Randomized, double-blind, dose-ranging study of the endometrial effects of a vaginal progesterone gel in estrogen-treated postmenopausal women

Hormone Therapy in Menopause: Concepts, Controversies, and Approach to Treatment

Hormone therapy (HT) is an effective treatment for menopausal symptoms, including vasomotor symptoms and genitourinary syndrome of menopause. Randomized trials also demonstrate positive effects on bone health, and age-stratified analyses indicate more favorable effects on coronary heart disease and all-cause mortality in younger women (close proximity to menopause) than in women more than a decade past menopause. In the absence of contraindications or other major comorbidities, recently menopausal women with moderate or severe symptoms are appropriate candidates for HT. The Women's Health Initiative (WHI) hormone therapy trials-estrogen and progestin trial and the estrogen-alone trial-clarified the benefits and risks of HT, including how the results differed by age. A key lesson from the WHI trials, which was unfortunately lost in the posttrial cacophony, was that the risk:benefit ratio and safety profile of HT differed markedly by clinical characteristics of the participants, especially age, time since menopause, and comorbidity status. In the present review of the WHI and other recent HT trials, we aim to provide readers with an improved understanding of the importance of the timing of HT initiation, type and route of administration, and of patient-specific considerations that should be weighed when prescribing HT.

Efficacy of four vaginal progesterones for luteal phase support in frozen-thawed embryo transfer cycles: A randomized clinical trial

PURPOSE

To investigate the efficacy of four vaginal progesterones, Lutinus, Utrogestan, Luteum, and Crinone, as luteal phase support (LPS) in frozen-thawed embryo transfer (Frozen-ET) cycles.

METHODS

Patients undergoing autologous Frozen-ET of one cleavage-stage embryo or one blastocyst. Two hundred fifty-nine Frozen-ET cycles were randomized to four groups for LPS: Lutinus, Utrogestan, Luteum, and Crinone. The clinical pregnancy rate (CPR), fetal heartbeat rate (FHR), and miscarriage rate (MR) were analyzed using the Mann-Whitney or Kruskal-Wallis test and Fisher exact test.

RESULTS

Two hundred thirty-five Frozen-ET cycles were analyzed: 63 cycles in the Lutinus group, 60 in the Utrogestan group, 56 in the Luteum group, and 56 in the Crinone group. No significant differences were observed between the four groups in CPR (Lutinus, Utrogestan, Luteum, and Crinone: 34.9%, 33.3%, 37.5%, and 35.7%, respectively; P = .976), FHR (26.9%, 31.6%, 30.3%, and 25.0%, respectively; P = .857), and MR (31.8%, 10.0%, 19.0%, and 30.0%, respectively; P = .306). Multivariate logistic regression analysis also revealed that there were no statistically significant differences between the four groups with regard to CPR, FHR, and MR.

CONCLUSION

There was no clinically significant difference in pregnancy outcomes between the four vaginal progesterone groups for LPS in Frozen-ET cycles.

Evidence on the use of progesterone in menopausal hormone therapy

A need exists for a regulatory agency-approved hormone therapy (HT) with naturally occurring hormones combining progesterone (P4) and estradiol (E2), since no single product contains both endogenous hormones. Many women choose HT with P4 and millions of women around the world are using unapproved, poorly regulated compounded HT. The use of natural P4 in HT results, for the most part, in favorable outcomes without deleterious effects, as shown in clinical studies of postmenopausal women. Importantly, P4 used in HT prevents endometrial hyperplasia from estrogens while helping relieve vasomotor symptoms and improving quality-of-life measures. Additionally, risk of venous thromboembolism and breast cancer does not appear to increase with use of P4 plus estrogens as shown with synthetic progestins plus estrogens in large observations studies, and no detrimental effects of P4 in HT have been found on outcomes related to cardiovascular disease or cognition. A regulatory agency-approved HT with naturally occurring E2/P4 could be an option for the millions of women who desire a bioidentical product and/or are exposed to potential risks of inadequately studied and under-regulated compounded HT.

Management of symptomatic vulvovaginal atrophy: 2013 position statement of The North American Menopause Society

OBJECTIVE

To update and expand the previous position statement of The North American Menopause Society (NAMS) on the management of symptomatic vulvovaginal atrophy (VVA) in postmenopausal women.

METHODS

NAMS searched PubMed for medical literature on VVA published since their 2007 position statement on the role of local vaginal estrogen for treatment of vaginal atrophy in postmenopausal women. A panel of acknowledged experts in the field of genitourinary health reviewed the literature to evaluate new evidence on local estrogen as well as on other management options available or in development for symptomatic VVA. The panel's conclusions and recommendations were reviewed and approved by the NAMS Board of Trustees.

RESULTS

Symptomatic VVA can significantly impair the quality of life (QOL) of postmenopausal women and may be underdiagnosed. In most cases, it can be managed successfully. A number of over-the-counter and government-approved prescription therapies available in the United States and Canada demonstrate effectiveness, depending on the severity of VVA symptoms. These include vaginal lubricants and moisturizers, vaginal estrogen, hormone therapy, and the selective estrogen-receptor modulator ospemifene (indicated for dyspareunia). Long-term studies on the endometrial safety of local estrogen and ospemifene are lacking. Changes in the vaginal microbiome have various effects on symptoms.

CONCLUSIONS

Clinicians can improve the sexual health and QOL of postmenopausal women by educating women about, diagnosing, and appropriately managing symptomatic VVA. Choice of therapy depends on the severity of symptoms, the effectiveness and safety of therapy for the individual patient, and patient preference. Estrogen therapy is the most effective treatment for moderate to severe symptoms, although a direct comparison of estrogen and ospemifene is not available. Nonhormonal therapies available without a prescription provide sufficient relief for most women with mild symptoms. When low-dose estrogen is administered locally, a progestogen is not indicated for women without a uterus and generally is not indicated for women with an intact uterus. However, endometrial safety has not been studied in clinical trials beyond 1 year. There are insufficient data to confirm the safety of local estrogen in women with breast cancer; management of VVA should take the woman's needs and the recommendation of her oncologist into consideration. Research on the vaginal microbiome may lead to other therapies in the future.

Efficacy of micronised vaginal progesterone versus oral dydrogestrone in the treatment of irregular dysfunctional uterine bleeding: a pilot randomised controlled trial

BACKGROUND

The vaginal route is more effective than the other drug delivery routes for some specific indications.

AIM

To compare the efficacy of a vaginal progesterone preparation with that of oral dydrogesterone.

METHODS

A total of 69 women with irregular dysfunctional uterine bleeding were randomly assigned into one of two groups: oral dydrogesterone group (n = 35) and vaginal progesterone group (n = 34). At the end of a three-month treatment period, the women were re-evaluated. The endometrial histology findings and menstrual cycle characteristics were used as primary outcome measures. Pearson chi-square and Fisher's exact test were used for data analysis.

RESULTS

Findings from 54 eligible women were evaluated. There was no statistically significant difference in both menstrual recordings and endometrial histology results between the groups.

CONCLUSIONS

Vaginal micronised progesterone could be an alternative to oral preparations in the treatment of dysfunctional uterine bleeding. This needs to be further evaluated in adequately controlled randomised trials against other effective treatments.

Could transdermal estradiol + progesterone be a safer postmenopausal HRT? A review

Hormone replacement therapy (HRT) in young postmenopausal women is a safe and effective tool to counteract climacteric symptoms and to prevent long-term degenerative diseases, such as osteoporotic fractures, cardiovascular disease, diabetes mellitus and possibly cognitive impairment. The different types of HRT offer to many extent comparable efficacies on symptoms control; however, the expert selection of specific compounds, doses or routes of administration can provide significant clinical advantages. This paper reviews the role of the non-oral route of administration of sex steroids in the clinical management of postmenopausal women. Non-orally administered estrogens, minimizing the hepatic induction of clotting factors and others proteins associated with the first-pass effect, are associated with potential advantages on the cardiovascular system. In particular, the risk of developing deep vein thrombosis or pulmonary thromboembolism is negligible in comparison to that associated with oral estrogens. In addition, recent indications suggest potential advantages for blood pressure control with non-oral estrogens. To the same extent, a growing literature suggests that the progestins used in association with estrogens may not be equivalent. Recent evidence indeed shows that natural progesterone displays a favorable action on the vessels and on the brain, while this might not be true for some synthetic progestins. Compelling indications also exist that differences might also be present for the risk of developing breast cancer, with recent trials indicating that the association of natural progesterone with estrogens confers less or even no risk of breast cancer as opposed to the use of other synthetic progestins. In conclusion, while all types of hormone replacement therapies are safe and effective and confer significant benefits in the long-term when initiated in young postmenopausal women, in specific clinical settings the choice of the transdermal route of administration of estrogens and the use of natural progesterone might offer significant benefits and added safety.

Effects of estradiol with oral or intravaginal progesterone on risk markers for breast cancer in a postmenopausal monkey model

OBJECTIVE

To evaluate the effects of oral estradiol given with either oral or intravaginal micronized progesterone (P4) on risk biomarkers for breast cancer in a postmenopausal monkey model.

DESIGN

This experiment was a two-way crossover study in which 20 ovariectomized adult female cynomolgus macaques were treated (in equivalent doses for women) with oral estradiol (1 mg/d) + oral micronized P4 (200 mg/d) or intravaginal P4 delivered by Silastic rings (6- to 10-mg/d release rate). Hormone treatments lasted 2 months and were separated by a 1-month washout period. The primary outcome measure was breast epithelial proliferation.

RESULTS

Serum P4 concentrations were significantly greater in subjects receiving oral P4 (10.9 ng/mL) compared with intravaginal P4 (3.8 ng/mL) at 2 to 3 hours after oral dosing (P<0.0001) but not at 24 to 28 hours after oral dosing (2.9 ng/mL for oral P4 vs 3.2 ng/mL for intravaginal P4 at 2 months, P=0.19). Serum estradiol concentrations were significantly lower after oral P4 than after intravaginal P4 (P<0.05 for all time points). Oral P4 resulted in significantly decreased body weight (-2.5%) compared with intravaginal P4 (+3.6%) (P=0.0001). Markers of breast proliferation, sex steroid receptor expression, and endometrial area did not differ significantly between oral P4 and intravaginal P4 treatments (P>0.1 for all).

CONCLUSIONS

Despite different pharmacodynamic profiles, oral and intravaginal P4 had similar effects on biomarkers in the postmenopausal breast.

Pharmacology of estrogens and progestogens: influence of different routes of administration

This review comprises the pharmacokinetics and pharmacodynamics of natural and synthetic estrogens and progestogens used in contraception and therapy, with special consideration of hormone replacement therapy. The paper describes the mechanisms of action, the relation between structure and hormonal activity, differences in hormonal pattern and potency, peculiarities in the properties of certain steroids, tissue-specific effects, and the metabolism of the available estrogens and progestogens. The influence of the route of administration on pharmacokinetics, hormonal activity and metabolism is presented, and the effects of oral and transdermal treatment with estrogens on tissues, clinical and serum parameters are compared. The effects of oral, transdermal (patch and gel), intranasal, sublingual, buccal, vaginal, subcutaneous and intramuscular administration of estrogens, as well as of oral, vaginal, transdermal, intranasal, buccal, intramuscular and intrauterine application of progestogens are discussed. The various types of progestogens, their receptor interaction, hormonal pattern and the hormonal activity of certain metabolites are described in detail. The structural formulae, serum concentrations, binding affinities to steroid receptors and serum binding globulins, and the relative potencies of the available estrogens and progestins are presented. Differences in the tissue-specific effects of the various compounds and regimens and their potential implications with the risks and benefits of hormone replacement therapy are discussed.

Bleeding profiles and effects on the endometrium for women using a novel combination of transdermal oestradiol and natural progesterone cream as part of a continuous combined hormone replacement regime

OBJECTIVE

Many women are seeking alternatives to conventional forms of hormone replacement. This study evaluates the endometrial effects of natural progesterone cream used in conjunction with transdermal oestradiol.

DESIGN

Open plan study conducted over 48 weeks.

SETTING

Tertiary referral London teaching hospital.

POPULATION

Women at least two years postmenopausal.

METHODS

Women were recruited nationally. They applied 40 mg transdermal natural progesterone cream and 1 mg transdermal oestradiol daily.

MAIN OUTCOME MEASURES

Endometrial histology, assessed by pipelle endometrial biopsy, ultrasound assessment of endometrial thickness and bleeding diaries.

RESULTS

Fifty-four women were recruited of which 41 completed the study. Mean age was 57.4 years. Thirty-two percent of women had evidence of inadequate endometrial opposition (proliferative or hyperplastic) at the end of 48 weeks. At baseline, women had a mean endometrial thickness of 3.3 mm, which had significantly thickened to a mean of 5.3 mm by 24 weeks (P < 0.001). By 48 weeks, there was significantly greater increase in endometrial thickness from baseline in those women who displayed inadequate endometrial opposition, compared with those women who had adequate endometrial opposition (P= 0.004). At 24 weeks, 48% of women had remained entirely amenorrhoeic. By the end of the study, 35% of women had been entirely amenorrhoeic and 50% had had either no bleeding or spotting alone. The number of bleeding episodes did not reduce with time.

CONCLUSIONS

The dose of natural progesterone cream in this study was insufficient to fully attenuate the mitogenic effect of oestrogen on the endometrium. We would not recommend this combination of hormones to be used by postmenopausal women.

Why consider vaginal drug administration?

OBJECTIVE

To review the anatomy and physiology of the vagina, the merits of vaginal drug administration, and the currently available vaginal drug-administration systems.

DESIGN

Review of basic and clinical research.

RESULT(S)

Although clinicians commonly use topically administered drugs in the vagina, this route for systemic drug administration is somewhat novel. Experience with a variety of products demonstrates that the vagina is a highly effective site for drug delivery, particularly in women's health. The vagina is often an ideal route for drug administration because it allows for the administration of lower doses, steady drug levels, and less frequent administration than the oral route. With vaginal drug administration, absorption is unaffected by gastrointestinal disturbances, there is no first-pass effect, and use is discreet. Knowledge of anatomy, physiology, histology, and immunology of the vagina should allow clinicians to reassure their patients concerning this mode of delivery. Greater understanding and experience by clinicians should lead to increased use and acceptance of the vagina as a route for drug administration.

CONCLUSION(S)

The safety and efficacy of vaginal administration have been well established. The vaginal route of drug delivery is acceptable and may even be a preferable route of administration for many drugs, particularly hormones, whether for contraception or postmenopausal estrogen therapy.

Role of progestogen in hormone therapy for postmenopausal women: position statement of The North American Menopause Society

OBJECTIVE

To create an evidence-based position statement regarding the role of progestogen in postmenopausal hormone therapy (estrogen plus a progestogen, or EPT) for the management of menopause-related symptoms.

DESIGN

NAMS followed the general principles established for evidence-based guidelines to create this document. Clinicians and researchers acknowledged to be experts in the field of postmenopausal hormone therapy were enlisted to review the evidence obtained from the medical literature and develop a position statement for approval by the NAMS Board of Trustees.

RESULTS

The primary role of progestogen in postmenopausal hormone therapy is endometrial protection. Unopposed estrogen therapy (ET) is associated with a significantly increased risk of endometrial hyperplasia and adenocarcinoma. Adding the appropriate dose and duration of progestogen to ET has been shown to lower that risk to the level found in never-users of ET. The clinical goal of progestogen in EPT is to provide endometrial protection while maintaining estrogen benefits and minimizing progestogen-induced side effects, particularly uterine bleeding. EPT discontinuance correlates with uterine bleeding-women with more days of amenorrhea have higher rates of continuance. All US Food and Drug Administration-approved progestogen formulations will provide endometrial protection if the dose and duration are adequate. Progestogens may diminish the beneficial effects of ET on cardiovascular risk factors. However, no EPT (or ET) regimen should be initiated for the primary or secondary prevention of cardiovascular heart disease. Some progestogens may negatively affect mood. Adding progestogen to ET does not decrease the breast cancer risk, although it does not seem to increase mortality. Progestogen increases mammographic density, which is reversed after discontinuation of use. Progestogen has limited effect on the bone-enhancing action of ET. In general, the side effects of added progestogen are mild, although they may be severe in a small percentage of women.

CONCLUSIONS

Progestogen should be added to ET for all postmenopausal women with an intact uterus to prevent the elevated risk of estrogen-induced endometrial hyperplasia and adenocarcinoma. There is no consensus on a preferred regimen for all women. By changing the progestogen type, route, or regimen, clinicians can individualize therapy to minimize side effects, especially uterine bleeding, and limit any effects on ET benefits while providing adequate endometrial protection.

Effect of sequential transdermal progesterone cream on endometrium, bleeding pattern, and plasma progesterone and salivary progesterone levels in postmenopausal women

BACKGROUND

Transdermal progesterone is being used in some countries as a purported treatment for menopausal symptoms, either alone or prescribed in conjunction with estrogen, but little information exists regarding the biological activity and effectiveness of this method of delivery of progesterone in protecting the endometrium from excess proliferation. This study was designed to evaluate the use of sequential transdermal progesterone. End-points evaluated included endometrial cellular response and bleeding pattern as well as plasma hormone levels and salivary progesterone estimations.

METHOD

Twenty-seven postmenopausal women were treated with continuous transdermal estrogen (28-day cycle) and a cream containing 16, 32 or 64 mg of progesterone in each 4-cm extrusion from a tube of Pro-Feme administered daily in a sequential (days 15-28 of cycle) regimen. Blood and endometrial samples were analyzed for progesterone response prior to therapy, after the first 14 days of unopposed transdermal estrogen and following 14 days of transdermal progesterone. Saliva samples were taken during the last 14 days of the 84-day study, when the final progesterone cream therapy was being applied.

RESULTS

Hormone assay indicated that physiological levels of estradiol were achieved, but progesterone levels were insufficient to induce any detectable change in the endometrium. Only one patient experienced bleeding during the study period. Levels of salivary progesterone were so variable as to be considered completely unreliable in determining the potential influence on biological activity.

INTERPRETATION

Pro-Feme transdermal progesterone administered in a 16-, 32- or 64-mg daily dose for 14 days in a sequential regimen does not appear to be effective in inducing a secretory change in a proliferative endometrium. Salivary progesterone levels were not of value in managing the therapy of postmenopausal women.

A study to evaluate serum and urinary hormone levels following short and long term administration of two regimens of progesterone cream in postmenopausal women

OBJECTIVE

To determine the pharmacokinetics of a progesterone cream following short and long term dermal administration.

DESIGN

Single-centre, randomised, multiple-dose, open-label study.

SETTING

Reproductive Medicine Trust, London.

POPULATION

Twenty-four healthy postmenopausal women aged between 40 and 65 years were recruited through an advertisement in a local newspaper.

METHODS

The women were randomly allocated to progesterone cream 40 mg daily or 20 mg, twice daily, for 42 days.

MAIN OUTCOME MEASURES

The concentration of progesterone in the serum was measured on days 1 and 42 before the morning dose, and at 2, 4, 6, 12 and 24 hours after the morning dose. Serum follicle stimulating hormone, oestradiol, testosterone and urinary pregnanediol-3-glucuronide were also measured on days 1 and 42.

RESULTS

Three subjects dropped out before using the cream and two more dropped out after the first treatment leaving a reportable sample of 19 women. There was a rise in the mean progesterone concentration at each sampling time between days 1 and 42. There was evidence of a rise in pregnanediol-3-glucuronide over the course of the study. There was no change in follicle stimulating hormone, oestradiol or testosterone. There was no difference between the two regimens.

CONCLUSIONS

Transdermal progesterone (40 mg) per day for 42 days causes a small increase in serum progesterone concentration, although there is wide variation. Whether such levels are of clinical benefit remains to be seen.

Prescribing hormone replacement therapy for menopausal symptoms

This paper addresses the clinical presentation of menopause, pretreatment assessment for hormone replacement therapy, benefits and risks of this treatment, common hormone replacement regimens and their side effects, and patient management. The case-based discussion focuses on the clinical management of a patient who is considering hormone replacement therapy for menopausal symptoms.

The menopause

Menopause is diagnosed after 12 months of amenorrhoea resulting from the permanent cessation of ovarian function. The mean age at menopause is 51 years. The perimenopause, a time of changing ovarian function, precedes the final menses by several years. The physiology and clinical manifestations of this transition to menopause are not well understood; however, some symptoms, such as hot flashes, certainly begin in the perimenopause. Causal associations between menopause and several symptoms and diseases are proposed. The evidence for these associations varies and is reviewed. Hormone replacement therapy can be directed at symptom relief or at prevention or treatment of chronic diseases. Doses and routes of hormone replacement therapy vary by indication. Complications of hormone replacement therapy depend on the regimen used. Knowing the expected vaginal bleeding pattern for each hormone replacement therapy regimen is important, since unexpected bleeding may signal endometrial hyperplasia. Postmenopausal hormone therapy is a complex intervention that produces positive and negative specific health effects. Overall, based on observational studies, postmenopausal women who use hormones have a 30-50% lower all-cause mortality rate than those who do not use hormones. It is important to recognise that the value that individual women place on various health outcomes associated with hormone replacement therapy may differ. Thus, the decision to use hormone replacement therapy should be made jointly by each woman and her health-care provider, after careful consideration of possible benefits, risks, and her personal preferences.

A new clinical option for hormone replacement therapy in women with secondary amenorrhea: effects of cyclic administration of progesterone from the sustained-release vaginal gel Crinone (4% and 8%) on endometrial morphologic features and withdrawal bleeding

OBJECTIVE

The objective of this study was to evaluate the safety and efficacy of 2 doses of a transvaginal polycarbophil-based progesterone gel (4% and 8%) in hormone replacement therapy.

STUDY DESIGN

This multicenter, randomized, parallel-group, open-label 3-month study included 127 women with secondary amenorrhea. Estrogenized patients applied transvaginal progesterone (4% or 8%) every other day for 6 doses per month. Efficacy was based on endometrial biopsy findings and withdrawal bleeding. McNemar's test was used to compare incidence of adverse events before and during treatment.

RESULTS

Progestational changes were found in 92% (Crinone 4%) and 100% (Crinone 8%) of patients with evaluable biopsies. Withdrawal bleeding was experienced by 81% (Crinone 4%) and 82% (Crinone 8%) of the patients. No patient experienced any serious side effect related to treatment. The incidence of most side effects, including psychologic symptoms, decreased with progesterone treatment compared with estrogen alone therapy. Compliance exceeded 98% for both doses.

CONCLUSIONS

Crinone is a novel, effective, and well-tolerated option for hormone replacement therapy in women with secondary amenorrhea.