Efficacy of a new 7-day transdermal sequential estradiol/levonorgestrel patch in women

Variation in menopausal vasomotor symptoms outcomes in clinical trials: a systematic review

BACKGROUND

There is substantial variation in how menopausal vasomotor symptoms are reported and measured among intervention studies. This has prevented meaningful comparisons between treatments and limited data synthesis.

OBJECTIVES

To review systematically the outcome reporting and measures used to assess menopausal vasomotor symptoms from randomised controlled trials of treatments.

SEARCH STRATEGY

We searched MEDLINE, Embase, and Cochrane Central Register of Controlled Trials from inception to May 2018.

SELECTION CRITERIA

Randomised controlled trials with a primary outcome of menopausal vasomotor symptoms in women and a sample size of at least 20 women per study arm.

DATA COLLECTION AND ANALYSIS

Data about study characteristics, primary vasomotor-related outcomes and methods of measuring them.

MAIN RESULTS

The search identified 5591 studies, 214 of which were included. Forty-nine different primary reported outcomes were identified for vasomotor symptoms and 16 different tools had been used to measure these outcomes. The most commonly reported outcomes were frequency (97/214), severity (116/214), and intensity (28/114) of vasomotor symptoms or a composite of these outcomes (68/214). There was little consistency in how the frequency and severity/intensity of vasomotor symptoms were defined.

CONCLUSIONS

There is substantial variation in how menopausal vasomotor symptoms have been reported and measured in treatment trials. Future studies should include standardised outcome measures which reflect the priorities of patients, clinicians, and researchers. This is most effectively achieved through the development of a Core Outcome Set. This systematic review is the first step towards development of a Core Outcome Set for menopausal vasomotor symptoms.

TWEETABLE SUMMARY

Menopausal hot flushes and night sweats have been reported in 49 different ways in clinical research. A core outcome set is urgently required.

Comparison of efficacy and local tolerability of estradiol metered-dose transdermal spray to estradiol patch in a network meta-analysis

OBJECTIVES

Transdermal hormone replacement therapy is preferred for menopausal vasomotor symptoms. Our purpose was to compare the efficacy and local tolerability of a patch and a metered-dose transdermal spray that have never been directly compared.

METHOD

The relative change in the number of hot flushes between baseline and week 12 was selected as an efficacy indicator and the frequency of local skin reactions as a tolerability indicator. A network meta-analysis was performed to compare efficacy. Application site tolerability was compared descriptively.

RESULTS

Overall 46 studies were identified. In the efficacy analysis, eight active treatment arms and a placebo arm were determined based on the estradiol daily dose (from 14 μg to 50 μg). All but one had a significantly higher effect on relative change in the number of hot flushes than did the placebo. We found no evidence for different efficacy of the patch and the metered-dose transdermal spray. The latter performed better in terms of local skin reactions.

CONCLUSION

The patch and the metered-dose transdermal spray seem to have the same efficacy on vasomotor symptoms in estradiol hormone replacement. The local tolerability of the metered-dose transdermal spray is favorable.

Quantitative efficacy of soy isoflavones on menopausal hot flashes

AIM

This study aimed to quantitate the efficacy of soy isoflavones in the treatment of menopausal hot flashes.

METHODS

Model based meta-analysis (MBMA) was used to quantitate the efficacy of soy isoflavones. We conducted a systemic literature search to build a time-effect model for placebo and soy isoflavones in treating menopausal hot flashes. Studies were identified, subjected to inclusion and exclusion criteria, and reviewed.

RESULTS

From 55 articles, 16 studies of soy isoflavones met the inclusion criteria, and contained 65 and 66 mean effect values in placebo and soy isoflavone groups, respectively, from about 1710 subjects. Interestingly, the developed model was found to describe adequately the time course of hot flashes reduction after administration of placebo and soy isoflavones. Using this model, we found that the maximal percentage change of hot flashes reduction by soy isoflavones was 25.2% after elimination of the placebo effect, accounting for 57% of the maximum effects of estradiol (Emax-estradiol  = 44.9%). However, a time interval of 13.4 weeks was needed for soy isoflavones to achieve half of its maximal effects, much longer than estradiol, which only required 3.09 weeks. These results suggest that treatment intervals of 12 weeks are too short for soy isoflavones, which require at least 48 weeks to achieve 80% of their maximum effects.

CONCLUSIONS

Soy isoflavones show slight and slow effects in attenuating menopausal hot flashes compared with estradiol.

A Review of Drospirenone for Safety and Tolerability and Effects on Endometrial Safety and Lipid Parameters Contrasted with Medroxyprogesterone Acetate, Levonorgestrel, and Micronized Progesterone

BACKGROUND

Drospirenone, a novel synthetic progestin, possesses characteristics more like natural progesterone than other synthetic progestins, such as medroxyprogesterone acetate and levonorgestrel. The antiandrogenic and antimineralocorticoid properties of drospirenone may, in the context of menopausal management, provide potential novel benefits in its effect on lipids and blood pressure while reducing the occurrence of water retention, acne vulgaris, and hirsutism.

METHODS

This review compares safety and tolerability data from clinical trials of drospirenone, medroxyprogesterone acetate, levonorgestrel, and micronized progesterone.

RESULTS

Results suggest that drospirenone possesses a generally well-accepted side effect profile and resembles comparator oral progestogens in conferring endometrial protection with no significant effect on weight. One study indicates that drospirenone may have a benign effect on lipid parameters, having been seen to significantly lower total cholesterol and lowdensity lipoprotein levels while maintaining high-density lipoprotein and triglyceride levels. Drospirenone also differs from the other progestogens in lowering blood pressure levels in hypertensive patients while having a mild blood pressure-lowering effect on nonhypertensive patients.

CONCLUSIONS

Among pharmacological options for menopause management, drospirenone may provide certain advantages over other progestogens in its effect on risk factors for cardiovascular disease and, thus, constitutes a useful addition to the menopausal armamentarium.

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.

A pilot study to examine a combination botanical for the treatment of menopausal symptoms

OBJECTIVE

Hormone replacement therapy has become a controversial treatment for symptoms of menopause, leading many women and their physicians to search for safer, effective alternatives. Certain botanicals are known to contain phytoestrogenic activity, which may be helpful in alleviating menopausal symptoms. We report the results of a study using a combination botanical supplement to treat menopausal symptoms.

DESIGN

Prospective pilot study.

SETTING/LOCATION

Family practice medical center, Phoenix metropolitan area.

SUBJECTS

Eight (8) women with moderate vasomotor and somatic symptoms of menopause.

INTERVENTION

Combination botanicals daily for 3 months.

OUTCOME MEASURES

Modified Kupperman Index (KI), daily hot flashes severity, and overall quality of life (QoL) using the SF-36 index, which were collected at enrollment, during treatment, and at the end of treatment.

RESULTS

Mean KI total symptoms decreased from 30.3 +/- 7.5 to 22.9 +/- 8.4 (95% CI, 25-34), p = 0.0028. Daily hot flashes decreased from 68.1 +/- 14.3 to 39.6 +/- 9.7 (95% CI, 38-46), p = 0.0003, and the overall QoL also improved at the end of treatment.

CONCLUSIONS

This pilot study demonstrates the potential benefit of a combination botanical for improving moderate menopausal symptoms in women. The efficacy and role of combination botanicals for long-term use to reduce menopausal symptoms requires further exploration.

Levonorgestrel and 17beta-estradiol given transdermally for the prevention of postmenopausal osteoporosis

AIM

To evaluate the efficacy and safety of a new transdermal continuous combined hormone replacement therapy (HRT) for the prevention of postmenopausal osteoporosis.

METHODS

212 osteopenic (lumbar spine and/or hip (femoral neck) bone mineral density (BMD) between -1.0 and -2.5 S.D. of the premenopausal mean value) postmenopausal women aged 45-65 years participated in a 2-year prospective study. Treatments were 45 microg 17beta-estradiol combined with 30 (n = 69) or 40 microg (n = 72) levonorgestrel daily or placebo (n = 71) given as a 7-day patch. All received a daily supplement of 500 mg calcium. BMD at lumbar spine (L2-L4), hip and total body, as well as blood and urinary biochemical markers of bone turnover (serum osteocalcin (sOC), serum bone-specific alkaline phosphatase (sBSAP), urinary calcium (uCa) and urinary CrossLaps (uCTX)) were measured regularly.

RESULTS

BMD at the lumbar spine, hip and total body increased by 8, 6 and 3% (P < 0.001), respectively, in the hormone groups versus placebo. The bone markers all decreased accordingly (sOC: 37%, sBSAP: 34% and uCTX: 65% from baseline (all P < 0.001)), except for uCa that did not change significantly. No significant dose-related effect of levonorgestrel was found. Vaginal bleeding/spotting decreased from 48 to 25% of the HRT-treated women during the study period. Skin tolerance was good in 84% of the women with no difference between the study groups. No incidences of endometrial hyperplasia, uterine or mammary cancer occurred.

CONCLUSION

The transdermal combination of 17beta-estradiol and levonorgestrel has a positive effect on BMD in an osteopenic postmenopausal population. Furthermore, a high safety profile was observed.

The menopausal transition: characteristics and management

The menopausal transition is a complex period in a woman's life, reflecting ovarian ageing and concomitant hormonal changes, in addition to social and metabolic changes. These changes, in turn, influence the signs and symptoms common to this period. Symptoms which are influenced by the hormonal fluctuations occurring during the menopausal transition include vasomotor symptoms and vaginal dryness; others are breast tenderness, poor sleep and pre-menstrual dysphoria. Hormonal therapy has been shown to be first-line therapy for many of these symptoms. Other types of pharmacotherapies may be helpful, including selective serotonergic uptake inhibitors for vasomotor symptoms. Characteristic signs of the menopausal transition include abnormal uterine bleeding, best managed with hormonal pharmacotherapy; diminishing bone mineral density, which may warrant diagnostic intervention, and may benefit from dietary and lifestyle modifications; and increased body-mass index and worsening lipid profile, which also may benefit from dietary and lifestyle modifications.