A novel oestradiol--desogestrel preparation for hormone replacement therapy: effects on hormones, lipids, bone, climacteric symptoms and endometrium

British menopause society tools for clinicians: Progestogens and endometrial protection

Progestogen administration is required to oppose naturally produced or administered estrogens to provide endometrial protection. Within HRT regimens, this should be delivered for at least the same duration as that produced during the luteal phase of the monthly cycle and in the recommended doses to protect against the risk of endometrial hyperplasia and endometrial cancer. This includes progestogens administered for 12-14 days a month in sequential regimens and continuous daily intake in continuous combined HRT regimens. Shorter durations and lower doses of progestogen intake are likely to be associated with an increased risk of breakthrough bleeding, endometrial hyperplasia, and endometrial cancer.

Étude observationnelle des critères déterminant le choix du traitement hormonal de la ménopause, lors de l’instauration et son adaptation

OBJECTIVES

Multicentre observational longitudinal prospective study in France; search for criteria involved in the choice of the initial dose of oestrogen at the initiation of hormone replacement therapy (HRT); search for explicative and predictive factors for treatment adaptation.

PATIENTS AND METHODS

STATISTICS

description and analysis (factorial analysis of multiple correspondences) of the criteria involved in the choice of the initial dose of oestrogen; percentage of women with treatment adaptation ; analysis (univariate, multivariate) of predictive factors for adaptation.

RESULTS

Six hundred and fifty postmenopausal women, first treated with HRT, with complete data on modification (or not) of their treatment were included. Initial estrogen dose was dose 1 (or low dose) in 66% of patients, dose 2 (or standard dose) in 34 % of patients (N = 643). The preponderant type of HRT use was discontinuous sequential therapy and transdermal formulation. Criteria involved in the choice of the low initial dose (dose 1) were moderate hot flushes, complaint about weight gain, choice of the patient, breast tolerability, uterine bleeding, general safety, hepatic first pass. Criteria involved in the choice of the standard initial dose (dose 2) were important hot flushes, and prevention of postmenopausal osteoporosis. Treatment was adapted in 369 patients e.g. 56.8% of the population (95% CI: 53-60.6 %). The main changes (N = 291) were in 37.5% of the cases (N = 109) a decrease in the dose of estrogen (16.7% of the women (N = 37) initially under dose 2 - or standard dose) or an increase in the dose of oestrogen (17.1% of the women (N = 72) initially under dose 1 - or low dose). In 25% of the cases, there was a change in the dose or type of progestogen, in favor of norpregnane or pregnane derivates.

DISCUSSION AND CONCLUSION

The following factors were associated with a decreased probability of treatment adaptation: more than 5 hot flushes at enrolment, initial dose chosen taking into account tolerance factors, history of hysterectomia, and known diabetes. Conversely, the existence of antihypertensive treatment was associated with an increased probability of treatment adaptation.

Overview on the effects of progestins on bone

In view of the fact that fractures are the clinically relevant events, risk factors for fractures are discussed first. Bone mineral density (BMD) appears to be a much less important risk factor for the most severe hip fractures than the risk of falling. No results of experimental studies on hormones and fractures at advanced age are available. An overview of the effects of progestins on bone is given. Effects of progestins on bone have been studied by in vitro experiments using cell lines and by more relevant clinical observations. Prospective studies have been conducted following the use of progestins contained in oral contraceptives, alone or in combination with oestrogens; long-term contraception by injection of depot preparations; so-called "add-back" hormonal therapy attempting to reverse the adverse effects of gonadotropin releasing hormone agonists on bone and after different regimens of hormone replacement therapy (HRT) in postmenopausal women. From the data there are no indications that the various progestins, used in clinical practice, have either a bone-protective or an oestrogen antagonistic activity. Progestins do not add or subtract much of the protective action of oestrogens on the bones.

A double-blind, randomized, comparative study evaluating clinical effects of two sequential estradiol-progestogen combinations containing either desogestrel or medroxyprogesterone acetate in climacteric women

OBJECTIVES

The aim of this study was to compare a new sequential estradiol-desogestrel (E2-DSG) hormone replacement regimen (Liseta) with one of the standard treatments i.e. estradiol valerate-medroxyprogesterone acetate (E2V-MPA) combination (Klimalet) regarding the alleviation of climacteric symptoms, vaginal bleeding pattern and the occurrence of adverse experiences.

METHODS

In a multicenter study performed in Denmark, a total of 376 perimenopausal women with climacteric symptoms were randomly allocated to oral sequential treatment with either E2-DSG (1.5 mg E2 for 24 days with 0.15 mg DSG for the last 12 days followed by a placebo tablet for 4 days) (n = 186) or with E2V-MPA (2 mg E2V for 21 days with 10 mg MPA for the last 10 days) (n = 190). Treatments were administered, using a double-blind, double-dummy technique for 6 cycles of 28 days.

RESULTS

Three hundred and seventeen women, 158 in the E2-DSG and 159 in the E2V-MPA group, completed six treatment cycles. Both treatments reduced menopausal symptoms rapidly and to a similar extent. Hot flushes were present in 88% of the women in both groups. After six treatment cycles, hot flushes were no longer present in 71 and 62% of the women in the E2-DSG and E2V-MPA group, respectively. Perspiration decreased from 80 to 65% in the E2-DSG group and from 82 to 63% in the E2V-MPA group. Mood disturbances were present in 82% of the women in the E2-DSG at baseline, and in 52% after six cycles. In the E2V-MPA group the corresponding figures were 68 and 42%, respectively. The bleeding pattern was comparable in both treatment groups. Regular withdrawal (expected) bleeding appeared in 90-92% and in 85-90% of the women in cycles 1-5 with E2-DSG and E2V-MPA, respectively. Irregular bleeding (including spotting) occurred in 15.2% of the women receiving E2-DSG and in 20.1% of the women treated with E2V-MPA in cycle 6. In both treatment groups there was a tendency of a slight decrease in blood pressure. Adverse events were in less than 10% in each group the reason to discontinue treatment.

CONCLUSIONS

Both treatments effectively alleviated menopausal complaints and presented good cycle control. Bleeding pattern and mood disturbances appeared to be more favorable influenced by E2-DSG.

Bioavailability and bioequivalence of etonogestrel from two oral formulations of desogestrel: Cerazette and Liseta

In a three-period cross-over study with 24 healthy young females (study part 1), the bioavailability of etonogestrel (3-ketodesogestrel) was determined after a single oral dose of two Cerazette tablets (each containing 75 microg desogestrel), one Liseta tablet (containing 150 microg desogestrel and 1.5 mg 17beta-estradiol), and an intravenous dose of 150 microg etonogestrel. Etonogestrel serum levels from 23 subjects could be analysed by radio-immunoassay. The geometric mean bioavailability of etonogestrel from Cerazette and Liseta tablets was 0.79 and 0.82, with 95% confidence intervals of 0.73-0.86 and 0.76-0.88, respectively. Also, the oral formulations were found to be bioequivalent. Subsequently, the single-dose pharmacokinetic parameters of etonogestrel from Cerazette tablets were compared with those after multiple dosing of one Cerazette tablet once daily for 7 days, in a subgroup of 12 subjects (study part 2). A steady state was observed from the fourth day of daily dosing onwards, with time-invariant parameters except for a 14% lower dose-normalised AUC. The least-squares geometric means of the elimination half-life of etonogestrel were approximately 30 h for the three single-dose treatments in study part 1, as well as for the single- and multiple-dose treatments of Cerazette in study part 2, without differences between groups.

Estrogen Replacement Therapy, Serum Lipids, and Polymorphism of the Apolipoprotein E Gene

Background: Pharmacogenomics, the study of genetic loci that modulate drug responsiveness, may help to explain why estrogen replacement therapy (ERT) has differential effects on serum lipid and lipoprotein concentrations in postmenopausal women who inherit distinct alleles of the apolipoprotein E gene (APOE).

Methods: We compared total-cholesterol, triglyceride, and lipoprotein (LDL and HDL) concentrations in 66 postmenopausal women receiving ERT ([+]ERT) with 174 postmenopausal women not receiving ERT ([−]ERT), controlling for three APOE genotypes divided into three groups: E2 (ε2/ε3, n = 31), E3 (ε3/ε3, n = 160), and E4 (ε3/ε4 + ε4/ε4, n = 49).

Results: Mean total-cholesterol concentrations were lower in all three [+]ERT groups compared with their [−]ERT counterparts but were statistically significant only for women in group E4 (P = 0.014). The mean LDL-cholesterol concentrations were significantly lower in all three [+]ERT groups compared with their [−]ERT counterparts (P ≤0.005). Although all three groups of [+]ERT women tended to have higher mean HDL-cholesterol concentrations compared with their [−]ERT counterparts, the differences were not statistically significant. [+]ERT women in groups E2 and E3 had significantly higher (P <0.05) triglyceride concentrations than their [−]ERT counterparts. In [+]ERT women, the ratios of total and LDL-cholesterol to HDL-cholesterol were significantly higher in group E3 and E4 women compared with E2 women (P <0.006). Group E4 [+]ERT women had ratios of total and LDL-cholesterol to HDL-cholesterol that were comparable to group E2 [−]ERT women.

Conclusions: Triglyceride concentrations in group E2 [+]ERT women may need to be monitored more closely than those in E3 or E4 [+]ERT women. Group E4 women should probably be targeted for ERT. Results suggest that APOE genotypes have a differential effect on serum lipids and lipoproteins in [+]ERT postmenopausal women.

Bioequivalence assessment of three different estradiol formulations in postmenopausal women in an open, randomized, single-dose, 3-way cross-over study

OBJECTIVE

The aim of the study was to assess the bioavailability of estradiol (E2) following oral, single-dose administration of equimolar doses of three HRT preparations in a 3-way cross-over study in postmenopausal women.

METHODS

18 healthy subjects were enrolled. Free E2 and estrone (E1) serum concentrations were determined using commercially available immunoassay kits. Bioequivalence testing was performed between the following oral formulations: (a) 1.5 mg E2 tablets versus 2 mg E2V tablets; and (b) 1.5 mg E2 plus 0.15 mg DSG tablets versus 1.5 mg E2 tablets.

RESULTS

For both E2 and E1 the E2 tablet was bioequivalent with both the E2V and the E2/DSG tablet with respect to the rate and extent of absorption (bioavailability). Although the mean tmax values of the three tablet formulations were similar, the variability was too large to prove formal bioequivalence.

CONCLUSION

E2 tablets and E2/DSG tablets were bioequivalent and also bioequivalence of E2 tablets with commercially available E2V was found, which ensures a sequential HRT preparation without large variations in estrogen serum concentrations.

Relationship between apolipoprotein E polymorphism, menopausal symptoms, and serum lipids during hormone replacement therapy

OBJECTIVE

Menopausal women receive hormone replacement therapy (HRT) to relieve symptoms and to help prevent osteoporosis or atherosclerotic disease. We investigated the association of apolipoprotein (apo) E polymorphism with menopausal symptoms, body fat mass and lipid profile in 236 women, together with the lipid changes accompanying HRT administration in 172 women from this population who were postmenopausal.

STUDY DESIGN

The subjects were divided into three groups according to apo E phenotype: group E2, apo E2/2 and 2/3; group E3, apo E3/3; group E4, apo E4/3 and 4/4. Typical menopausal symptoms were classified into four degrees of severity; body fat mass, lipid profile, and serum lipid levels were measured before and 6 months after oral HRT.

RESULTS

There were no significant differences between the symptoms of the three groups. The serum levels of apo E were the highest in group E2 and lowest in group E4. Analogous tendencies were seen in the mean levels of total cholesterol (TC), low density lipoprotein cholesterol (LDL-C), and apo B, with group E4 having the highest levels and group E2 the lowest. Triglyceride levels (TG) were the highest in group E2, but the difference was not significant. These parameters suggest that group E4 had the highest risk of cardiovascular disease. The LDL-C/high density lipoprotein cholesterol (HDL-C) ratio was improved from 2.18 before HRT to 1.52 after HRT in group E2; from 2.26 to 1.92 in group E3; and from 2.57 to 2.10 in group E4.

CONCLUSION

The apo E phenotype was not associated with any difference in menopausal symptoms. Group E4 had the highest risk for cardiovascular disease, and group E2 the lowest. Oral HRT could be recommended for the women in group E4.

The effects of different doses of medroxyprogesterone acetate on serum lipids, lipoprotein levels and atherogenic index in the menopausal period

The purpose of our study was to make a contribution to research in determining the least harmful progestogen dose for women who have not had their uterus removed. The study was an open comparative trial. The patients were consecutively assigned to two groups. The first group (n = 19) were given 0.625-mg conjugated equine estrogen plus 5-mg medroxyprogesterone acetate (MPA), and the second (n = 18) 0.625-mg conjugated equine estrogen plus 2.5-mg MPA. Serum total cholesterol (T-cholesterol), triglyceride, high-density lipoprotein cholesterol (HDL-C) and low-density lipoprotein cholesterol (LDL-C) levels plus LDL-C/HDL-C values (atherogenic index) were measured before the study and again after 6 and 12 months. These values were compared with ANOVA and postANOVA tests (Scheffe) within the groups and with unpaired t-test between the two groups. The triglyceride serum levels in the first group were decreased in the 12th month compared to baseline levels. In addition, LDL-C/HDL-C values were significantly decreased in the 6th month, but these values slightly increased in the following 6 months. In the second group, T-cholesterol, triglyceride, LDL-C and atherogenic index were decreased in the 12th month when compared to baseline levels within the groups. This decrease was statistically significant (p < 0.05). There was no significant difference between the two groups (p > 0.05). Hormone replacement therapy with continuous 0.625-mg conjugated equine estrogen and 2.5-mg MPA had a better effect on lipid profiles than 0.625-mg conjugated equine estrogens and 5-mg MPA after 12 months of treatment.

Enterohepatic cycling and pharmacokinetics of oestradiol in postmenopausal women

The pharmacokinetics and enterohepatic cycling of oestradiol have been studied after three oral, single-dose administrations of equimolar doses of oestradiol alone, oestradiol plus desogestrel and oestradiol valerate, in a 3-way cross-over mode in 18 healthy postmenopausal women. Oestradiol was readily absorbed and metabolized to oestrone, which reached much higher serum concentrations (140pgmL(-1)) than its parent compound (35pgmL(-1)). All three formulations had the same kinetic profile and were bioequivalent on testing. Noticeable first and second absorption phases were apparent from the oestradiol and oestrone serum concentration-time curves for all oestradiol formulations. The mean serum concentration-time curves of the metabolite oestrone (corrected for endogenous oestrone) showed a second maximum at approximately 25h. By means of line feathering, serum concentration-time curves were constructed which belonged to the first, second and third phases of absorption. The maximum serum concentration, Cmax, of the second absorption or recirculation of oestrone was 20% that of the first, and the Cmax of the third circulation was 50% that of the second. The areas under the serum-concentration-time curves (AUC) for the second and third recirculations were similar-each comprised 12-13% of the total AUC. The oral clearance values of the recirculations were constant (590Lh(-1)). Enterohepatic recirculation of endogenous compounds is aimed at maintaining a steady-state serum concentration for immediate use and hydrolysis in the target organs. It is concluded that exogenously added oestradiol and its metabolites follow the recirculation pathways of the endogenous oestrogen pool.

Impact of percutaneous oestradiol gels in postmenopausal hormone replacement therapy on clinical symptoms and endometrium

OBJECTIVE

To compare the effects on endometrium, climacteric symptoms and the menstrual cycle, and the clinical and biological tolerance of two percutaneous oestradiol gels used as hormone replacement therapy.

DESIGN

A large open randomised multicentre study.

SETTING

France and Belgium.

PARTICIPANTS

Two-hundred and fifty-four women with an intact uterus and who had experienced a natural menopause received either Oestrogel (n = 126) or Estreva, a new formulation of oestradiol gel (n = 128), (1.5 mg of oestradiol/day) for the 24 first days of each calendar month during six consecutive months. Nomegestrol acetate (Lutenyl), a norprogesterone derivative, was administered (5 mg/day) from day 11 to day 24 of each oestradiol cycle.

MAIN OUTCOME MEASURES

Examination of endometrial biopsies taken before treatment and between days 18 and 24 of the last treatment cycle, climacteric symptoms assessed using a modified Kupperman index, control of menstrual cycle evaluated by diary cards, and clinical and biological tolerance.

RESULTS

Both treatments lowered the frequency and intensity of hot flushes and the global Kupperman index. 96% of the cycles were followed by withdrawal bleeding. Breakthrough bleeding or spotting resulted in premature discontinuation of treatment in one volunteer. Mastodynia occurred in 20 women and contributed to the premature termination of treatment in three of them. Endometrial biopsies taken at the end of treatment showed identical histologies in both groups, with a secretory pattern in the majority of women, and absence of hyperplasia.

CONCLUSIONS

This trial confirmed that, when the two oestradiol gels tested were administered cyclically with nomegestrol acetate to postmenopausal women, they were well tolerated, effective and suitable for the treatment of oestrogen deficiency syndrome.

A randomized, double-blind, multicentre study comparing the clinical effects of two sequential estradiol-progestin combinations containing either desogestrel or norethisterone acetate in climacteric women with estrogen deficiency symptoms

OBJECTIVES

The aim of this study was to compare a new estradiol-desogestrel (E2-DG) regimen with an E2-norethisterone acetate (NETA) combination (Trisekvens) regarding the treatment of menopausal complaints, bleeding pattern, histology of the endometrium and the occurrence of adverse experiences.

METHODS

A total of 310 peri-/postmenopausal women with climacteric symptoms were randomly allocated to oral sequential treatment with either the E2-DG combination (1.5 mg E2 for 24 days with 0.15 mg DG for the last 12 days followed by 1 placebo tablet for 4 days) or with the E2-NETA combination (Trisekvens, 2 mg E2 for 22 days with 1 mg NETA for the last 10 days followed by 1 mg E2 for 6 days). Treatments were administered double-blind for 12 cycles of 28 days.

RESULTS

One hundred and four women, 48 in the E2-DG group and 56 in the E2-NETA group, discontinued the study due to bleeding irregularities and various adverse effects. Both treatments reduced menopausal symptoms and complaints effectively and almost equally. The alleviation of perspirations and the improvement of general fitness were more apparent (P = 0.009) during cycle 1 with the E2-NETA treatment but were greater (P < 0.02) during the last 9/10-12 cycles of E2-DG treatment compared to E2-NETA. Regular withdrawal bleeding appeared in 93% and 90% of the women during treatment with E2-DG and E2-NETA, respectively. Intermenstrual bleeding occurred in 8% of women receiving E2-DG and in 13% of women treated with E2-NETA. The corresponding figures for intermenstrual bleeding-spotting were 21% and 22%. Secretory endometrium was detected in 65% and 54% of the samples taken at the end of treatment with E2-DG and E2-NETA, respectively. No hyperplasia or atypia was found. No serious adverse events related to treatment occurred.

CONCLUSIONS

Both regimens alleviated effectively menopausal complaints and did not induce hyperplasia of endometrium. The minor differences recorded between the two regimens were probably due to the differences in their composition concerning the amount of estradiol and its distribution along the cycle, the amount and type of progestin and the length of estradiol/progestin combination phase.

Effect of postmenopausal estrogen replacement therapy on lipoproteins

OBJECTIVES

To investigate the association between menopause and lipoproteins and the effect of hormone replacement therapy (HRT).

METHODS

Total cholesterol, LDL cholesterol, HDL cholesterol and triglycerides were estimated in 50 postmenopausal women and 25 ovulating women who served as controls. The lipoprotein estimations were repeated after 1 year of therapy with natural estrogen-norgestrel combination.

RESULTS

More postmenopausal women than younger women had lipoprotein values in the high-risk status (P <0.001). There were no significant changes in lipoprotein levels (P >0.05) after HRT. Women with a body mass index below 26 kg/m2 had a significant reduction in their lipoprotein risk status (P <0.01).

CONCLUSION

There was no demonstrably clear effect of the estrogen-progestin combination on lipoprotein levels, probably because of other compounding variables such as obesity, lack of exercise and the type of progestin used.

Long-term hormone replacement treatment in menopause: new choices, old apprehensions, recent findings

In recent years there has been an increase in the use of parenteral oestradiol as an alternative to the conventional oral preparations used in hormone replacement treatment (HRT) in menopause, such as conjugated equine oestrogens (CEE). The latter have been subject in the past to apprehensions, partly due to misunderstanding and oversimplification but also in relation to problems that have arisen during the history of HRT, for example the increase in endometrial cancer risk deriving from the use of non-progestogen-opposed treatment. However, confidence in long-term HRT comes from the epidemiological findings, which refer mainly to the use of oral CEE unopposed by progestogen: a reduced risk of osteoporotic fractures and of cardiovascular disease, and a very limited risk of breast cancer. Oral oestrogens produce marked hepatocellular effects. These effects are, on the whole, favourable from the point of view of cardiovascular risk. In addition, it cannot be excluded that some hepatocellular effects of oral oestrogen, for example increased sex hormone binding globulin levels and reduced circulating insulin-like growth factor I activity, offer protection to the breast. As progestogen supplementation is needed in non-hysterectomized women, priority should be given to preparations, such as progesterone or dydrogesterone, that feature good endometrial activity without opposing oestrogen hepatocellular effects.