Extremely high levels of estradiol and estrone occur during EMP therapy. The estrogenic metabolites of EMP are responsible for its most common adverse effects and its cardiovascular toxicity. EMP has been described as having relatively weak estrogenic effects in some publications. However, it has shown essentially the same rates and degrees of estrogenic effects, such as breast tenderness, gynecomastia, cardiovascular toxicity, changes in liver protein synthesis, and testosterone suppression, as high-dose diethylstilbestrol and ethinylestradiol in clinical studies. The notion that EMP has relatively weak estrogen activity may have been based on animal research, which found that EMP had 100-fold lower uterotrophic effects than estradiol in rats, and may also not have taken into account the very high doses of EMP used clinically in humans.