors for the development of osteoporosis. In addition, other factors affecting the skeleton which are associated with osteoporosis include genetic factors (small build, family history), endocrine factors (nulliparity, thyrotoxicosis, hyperparathyroidism, Cushing's syndrome, hyperprolactinemia, type I diabetes), lifestyle (cigarette smoking, alcohol abuse, sedentary exercise habits) and nutrition (below average body weight, dietary calcium intake).

The mainstays of prevention and management of osteoporosis are estrogen, an adequate lifetime calcium intake, and exercise. Postmenopausal women absorb dietary calcium less efficiently than premenopausal women and require an average of 1500 mg/day of elemental calcium to remain in neutral calcium balance. By comparison, premenopausal women require about 1000 mg/day and the average calcium intake in the USA is 400-600 mg/day. Therefore, when not contraindicated, calcium supplementation may be helpful.

Weight-bearing exercise and nutrition may be important adjuncts to the prevention and management of osteoporosis. Immobilization and prolonged bed rest produce rapid bone loss, while weight-bearing exercise has been shown both to reduce bone loss and to increase bone mass. The optimal type and amount of physical activity that would prevent osteoporosis have not been established; however, in two studies an hour of walking and running exercises twice or three times weekly significantly increased lumbar spine bone mass.

CONTRAINDICATIONS

Estrogens/progestins combined should not be used in women under any of the following conditions or circumstances:

1. Known or suspected pregnancy, including use for missed abortion or as a diagnostic test for pregnancy. Estrogen or progestin may cause fetal harm when administered to a pregnant woman.
2. Known or suspected cancer of the breast.
3. Known or suspected estrogen-dependent neoplasia.
4. Undiagnosed abnormal genital bleeding.
5. Active or past history of thrombophlebitis, thromboembolic disorders, or stroke.
6. Liver dysfunction or disease.

PREMPRO or PREMPHASE therapy should not be used in patients hypersensitive to the ingredients contained in the tablets.

ALL BELOW PERTAIN TO THE USE OF THIS COMBINATION PRODUCT.

Based on experience with estrogens and/or progestins:

1. Induction of malignant neoplasms
   Endometrial cancer. The reported endometrial cancer risk among users of unopposed estrogen was about 2- to 12-fold greater than in nonusers and appears dependent on duration of treatment and on estrogen dose. There is no significant increased risk associated with the use of estrogens for less than one year. The greatest risk appears associated with prolonged use, with increased risks of 15- to 24-fold for five years or more. In three studies, persistence of risk was demonstrated for 8 to over 15 years after cessation of estrogen treatment. In one study, a significant decrease in the incidence of endometrial cancer occurred six months after estrogen withdrawal.
   A large clinical trial has demonstrated that when MPA is administered with Premarin, there is a markedly reduced incidence of endometrial hyperplasia, a possible precursor of endometrial cancer. Endometrial hyperplasia has been reported in a large clinical trial to occur at a rate of approximately 1% or less with PREMPRO AND PREMPHASE. Studies have also demonstrated a reduced risk of endometrial cancer when a progestin is administered with estrogen replacement therapy. In the large clinical trial described above, only a single case of endometrial cancer was reported to occur among women taking combination Premarin/MPA therapy.
   Clinical surveillance of all women taking estrogen/progestin combinations is important. Adequate diagnostic measures, including endometrial sampling when indicated, should be undertaken to rule out malignancy in all cases of undiagnosed persistent or recurring abnormal vaginal bleeding. There is no evidence that "natural" estrogens are more or less hazardous than "synthetic" estrogens at equivalent estrogen doses.
   Breast cancer. Some studies have reported a moderately increased risk of breast cancer (relative risk of 1.3 to 2.0) in those women on estrogen replacement therapy taking higher doses, or in those taking lower doses for prolonged periods of time, especially in excess of 10 years. The majority of studies, however, have not shown an association in women who have ever used estrogen replacement therapy.
   The effect of added progestins on the risk of breast cancer is unknown, although a moderately increased risk in those taking combination estrogen/progestin therapy has been reported. Other studies have not shown this relationship. In a one year clinical trial of PREMPRO, PREMPHASE and Premarin alone, 5 new cases of breast cancer were detected among 1377 women who received the combination treatments, while no new cases were detected among 347 women who received Premarin alone. The overall incidence of breast cancer in this clinical trial does not exceed that expected in the general population.
   In the three year clinical Postmenopausal Estrogen Progestin Intervention (PEPI) trial of 875 women to assess differences among placebo, unopposed Premarin, and three different combination hormone therapy regimens, one (1) new case of breast cancer was detected in the placebo group (n=174), one in the Premarin alone group (n=175), none in the continuous Premarin plus continuous medroxyprogesterone acetate group (n=174), and two (2) in the continuous Premarin plus cyclic medroxyprogesterone acetate group (n=174).
   Women on hormone replacement therapy should have regular breast examinations and should be instructed in breast self-examination, and women over the age of 50 should have regular mammograms.
2. Thromboembolic Disorders and Other Vascular Problems. In some studies, women on estrogen replacement therapy, given alone or in combination with a progestin, have been reported to have an increased risk of thrombophlebitis, and/or thromboembolic disease. The physician should be aware of the possibility of thrombotic disorders (thrombophlebitis, retinal thrombosis, cerebral embolism, and pulmonary embolism) during hormone replacement therapy and be alert to their earliest manifestations. Should any of these occur or be suspected, hormone replacement therapy should be discontinued immediately. Women who have risk factors for thrombotic disorders should be kept under careful observation.
3. Effects during pregnancy. Use in pregnancy is not recommended.
4. Gallbladder disease. Two studies have reported a 2- to 4-fold increase in the risk of surgically confirmed gallbladder disease in women receiving postmenopausal estrogens. In a large clinical trial, 5 of 1376 subjects taking Premarin alone or Premarin/Cycrin® at doses comparable to PREMPRO or PREMPHASE developed cholecystitis with cholelithiasis that required cholecystectomy.
5. Elevated blood pressure. Occasional blood pressure increases during estrogen replacement therapy have been attributed to idiosyncratic reactions to estrogens. More often, blood pressure has remained the same or has dropped. One study showed that postmenopausal estrogen users have higher blood pressure than nonusers. In a large clinical trial, transient elevations from baseline of 40 mm Hg or more systolic and 20 mm Hg or more diastolic were reported in less than 2% and 4% of postmenopausal subjects, respectively. Two other studies showed slightly lower blood pressure among estrogen users compared to nonusers. Postmenopausal estrogen use does not increase the risk of stroke. Nonetheless, blood pressure should be monitored at regular intervals with estrogen use.
6. Hypercalcemia.   Administration of estrogens may lead to severe hypercalcemia in patients with breast cancer and bone metastases. If this occurs, the drugs should be stopped and appropriate measures taken to reduce the serum calcium level.
7. Visual abnormalities.   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, medication should be withdrawn.

PRECAUTIONS

General

Based on experience with estrogens and/or progestins:

1. Cardiovascular Risk. A causal relationship between estrogen replacement therapy and reduction of cardiovascular disease in postmenopausal women has not been proven. Furthermore, the effect of added progestins on this putative benefit is not yet known.
   Current medical practice often includes the use of concomitant progestin therapy in women with intact uteri. While the effects of added progestins on the risk of ischemic heart disease are not known, medroxyprogesterone acetate at the doses in PREMPRO or PREMPHASE attenuates much of the favorable effect of conjugated estrogens on HDL levels, although it maintains the favorable effect of conjugated estrogens on LDL levels (see CLINICAL STUDIES ).
   Studies in the General Population:
   In recent years many published studies have suggested that there may be a cause-effect relationship between postmenopausal oral estrogen replacement therapy without added progestins and a decrease in cardiovascular disease in women. Although most of the observational studies which assessed this statistical association have reported a 20% to 50% reduction in coronary heart disease risk and associated mortality in estrogen takers, the following should be considered when interpreting these reports.
   Because only one of these studies was randomized and it was too small to yield statistically significant results, all relevant studies were subject to selection bias. Thus, the apparently reduced risk of coronary heart disease cannot be attributed with certainty to estrogen replacement therapy. It may instead have been caused by life-style and medical characteristics of the women studied with the result that healthier women were selected for estrogen therapy. In general, treated women were of higher socioeconomic and educational status, more slender, more physically active, more likely to have undergone surgical menopause, and less likely to have diabetes than the untreated women. Although some studies attempted to control for these selection factors, it is common for properly designed randomized trials to fail to confirm benefits suggested by less rigorous study designs. Ongoing large-scale trials are intended to further explore this relationship.
   The safety data regarding PREMPRO and PREMPHASE were obtained primarily from clinical trials and epidemiologic studies of postmenopausal Caucasian women, who were at generally low risk for cardiovascular disease and higher than average risk for osteoporosis. The safety profile of PREMPRO and PREMPHASE derived from these study populations cannot necessarily be extrapolated to other populations of diverse racial and/or demographic composition.
   Stuides in Women with Documented Coronary Heart Disease:
   In the Heart and Estrogen/progestin Replacement Study (HERS), 2763 postmenopausal women with documented coronary heart disease (CHD) who were taking their usual cardiac medications were randomized to Prempro 0.625 mg/2.5 mg or placebo. Documented CHD was defined as the presence of one or more of the following: previous myocardial infarction, previous percutaneous mechanical revascularization, previous coronary artery bypass graft surgery, or angiographic evidence of greater than 50% occlusion of one or more major coronary arteries. During an average follow-up of 4.1 years, treatment with Prempro did not reduce the overall rate of recurrent coronary heart disease events, defined as CHD death or nonfatal myocardial infarctions, in this predominantly elderly population (average age 66.7 years) with established coronary disease. There were more CHD events in the hormone group than in the placebo group in year 1 and fewer events in years 3 through 5.
   When considering prescribing an estrogen/progestin regimen, such as PREMPRO or PREMPHASE, physicians are advised to weigh the potential benefits and risks of therapy as applicable to each individual patient.
2. Use in hysterectomized women.   Existing data do not support the use of the combination of estrogen and progestin in postmenopausal women without a uterus. There are possible risks which may be associated with the inclusion of progestin in estrogen replacement regimens. The potential risks include some deterioration in glucose tolerance, as reported in a large clinical trial of PREMPRO and PREMPHASE, and less favorable effects on lipid metabolism as compared to the lipid effects of Premarin alone (see CLINICAL STUDIES ).
3. Physical examination. A complete medical and family history should be taken prior to the initiation of any estrogen/progestin therapy. The pretreatment and periodic physical examinations should include special reference to blood pressure, breasts, abdomen, and pelvic organs, and should include a Papanicolaou smear. As a general rule, estrogen should not be prescribed for longer than one year without another physical examination being performed.
4. Fluid retention. Because estrogens/progestins may cause some degree of fluid retention, conditions which might be influenced by this factor, such as asthma, epilepsy, migraine, and cardiac or renal dysfunction, require careful observation.
5. Uterine bleeding. Certain patients may develop abnormal uterine bleeding. In cases of undiagnosed abnormal uterine bleeding, adequate diagnostic measures are indicated. (See . )
6. The pathologist should be advised of estrogen/progestin therapy when relevant specimens are submitted.

Based on experience with estrogens:

1. Familial hyperlipoproteinemia. Estrogen therapy may be associated with massive elevations of plasma triglycerides leading to pancreatitis and other complications in patients with familial defects of lipoprotein metabolism.
2. Hypercoagulability.   Some epidemiological studies have shown that women taking estrogen replacement therapy have hypercoagulability primarily related to decreased antithrombin activity. This effect appears dose- and duration-dependent and is less pronounced than that associated with oral contraceptive use. Also, postmenopausal women tend to have changes in levels of coagulation parameters at baseline compared to premenopausal women. There is some suggestion that low-dose mestranol may increase the risk of thromboembolism in postmenopausal women. There is insufficient information on hypercoagulability in women who have had previous thromboembolic disease. In a clinical trial of 1724 patients, in which 204 PREMPRO™-treated patients and 107 PREMPHASE®-treated patients had metabolic studies performed, factors VII and X concentrations and plasminogen activity increased at the end of 1 year, and antithrombin III activity decreased in women receiving PREMPRO 0.625 mg/2.5 mg MPA or PREMPHASE 0.625 mg/5 mg MPA at the end of the year. At the end of the year, antithrombin III activity increased slightly in women receiving PREMPRO 0.625 mg/5.0 mg MPA.
3. Mastodynia.   Certain patients may develop undesirable manifestations of estrogenic stimulation such as mastodynia. In a large clinical trial of PREMPRO, PREMPHASE, and Premarin®, approximately one third of the subjects receiving PREMPRO and approximately one third of the subjects receiving PREMPHASE reported breast pain during treatment versus 12% for Premarin alone.

Based on experience with progestins:

1. Lipoprotein metabolism. See CLINICAL STUDIES .
2. Impaired glucose tolerance. See Use in hysterectomized women, above.
3. Depression.   Patients who have a history of depression should be observed and the drugs discontinued if the depression recurs to a serious degree.

Information for the Patient

See text of Patient Package Insert which appears after the HOW SUPPLIED section

Drug/Laboratory Test Interactions

1. Accelerated prothrombin time, partial thromboplastin time, and platelet aggregation time; increased platelet count; increased factors II, VII 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.
2. Increased thyroid-binding globulin (TBG) leading to increased circulating total thyroid hormone, as measured by protein-bound iodine (PBI), T ₄ levels (by column or by radioimmunoassay) or T ₃ levels by radioimmunoassay, T ₃ resin uptake is decreased, reflecting the elevated TBG. Free T ₄ and free T ₃ concentrations are unaltered.
3. Other binding proteins may be elevated in serum, i.e., corticosteroid binding globulin (CBG), sex hormone-binding globulin (SHBG), leading to increased circulating corticosteroids and sex steroids respectively. Free or biologically active hormone concentrations are unchanged. Other plasma proteins may be increased (angiotensinogen/renin substrate, alpha-1-antitrypsin, ceruloplasmin).
4. Increased plasma HDL and HDL-2 subfraction concentrations, reduced LDL cholesterol concentration, increased triglyceride levels.
5. Impaired glucose tolerance. For this reason, diabetic patients should be carefully observed while receiving estrogen/progestin therapy.
6. Reduced response to metyrapone test.
7. Reduced serum folate concentration.
8. Aminoglutethimide administered concomitantly with MPA may significantly depress the bioavailability of MPA.

Carcinogenesis, Mutagenesis, and Impairment of Fertility.

Long term continuous administration of natural and synthetic estrogens in certain animal species increases the frequency of carcinomas of the breasts, uterus, cervix, vagina, testis, and liver. (See CONTRAINDICATIONS and .)

In a two-year oral study of MPA in which female rats were exposed to dosages of up to 5000 µg/kg/day in their diets (50 times higher--based on AUC values--than the level observed experimentally in women taking 10 mg of MPA), a dose-related increase in pancreatic islet cell tumors (adenomas and carcinomas) occurred. Pancreatic tumor incidence was increased at 1000 and 5000 µg/kg/day, but not at 200 µg/kg/day.

A decreased incidence of spontaneous mammary gland tumors was observed in all three MPA-treated groups, compared to controls, in the two-year rat study. The mechanism for the decreased incidence of mammary gland tumors observed in the MPA-treated rats may be linked to the significant decrease in serum prolactin concentration observed in rats.

Beagle dogs treated with MPA developed mammary nodules, some of which were malignant. Although nodules occasionally appeared in control animals, they were intermittent in nature, whereas the nodules in the drug-treated animals were larger, more numerous, persistent, and there were some breast malignancies with metastases. It is known that progestogens stimulate synthesis and release of growth hormone in dogs. The growth hormone, along with the progestogen, stimulates mammary growth and tumors. In contrast, growth hormone in humans is not increased, nor does growth hormone have any significant mammotrophic role. Therefore, the MPA-induced increase of mammary tumors in dogs probably has no significance to humans. No pancreatic tumors occurred in dogs.

Pregnancy Category X

Estrogens/progestins should not be used during pregnancy. See CONTRAINDICATIONS .

Nursing Mothers

As a general principle, the administration of any drug to nursing mothers should be done only when clearly necessary since many drugs are excreted in human milk. Estrogen administration to nursing mothers has been shown to decrease the quantity and quality of the milk. Detectable amounts of progestin have been identified in the milk of mothers receiving the drug. The effect of this on the nursing infant has not been determined.

ADVERSE REACTIONS

(See regarding induction of neoplasia, adverse effects on the fetus, increased incidence of gallbladder disease, elevated blood pressure, thromboembolic disorders, visual abnormalities, and hypercalcemia and PRECAUTIONS for cardiovascular disease.)

In a one year clinical trial that included 678 women treated with PREMPRO, 351 women treated with PREMPHASE, and 347 women treated with Premarin, the following adverse events occurred at a rate >/= 5% (see Table 4):

The following adverse reactions also have been reported with estrogen and/or progestin therapy:

Genitourinary system. Changes in vaginal bleeding pattern and abnormal withdrawal bleeding or flow, breakthrough bleeding, spotting, change in amount of cervical secretion, premenstrual-like syndrome, cystitis-like syndrome, increase in size of uterine leiomyomata, vaginal candidiasis, amenorrhea, changes in cervical erosion.

Breasts. Tenderness, enlargement, galactorrhea.

Gastrointestinal. Nausea, cholestatic jaundice, changes in appetite, vomiting, abdominal cramps, bloating, increased incidence of gallbladder disease, pancreatitis.

Skin. Chloasma or melasma that may persist when drug is discontinued, erythema multiforme, erythema nodosum, hemorrhagic eruption, loss of scalp hair, hirsutism, itching, urticaria, pruritus, generalized rash, rash (allergic) with and without pruritus, acne.

Cardiovascular. In susceptible individuals, change in blood pressure, thrombophlebitis, pulmonary embolism, cerebral thrombosis and embolism.

CNS. Headache, dizziness, mental depression, nervousness, migraine, chorea, insomnia, somnolence.

Eyes. Neuro-ocular lesions, e.g., retinal thrombosis and optic neuritis. Steepening of corneal curvature, intolerance of contact lenses.

Miscellaneous. Increase or decrease in weight, edema, changes in libido, fatigue, backache, reduced carbohydrate tolerance, aggravation of porphyria, pyrexia, anaphylactoid reactions, anaphylaxis.

ACUTE OVERDOSAGE

Serious ill effects have not been reported following acute ingestion of large doses of estrogen/progestin-containing oral contraceptives by young children. Overdosage may cause nausea and vomiting, and withdrawal bleeding may occur in females.

DOSAGE AND ADMINISTRATION

PREMPRO therapy consists of a single tablet to be taken once daily.

1. For treatment of moderate-to-severe vasomotor symptoms and vulval and vaginal atrophy associated with menopause, patients should be started at the lowest effective dose--PREMPRO 0.625 mg/2.5 mg daily. Patients should be reevaluated at 3-month to 6-month intervals to determine if treatment for symptoms is still necessary.
   Adequate diagnostic measures, including endometrial sampling when indicated, should be undertaken to rule out malignancy in cases of undiagnosed persistent or recurring abnormal vaginal bleeding. In patients where bleeding or spotting remains a problem, after appropriate evaluation, consideration should be given to increasing the MPA dose to PREMPRO 0.625 mg/5 mg daily. This dose can be periodically reassessed by the health care provider.
2. For prevention of osteoporosis--PREMPRO 0.625 mg/2.5 mg daily. Patients should be monitored closely for signs of endometrial cancer, and appropriate diagnostic measures should be taken to rule out malignancy in the event of persistent or recurring abnormal vaginal bleeding. In patients where bleeding or spotting remains a problem, after appropriate evaluation, consideration should be given to increasing the MPA dose to PREMPRO 0.625 mg/5 mg daily. This dose can be periodically reassessed by the health care provider.

PREMPHASE therapy consists of two separate tablets; one maroon 0.625 mg Premarin tablet taken daily on days 1 through 14 and one light-blue tablet, containing 0.625 mg conjugated estrogens and 5 mg of medroxyprogesterone acetate, taken on days 15 through 28.

1. For treatment of moderate to severe vasomotor symptoms and vulvar and vaginal atrophy associated with menopause. Patients should be reevaluated at 3-month to 6-month intervals to determine if treatment for symptoms is still necessary. Adequate diagnostic measures, including endometrial sampling when indicated, should be undertaken to rule out malignancy in cases of undiagnosed persistent or recurring abnormal vaginal bleeding.
2. For prevention of osteoporosis. Treated patients with an intact uterus should be monitored closely for signs of endometrial cancer, and appropriate diagnostic measures should be taken to rule out malignancy in the event of persistent or recurring abnormal vaginal bleeding.

HOW SUPPLIED

PREMPRO™ therapy consists of a single tablet to be taken once daily.

PREMPRO 0.625 mg/2.5 mg

Each carton includes 3 EZ DIAL™ dispensers containing 28 tablets. One EZ DIAL™ dispenser contains 28 oval, peach tablets containing 0.625 mg of the conjugated estrogens found in Premarin® tablets and 2.5 mg of medroxyprogesterone acetate for oral administration.

PREMPRO 0.625 mg/5 mg

Each carton includes 3 EZ DIAL™ dispensers containing 28 tablets. One EZ DIAL™ dispenser contains 28 oval, light-blue tablets containing 0.625 mg of the conjugated estrogens found in Premarin® tablets and 5 mg of medroxyprogesterone acetate for oral administration.

PREMPHASE® therapy consists of two separate tablets; one maroon Premarin® tablet taken daily on days 1 through 14 and one light-blue tablet taken on days 15 through 28.

Each carton includes 3 EZ DIAL™ dispensers containing 28 tablets. One EZ DIAL™ dispenser contains 14 oval, maroon Premarin tablets containing 0.625 mg of conjugated estrogens and 14 oval, light-blue tablets that contain 0.625 mg of the conjugated estrogens found in Premarin tablets and 5 mg of medroxyprogesterone acetate (MPA) for oral administration.

The appearance of PREMPRO™ tablets is a trademark of Wyeth-Ayerst Laboratories.

The appearance of Premarin® tablets is a trademark of Wyeth-Ayerst Laboratories. The appearance of the conjugated estrogens/medroxyprogesterone acetate combination tablets is a registered trademark.

Store at controlled room temperature 20°C-25°C (68°F-77°F).

PRODUCT PHOTO(S):

INFORMATION FOR THE PATIENT

Your physician has prescribed PREMPRO or PREMPHASE, a combination of two hormones, an estrogen and a progestin. This leaflet describes the major benefits and risks of your treatment, as well as how and when treatment should be taken.

PREMPRO and PREMPHASE replace the hormones in your body which naturally decrease at menopause. The hormone combination you will be taking has been shown to provide the benefits of estrogen replacement therapy while lowering the frequency of a possible precancerous condition of the uterine lining. This therapy is not intended for women who have had a hysterectomy (surgical removal of the uterus).

Estrogens have several important uses but also some risks. You must decide, with your doctor, whether the risks of estrogens are acceptable when weighed against their benefits. The length of treatment with estrogens can vary from woman to woman. Check with your doctor to make sure you are using the lowest possible effective dose.

With PREMPRO or PREMPHASE therapy several menstrual-like bleeding patterns may occur. These may range from absence of bleeding to irregular bleeding. If bleeding occurs, it is frequently light spotting or moderate menstrual-like bleeding, but it may be heavy. If you experience vaginal bleeding while taking PREMPRO or PREMPHASE, you should discuss your bleeding pattern with your doctor and set up an appropriate schedule for follow-up care.

USES OF ESTROGEN

To reduce moderate to severe menopausal symptoms.   Estrogens are hormones produced by the ovaries of normal women. When a woman is between the ages of 45 and 55, the ovaries normally stop making estrogens. This leads to a drop in body estrogen levels that causes the "change of life" or menopause (the end of monthly menstrual periods). A sudden drop in estrogen levels also occurs if both ovaries are removed during an operation before natural menopause takes place. This is referred to as "surgical menopause."

When the estrogen levels begin dropping, some women develop very uncomfortable symptoms, such as feelings of warmth in the face, neck, and chest, or sudden intense episodes of heat and sweating ("hot flashes" or "hot flushes"). Using estrogen drugs can help the body adjust to lower estrogen levels and reduce these symptoms. In some women the symptoms are mild; in others they can be severe. These symptoms may last only a few months or longer. Taking PREMPRO or PREMPHASE can alleviate these symptoms. If you are not taking hormones for other reasons, such as the prevention of osteoporosis, you should take PREMPRO or PREMPHASE only as long as you need it for relief from your menopausal symptoms.

To prevent thinning of bones.   Osteoporosis is a thinning of the bones that makes them weaker and allows them to break more easily. The bones of the spine, wrists, and hips break most often in osteoporosis. Both men and women start to lose bone mass after about age 40, but women lose bone mass faster after the menopause. Using estrogens after the menopause slows down bone thinning and may prevent bones from breaking. Lifelong adequate calcium intake, either from diet (such as dairy products) or from calcium supplements (to reach a total daily intake of 1000 milligrams per day before menopause or 1500 milligrams per day after menopause), may help to prevent osteoporosis. Regular weight-bearing exercise (like walking and running for an hour, two or three times a week) may also help to prevent osteoporosis. Before you change your calcium intake or exercise habits, it is important to discuss these lifestyle changes with your doctor to find out if they are safe for you.

Since estrogen use has some risks, only women who are likely to develop osteoporosis should use estrogens for prevention. Women who are likely to develop osteoporosis often have the following characteristics:

• White or Asian race
• Small, slim body frame
• Cigarette-smoking habit
• Family history of osteoporosis (in a mother, sister, or aunt)
• Early menopause either natural or because of surgical removal of ovaries ("surgical menopause")

To treat vulvar and vaginal atrophy (itching, burning, dryness in or around the vagina, difficulty or burning on urination) associated with menopause.

WHO SHOULD NOT USE ESTROGENS

During pregnancy. If you think you may be pregnant, do not use any form of estrogen-containing drug. Using estrogens while you are pregnant may cause your unborn child to have birth defects. Estrogens do not prevent miscarriage.

If you have unusual vaginal bleeding which has not been evaluated by your doctor. Unusual vaginal bleeding can be a warning sign of cancer of the uterus, especially if it happens after menopause. Your doctor must find out the cause of the bleeding so that he or she can recommend the proper treatment. Taking estrogens without visiting your doctor can cause you serious harm if your vaginal bleeding is caused by cancer of the uterus.

If you have had cancer. Since estrogens increase the risk of certain types of cancer, you should not use estrogens if you have ever had cancer of the breast or uterus.

If you have any circulation problems.   Estrogen drugs should not be used except in unusually special situations in which your doctor decides that you need estrogen therapy so much that the risks are acceptable. Women with abnormal blood clotting conditions should avoid estrogen use (see RISKS OF ESTROGENS AND/OR PROGESTINS ).

When they do not work. During menopause, some women develop nervous symptoms or depression. Estrogens do not relieve these symptoms. You may have heard that taking estrogens for years after menopause will keep your skin soft and supple and keep you feeling young. There is no evidence for these claims and such long-term estrogen use may have serious risks.

After childbirth or when breastfeeding a baby. Estrogen should not be used to try to stop the breast from filling with milk after a baby is born. Such treatment may increase the risk of developing blood clots (see RISKS OF ESTROGENS AND/OR PROGESTINS ).

If you are breastfeeding, you should avoid using any drugs because many drugs pass through to the baby in the milk. While nursing a baby, you should take drugs only on the advice of your health-care provider.

RISKS OF ESTROGENS AND/OR PROGESTINS

Cancer of the uterus. If you use any drug which contains estrogen, it is important to visit your doctor regularly and report any unusual vaginal bleeding right away. Vaginal bleeding after menopause may be a warning sign of uterine cancer. Your doctor should evaluate any unusual vaginal bleeding to find out the cause.

The risk of cancer of the uterus increases when estrogens are used alone, the longer they are used, and when larger doses are taken. There is a higher risk of cancer of the uterus if you are overweight, diabetic, or have high blood pressure. The hormone combination you will be taking contains estrogen and progestin. This combination has been shown to provide the benefits of estrogen replacement therapy for the USES OF ESTROGEN listed above, while reducing the risk of a precancerous condition of the uterine lining (see OTHER INFORMATION , below).

However, additional risks may be associated with the inclusion of a progestin in estrogen treatment. The possible risks include less favorable effects on blood fats as compared to Premarin alone, unfavorable effects on blood sugars, and a possible increase in breast cancer risk (see Cancer of the breast, below). Usually, the smaller the dose and the shorter the duration of treatment, the more these effects are minimized. Check with your doctor to make sure you are using the lowest effective dose and only for as long as you need it.

If you have had your uterus removed, there is no risk of developing cancer of the uterus and no benefit to be gained by using a combination estrogen/progestin product.

Cancer of the breast. Most studies have not shown a higher risk of breast cancer in women who have ever used estrogens. However, some studies have reported that breast cancer developed more often (up to twice the usual rate) in women who used estrogens for long periods of time (especially more than 10 years), or who used high doses for shorter time periods. The effects of added progestin on the risk of breast cancer are unknown. Some studies have reported a somewhat increased risk, even higher than the possible risk associated with estrogens alone. Others have not. Regular breast examinations by a health professional and monthly self-examination are recommended for all women. Regular mammograms are recommended for all women over 50 years of age.

Gallbladder disease. Women who use estrogens after menopause are more likely to develop gallbladder disease needing surgery than women who do not use estrogens.

Inflammation of the Pancreas. Women with high triglyceride levels may have an increased risk of developing inflammation of the pancreas.

Abnormal blood clotting.   Taking estrogens may cause changes in your blood clotting system. These changes allow the blood to clot more easily, possibly allowing clots to form in your bloodstream. If blood clots do form in your bloodstream, they can cut off the blood supply to vital organs, causing serious problems. These problems may include a stroke (by cutting off blood to the brain), a heart attack (by cutting off blood to the heart), a pulmonary embolus (by cutting off blood to the lungs), or other problems. Any of these conditions may cause death or serious long-term disability.

Heart Disease. A recent 4-year study suggests that women with a history of coronary heart disease may have an increased risk of serious cardiac events during the first year of treatment with estrogen/progestin therapy. Therefore, if you have had a heart attack, or you have been told you have blocked coronary arteries (arteries to your heart) or have any heart problem, you should consult your physician regarding the potential benefits and risks of estrogen/progestin therapy.

Excess calcium in the blood.   Taking estrogens may lead to severe hypercalcemia in women with breast and/or bone cancer.

During pregnancy. There is an increased risk of birth defects in children whose mothers take this drug during the first four months of pregnancy. Several reports suggest an association between mothers who take these drugs in the first trimester of pregnancy and genital abnormalities in male and female babies. The risk to the male baby is the possibility of being born with a condition in which the opening of the penis is on the underside rather than the tip of the penis (hypospadias). Hypospadias occurs in about 5 to 8 per 1,000 male births and is about doubled with exposure to these drugs. There is not enough information to quantify the risk to exposed female fetuses. However, enlargement of the clitoris and fusion of the labia may occur, although rarely.

Therefore, since drugs of this type may induce mild masculinization of the external genitalia of the female fetus, as well as hypospadias in the male fetus, it is wise to avoid using the drug during the first trimester of pregnancy. These drugs have been used as a test for pregnancy, but such use is no longer considered safe because of possible damage to a developing baby. Also, more rapid methods for testing for pregnancy are now available. If you take PREMPRO or PREMPHASE and later find you were pregnant when you took it, be sure to discuss this with your doctor as soon as possible.

SIDE EFFECTS WITH ESTROGENS AND/OR

PROGESTINS

In addition to the risks listed above, the following side effects have been reported with estrogen and/or progestin use:

• Nausea, vomiting, pain, cramps, swelling, or tenderness in the abdomen.
• Yellowing of the skin and/or whites of the eyes.
• Breast tenderness or enlargement.
• Enlargement of benign tumors ("fibroids") of the uterus.
• Irregular bleeding or spotting.
• Change in amount of cervical secretion.
• Vaginal yeast infections.
• Retention of excess fluid. This may make some conditions worsen, such as asthma, epilepsy, migraine, heart disease, or kidney disease.
• A spotty darkening of the skin, particularly on the face; reddening of the skin; skin rashes.
• Worsening of porphyria.
• Headache, migraines, dizziness, faintness, or changes in vision (including intolerance to contact lenses).
• Mental depression.
• Involuntary muscle spasms.
• Hair loss or abnormal hairiness.
• Increase or decrease in weight.
• Changes in sex drive.
• Possible changes in blood sugar.

REDUCING THE RISKS OF ESTROGEN/PROGESTIN

If you decide to take an estrogen/progestin combination, you can reduce your risks by carefully monitoring your treatment.

See your doctor regularly. While you are taking PREMPRO or PREMPHASE, it is important to visit your doctor at least once a year for a checkup. If you develop vaginal bleeding while taking estrogens, you may need further evaluation. If members of your family have had breast cancer or if you have ever had breast lumps or an abnormal mammogram (breast X ray), you may need to have more frequent breast examinations.

Reassess your need for treatment. You and your doctor should reevaluate whether or not you still need estrogens at least every six months.

Be alert for signs of trouble. If any of these warning signals (or any other unusual symptoms) happen while you are using estrogen/progestin, call your doctor immediately:

• Abnormal bleeding from the vagina (possible uterine abnormality).
• Pains in the calves or chest, a sudden shortness of breath or coughing blood (indicating possible clots in the legs, heart, or lungs).
• Severe headache or vomiting, dizziness, faintness, or changes in vision or speech, weakness or numbness of an arm or leg (indicating possible clots in the brain or eye).
• Breast lumps (possible breast cancer; ask your doctor or health professional to show you how to examine your breasts monthly).
• Yellowing of the skin and/or whites of the eyes (possible liver problems).
• Pain, swelling, or tenderness in the abdomen (possible gallbladder problem).

OTHER INFORMATION

1. Estrogens increase the risk of developing a condition (endometrial hyperplasia) that may lead to cancer of the lining of the uterus. Taking progestins, another hormonal drug, with estrogens lowers the risk of developing this condition. Therefore, since your uterus has not been removed, your doctor has prescribed PREMPRO or PREMPHASE, which includes both a progestin and estrogens.
   You should know, however, that taking estrogens with progestins may have unhealthy effects on blood sugar, which might make a diabetic condition worse. Additional risks include a possible further increase in breast cancer risk which may be associated with long-term estrogen use.
   Some research has shown that estrogens taken without progestins may protect women against developing heart disease. However, this is not certain. The protection shown may have been caused by the characteristics of the estrogen-treated women and not by the estrogen treatment itself. In general, treated women were slimmer, more physically active, and were less likely to have diabetes than the untreated women. These characteristics are known to protect against heart disease.
   You are cautioned to discuss very carefully with your doctor or health-care provider all the possible risks and benefits of long-term estrogen and progestin treatment as they affect you personally.
2. Your doctor has prescribed this drug for you and you alone. Do not give the drug to anyone else.
3. If you will be taking calcium supplements as part of the treatment to help prevent osteoporosis, check with your doctor about the amounts recommended.
4. Keep this and all drugs out of the reach of children. In case of overdose, call your doctor, hospital, or poison control center immediately.
5. This leaflet provides the most important information about PREMPRO and PREMPHASE. If you want to read more, ask your doctor or pharmacist to let you read the professional labeling. The professional labeling is also published in a book called The Physicians' Desk Reference, which is available in bookstores and public libraries.

HOW SUPPLIED

PREMPRO™ is a combination of the conjugated estrogens found in Premarin® tablets and medroxyprogesterone acetate (MPA). Depending on the dosage strength, PREMPRO therapy consists of either a single peach tablet or a single light-blue tablet to be taken once daily.

PREMPRO 0.625 mg/2.5 mg

Each carton includes 3 EZ DIAL™ dispensers containing 28 tablets. One EZ DIAL™ dispenser contains 28 oval, peach tablets containing 0.625 mg of the conjugated estrogens found in Premarin® tablets and 2.5 mg of medroxyprogesterone acetate for oral administration.

PREMPRO 0.625 mg/5 mg

Each carton includes 3 EZ DIAL™ dispensers containing 28 tablets. One EZ DIAL™ dispenser contains 28 oval, light-blue tablets containing 0.625 mg of the conjugated estrogens found in Premarin® tablets and 5 mg of medroxyprogesterone acetate for oral administration.

The appearance of PREMPRO™ tablets is a trademark of Wyeth-Ayerst Laboratories.

PREMPHASE® is a combination of two separate tablets; one maroon Premarin® tablet taken daily on days 1 through 14 and one light-blue tablet taken on days 15 through 28.

Each carton includes 3 EZ DIAL™ dispensers containing 28 tablets. One EZ DIAL™ dispenser contains 14 oval, maroon Premarin tablets containing 0.625 mg of conjugated estrogens and 14 oval, light-blue tablets that contain 0.625 mg of the conjugated estrogens found in Premarin tablets and 5 mg of medroxyprogesterone acetate (MPA) for oral administration.

The appearance of Premarin® tablets is a trademark of Wyeth-Ayerst Laboratories. The appearance of the conjugated estrogens/medroxyprogesterone acetate combination tablets is a registered trademark.

Keep out of reach of children.

Store at controlled room temperature 20° C-25° C (68° F-77° F).

U.S. Patent Nos. 5,547,948; 5,210,081; Re. 36,247

Manufactured by:

Ayerst Laboratories Inc.

A Wyeth-Ayerst Company

Philadelphia, PA 19101

CI 6096-1 Issued January 6, 2000