Clinical equivalence of intranasal and oral 17beta-estradiol for postmenopausal symptoms

Advanced drug delivery technologies for postmenopausal effects

Postmenopause is the 12-month absence of menstrual periods, characterized by decreased estrogen and progesterone levels, leading to physical and psychological alterations such as hot flashes, mood swings, sleep disruptions, and skin changes. Present postmenopausal treatments include hormone replacement therapy, non-hormonal drugs, lifestyle modifications, vaginal estrogen therapy, bone health treatments, and alternative therapies. Advanced drug delivery systems (ADDSs) are essential in managing postmenopausal effects (PMEs), offering targeted and controlled delivery to alleviate symptoms and improve overall health. This review emphasizes such ADDSs for addressing PMEs. Emerging trends such as artificial ovaries are also reviewed. Additionally, the prospects of technologies such as additive manufacturing (3D and 4D printing) and artificial intelligence in further tailoring therapeutic strategies against PMEs are provided.

Intranasal administration of DHED protects against exhaustive exercise-induced brain injury in rats

DHED (10β,17β-dihydroxyestra-1,4-dien-3-one) is a brain-selective prodrug of 17β-estradiol and has been reported to have a strong neuroprotective effect. In this study, the exhaustive swimming rat model was used to investigate the therapeutic effects and mechanisms of intranasal DHED treatment. Male eight-week-old healthy Sprague Dawley rats were randomly divided into three groups: control group (Cont), exhaustive swimming (ES), and DHED + exhaustive swimming (DHED). The open-field test and beam-walking test were performed to measure exploratory behavior and general activity in rats. Immunofluorescence staining, western blotting, ELISA analysis and related assay kits were applied to measure brain damage, inflammatory cytokines, and apoptosis pathways. Behavioral data shows that DHED intranasal administration can prevent neurobehavioral impairment caused by exhaustive swimming. Using a series of bioanalytical assays, we demonstrated that DHED markedly abated neuronal injury compared to the exhaustive swimming group, as evidenced by the reduced expression of apoptosis-regulated proteins, the improvement of neural survival, and the prevention of myelin loss. In addition, mitochondrial fission was attenuated distinctly, and a dynamic equilibrium was restored. Intranasal administration of DHED likewise significantly suppressed reactive gliosis and the release of inflammatory cytokines in the rat cerebral motor cortex. Consistent with previous reports, DHED treatment ameliorated changes of excitatory neurotransmitters. These results provide strong support for the promising therapeutic effects of DHED on neuroprotection during exhaustive swimming. The underlying mechanisms may rely on mitochondrial dynamics, neuroinflammation, and the balance of neurotransmitters.

Intranasal drug delivery: opportunities and toxicologic challenges during drug development

Over the past 10 years, the interest in intranasal drug delivery in pharmaceutical R&D has increased. This review article summarises information on intranasal administration for local and systemic delivery, as well as for CNS indications. Nasal delivery offers many advantages over standard systemic delivery systems, such as its non-invasive character, a fast onset of action and in many cases reduced side effects due to a more targeted delivery. There are still formulation limitations and toxicological aspects to be optimised. Intranasal drug delivery in the field of drug development is an interesting delivery route for the treatment of neurological disorders. Systemic approaches often fail to efficiently supply the CNS with drugs. This review paper describes the anatomical, histological and physiological basis and summarises currently approved drugs for administration via intranasal delivery. Further, the review focuses on toxicological considerations of intranasally applied compounds and discusses formulation aspects that need to be considered for drug development.

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.

Cardiovascular risk assessment with oxidised LDL measurement in postmenopausal women receiving intranasal estrogen replacement therapy

OBJECTIVE

To investigate the effect of intranasal estrogen replacement therapy administered to postmenopausal women alone or in combination with progesterone on markers of cardiovascular risk.

METHODS

The study was conducted with 44 voluntary postmenopausal women. In group I (n = 15), the patients were treated with only intranasal estradiol (300 μg/day estradiol hemihydrate). In group II (n = 11), the patients received cyclic progesterone (200 mg/day micronized progesterone) for 12 days in each cycle in addition to continuous intranasal estradiol. Group III (n = 18) was the controls. Serum lipid profiles, oxidised low-density lipoprotein (LDL) and other markers of cardiovascular risk were assessed at baseline and at the 3rd month of the treatment.

RESULTS

Lipid profile, LDL apolipoprotein B, lipoprotein a, homocysteine, oxidised LDL values and oxidised LDL/LDL cholesterol ratio were not observed to change after 3 months compared to baseline values within each group (p > 0.016). In comparison to changes between the groups after the treatment, only oxidised LDL levels and oxidised LDL/LDL cholesterol ratios of group II were increased compared to control group (p < 0.05).

CONCLUSIONS

Intranasal estradiol alone did not appear to have an effect on markers of cardiovascular risk in healthy postmenopausal women. However, the addition of cyclic oral micronized progesterone to intranasal estradiol influenced the markers of cardiovascular risk negatively in comparison to non-users in healthy postmenopausal women.

Breast density changes associated with postmenopausal hormone therapy: post hoc radiologist- and computer-based analyses

OBJECTIVE

The aim of this study was to assess the impact of oral hormone therapy (HT) on breast density in postmenopausal women and to compare the use of computer-based automated approaches for the assessment of breast density with reference to traditional methods.

METHODS

Low-dose oral estrogen (1 mg) continuously combined with drospirenone (2 mg) was administered to postmenopausal women for up to 2 years (26 treatment cycles, 28 d/cycle) in a randomized, placebo-controlled trial. This post hoc analysis assessed the changes in breast density measured from digitized images by two radiologist-based approaches (Breast Imaging Reporting and Data System score and interactive threshold) and one computer-based technique (heterogeneity examination of radiographs). Correlations of temporal changes in breast density with changes in serum estradiol levels, biochemical markers of bone metabolism, and bone mineral density at the spine and femur were also assessed.

RESULTS

Breast density assessed by the radiologist-based approaches increased significantly from baseline in the HT group (P < 0.01), with significant divergence from placebo at 2 years (P < 0.01). Heterogeneity examination of radiograph score by computer-based technique was unchanged in the HT group and decreased significantly with placebo (P < 0.001) to produce a significant group divergence (P < 0.05). Changes in mammographic markers by radiologist- and computer-based approaches correlated with each other in the HT group (P < 0.01) but not in the placebo group.

CONCLUSIONS

HT for 2 years in postmenopausal women significantly increased radiologist-assessed breast density compared with placebo, in addition to significant changes in estrogen levels, markers of bone metabolism, and bone mineral density. Computer-automated techniques may be comparable with and offer advantages over traditional methods.

Hormone Replacement Therapy: A Critical Review

The aim of this chapter is to review the most recent aspects of hormone replacement therapy (HRT), and to clarify its impact on associated health conditions amidst growing uncertainties. Special emphasis has been placed on its effect on cardiovascular conditions and breast cancer, the two most important outcomes affected by HRT, and on identifying ideal candidates for HRT as well as defining the optimum new HRT regimens.

The role of intranasal estradiol spray in the management of moderate to severe vasomotor symptoms in menopausal women

Hormone therapy (HT) is the most effective treatment at present available for climacteric symptoms. As harmful effects were highlighted in recent randomized clinical trials, the risk-benefit ratio does not favor the use of HT for prevention of cardiovascular diseases and bone fractures in postmenopausal women. Nevertheless, experimental and clinical trials suggest that adverse effects of HT basically depend on the estrogen and progestin formulation, dosage, route of administration, patient's age, associated diseases, and duration of treatment. All estrogen formulations and routes of administration have comparable beneficial effects on vasomotor and urogenital symptoms and on bone structure. But adverse effects may differ. Thus, cardiovascular and invasive breast cancer risks are higher with oral estrogen than with transdermal estradiol. However, transdermal estradiol is not free of inconveniences such as differences among individuals in absorption rates, loss of patches due to poor adhesion, and skin irritation. HT requires careful adjustment to each individual patient and continuous monitoring of clinical evolution. In the future, this adjustment and maybe the use of alternative routes such as intranasal could benefit from genetic screening to maximize in each individual the ratio between positive and adverse effects of HT.

Dopaminergic and serotonergic activity in neostriatum and nucleus accumbens enhanced by intranasal administration of testosterone

Testosterone was administered intranasally in anesthetized male rats, and its effects on the activity of dopaminergic and serotonergic neurons in the neostriatum and nucleus accumbens were assessed by means of microdialysis and HPLC. The treatment (0.5, 1.0 or 2.0 mg/kg of testosterone or vehicle, 10 microl volume) was applied in both nostrils, half (5 microl) into each. Subcutaneous injections of testosterone (2.0, 4.0 or 8.0 mg/kg) or vehicle were tested in other subjects. Samples were collected for 5 h. In the neostriatum, an increase of dopamine occurred after 2.0 mg/kg. Serotonin levels increased after 1.0 mg/kg dose. In the nucleus accumbens, dopamine and serotonin increased after 1.0 mg/kg and 2.0 mg/kg doses. Subcutaneous administration of 8.0 mg/kg testosterone increased dopamine and serotonin in the neostriatum only. We conclude that intranasal administration of testosterone is a more efficacious way for targeting the brain than the subcutaneous route, and may be considered as a means to activate central dopaminergic and serotonergic systems.

Intranasal administration of progesterone increases dopaminergic activity in amygdala and neostriatum of male rats

We evaluated the effects of intranasal administration of progesterone (PROG) on the activity of dopaminergic neurons in the brain of anesthetized rats by means of microdialysis. Male Wistar rats were implanted with guide cannulae in the basolateral amygdala and neostriatum. Three to 5 days later, they were anesthetized with urethane, and dialysis probes were inserted. After a stabilization period of 2 h, four 30-min samples were collected. Thereafter, the treatment (0.5, 1.0 or 2.0 mg/kg of PROG dissolved in a viscous castor oil mixture, or vehicle) was applied into the nose in a volume of 10 microl (5 microl in each nostril). In other animals, an s.c. injection of PROG (1.0, 2.0 or 4.0 mg/kg) or vehicle was given. Samples of both application ways were collected at 30-min interval for 4 h after the treatment and immediately analyzed with high performance liquid chromatography and electrochemical detection. Intranasal administration of 2 mg/kg of PROG led to an immediate (within 30 min after the treatment) significant increase in the basolateral amygdala dopamine levels. In the neostriatum, the 2 mg/kg dose led to a delayed significant increase in dopamine. S.c. administration of 4 mg/kg of PROG was followed by a delayed significant increase in dopamine, both, in the basolateral amygdala and neostriatum, but smaller in magnitude in comparison to the intranasal treatment. This is the first study to demonstrate dopamine-enhancing effects of PROG, not only in the neostriatum, but also in the basolateral amygdala. Our results indicate that the intranasal route of administration of PROG is a more efficacious way for targeting the brain than the s.c. route.

Differing transcriptional responses to pulsed or continuous estradiol exposure in human umbilical vein endothelial cells

This study used human umbilical vein endothelial cells (HUVECs) that were treated with 17beta-estradiol for 5 days as 1h pulse or 24h continuous treatment at concentrations such that the 24h exposure (concentration x time) was identical in both conditions. Cell proliferation was studied and gene expression profiling was carried out using the Affymetrix GeneChip microarray analysis. Changes in morphology and apoptosis in HUVECs were examined with electron microscopy. Time-course studies of expression of genes vascular endothelial growth factor (VEGF), inducible nitric oxide synthase (iNOS) and endothelial nitric oxide synthase (eNOS) were performed by quantitative PCR. We observed that cell proliferation was significantly decreased over days 3-5 with pulsed estradiol treatment relative to constant exposure. Microarray results showed that after 5 days, 801 genes differed (P<0.05) between continuous versus pulsed estradiol treatment. Functional analysis showed a significant number of genes to be associated with apoptosis and cell cycle pathways. We did not find any evidence of apoptosis from flow cytometry or electron microscopy examination. Our study highlights a large number of significantly different molecular responses to estradiol depending upon the mode of administration of estradiol. Significant changes were observed in genes involved in apoptosis and proliferation including VEGF, IGF receptors, and tumor protein p53.

Hemostatic markers in healthy postmenopausal women during intranasal and oral hormone therapy

OBJECTIVE

To study changes in the hemostatic balance during intranasal compared with oral administration of 17beta-estradiol (E2) and norethisterone (NET) or NET acetate in postmenopausal women. A wide range of markers of coagulation and fibrinolysis associated with coronary artery disease was tested.

DESIGN

In a two-center, randomized, double-blind, comparative trial, 90 healthy postmenopausal women (aged 56.6 +/- 4.7 y) received daily continuous combined hormone therapy, either E2/NET 175 microg/275 mug intranasally as a spray (n = 47) or E2/NET acetate 1 mg/0.5 mg orally as a capsule (n = 43) for 1 year. Hemostatic markers were measured in blood samples taken at baseline and after 12, 24, and 52 weeks of treatment.

RESULTS

After 52 weeks of treatment, changes in the intranasal group in markers of coagulation-fibrinogen (-1.3%), factor VII activity (-14.0%), and prothrombin fragment 1 + 2 (+5.8%)-were significantly less (P < 0.05) than the changes in the oral group for these parameters (-6.5%, -20.3%, and +19.0%, respectively). Changes in activated factor VII did not differ between the groups. Neither group showed significant changes in thrombin-antithrombin complex. In the intranasal group, decreases in markers of fibrinolysis-tissue-type plasminogen activator (-10.4%) and plasminogen activator inhibitor-1 antigen (-13.8%)-were significantly less (P < 0.05) than the decreases in the oral group (-17.8% and -38.0%, respectively). A decrease in plasminogen activator inhibitor-1 activity and increases in D-dimer and plasmin-alpha2-antiplasmin complex did not differ between the groups. No differences were found between the groups in homocysteine, which overall was unaltered in both groups.

CONCLUSIONS

During intranasal E2/NET therapy, changes in the coagulatory and fibrinolytic markers were to some extent less than those observed during oral therapy.

Do different delivery systems of estrogen therapy influence serum lipids differently in surgically menopausal women?

AIM

To compare the influence of different delivery forms of estrogen therapy (ET) on serum lipid levels.

METHODS

For this prospective, randomized, controlled study, 132 surgically menopausal women were assigned to 12 months of therapy with oral conjugated estrogen 0.625 mg/day (n = 35), intranasal 300 microg/day estradiol hemihydrate (n = 33), percutaneous gel 1.5 mg/day estradiol hemihydrate (n = 32) or no treatment (control group, n = 32). Total cholesterol (t-Chol), triglycerides, high-, low-, and very low-density lipoprotein (HDL-Chol, LDL-Chol, and VLDL-Chol, respectively) levels were determined at baseline, and cycles 6 and 12. Data were analyzed using repeated measures ANOVA.

RESULTS

All delivery forms significantly decreased t-Chol and LDL-Chol while increasing HDL-Chol after 6 and 12 cycles. The oral route significantly increased whereas other modalities significantly decreased serum triglycerides after cycle 6 and 12. VLDL-Chol levels were significantly increased using the oral route after cycle 12 while intranasal and percutaneous gel forms decreased the level after cycles 6 and 12.

CONCLUSION

Oral, intranasal and transdermal gel delivery modes of ET have beneficial effects on serum lipids, as shown by decreased t-Chol and LDL-Chol, and increased HDL-Chol levels in surgically menopausal women. The oral form should be used with care in women with hypertriglyceridemia and with increased VLDL-Chol levels. However, the oral route seems to be more effective in decreasing LDL-Chol levels than the percutaneous gel form.

Effects of non-oral postmenopausal hormone therapy on markers of cardiovascular risk: a systematic review

OBJECTIVE

To review the effects of non-oral administration of postmenopausal hormone therapy (HT) on risk markers for atherosclerotic and venous thromboembolic disease.Non-oral postmenopausal HT appears not to increase venous thromboembolic risk, whereas the effect on coronary heart disease risk is less clear.

DESIGN

Systematic review of literature obtained from MEDLINE, EMBASE, and CENTRAL databases from 1980 until and including April 2006. Terms for "postmenopausal hormone therapy" and for "non-oral administration" were combined in the search.

SETTING

Randomized clinical trials.

PATIENT(S)

Postmenopausal women, both healthy and with established cardiovascular disease or specified cardiovascular risk factors

INTERVENTION(S)

Non-oral HT (e.g., transdermal or intranasal) compared with oral HT or no treatment/placebo.

MAIN OUTCOME MEASURE(S)

Lipoprotein(a), homocysteine, C-reactive protein (CRP), cell adhesion molecules, markers of endothelial dysfunction, coagulation, and fibrinolysis.

RESULT(S)

Seventy-two studies investigating either transdermal or intranasal administration were included. For non-oral HT, decreases in lipoprotein(a), cell adhesion molecules, and factor VII generally were significant, resistance to activated protein C (APCr) was slightly increased, and other markers including CRP and homocysteine did not change. Compared with oral HT, changes in CRP and APCr were smaller, changes in cell adhesion molecules and some fibrinolytic parameters tended to be smaller, whereas changes in other factors including lipoprotein(a) and homocysteine did not differ.

CONCLUSION(S)

Potentially unfavorable changes seen with oral HT on two important markers, CRP and APCr, are substantially smaller with non-oral HT. Non-oral HT has minor effects on the other cardiovascular risk markers studied. Therefore, compared with oral HT, non-oral HT appears be safer with respect to atherosclerotic and venous thromboembolic disease risk.

Effects of intranasal versus oral hormone therapy on asymmetric dimethylarginine in healthy postmenopausal women: a randomized study

OBJECTIVE

Oral estrogens reduce asymmetric dimethylarginine (ADMA), an endogenous inhibitor of nitric oxide synthase, and an independent risk factor for cardiovascular disease. This study was conducted to compare the effect on ADMA between intranasal and oral 17beta-estradiol (E2) combined with norethisterone (acetate) (NET(A)) administration in postmenopausal women.

METHODS

In a two-center, randomized, double-blind, comparative study 90 healthy postmenopausal women (age 56.6+/-4.7 years) received daily continuous combined intranasal E2/NET 175 microg/275 microg (n=47) or oral E2/NETA 1 mg/0.5 mg (n=43) for one year. At baseline, week 12 and 52, plasma concentrations of ADMA, arginine and symmetric dimethylarginine (SDMA) were measured by high-performance liquid chromatography.

RESULTS

Oral E2/NETA reduced ADMA concentrations (-7.4%; 95% confidence interval (CI) -10.4 to -4.4%), while intranasal E2/NET had no effect (-0.8%; 95% CI -3.7 to 2.1%) after 52 weeks. In both groups, arginine was transiently decreased compared to baseline at week 12 (intranasal: -6.1%; 95% CI -9.1 to -3.0%; oral: -6.5%; 95% CI -10.9 to -2.1%). Only oral E2/NETA reduced SDMA concentrations.

CONCLUSIONS

Oral administration of E2/NETA reduced ADMA and SDMA concentrations, whereas intranasal administration did not. Both treatments transiently reduced arginine. The decrease in ADMA by oral estrogens could be a key phenomenon in the modulation of nitric oxide synthesis by postmenopausal hormone therapy.

Less Effect of Intranasal Than Oral Hormone Therapy on Factors Associated With Venous Thrombosis Risk in Healthy Postmenopausal Women

Objective— To compare the effects of intranasal and oral administration of 17β-estradiol (E 2 ) and norethisterone(acetate) [NET(A)] in healthy postmenopausal women on activated protein C (APC) resistance and other hemostatic parameters associated with venous thrombosis.

Methods and Results— In this 2-center, randomized, double-blind, 1-year trial, 90 postmenopausal women (56.6±4.7 years of age) received daily either an intranasal spray with 175 μg/275 μg E 2 /NET (n=47) or 1 mg/0.5 mg oral E 2 /NETA (n=43). Normalized APC sensitivity ratios (nAPCsr) were determined with a thrombin generation-based APC resistance test. After 1 year, the increase in nAPCsr was smaller in the intranasal than in the oral group: 11% (95% CI, 1% to 22%) versus 53% (95% CI, 37% to 72%). Overall, the decrease in antithrombin and increase in prothrombin fragment 1+2 (F1+2) were smaller and the decrease in free protein S larger in the intranasal compared with the oral group after 1 year. In both groups, the decreases in protein C and prothrombin, and the increase in d -dimer were similar.

Conclusion— Compared with oral E 2 /NETA therapy, intranasal administration of E 2 /NET had less effect on APC resistance and on a number of other parameters associated with venous thrombosis. This observation suggests the possibility of a lower venous thrombosis risk for intranasal E 2 /NET compared with oral therapy.

Drug delivery systems for hormone therapy

Various types of formulations and delivery devices have been developed for hormone therapy (HT) and their modes of hormone action and patient responses have been evaluated. Although the Women's Health Initiative (WHI) reported the controversial results on estrogen/progestin combination therapy, HT still remains a primary therapeutic option for the treatment of menopausal symptoms and osteoporosis. As a novel alternative to HT may not be probable in clinical use for the next decade, the currently available formulations containing estrogen and progestogen should be properly optimized for HT. The extensive reviews and comparisons on the characteristics of various types of HT could lead to the development of an efficient delivery formulation which maximizes patient compliance and minimizes adverse effects for individual users.

Intranasal continuous combined 17β-estradiol/norethisterone therapy improves the lipid profile in healthy postmenopausal women

OBJECTIVE

To compare the effects of continuous combined 17beta-estradiol (E2) plus norethisterone (acetate) [NET(A)] therapy by either intranasal or oral administration on the lipid profile in postmenopausal women.

DESIGN

Randomized, double-blind, multicenter trial.

SETTING

Gynecologic outpatient department.

PATIENT(S)

Two-hundred thirty-three healthy postmenopausal women.

INTERVENTION(S)

Women received continuous combined hormone therapy, either intranasal E2/NET (175 microg/275 microg) as a spray (n = 117) or oral E2/NETA (1 mg/0.5 mg) as a capsule (n = 116), for 1 year.

MAIN OUTCOME MEASURE(S)

Fasting plasma concentrations of lipids and (apo)lipoproteins; and atherogenic indices at baseline and after 12, 24, and 52 weeks of treatment.

RESULT(S)

We found a significant (P < .001) decrease from baseline in both treatment groups in total, low-density lipoprotein- (LDL), high-density lipoprotein- (HDL), and HDL2-cholesterol, in triglycerides, apolipoprotein B (apoB), and lipoprotein(a). Levels of HDL3-cholesterol and apolipoprotein A1 (apoA1) were transiently decreased in the intranasal group. In the oral group, compared with the intranasal group, the decrease was larger for ratio total and LDL-cholesterol and lipoprotein(a) and smaller for triglycerides and apoA1. In the oral group, the ratios total/HDL cholesterol and LDL/HDL cholesterol were lowered, and the ratio apoB/LDL was increased, more than in the intranasal group.

CONCLUSION(S)

Both intranasal and oral E2/NET(A) therapy improved the lipid profile of healthy postmenopausal women, with some effects being more pronounced after oral administration.

Pulsed estrogen therapy improves postmenopausal quality of life: a 2-year placebo-controlled study

OBJECTIVE

To investigate the effect of pulsed estrogen therapy S21400 (intranasal 17 beta-estradiol) on different quality of life (QoL) dimensions in early postmenopausal women treated with S21400 150 microg per day, S21400 300 microg per day, or placebo in a double blind, randomized, controlled 2-year study.

STUDY DESIGN

QoL was assessed based on the validated Women's Health Questionnaire designed for peri- and post-menopausal women. Three hundred and thirty-five healthy, early postmenopausal Danish women, 53 years of age in average, who completed one questionnaire at baseline and one under study treatment were included in the analysis set. All analyses were performed on an intention-to-treat basis.

RESULTS

QoL improved significantly in both S21400 groups compared to placebo in the dimensions 'memory/concentration', 'vasomotor symptoms', 'sleep problems' and 'sexual behavior' (difference in mean change scores being respectively +7.9, +28.3, +9.9 and +10.8%, p < 0.001, between the S21400 300 microg and placebo group). There were no significant differences between actively treated groups and placebo in the dimensions 'anxiety/depressed mood' and 'well-being'.

CONCLUSION

Pulsed estradiol therapy had a pronounced effect not only on vasomotor symptoms but also a significant and clinically relevant improvement in several other QoL dimensions.

No increase in C-reactive protein levels during intranasal compared to oral hormone therapy in healthy post-menopausal women

BACKGROUND

Inflammation plays an important role in the development of atherosclerotic disease. Oral post-menopausal hormone therapy increases serum C-reactive protein (CRP) levels. This study compared the effects of intranasal and oral administration of 17beta-estradiol (E2) combined with norethisterone acetate (NETA) on markers of inflammation in healthy post-menopausal women.

METHODS

Ninety healthy post-menopausal women (age 56.6 +/- 4.7 years) participated in this 1-year trial. After computerized block randomization, they daily received, in a double-blind fashion, either intranasal E2/NET [175 microg/275 microg (n = 47)] or oral E2/NETA [1 mg/0.5 mg (n = 43)]. Concentrations of high sensitivity CRP and adhesion molecules were measured at baseline and after 12, 24 and 52 weeks of treatment.

RESULTS

CRP levels were increased (P = 0.001) in the oral but not in the intranasal group. The increase in the oral group was highest at week 12 (64.9%) and was larger (P < 0.01) compared with the non-significant increase (8.6%) found in the intranasal group. Both groups showed decreases (P < 0.001) in soluble vascular cell adhesion molecule (sVCAM), soluble intracellular adhesion molecule (sICAM) and sE-selectin. The decreases were larger (P < 0.01) in the oral than in the intranasal group.

CONCLUSION

Intranasal E2/NET therapy did not significantly increase CRP levels, in contrast to the increase observed in the oral E2/NETA treatment group. Both intranasal and oral therapy lowered plasma concentrations of adhesion molecules, however, more so in the oral group.

Choice of delta: requirements and reality--results of a systematic review

An essential problem in planning clinical non-inferiority or equivalence studies is the specification of the 'irrelevant difference' (irrelevance margin; delta). This quantifies the amount of non-inferiority or difference, respectively, between a new test therapy and an established standard treatment which is to be considered as tolerable. In the past, most recommendations and guidelines for clinical non-inferiority and equivalence studies contained only general statements and formulations concerning the specification of delta. The current unsatisfactory situation was the reason for performing a systematic review of published clinical non-inferiority and equivalence studies. It was the aim to gain an overview on the irrelevance margins used in such studies, and on reasons for choosing the particular margins. For the sake of comparability, the irrelevance margins were converted into standardized differences and odds ratios. Overall, there were 332 non-inferiority or equivalence trials obtained by means of an extensive literature search. The results of the systematic review show that current requirements on the choice of delta and the reality of recent clinical non-inferiority and equivalence trials differ substantially. In about one half of the trials a difference of 0.5 standard deviations or more was regarded as 'irrelevant' explicitly or implicitly. Estimates of standard-placebo differences formed the basis of the irrelevance margin in less than every tenth trial. Reasons for this very low proportion might be (1) the possibly resulting very small irrelevance margins, and (2) unsolved problems of the requirements themselves. Overall, it seems that a more global definition of 'irrelevance' might be warranted.

Mastalgia

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Intranasal versus transdermal matrix oestrogen replacement in Australasian women

OBJECTIVES

To compare the efficacy and patient acceptability of intranasal and transdermal 17beta-oestradiol delivery systems for postmenopausal symptoms in Australasian women.

METHODS

Symptomatic postmenopausal women were randomly assigned to treatment with either intranasal 17beta-oestradiol, 300 microg daily (n = 66) or transdermal matrix patch 17beta-oestradiol, 50 microg/day (n = 66) for 12 weeks, followed by a 4-week period with the alternate treatment. Efficacy was compared between groups using the modified Greene climacteric scale, the menopause quality of life (MENQOL) questionnaire and vasomotor symptoms at week 12. Patient acceptability was compared by a satisfaction questionnaire at week 16 and patient preference at week 16.

RESULTS

Intranasal and transdermal therapy produced significant reductions in both the Modified Greene and MENQOL scores, and in the occurrence of hot flushes and night sweats at week 12. The overall rate of reported vasomotor symptoms was lower on patients treated with the nasal spray. Both therapies were well tolerated with similar adverse event rates. Satisfaction and preference were similar for both modes of drug delivery.

CONCLUSIONS

Intranasal oestradiol therapy route has comparable efficacy and safety to that of transdermal oestradiol matrix patch therapy with no difference in patient preference or satisfaction.

Differential estrogen signaling in endothelial cells upon pulsed or continuous administration

While experimental evidence demonstrates that estrogen protects vascular cells, clinical trials on hormone replacement therapies (HRT) fail to report cardiovascular benefits. This discrepancy may indicate that estrogen signaling during HRT may not be fully effective in vascular cells, possibly due to the way of delivering estrogens to vascular tissues. We therefore, tested whether a different kinetics of exposure of endothelial cells to estrogens may alter the balance between transcriptional and non-transcriptional signaling.

METHODS AND RESULTS

Cultured human umbilical vein endothelial cells (HUVEC) were exposed to equal amounts of 17beta-estradiol administered transiently (7 nM for 1 h) or continuously (0.29 nM for 24 h), using endothelial nitric oxide synthase (eNOS) expression and activity as functional endpoints. Transient and continuous administrations equally increased eNOS expression, implying that a short contact between hormone and cells is sufficient to trigger genomic pathways. In agreement, in ovariectomized rats pulse-like changes in plasma estradiol or stable levels equally increased aortic eNOS. More importantly, we extensively show that transient estradiol administration results in preferential recruitment of non-genomic pathways, leading to more vivid activation of MAPK and phosphatidylinositol-3 kinase (PI3K) cascades.

CONCLUSIONS

Our data suggest that the kinetics of contact of estrogen with the cells could represent a sensor for estrogen receptor (ER) signaling towards non-genomic or genomic pathways. These findings deepen our understanding of estrogen signaling, and have important implications for the design of safer and more effective HRT.

Intranasal 17β-estradiol treatment and Vitamin B12, folate and homocysteine in menopause

OBJECTIVE

This study assessed the effect of intranasal administration of 17beta-estradiol (Aerodiol) on plasma levels of homocysteine, Vitamin B12 and folate in postmenopausal women.

METHODS

In all, 26 symptomatic postmenopausal women who had undergone hysterectomy and oophorectomy at least 12 months previously participated in this 6-month randomized prospective clinical study. Menopause was determined by serum FSH level >30 microIU/ml and serum estradiol concentration <30 pg/ml. Intranasal 17beta-estradiol treatment was given once daily at a standard daily dose of 300 microg to 16 women, and 10 did not receive any treatment.

RESULTS

In the group receiving intranasal 17beta-estradiol, mean (+/-S.D.) plasma homocysteine level decreased significantly from pre-treatment values (from 16.68+/-4.33 to 14.15+/-1.18 nmol/ml, p=0.029) and the mean folate level increased (from 4.11+/-0.80 to 5.64+/-1.87 ng/ml, p=0.012). Vitamin B12 levels showed a tendency towards increasing. In the treated group, significant negative correlations were observed between homocysteine and folate values (r=-0.586, p=0.017) and between homocysteine and Vitamin B12 values (r=-0.672, p=0.004). No significant changes were observed in the untreated group.

CONCLUSION

The reduction in plasma homocysteine levels observed after 6 months' treatment with intranasal 17beta-estradiol may reflect an alteration in folate and Vitamin B12 homeostasis.

Pulsed estradiol exposure has a limited ability to induce uterine proliferation in ovariectomised female Wistar rats

All post-menopausal hormone replacement therapies (HRT) aim to provide a steady mid-follicular serum concentration of estrogen, with the exception of pulsed estrogen therapy, which concentrates estradiol (E2) exposure in the few hours following administration. This study was carried out to identify and characterise cellular and molecular mechanisms specifically involved in the response of the uterus to pulsed E2. Ovariectomised Wistar rats were treated with E2 for 10 days via IV route to mimic pulsed therapy (1, 4, 10 and 250 microg/kg) or with a subcutaneous pump to mimic standard HRT (10 and 250 microg/kg). Pulsed estrogen therapy effects on uterus was revealed by general E2 sensitivity markers (C3 mRNA, progesterone receptor (PR)) from the lower dose with no over stimulation even at the highest dose conversely to what observed with continuous exposure. Uterotrophic effect of pulsed E2 (uterine weight and epithelium thickness) was observed at all dose administered but with a limited maximal effect comparable to the ranges measurable in sham animals. This data corroborates with proliferating cell nuclear antigen (PCNA) expression in the uterine epithelium used as a marker of proliferation. PCNA was significantly induced after continuous administration but only slightly after pulsed E2 (250 microg/kg). In summary, pulsed E2 leads to a more limited proliferative effect than with continuous E2 in the uterus.

The effects of 17β-oestradiol plus dydrogesterone compared with conjugated equine oestrogens plus medroxyprogesterone acetate on lipids, apolipoproteins and lipoprotein(a)

OBJECTIVE

To compare the effects of 17 beta-oestradiol plus dydrogesterone with conjugated equine oestrogens plus medroxyprogesterone acetate on serum lipids, apolipoproteins and lipoprotein(a) in postmenopausal women.

METHODS

A multi-centre, prospective, randomised, double-blind, comparative one-year study in 362 healthy postmenopausal women aged 39-74 years with an intact uterus. Fasting blood samples were taken at baseline and after 28 and 52 weeks of treatment. Participants received daily oral treatment with continuous combined 1 mg micronised 17 beta-oestradiol/5 mg dydrogesterone (E/D: n=180) or 0.625 mg conjugated equine oestrogens/5 mg medroxyprogesterone acetate (CEE/MPA: n=182).

RESULTS

Significant differences between the two groups after 52 weeks were observed for total cholesterol (E/D: -1.7%; CEE/MPA: -7.3%), LDL-cholesterol (E/D: -4.5%; CEE/MPA: -11.3%), HDL-cholesterol (E/D: +15.3%; CEE/MPA: +7.5%), triglycerides (E/D: +9.8%; CEE/MPA: +16.6%), VLDL-triglycerides (E/D: -3.3%; CEE/MPA: +10.0%), lipoprotein(a) (E/D: 0.0%; CEE/MPA: -25.2%) and for the ratio apolipoprotein B/LDL-cholesterol (E/D: +0.9%; CEE/MPA +5.9%).

CONCLUSIONS

E/D and CEE/MPA differ in their anti-atherogenic effects on lipids and lipoproteins. This however can not easily be translated to differences in clinical cardiovascular outcomes.

Comparison of intranasal and transdermal estradiol on nasal mucosa in postmenopausal women

OBJECTIVE

To compare nasal symptomatology and function and local concentrations of estradiol (E2), estradiol receptor (ERalpha), vasoactive intestinal peptide (VIP), substance P (SP) and neuropeptide Y (NPY) in nasal biopsies of 20 postmenopausal women complaining of paradoxical nasal stuffiness before and after treatment with intranasal or transdermal E2.

DESIGN

Twenty healthy postmenopausal women willing to start hormone therapy (HT) were allocated to one of two groups, using a computer-generated randomization list. Ten postmenopausal women were treated with transdermal 17beta-estradiol 50 microg daily plus nomegestrole acetate 5 mg/day for 12 days per 28-day cycle for 6 months (Group A). Ten postmenopausal women were treated with intranasal 17beta-estradiol 300 microg/day (one spray delivery of 150 microg per nostril) plus nomegestrole acetate 5 mg/day for 12 days per 28-day cycle for 6 months (Group B). Fourteen fertile women undergoing nasal mucosa biopsy during plastic surgery were used as controls for the immunohistochemical evaluation (Group C). All women in groups A and B underwent evaluation of nasal stuffiness score, mucociliary transport time, rhinoscopy, and active anterior rhinomanometry at the beginning of the study and after, VIP, SP, and 6 months of HT. Nasal biopsies and evaluation of local concentrations of E2, ERalpha NPY were performed in groups A and B before and after 6 months of HT and in group C.

RESULTS

Both intranasal and transdermal HT improve nasal symptomatology and nasal mucosa appearance and reduce mean mucociliary transport time. The effectiveness of intranasally administered therapy at improving nasal function is significantly better than transdermal therapy. In comparison with premenopausal controls, untreated postmenopausal women of group A and B showed significantly decreased immunopositivity for E2, ERalpha, and SP. HT induced a significant increase in E2, ERalpha, VIP, and SP and a decrease in NPY immunopositivity. Intranasal therapy was associated with a significantly higher immunopositivity for VIP and SP.

CONCLUSIONS

HT improves nasal function and symptomatology in postmenopausal women with paradoxical nasal stuffiness, modulating nasal mucosa function through an action on cholinergic, adrenergic, and sensory peptides. Intranasally administered HT is more effective at improving nasal function than transdermal HT.

Drug delivery systems for oestrogenic hormones and antagonists: the need for selective targeting in estradiol-dependent cancers

The pleiotropic activity of oestrogens and their mechanism of action via their binding to the two oestrogen receptors alpha (ER alpha) and beta (ER beta) subtypes in the different tissues where oestrogens exert their action have been briefly described. The fate of these compounds trapped into different galenic forms is discussed with regard to their therapeutic applications. Firstly, the advantages and disadvantages of the different forms (pills, i.v. forms and transdermal patches) used in contraception are compared. Secondly, the therapeutic use of formulated oestrogens for the post-menopausal hormone replacement therapy (HRT) is analysed through the various results obtained in different trials. The link between HRT and the risks of breast cancer and cardiovascular disease is underlined. Finally, comparing the activity of selective oestrogen receptor modulators such as tamoxifen and pure anti-oestrogens such as RU58668 and ICI182780, we analysed the reasons leading to the need for a tumor targeting of the latters, but not of the former for the treatment of oestrogen-dependent breast cancer. Different injectable and biodegradable formulations, that lead to a remarkable anti-tumor efficiency in xenografts, have been recently developed and we believe that they may represent promising new administration ways of added therapeutic values for anti-oestrogens. Such devices could be extended to the delivery of other anti-cancer drugs with more aggressive activities than anti-oestrogens.

Prevention of postmenopausal bone loss by pulsed estrogen therapy: comparison with transdermal route

OBJECTIVE

To compare the efficacy of pulsed estrogen therapy following intranasal 17beta-estradiol (E2) (S21400) with patch E2 in preventing postmenopausal bone loss and on bone turnover.

METHODS

In this multinational open study, 361 postmenopausal women aged 51.5 (S.D. 4.6) years were treated with S21400 300 microg per day or patch E2 (delivering 50 microg per day), two patches per week, for 56 weeks. Bone mineral density (BMD) was assessed at the spine and hip using dual X-ray absorptiometry at baseline and week 56 (W56). Bone turnover markers (osteocalcin, bone alkaline phosphatase, urinary type I collagen C-telopeptides) were measured at baseline and weeks 12, 28 and 56.

RESULTS

Spine and hip bone mineral density significantly increased in both groups (P < 0.001 versus baseline). Mean (S.D.) percent increases were 2.1 (3.0) at the spine (both groups), and 1.2 (2.4) and 1.1 (2.2) at the hip in the S21400 and patch E2 groups, respectively. Bone mineral density also significantly increased (P < 0.001 versus baseline) in osteopenic patients following S21400 and patch E2: 3.1 (3.5) and 2.4 (3.5) at the spine, and 2.0 (2.6) and 1.2 (2.7) at the hip, respectively. Bone metabolism was normalized at week 56 with a significant decrease (P < 0.001) from baseline in all markers: 56% and 53% for type I collagen C-telopeptides, and 24% and 25% for osteocalcin in the S21400 and patch E2 groups, respectively.

CONCLUSION

Pulsed estrogen therapy was as effective in normalizing bone turnover and preventing postmenopausal bone loss as a reservoir patch.

Pulsed estrogen therapy in prevention of postmenopausal osteoporosis. A 2-year randomized, double blind, placebo-controlled study

The aim of this study was to evaluate the efficacy of pulsed estrogen therapy (intranasal 17beta-estradiol) in the prevention of postmenopausal bone loss. A total of 386 women (40-65 years old), less than 5 years past menopause, were randomized to intranasal placebo, 17beta-estradiol 150 micro g, or 300 micro g daily for 2 years. Women with an intact uterus received micronised progesterone 200 mg per day, 14 days of each 28-day cycle. Women randomised to placebo-treatment received placebo progesterone. The primary endpoints were changes in BMD at the spine (L2-L4) and femoral neck. Secondary endpoints were changes in bone turnover markers: serum osteocalcin (sOC) as a marker of bone formation and urinary C-terminal telopeptides (uCTX) as a marker of bone resorption. BMD increased at all measured sites in women receiving active treatment in a dose-related manner, the difference compared to placebo being 5.2% and 6.7% at the spine, and 3.2% and 4.7 % at the hip, respectively, with 150 microg and 300 microg ( P<0.001). On the other hand, a decrease versus baseline of -3.2% and -3.3% at the spine and hip, respectively, was observed in women receiving placebo ( P<0.001). In the patients with at least one risk factor for osteoporotic fracture, the difference between placebo and 150 microg or 300 micro g was even higher at the spine (5.4% and 7.4%, respectively), and at the femoral neck (4.0% and 5.2%, respectively). Correspondingly, uCTX decreased from baseline by 39% and 46 %, and sOC by 22% and 27%, in the 150 micro g group and 300 micro g group (all P<0.001 versus placebo). A strong correlation was found between variations of bone turnover markers after 1 year and BMD after 2 years, emphasizing that bone markers can predict BMD response during hormonal treatment. Acceptability and general tolerance were good. This study demonstrates that pulsed estrogen therapy at the dose of 150 microg and 300-microg per day prevents bone loss in a dose-dependant manner at each site studied, and normalizes bone turnover markers to premenopausal levels.

Menopause: new therapies

The risk-benefit ratio of traditional postmenopausal hormone therapy is considered by many to be unacceptable. Low-dose oestrogen-progestin therapy (oral or non-oral and continuous or pulsatile) may have a better risk-benefit ratio, but this remains unproven. Steroids with selective tissue activation, such as tibolone, alleviate symptoms and protect against bone loss, but long-term safety data are lacking. Selective oestrogen receptor modulators (SERMs), such as raloxifene, prevent bone loss when used alone, and may soon be combined with oestradiol to treat symptoms and prevent osteoporotic fracture. Effects of SERMs on the cardiovascular system are currently being evaluated.

Intranasal hormone replacement therapy

Although the optimal route of delivery for hormone replacement therapy has not yet been determined, desirable qualities would include good efficacy, easy administration, minimal side effects, and optimal therapeutic profile. This would potentially serve to improve patient compliance and satisfaction. The intranasal route has been evaluated for the administration of menopausal hormones and seems to fulfill these requirements. The intranasal route would also seem to be a viable alternative for drugs that are poorly absorbed after ingestion by avoiding hepatic first-pass elimination. The intranasal route is, therefore, innovative for the delivery of natural sex steroids in postmenopausal women receiving hormone replacement therapy. Early studies demonstrate that it is safe, effective, and acceptable to postmenopausal women. In addition, the nasal administration of a combination of estradiol and progesterone would seem to be an attractive way to deliver hormones to nonhysterectomized postmenopausal women. Providing alternative routes of administration may also enhance compliance.

The influence of the route of administration of 17beta-estradiol, intravenous (pulsed) versus oral, upon DMBA-induced mammary tumour development in ovariectomised rats

A wide variety of routes of administration and formulations are employed in estrogen replacement therapy. These exhibit differences in the pharmacokinetics and metabolism of estradiol and in the resulting biological effects. This study set out to investigate the effects of pulsed estrogen administration (via the nasal route) compared to oral therapy, as a reference, with regard to breast cancer risk. This was assessed in an experimental model whereby mammary tumours were induced by 7,12-dimetbylbenz(a)anthracene in ovariectomised rats. To mimic a pulsed treatment given via the nasal route doses of estrogen were administered by I.V. route (0.4, 10 and 250 microg/kg). These dosages were predicted to have similar estrogenic activity to doses administered by the oral route (100, 300 and 900 microg/kg). Controls were groups of ovariectomised and SHAM-operated rats and ovarectomised rats administered with either vehicle alone. Two studies were carried out on separate populations of rats and ran in parallel. Tumour appearance (study 1) and tumour growth (study 2) were evaluated. In study I (n = 20/group), treatments with estradiol were conducted for 20 weeks after carcinogen administration; in study 2 (n = 10/group), an 8-week treatment with estradiol was initiated once 7,12-dimethylbenz(a)anthracene-induced tumours appeared. Intravenous dose levels achieved equivalent estrogenicity to corresponding oral dose levels, as assessed by measuring uterus weight. Estrogen deficit was made up by both routes but only the higher doses restored physiological uterus weight. Nevertheless administration via the I.V. route resulted in a lower rate of tumour incidence (p < or = 0.05) than the rate recorded for the oral route. In addition, tumour development was lower with the I.V. route. In conclusion, in this experimental model, pulsed estrogen therapy with 17beta-estradiol administered via the I.V. route resulted in a reduced effect on mammary carcinogenesis when compared to oral administration.

Hormone replacement therapy in postmenopausal women and its effects on plasma lipid levels

Postmenopausal women run the same risks of coronary heart disease as men. The lipid alterations observed at this time reflect increased blood levels of total cholesterol, low-density lipoprotein cholesterol (LDL-C) and lipoprotein (a), and reduced high-density lipoprotein cholesterol (HDL-C) levels. These changes lead to a higher risk of coronary artery disease, and hormonal therapy has a favorable effect on lipid metabolism. In this paper we review the literature on hormone replacement therapy (HRT) in postmenopausal women with the emphasis on the role of lipids in the pathogenesis of coronary heart disease, and on the action of estrogens and their correlation with progestogens, as well as routes of HRT administration. We conclude that the HRT changes the lipid profile in a potentially anti-atherogenic direction, usually reducing LDL-C and increasing HDL-C and triglycerides. Otherwise, for postmenopausal women with established coronary disease HRT is not recommended.

Therapeutic value and long-term safety of pulsed estrogen therapy

OBJECTIVES

To demonstrate equivalent efficacy for menopausal symptoms between Aerodiol nasal spray and reference oral estradiol therapy, and to investigate the endometrial safety and tolerability of Aerodiol in the long term.

METHODS

The efficacy of Aerodiol 300 microg, once daily, was compared with oral estradiol 2 mg/day in a randomized, double-blind trial. A statistical test of noninferiority was performed on the mean absolute Kupperman index (KI) obtained after 14 and 23 weeks of the two treatments. Long-term safety was assessed in a 1-year open-label study. The initial Aerodiol dose was 300 microg/day, and was adjusted if required. Endometrial biopsies were obtained at inclusion and at the end of the trial and examined independently by two pathologists.

RESULTS

In the equivalence trial, the KI improved similarly in the Aerodiol group (n=317) and the oral estradiol group (n=342). Aerodiol was shown statistically to be at least as effective as oral therapy (P<0.001), but the incidences of mastalgia and withdrawal bleeding were significantly lower in the Aerodiol group (P<0.01 and P<0.001, respectively). In the long-term safety trial (n=408), the rate of Aerodiol treatment continuation at 12 months was 85%, and there was no incidence of endometrial hyperplasia or cancer. Aerodiol dose adaptation was performed by 29% of women.

CONCLUSIONS

Aerodiol was shown to have equivalent efficacy to reference oral estradiol therapy, but with better gynaecological acceptability. The endometrial safety of Aerodiol was confirmed in the long term, and the ability to adjust the dosage easily was of benefit to a substantial proportion of women.

Aerodiol versus the transdermal route: perspectives for patient preference

OBJECTIVE

to compare the efficacy, tolerability and user preference of Aerodiol intranasal and transdermal patch administration of 17 beta-estradiol for climacteric symptoms.

METHODS

an open-label, multicenter, crossover trial in which recently postmenopausal women were randomized to receive either Aerodiol 300 microg daily (n=176), or transdermal 17 beta-estradiol (reservoir patches delivering 50 microg/day), 2 patches per week (n=185), for 12 weeks, followed by 4 weeks of the alternative treatment. Efficacy was assessed primarily by the Kupperman index at the end of each treatment period. User satisfaction was assessed by questionnaire at weeks 12 and 16, and at week 16 the women chose which treatment they preferred to use for a further 40-week period.

RESULTS

Aerodiol and transdermal patch therapy produced marked and similar reductions in the Kupperman index and the incidence of hot flushes at weeks 12 and 16. The reduction in the Kupperman index at week 12 was statistically equivalent for the two treatments. The tolerability of both treatments was good, with similar numbers of emergent adverse events reported in both groups. The incidence of moderate or severe mastalgia, however, was significantly lower with Aerodiol (P=0.02). Significantly more women chose to continue treatment with Aerodiol than with the transdermal patch (66 vs. 34%, P<0.001). When all women had experienced both treatments, reported levels of satisfaction were significantly higher with Aerodiol than with transdermal therapy (P<0.001 for all six categories assessed).

CONCLUSIONS

Aerodiol and transdermal patch treatments were of similar efficacy and tolerability. Levels of user preference and satisfaction, however, were higher with Aerodiol, which should contribute towards good long-term compliance with this therapy.

Perspectives in hormone replacement therapy

Estrogens have been convincingly shown to be highly effective in preventing and reversing menopause-related conditions, such as hot flushes, urogenital complaints, and postmenopausal bone loss. Observational studies report that long-term, estrogen-containing, postmenopausal hormone replacement therapy (HRT) leads to a substantial reduction in hip fractures, myocardial infarction, and possibly colonic cancer, with important consequences for health and quality of life. Estrogen replacement may postpone the onset of Alzheimer's disease and extend life. While many of these effects are biologically plausible, with a variety of cellular mechanisms being involved, only ongoing and future large-scale randomized clinical trials can and should define the effects of HRT more precisely. Long-term compliance is a key issue for long-term benefits, and offering women a choice of administration routes and regimens can only be beneficial in this respect. Pills, patches, gels, and implants are all widely prescribed. Intravaginal or intranasal forms of administration, which are very easy to use and adaptable on an individual level, are among the new options which could improve long-term continuation of HRT use. Fear of breast cancer and recurrence of vaginal bleeding are real concerns for many women considering HRT. This has led to research into lower-dose, estrogen-containing regimens, into continuous combined regimens, and into the potential of estrogen receptor alpha or beta binding molecules that may help to prevent such problems from arising. The prospects for safe and effective postmenopausal HRT with either estrogens or estrogen-like drugs are very promising when these drugs are used in a patient-tailored, risk profile-based manner.

Effects of postmenopausal hormone replacement therapy on lipid, lipoprotein, and apolipoprotein (a) concentrations: analysis of studies published from 1974-2000

OBJECTIVE

To establish reference estimates of the effects of different hormone replacement therapy (HRT) regimens on lipid and lipoprotein levels.

DESIGN

Review and pooled analysis of prospective studies published up until the year 2000.

SETTING

Clinical trials centers, hospitals, menopause clinics.

PATIENT(S)

Healthy postmenopausal women.

INTERVENTION(S)

Estrogen alone, estrogen plus progestogen, tibolone, or raloxifene in the treatment of menopausal symptoms.

MAIN OUTCOME MEASURE(S)

Serum high- and low-density lipoprotein (HDL and LDL) cholesterol, total cholesterol, triglycerides, and lipoprotein (a).

RESULT(S)

Two-hundred forty-eight studies provided information on the effects of 42 different HRT regimens. All estrogen alone regimens raised HDL cholesterol and lowered LDL and total cholesterol. Oral estrogens raised triglycerides. Transdermal estradiol 17-beta lowered triglycerides. Progestogens had little effect on estrogen-induced reductions in LDL and total cholesterol. Estrogen-induced increases in HDL and triglycerides were opposed according to type of progestogen, in the order from least to greatest effect: dydrogesterone and medrogestone, progesterone, cyproterone acetate, medroxyprogesterone acetate, transdermal norethindrone acetate, norgestrel, and oral norethindrone acetate. Tibolone decreased HDL cholesterol and triglyceride levels. Raloxifene reduced LDL cholesterol levels. In 41 studies of 20 different formulations, HRT generally lowered lipoprotein (a).

CONCLUSION(S)

Route of estrogen administration and type of progestogen determined differential effects of HRT on lipid and lipoprotein levels. Future work will focus on the interpretation of the clinical significance of these changes.

Endometrial safety and tolerability of AERODIOL(R) (intranasal estradiol) for 1 year

OBJECTIVE

the purpose of this study was to assess the endometrial safety and patient acceptability of a pulsed estrogen therapy provided by S21400 (intranasal 17 beta-estradiol) in the treatment of postmenopausal symptoms.

DESIGN

postmenopausal women (n=408) entered an open-label, community based, multicentre trial. Patients received S21400 plus sequential (>90% of patients) or continuous progestogen. Treatment was initiated with a standard daily dose of 300 microg but dose adaptation was possible every 3 months from 150 to 600 microg daily. Endometrial biopsies were performed at entry and at 12 months, and bleeding patterns were recorded at 3-monthly intervals throughout the trial.

RESULTS

71% of patients received 300 microg per day S21400 throughout the study, 3% had their dose decreased, 19% had their dose increased and 7% had their dose both decreased and increased. Three hundred and eleven biopsies were obtained after 12 months of treatment, there were no cases of endometrial hyperplasia. The 95% confidence interval [CI] for the rate of incidence was 0-1.2%. Cyclical bleeding occurred in 82% of sequential treatment cycles. Unexpected bleeding occurred in 5% of the treatment cycles. Presence of unexpected bleeding varied according to the treatment regimen, 15 and 4% of the cycles with combined continuous and sequential regimen, respectively. Unexpected bleeding was mostly spotting. Nasal treatment was well accepted. Nasal symptoms (itching sensation, rhinorrhea and sneezing) were mostly mild in intensity and they led to treatment withdrawal in approximately 3% of patients. The rate of treatment continuation was 85% at 1 year.

CONCLUSIONS

S21400, in combination with continuous or sequential progestogen, exhibits good endometrial safety and patient acceptability in postmenopausal women.