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Palacios S, Rebelo C, Casquilho A, Costa AR, Cagnacci A, Cano A, Castelo-Branco C, Di Carlo C, Romão F, Geraldes F, Gambacciani M, Fasero M, Coronado P, Carvalho MJ, Nappi RE. POESIT recommendations on management of body-identical hormones in menopausal symptoms. Climacteric 2024:1-11. [PMID: 38978340 DOI: 10.1080/13697137.2024.2368486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Accepted: 06/09/2024] [Indexed: 07/10/2024]
Abstract
Many women seek treatment to improve menopausal vasomotor symptoms (VMS). The selection of women most likely to benefit from menopause hormone therapy (MHT) is crucial in clinical practice. There is general agreement that women younger than 60 years or who initiate MHT within the first 10 years of menopause, with no contraindications, have greater benefits considering symptomatic relief and additional advantages. This group may have the advantage of protection from osteoporosis and from other chronic diseases that affect postmenopausal women, namely cardiovascular disease (CVD). Cumulating evidence supports MHT for symptomatic women. However, inadequate use according to the needs of symptomatic women led to a burden of suffering worldwide. In recent years, the emergent use of non-regulated body-identical hormones (non-rBHT) can expose patients to potential harms. These hormone preparations are not regulated through the same tests of safety, efficacy or dosing consistency as regulated-BHT (r-BHT). The POESIT (Portugal + Spain + Italy) recommendations highlight the use of 17β-estradiol (E2) and micronized progesterone (P4) as the real r-BHT. In addition, the group emphasizes as an example the data from the REPLENISH study with 1 mg E2/100 mg P4. The combination of the two hormones in one convenient pill showed a clear reduction or elimination of hot flashes and an improvement in sleep quality and, consequently, quality of life. At the same time, this combination has shown high rates of amenorrhea and no significant impact on lipid, glucose or coagulation parameters. Both the REPLENISH study and a real-life retrospective study pointed to the possibility of a lower risk of venous thromboembolism (VTE) with this formulation than with other combinations.
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Affiliation(s)
- Santiago Palacios
- Service of Gynecology, Palacios' Institute of Women's Health, Madrid, Spain
| | - Cláudio Rebelo
- Department of Gynaecology and Obstetrics, Hospital CUF-Porto, Porto, Portugal
| | - Ana Casquilho
- Department of Obstetrics and Gynaecology, Faro Hospital, Faro, Portugal
| | - Ana Rosa Costa
- Department of Gynaecology and Obstetrics, Universitary and Clinical Centre São João, Porto, Portugal
| | - Angelo Cagnacci
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics Maternal and Infant Health, University of Genova, Italy
| | - Antonio Cano
- Department of Pediatrics, Obstetrics and Gynecology, University of Valencia, Valencia, Spain
| | - Camil Castelo-Branco
- Clinical Institute of Gynecology, Obstetrics and Neonatology, Hospital Clínic de Barcelona, Barcelona, Spain
- Department of Surgery and Medical-Surgica Specialities - Faculty of Medicine, University of Barcelona, Barcelona, Spain
| | - Costantino Di Carlo
- Department of Public Health, University of Naples Federico II, Naples, Italy
| | - Fátima Romão
- Hospital do SAMS - Lisboa, Hospital da Luz - Setúbal, Setúbal, Portugal
| | - Fernanda Geraldes
- Gynecology Service, Department of Gynecology, Obstetrics and Neonatology, Hospitalar, Universitary Centre of Coimbra, Coimbra, Portugal
| | - Marco Gambacciani
- Menopause and Osteoporosis Unit, San Rossore Clinical Center, Pisa, Italy
| | - Maria Fasero
- Service of Obstetrics and Gynecology, Hospital Sanitas La Zarzuela, Madrid, Spain
- Service of Gynecology, Clinica Corofas. Corofas Menopause, Madrid, Spain
- Department of Gynecology, Universidad Francisco de Vitoria, Madrid, Spain
- Asociación Española para el Estudio de la Menopausia (AEEM), Spain
| | - Pluvio Coronado
- Asociación Española para el Estudio de la Menopausia (AEEM), Spain
- Women's Health Institute of the Hospital Clínico San Carlos, IdISSC. Complutense University, Madrid, Spain
| | - Maria João Carvalho
- Gynecology Service, Department of Gynecology, Obstetrics and Neonatology, Hospitalar, Universitary Centre of Coimbra, Coimbra, Portugal
- Universitary Clinic of Gynecology, Faculty of Medicine, University of Coimbra, Coimbra, Portugal
- Institute of Biophysics and Institute for Clinical and Biomedical Research (iCBR), Area of Environment Genetics and Oncobiology (CIMAGO), Faculty of Medicine, University of Coimbra, Coimbra, Portugal
- Centre for Innovative Biomedicine and Biotechnology (CIBB), University of Coimbra, Coimbra, Portugal
- Clinical Academic Center of Coimbra (CACC), Coimbra, Portugal
| | - Rossella E Nappi
- Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
- Chief of the Research Center for Reproductive Medicine and Director of the Gynecological Endocrinology & Menopause Unit, IRCCS San Matteo Foundation, Pavia, Italy
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2
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Oliveira TS, Campos HM, Costa RM, Georg RC, Leite JA, Tostes RC, Costa EA, Santos FCA, Lobato NS, Filgueira FP, Ghedini PC. Estrone-mediated lowering of ROS and NOX4 improves endothelial function in ovariectomized wistar rats. NAUNYN-SCHMIEDEBERG'S ARCHIVES OF PHARMACOLOGY 2024:10.1007/s00210-024-03106-7. [PMID: 38643455 DOI: 10.1007/s00210-024-03106-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Accepted: 04/13/2024] [Indexed: 04/22/2024]
Abstract
Estrone (E1) constitutes the primary component in oral conjugated equine estrogens (CEEs) and serves as the principal estrogen precursor in the female circulation in the post-menopause. E1 induces endothelium-dependent vasodilation and activate PI3K/NO/cGMP signaling. To assess whether E1 mitigates vascular dysfunction associated with postmenopause and explore the underlying mechanisms, we examined the vascular effects of E1 in ovariectomized (OVX) rats, a postmenopausal experimental model. Blood pressure was measured using tail-cuff plethysmography, and aortic rings were isolated to assess responses to phenylephrine, acetylcholine (ACh), and sodium nitroprusside. Responses to ACh in rings pre-incubated with superoxide dismutase (SOD), catalase (CAT), or apocynin were also evaluated. Protein expression of SOD, CAT, NOX1, NOX2, and NOX4 was determined by Western blotting. E1 treatment resulted in decreased body weight and retroperitoneal fat, increased uterine weight, and prevented elevated blood pressure in the OVX group. Furthermore, E1 improved endothelium-dependent ACh vasodilation, activated compensatory antioxidant mechanisms - i.e. increased SOD and CAT antioxidant enzymes activity, and decreased NOX4 expression. This, in turn, helped prevent oxidative stress and endothelial dysfunction in OVX rats. Additionally, E1 treatment reversed the increased total LDL cholesterol observed in the OVX group. The findings underscore protective effects of E1 on the cardiovascular system, counteracting OVX-related oxidative stress and endothelial dysfunction in Wistar rats. E1 exhibits promising therapeutic benefits for managing cardiovascular health, particularly in postmenopausal conditions.
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Affiliation(s)
- Thiago S Oliveira
- Department of Pharmacology, Institute of Biological Sciences, Federal University of Goiás, Goiânia, GO, Brazil
- Department of Pharmacy, Laboratory of Experimental Pharmacology, FCBS, Federal University of the Jequitinhonha and Mucuri Valleys, Diamantina, MG, Brazil
| | - Hericles M Campos
- Department of Pharmacology, Institute of Biological Sciences, Federal University of Goiás, Goiânia, GO, Brazil
| | - Rafael M Costa
- Department of Pharmacology, Laboratory of Vascular Biology, Ribeirao Preto Medical School, University of São Paulo, Ribeirão Preto, SP, Brazil
- School of Medicine, Federal University of Jataí, Jataí, Brazil
| | - Raphaela C Georg
- Department of Pharmacology, Institute of Biological Sciences, Federal University of Goiás, Goiânia, GO, Brazil
| | - Jacqueline A Leite
- Department of Pharmacology, Institute of Biological Sciences, Federal University of Goiás, Goiânia, GO, Brazil
| | - Rita C Tostes
- Department of Pharmacology, Laboratory of Vascular Biology, Ribeirao Preto Medical School, University of São Paulo, Ribeirão Preto, SP, Brazil
| | - Elson A Costa
- Department of Pharmacology, Institute of Biological Sciences, Federal University of Goiás, Goiânia, GO, Brazil
| | - Fernanda Cristina A Santos
- Department of Pharmacology, Institute of Biological Sciences, Federal University of Goiás, Goiânia, GO, Brazil
| | - Núbia S Lobato
- School of Medicine, Federal University of Jataí, Jataí, Brazil
| | | | - Paulo César Ghedini
- Department of Pharmacology, Institute of Biological Sciences, Federal University of Goiás, Goiânia, GO, Brazil.
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Stute P, Walker LJ, Eicher A, Pavicic E, Kolokythas A, Theis S, von Gernler M, von Wolff M, Vollrath S. Progestogens for endometrial protection in combined menopausal hormone therapy: A systematic review. Best Pract Res Clin Endocrinol Metab 2024; 38:101815. [PMID: 37634998 DOI: 10.1016/j.beem.2023.101815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/29/2023]
Abstract
Menopausal women with an intact uterus choosing estrogens for menopausal symptom relief require a progestogen for endometrial protection. The aim of this systematic review was to evaluate the risks of endometrial hyperplasia resp. malignancy with different progestogens used in combined MHT. Overall, 84 RCTs were included. We found that 1) most studies were done with NETA, followed by MPA, MP and DYD and LNG, 2) most progestogens were only available as oral formulations, 3) the most frequently studied progestogens (oral MP, DYD, MPA, oral and transdermal NETA, transdermal LNG) were assessed in continuously as well as in sequentially combined MHT regimens, 4) FDA endometrial safety criteria were only fulfilled for some progestogen formulations, 5) most studies demonstrated endometrial protection for the progestogen dose and time period examined. However, 6) study quality varied which should be taken into account, when choosing a combined MHT, especially if off-label-use is chosen.
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Affiliation(s)
- Petra Stute
- Department of Obstetrics and Gynecology, University Clinic Inselspital, Friedbuehlstrasse 19, 3010 Bern, Switzerland.
| | - Linus Josef Walker
- School of Medicine, University of Bern, Murtenstrasse 11, 3008 Bern, Switzerland.
| | - Astrid Eicher
- School of Medicine, University of Bern, Murtenstrasse 11, 3008 Bern, Switzerland.
| | - Elena Pavicic
- School of Medicine, University of Bern, Murtenstrasse 11, 3008 Bern, Switzerland.
| | - Argyrios Kolokythas
- Department of Obstetrics and Gynecology, McGill University Health Centre, 1001 Bd Décarie, Montréal, QC H4A 3J1, Canada.
| | - Susanne Theis
- Department of Obstetrics and Gynecology, University of Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany.
| | - Marc von Gernler
- Medical Library, University Library of Bern, University of Bern, Baltzerstrasse 4, 3012 Bern, Switzerland.
| | - Michael von Wolff
- Department of Obstetrics and Gynecology, University Clinic Inselspital, Friedbuehlstrasse 19, 3010 Bern, Switzerland.
| | - Sabrina Vollrath
- Department of Obstetrics and Gynecology, University Clinic Inselspital, Friedbuehlstrasse 19, 3010 Bern, Switzerland; Swiss Federal Institute of Sport Magglingen (SFISM), Hauptstrasse 247, 2532 Magglingen, Switzerland.
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Patil N, Maheshwari R, Wairkar S. Advances in progesterone delivery systems: Still work in progress? Int J Pharm 2023; 643:123250. [PMID: 37481096 DOI: 10.1016/j.ijpharm.2023.123250] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Revised: 07/03/2023] [Accepted: 07/17/2023] [Indexed: 07/24/2023]
Abstract
Progesterone is a natural steroidal sex hormone in the human body, mainly secreted through the adrenal cortex, ovary, and placenta. In humans, progesterone is essential for endometrium transformation in the uterus at the time of ovulation and maintenance of pregnancy. When the body cannot produce enough progesterone for specific ailments, it is administered via different routes such as oral, vaginal, transdermal, topical, parental, and intranasal routes. Although progesterone is commercially available in multiple conventional formulations, low solubility, less permeability and extensive hepatic first-pass metabolism are the major constraints to its delivery. These challenges can be overcome substantially by formulating progesterone into novel delivery systems like lipid carriers, polymeric carriers, hydrogels, several nanocarriers, depot and controlled release systems. Various research papers and patents have been published in the last two decades on progesterone delivery systems; clinical studies were conducted to establish safety and efficacy. This review is focused on the pharmacodynamic and pharmacokinetic parameters of progesterone, its delivery constraints, and various advanced delivery systems of progesterone.
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Affiliation(s)
- Nikhil Patil
- Shobhaben Pratapbhai Patel School of Pharmacy & Technology Management, SVKMs NMIMS, V.L. Mehta Road, Vile Parle (W), Mumbai, Maharashtra 400056, India
| | - Ronak Maheshwari
- Shobhaben Pratapbhai Patel School of Pharmacy & Technology Management, SVKMs NMIMS, V.L. Mehta Road, Vile Parle (W), Mumbai, Maharashtra 400056, India
| | - Sarika Wairkar
- Shobhaben Pratapbhai Patel School of Pharmacy & Technology Management, SVKMs NMIMS, V.L. Mehta Road, Vile Parle (W), Mumbai, Maharashtra 400056, India.
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Lara LA, Cartagena-Ramos D, Figueiredo JB, Rosa-E-Silva ACJ, Ferriani RA, Martins WP, Fuentealba-Torres M. Hormone therapy for sexual function in perimenopausal and postmenopausal women. Cochrane Database Syst Rev 2023; 8:CD009672. [PMID: 37619252 PMCID: PMC10449239 DOI: 10.1002/14651858.cd009672.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/26/2023]
Abstract
BACKGROUND The perimenopausal and postmenopausal periods are associated with many symptoms, including sexual complaints. This review is an update of a review first published in 2013. OBJECTIVES We aimed to assess the effect of hormone therapy on sexual function in perimenopausal and postmenopausal women. SEARCH METHODS On 19 December 2022 we searched the Gynaecology and Fertility Group Specialised Register, CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, LILACS, ISI Web of Science, two trials registries, and OpenGrey, together with reference checking and contact with experts in the field for any additional studies. SELECTION CRITERIA We included randomized controlled trials that compared hormone therapy to either placebo or no intervention (control) using any validated assessment tool to evaluate sexual function. We considered hormone therapy: estrogen alone; estrogen in combination with progestogens; synthetic steroids, for example, tibolone; selective estrogen receptor modulators (SERMs), for example, raloxifene, bazedoxifene; and SERMs in combination with estrogen. DATA COLLECTION AND ANALYSIS We used standard methodological procedures recommended by Cochrane. We analyzed data using mean differences (MDs) and standardized mean differences (SMDs). The primary outcome was the sexual function score. Secondary outcomes were the domains of sexual response: desire; arousal; lubrication; orgasm; satisfaction; and pain. We assessed the certainty of the evidence using the GRADE approach. MAIN RESULTS We included 36 studies (23,299 women; 12,225 intervention group; 11,074 control group), of which 35 evaluated postmenopausal women; only one study evaluated perimenopausal women. The 'symptomatic or early postmenopausal women' subgroup included 10 studies, which included women experiencing menopausal symptoms (symptoms such as hot flushes, night sweats, sleep disturbance, vaginal atrophy, and dyspareunia) or early postmenopausal women (within five years after menopause). The 'unselected postmenopausal women' subgroup included 26 studies, which included women regardless of menopausal symptoms and women whose last menstrual period was more than five years earlier. No study included only women with sexual dysfunction and only seven studies evaluated sexual function as a primary outcome. We deemed 20 studies at high risk of bias, two studies at low risk, and the other 14 studies at unclear risk of bias. Nineteen studies received commercial funding. Estrogen alone versus control probably slightly improves the sexual function composite score in symptomatic or early postmenopausal women (SMD 0.50, 95% confidence interval (CI) (0.04 to 0.96; I² = 88%; 3 studies, 699 women; moderate-quality evidence), and probably makes little or no difference to the sexual function composite score in unselected postmenopausal women (SMD 0.64, 95% CI -0.12 to 1.41; I² = 94%; 6 studies, 608 women; moderate-quality evidence). The pooled result suggests that estrogen alone versus placebo or no intervention probably slightly improves sexual function composite score (SMD 0.60, 95% CI 0.16 to 1.04; I² = 92%; 9 studies, 1307 women, moderate-quality evidence). We are uncertain of the effect of estrogen combined with progestogens versus placebo or no intervention on the sexual function composite score in unselected postmenopausal women (MD 0.08 95% CI -1.52 to 1.68; 1 study, 104 women; very low-quality evidence). We are uncertain of the effect of synthetic steroids versus control on the sexual function composite score in symptomatic or early postmenopausal women (SMD 1.32, 95% CI 1.18 to 1.47; 1 study, 883 women; very low-quality evidence) and of their effect in unselected postmenopausal women (SMD 0.46, 95% CI 0.07 to 0.85; 1 study, 105 women; very low-quality evidence). We are uncertain of the effect of SERMs versus control on the sexual function composite score in symptomatic or early postmenopausal women (MD -1.00, 95% CI -2.00 to -0.00; 1 study, 215 women; very low-quality evidence) and of their effect in unselected postmenopausal women (MD 2.24, 95% 1.37 to 3.11 2 studies, 1525 women, I² = 1%, low-quality evidence). We are uncertain of the effect of SERMs combined with estrogen versus control on the sexual function composite score in symptomatic or early postmenopausal women (SMD 0.22, 95% CI 0.00 to 0.43; 1 study, 542 women; very low-quality evidence) and of their effect in unselected postmenopausal women (SMD 2.79, 95% CI 2.41 to 3.18; 1 study, 272 women; very low-quality evidence). The observed heterogeneity in many analyses may be caused by variations in the interventions and doses used, and by different tools used for assessment. AUTHORS' CONCLUSIONS Hormone therapy treatment with estrogen alone probably slightly improves the sexual function composite score in women with menopausal symptoms or in early postmenopause (within five years of amenorrhoea), and in unselected postmenopausal women, especially in the lubrication, pain, and satisfaction domains. We are uncertain whether estrogen combined with progestogens improves the sexual function composite score in unselected postmenopausal women. Evidence regarding other hormone therapies (synthetic steroids and SERMs) is of very low quality and we are uncertain of their effect on sexual function. The current evidence does not suggest the beneficial effects of synthetic steroids (for example tibolone) or SERMs alone or combined with estrogen on sexual function. More studies that evaluate the effect of estrogen combined with progestogens, synthetic steroids, SERMs, and SERMs combined with estrogen would improve the quality of the evidence for the effect of these treatments on sexual function in perimenopausal and postmenopausal women.
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Affiliation(s)
- Lucia A Lara
- Department of Obstetrics and Gynecology, Medical School of Ribeirao Preto, University of Sao Paulo, Ribeirao Preto, Brazil
| | | | - Jaqueline Bp Figueiredo
- Department of Obstetrics and Gynecology, Medical School of Ribeirao Preto, University of Sao Paulo, Ribeirao Preto, Brazil
- Ultrasonography and Retraining Medical School of Ribeirao Preto (EURP), Ribeirao Preto, Brazil
| | - Ana Carolina Js Rosa-E-Silva
- Department of Obstetrics and Gynecology, Medical School of Ribeirao Preto, University of Sao Paulo, Ribeirao Preto, Brazil
| | - Rui A Ferriani
- Department of Obstetrics and Gynecology, Medical School of Ribeirao Preto, University of Sao Paulo, Ribeirao Preto, Brazil
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Davis SR, Magraith K. Advancing menopause care in Australia: barriers and opportunities. Med J Aust 2023; 218:500-502. [PMID: 37330995 DOI: 10.5694/mja2.51981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 04/19/2023] [Accepted: 04/24/2023] [Indexed: 06/20/2023]
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Wright AC, Beaudoin FL, McQueen RB, Yeung K, Moradi A, Herron-Smith S, Gutierrez E, Lin GA, Pearson SD. The effectiveness and value of fezolinetant for moderate-to-severe vasomotor symptoms associated with menopause: A summary from the Institute for Clinical and Economic Review's Midwest Public Advisory Council. J Manag Care Spec Pharm 2023; 29:692-698. [PMID: 37276043 PMCID: PMC10387909 DOI: 10.18553/jmcp.2023.29.6.692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
| | - Francesca L Beaudoin
- Institute for Clinical and Economic Review, Boston, MA
- Department of Epidemiology, Brown University, Providence, RI
| | | | - Kai Yeung
- Kaiser Permanente Washington Health Research Institute, Seattle
| | - Ashton Moradi
- Institute for Clinical and Economic Review, Boston, MA
| | | | | | - Grace A Lin
- Institute for Clinical and Economic Review, Boston, MA
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8
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Panay N, Nappi RE, Stute P, Palacios S, Paszkowski T, Kagan R, Archer DF, Héroux J, Boolell M. Oral estradiol/micronized progesterone may be associated with lower risk of venous thromboembolism compared with conjugated equine estrogens/medroxyprogesterone acetate in real-world practice. Maturitas 2023; 172:23-31. [PMID: 37084589 DOI: 10.1016/j.maturitas.2023.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 04/03/2023] [Accepted: 04/07/2023] [Indexed: 04/23/2023]
Abstract
OBJECTIVES The Women's Health Initiative study reported an increased risk of venous thromboembolism among menopausal women treated with conjugated equine estrogens/medroxyprogesterone acetate (CEE/MPA) versus placebo. Newer hormone therapies may have a lower venous thromboembolism risk. The study compared the risk of venous thromboembolism between women treated with the combined oral product 17β-estradiol/micronized progesterone (E2/P4) and those treated with oral CEE/MPA regimens. STUDY DESIGN In a retrospective longitudinal study using real-world claims data from April 2019 to June 2021, women aged 40 years or more treated with oral E2/P4 or oral CEE/MPA who did not have a venous thromboembolism diagnosis before first dispensing claim of CEE/MPA or E2/P4 identified on or after May 1st 2019 (index date) were observed for 6 months or more after the index date. Oral E2/P4 and oral CEE/MPA had been prescribed by the treating physician in real-world practice and were observed through pharmacy dispensing records. MAIN OUTCOME MEASURES Venous thromboembolism risk was compared between women receiving oral E2/P4 versus oral CEE/MPA. RESULTS The study included 36,061 women treated with oral E2/P4 or oral CEE/MPA. In the analyses weighted by the inverse probability of treatment for control of potential confounding factors, the incidence of venous thromboembolism was significantly lower for oral E2/P4 compared with oral CEE/MPA (37/10,000 women-years for oral E2/P4 vs 53/10,000 women-years for oral CEE/MPA; incidence rate ratio 0.70, 95 % confidence interval: 0.53-0.92). CONCLUSIONS Real-world evidence suggests that the risk of venous thromboembolism is significantly lower among women treated with oral E2/P4 compared with oral CEE/MPA.
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Affiliation(s)
- Nick Panay
- Imperial College Healthcare NHS Trust, The Bays, S Wharf Rd, London W2 1NY, United Kingdom; Chelsea and Westminster NHS Foundation Trust, 369 Fulham Road, 116, London SW10 9NH, United Kingdom; Queen Charlotte's & Chelsea Hospital, Du Cane Rd, London W12 0HS, United Kingdom
| | - Rossella E Nappi
- Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Research Center for Reproductive Medicine, Gynecological Endocrinology and Menopause, IRCCS San Matteo Foundation, Piazzale Golgi 2, 27100 Pavia, Italy
| | - Petra Stute
- Department of Obstetrics and Gynecology, Inselspital, University Clinic Bern, Friedbühlstr. 19, 3010 Bern, Switzerland
| | - Santiago Palacios
- Palacios Institute of Women's Health and Medicine, Calle Antonio Acuña, 9, Madrid 28009, Spain
| | - Tomasz Paszkowski
- III Chair and Department of Gynecology, Medical University of Lublin, 8 Jaczewskiego St., 20-954 Lublin, Poland
| | - Risa Kagan
- Sutter East Bay Medical Group, Affiliated with Sutter East Bay Medical Foundation, Department of Obstetrics, Gynecology and Reproductive Sciences, UCSF, 2500 Milvia Street, Berkeley, CA, USA
| | - David F Archer
- Clinical Research Center, Department of Obstetrics and Gynecology, Eastern Virginia Medical School, 601 Colley Avenue, Suite 241, Norfolk, VA 23507, USA
| | - Julie Héroux
- Heroux Consulting, Vrouwe Meilendislaan 14, Den Haag 2553EX, Netherlands
| | - Mitra Boolell
- Theramex HQ UK Ltd., Sloane Square House, 1 Holbein Place, London SW1W 8NS, United Kingdom.
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9
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Simon JA, Anderson RA, Ballantyne E, Bolognese J, Caetano C, Joffe H, Kerr M, Panay N, Seitz C, Seymore S, Trower M, Zuurman L, Pawsey S. Efficacy and safety of elinzanetant, a selective neurokinin-1,3 receptor antagonist for vasomotor symptoms: a dose-finding clinical trial (SWITCH-1). Menopause 2023; 30:239-246. [PMID: 36720081 PMCID: PMC9970022 DOI: 10.1097/gme.0000000000002138] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 10/26/2022] [Accepted: 10/26/2022] [Indexed: 02/01/2023]
Abstract
OBJECTIVE Neurokinin (NK)-3 and NK-1 receptors have been implicated in the etiology of vasomotor symptoms (VMS) and sleep disturbances associated with menopause. This phase 2b, adaptive, dose-range finding study aimed to assess the efficacy and safety of multiple doses of elinzanetant (NT-814), a selective NK-1,3 receptor antagonist, in women experiencing VMS associated with menopause, and investigate the impact of elinzanetant on sleep and quality of life. METHODS Postmenopausal women aged 40 to 65 years who experienced seven or more moderate-to-severe VMS per day were randomized to receive elinzanetant 40, 80, 120, or 160 mg or placebo once daily using an adaptive design algorithm. Coprimary endpoints were reduction in mean frequency and severity of moderate-to-severe VMS at weeks 4 and 12. Secondary endpoints included patient-reported assessments of sleep and quality of life. RESULTS Elinzanetant 120 mg and 160 mg achieved reductions in VMS frequency versus placebo from week 1 throughout 12 weeks of treatment. Least square mean reductions were statistically significant versus placebo at both primary endpoint time points for elinzanetant 120 mg (week 4: -3.93 [SE, 1.02], P < 0.001; week 12: -2.95 [1.15], P = 0.01) and at week 4 for elinzanetant 160 mg (-2.63 [1.03]; P = 0.01). Both doses also led to clinically meaningful improvements in measures of sleep and quality of life. All doses of elinzanetant were well tolerated. CONCLUSIONS Elinzanetant is an effective and well-tolerated nonhormone treatment option for postmenopausal women with VMS and associated sleep disturbance. Elinzanetant also improves quality of life in women with VMS.
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Affiliation(s)
- James A. Simon
- From the George Washington University, IntimMedicine Specialists, Washington, DC
| | - Richard A. Anderson
- MRC Centre for Reproductive Health, Queens Medical Research Institute, University of Edinburgh, Edinburgh, United Kingdom
| | | | | | | | - Hadine Joffe
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Mary Kerr
- NeRRe Therapeutics, Stevenage, United Kingdom
| | - Nick Panay
- Queen Charlotte's and Chelsea and Westminster Hospitals, Imperial College, London, United Kingdom
| | | | | | - Mike Trower
- NeRRe Therapeutics, Stevenage, United Kingdom
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Graham S, Archer DF, Simon JA, Ohleth KM, Bernick B. Review of menopausal hormone therapy with estradiol and progesterone versus other estrogens and progestins. Gynecol Endocrinol 2022; 38:891-910. [PMID: 36075250 DOI: 10.1080/09513590.2022.2118254] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Objective: The objective of the present document was to review/summarize reported outcomes compared between menopausal hormone therapy (MHT) containing estradiol (E2) versus other estrogens and MHT with progesterone (P4) versus progestins (defined as synthetic progestogens).Methods: PubMed and EMBASE were systematically searched through February 2021 for studies comparing oral E2 versus oral conjugated equine estrogens (CEE) or P4 versus progestins for endometrial outcomes, venous thromboembolism (VTE), cardiovascular outcomes, breast outcomes, cognition, and bone outcomes in postmenopausal women.Results: A total of 74 comparative publications were identified/summarized. Randomized studies suggested that P4 and progestins are likely equally effective in preventing endometrial hyperplasia/cancer when used at adequate doses. E2- versus CEE-based MHT had a similar or possibly better risk profile for VTE and cardiovascular outcomes, and P4- versus progestin-based MHT had a similar or possibly better profile for breast cancer and cardiovascular outcomes. E2 may potentially protect better against age-related cognitive decline and bone fractures versus CEE; P4 was similar or possibly better versus progestins for these outcomes. Limitations are that many studies were observational and some were not adequately powered for the reported outcomes.Conclusions: Evidence suggests a differential effect of MHT containing E2 or P4 and those containing CEE or progestins, with some evidence trending to a potentially better safety profile with E2 and/or P4.
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Affiliation(s)
| | - David F Archer
- Department of Obstetrics and Gynecology, Clinical Research Center, Eastern Virginia Medical School, Norfolk, VA
| | - James A Simon
- School of Medicine, George Washington University, Washington, DC
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Einfluss einer Hormonersatztherapie in der Peri- und Postmenopause auf das Krebsrisiko. GYNAKOLOGISCHE ENDOKRINOLOGIE 2022. [DOI: 10.1007/s10304-022-00460-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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12
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Ruan X, Mueck AO. Primary choice of estrogen and progestogen as components for HRT: a clinical pharmacological view. Climacteric 2022; 25:443-452. [PMID: 35638518 DOI: 10.1080/13697137.2022.2073811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Prescribing hormone replacement therapy (HRT) requires consideration of the selection of its two components, the estrogen and the progestogen. In terms of the estrogen, the decision is mainly whether to use estradiol (E2) or conjugated equine estrogens (CEE). These are the components needed to efficiently treat climacteric symptoms or/and prevent osteoporosis, currently the only labeled indications. There is still controversy regarding the adequate dosages comparing E2 and CEE; however, the consensus is that the differences in the efficacy of E2 and CEE are not a real issue. Therefore, other criteria have to be used. The first reason to add the progestogen is to avoid the development of endometrial cancer (i.e. to achieve 'endometrial safety'). Any available 'fixed-combined' HRT preparation has to be tested for sufficient endometrial efficacy, because the first question the health authorities ask before product registration relates to endometrial safety. We can generally rely on the endometrial safety of these fixed-combined products. However, it could be that we want to use 'free' combinations, which are necessary if we use transdermal E2 (patches, gel, spray), but also to individualize schedules, for example when treating bleeding problems. The question here is how to attain knowledge about the endometrial efficacy of the different progestogens and how to monitor therapy. We will try to answer these two questions from a 'clinical pharmacology' point of view, as a discipline which preferably considers pharmacological properties, but also relating to clinical practice, to achieve individualized therapy with optimal efficacy, best tolerability and minimal risks.
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Affiliation(s)
- X Ruan
- Department of Gynecological Endocrinology, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing Maternal and Child Health Care Hospital, Beijing, China.,Department of Women's Health, Research Centre for Women's Health and University Women's Hospital of Tuebingen, University of Tuebingen, Tuebingen, Germany
| | - A O Mueck
- Department of Gynecological Endocrinology, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing Maternal and Child Health Care Hospital, Beijing, China.,Department of Women's Health, Research Centre for Women's Health and University Women's Hospital of Tuebingen, University of Tuebingen, Tuebingen, Germany
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13
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Ruan X, Mueck AO. Optimizing menopausal hormone therapy: for treatment and prevention, menstrual regulation, and reduction of possible risks. GLOBAL HEALTH JOURNAL 2022. [DOI: 10.1016/j.glohj.2022.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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McClung MR, Kagan R, Graham S, Bernick B, Mirkin S, Constantine G. Effects of E2/P4 oral capsules on bone turnover in women with vasomotor symptoms. Menopause 2022; 29:304-308. [PMID: 35213517 PMCID: PMC8862769 DOI: 10.1097/gme.0000000000001915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 10/11/2021] [Accepted: 10/11/2021] [Indexed: 12/03/2022]
Abstract
OBJECTIVE To evaluate bone turnover markers (BTM) in the REPLENISH trial (NCT01942668). METHODS REPLENISH evaluated oral estradiol/progesterone (E2/P4) for the treatment of moderate to severe vasomotor symptoms (VMS) in postmenopausal women with a uterus. Eligible women for this analysis had ≥50 moderate to severe VMS/wk, were <5 years since last menstrual period, and had BTM measurements at baseline, and months 6 and 12. Percent changes for three BTM (bone-specific alkaline phosphatase [BSAP], C-terminal telopeptide of type I collagen [CTX-1], and N-terminal propeptide of type I procollagen [P1NP]) assessed by immunoassay methods were evaluated from baseline to months 6 and 12 for the 1 mg E2/100 mg P4, 0.5 mg E2/100 mg P4, and placebo groups. RESULTS A total of 157 women (40-61 y, 69% White) were analyzed. Mean baseline values ranged from 14.0 to 14.3 U/L for BSAP, 0.34 to 0.39 ng/mL for CTX-1, and 76.9 to 79.3 ng/mL for PINP. Mean differences in percent change from baseline for both E2/P4 doses versus placebo significantly decreased at months 6 and 12 and ranged from -8% to -16% for BSAP (all, P < 0.05), -30% to -41% for CTX-1 (all, P ≤ 0.001), and -14% to -29% for PINP (all, P < 0.01). CONCLUSIONS REPLENISH data provide support for a potential skeletal benefit of E2/P4 when it is used for the treatment of moderate to severe VMS. Further studies are warranted.
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Affiliation(s)
- Michael R. McClung
- Oregon Osteoporosis Center, Portland, OR
- Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, VIC, Australia
| | - Risa Kagan
- University of California, San Francisco and Sutter East Bay Medical Foundation, Berkeley, CA
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Miyazaki K, Kaneko M, Narukawa M. Factors associated with high placebo response in clinical studies of hot flashes: a meta-analysis. Menopause 2021; 29:239-246. [PMID: 35084377 DOI: 10.1097/gme.0000000000001895] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
IMPORTANCE High placebo response can often mask the evaluation of active treatment in clinical studies for women with hot flashes and potentially undermine the evaluation of new treatments. OBJECTIVE The aim of this meta-analysis was to determine the factors associated with high placebo response (defined as the reduction in the mean number of hot flash frequency from baseline) in randomized, controlled, double-blind studies enrolling women with hot flashes. EVIDENCE REVIEW To identify eligible studies, Embase, MEDLINE, and BIOSIS Previews were searched for English-language articles published between April 1975 and August 2020. Placebo-controlled, double-blind, randomized studies that assessed changes in hot flash frequency were included if they satisfied the defined criteria. We conducted univariate and multivariate analyses using categorical and numerical data. Categorical data included the following variables and levels in brackets: active treatment type (hormone therapy /non- hormone therapy /complementary and alternative medicine), administration route (oral/non-oral), study region (in/excluded the US), breast cancer population (in/excluded), entry criteria of hot flash severity (moderate to severe only/all included), parallel or crossover study, placebo run-in period before treatment (yes/no), and menopausal status (postmenopausal only/include perimenopausal/include premenopausal). Numerical data included published year, pretreatment period duration, treatment period duration, number of sites, number of total participants, number of placebo participants, number of treatment arms, mean age, BMI, and hot flash frequency at baseline. FINDINGS Forty-three of the 802 identified publications were included in the review. Multivariate analysis identified three individual factors associated with high placebo response: treatment period duration, number of treatment arms, and BMI. CONCLUSIONS AND RELEVANCE We identified several factors associated with high placebo response in clinical studies of women with hot flashes. Knowing these factors may enable proactive implementation of operational and analytic strategies that further aid in determining the true treatment effect of an intervention.
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Affiliation(s)
- Kentaro Miyazaki
- Department of Clinical Medicine (Pharmaceutical Medicine), Graduate School of Pharmaceutical Sciences, Kitasato University, Tokyo, Japan
- Astellas Pharma Inc, Tokyo, Japan
| | - Masayuki Kaneko
- Department of Hospital Pharmaceutics, School of Pharmaceutical Sciences, Showa University, Tokyo, Japan
| | - Mamoru Narukawa
- Department of Clinical Medicine (Pharmaceutical Medicine), Graduate School of Pharmaceutical Sciences, Kitasato University, Tokyo, Japan
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Gallez A, Blacher S, Maquoi E, Konradowski E, Joiret M, Primac I, Gérard C, Taziaux M, Houtman R, Geris L, Lenfant F, Marangoni E, Sounni NE, Foidart JM, Noël A, Péqueux C. Estetrol Combined to Progestogen for Menopause or Contraception Indication Is Neutral on Breast Cancer. Cancers (Basel) 2021; 13:cancers13102486. [PMID: 34065180 PMCID: PMC8160902 DOI: 10.3390/cancers13102486] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 04/23/2021] [Accepted: 05/07/2021] [Indexed: 12/23/2022] Open
Abstract
Simple Summary Hormonal treatments, especially those used to treat menopause symptoms are known to increase breast cancer risk. It is thus necessary to identify new formulations with a better benefit/risk profile. The aim of this translational study was to evaluate the breast cancer risk associated with a combination of a natural estrogen named estetrol, with progestogens such as natural progesterone and drospirenone. Since the assessment of breast cancer risk in patients during drug development is not possible given the requirement of long-term studies in large populations, this study provides new evidence that a therapeutic dose of estetrol for menopause treatment or contraception, combined with progesterone or drospirenone, may provide a better benefit/risk profile toward breast cancer risk compared to the hormonal treatments currently available for patients. Abstract Given the unequivocal benefits of menopause hormone therapies (MHT) and combined oral contraceptives (COC), there is a clinical need for new formulations devoid of any risk of breast cancer promotion. Accumulating data from preclinical and clinical studies support that estetrol (E4) is a promising natural estrogen for MHT and COC. Nevertheless, we report here that E4 remains active on the endometrium, even under a dose that is neutral on breast cancer growth and lung metastasis dissemination. This implies that a progestogen should be combined with E4 to protect the endometrium of non-hysterectomized women from hyperplasia and cancer. Through in vivo observations and transcriptomic analyses, our work provides evidence that combining a progestogen to E4 is neutral on breast cancer growth and dissemination, with very limited transcriptional impact. The assessment of breast cancer risk in patients during the development of new MHT or COC is not possible given the requirement of long-term studies in large populations. This translational preclinical research provides new evidence that a therapeutic dose of E4 for MHT or COC, combined with progesterone or drospirenone, may provide a better benefit/risk profile towards breast cancer risk compared to hormonal treatments currently available for patients.
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Affiliation(s)
- Anne Gallez
- Laboratory of Biology, Tumors and Development, GIGA-Cancer, University of Liège, 4000 Liège, Belgium; (A.G.); (S.B.); (E.M.); (E.K.); (I.P.); (N.E.S.); (J.-M.F.); (A.N.)
| | - Silvia Blacher
- Laboratory of Biology, Tumors and Development, GIGA-Cancer, University of Liège, 4000 Liège, Belgium; (A.G.); (S.B.); (E.M.); (E.K.); (I.P.); (N.E.S.); (J.-M.F.); (A.N.)
| | - Erik Maquoi
- Laboratory of Biology, Tumors and Development, GIGA-Cancer, University of Liège, 4000 Liège, Belgium; (A.G.); (S.B.); (E.M.); (E.K.); (I.P.); (N.E.S.); (J.-M.F.); (A.N.)
| | - Erika Konradowski
- Laboratory of Biology, Tumors and Development, GIGA-Cancer, University of Liège, 4000 Liège, Belgium; (A.G.); (S.B.); (E.M.); (E.K.); (I.P.); (N.E.S.); (J.-M.F.); (A.N.)
| | - Marc Joiret
- Biomechanics Research Unit, GIGA-In Silico Medicine, University of Liège, 4000 Liège, Belgium; (M.J.); (L.G.)
| | - Irina Primac
- Laboratory of Biology, Tumors and Development, GIGA-Cancer, University of Liège, 4000 Liège, Belgium; (A.G.); (S.B.); (E.M.); (E.K.); (I.P.); (N.E.S.); (J.-M.F.); (A.N.)
| | - Céline Gérard
- Mithra Pharmaceuticals, rue Saint-Georges 5/7, 4000 Liège, Belgium; (C.G.); (M.T.)
| | - Mélanie Taziaux
- Mithra Pharmaceuticals, rue Saint-Georges 5/7, 4000 Liège, Belgium; (C.G.); (M.T.)
| | - René Houtman
- Precision Medicine Lab, 5349 AB Oss, The Netherlands;
| | - Liesbet Geris
- Biomechanics Research Unit, GIGA-In Silico Medicine, University of Liège, 4000 Liège, Belgium; (M.J.); (L.G.)
| | - Françoise Lenfant
- INSERM U1048, Institut des Maladies Métaboliques et Cardiovasculaires, University Paul Sabatier, 31432 Toulouse, France;
| | - Elisabetta Marangoni
- Translational Research Department, Institute Curie, PSL Research University, 75248 Paris, France;
| | - Nor Eddine Sounni
- Laboratory of Biology, Tumors and Development, GIGA-Cancer, University of Liège, 4000 Liège, Belgium; (A.G.); (S.B.); (E.M.); (E.K.); (I.P.); (N.E.S.); (J.-M.F.); (A.N.)
| | - Jean-Michel Foidart
- Laboratory of Biology, Tumors and Development, GIGA-Cancer, University of Liège, 4000 Liège, Belgium; (A.G.); (S.B.); (E.M.); (E.K.); (I.P.); (N.E.S.); (J.-M.F.); (A.N.)
| | - Agnès Noël
- Laboratory of Biology, Tumors and Development, GIGA-Cancer, University of Liège, 4000 Liège, Belgium; (A.G.); (S.B.); (E.M.); (E.K.); (I.P.); (N.E.S.); (J.-M.F.); (A.N.)
| | - Christel Péqueux
- Laboratory of Biology, Tumors and Development, GIGA-Cancer, University of Liège, 4000 Liège, Belgium; (A.G.); (S.B.); (E.M.); (E.K.); (I.P.); (N.E.S.); (J.-M.F.); (A.N.)
- Correspondence: ; Tel.: +32-4-366-2569
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Genazzani AR, Monteleone P, Giannini A, Simoncini T. Pharmacotherapeutic options for the treatment of menopausal symptoms. Expert Opin Pharmacother 2021; 22:1773-1791. [PMID: 33980106 DOI: 10.1080/14656566.2021.1921148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Introduction: Menopausal symptoms can be very overwhelming for women. Over the years, many pharmacotherapeutic options have been tested, and others are still being developed. Hormone therapy (HT) is the most efficient therapy for managing vasomotor symptoms and related disturbances. The term HT comprises estrogens and progestogens, androgens, tibolone, the tissue-selective estrogen complex (TSEC), a combination of bazedoxifene and conjugated estrogens, and the selective estrogen receptor modulators, such as ospemifene. Estrogens and progestogens and androgens may differ significantly for chemical structure and can be delivered through different routes, thereby displaying various pharmacological and clinical properties. Tibolone, TSEC and SERM also exhibit unique pharmacodynamics that can be exploited to obtain distinctive therapeutic effects. Non-hormonal options fall mainly into the selective serotonin reuptake inhibitor (SSRI) and selective noradrenergic reuptake inhibitor (SNRI), GABA-analogue drug classes.Areas covered: Herein, the authors describe the pharmacokinetics and pharmacodynamics of hormonal (androgens, estrogens, progestogens, tibolone, TSEC, SERMs) and non-hormonal (SSRIs, SNRIs, Gabapentin, Pregabalin, Oxybutynin, Neurokinin antagonists) treatments for menopausal symptoms and report essential clinical trial data in humans.Expert opinion: Patient tailoring of treatment is key to managing symptoms of menopause. Physicians must have in-depth knowledge of the pharmacology of compounds to tailor therapy to the individual patient's characteristics and needs.
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Affiliation(s)
- Andrea R Genazzani
- Division of Obstetrics and Gynecology, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Patrizia Monteleone
- Division of Obstetrics and Gynecology, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Andrea Giannini
- Division of Obstetrics and Gynecology, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Tommaso Simoncini
- Division of Obstetrics and Gynecology, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
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A multicenter, randomized study to select the minimum effective dose of estetrol (E4) in postmenopausal women (E4Relief): part 1. Vasomotor symptoms and overall safety. ACTA ACUST UNITED AC 2021; 27:848-857. [PMID: 32379217 PMCID: PMC7386865 DOI: 10.1097/gme.0000000000001561] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Objective: The aim of this study was to select the minimum effective dose of estetrol (E4) for the treatment of vasomotor symptoms in postmenopausal women. Methods: This was a multicenter, randomized, double-blind, placebo-controlled study. Postmenopausal women (n = 257, of whom 32 were hysterectomized) aged 40 to 65 years, with ≥7 moderate to severe hot flushes (HFs) per day, or 50 or more moderate to severe HFs weekly, received 2.5, 5, 10, or 15 mg E4, or placebo once-daily for a period of 12 weeks. Efficacy was assessed by recording the frequency and severity of HFs. Overall safety was assessed by recording adverse events, measuring endometrial thickness, and monitoring bleeding patterns. Treatment groups were compared using analysis of covariance. Results: The frequency of moderate to severe HFs decreased with all E4 doses. The difference in the percentage change of weekly HF frequency was significant for 15 mg E4 versus placebo at both W4 (−66% vs −49%, P = 0.032) and W12 (−82% vs −65%, P = 0.022). The decrease in severity of HFs was significantly more pronounced for 15 mg E4 than for placebo at both W4 (−0.59 vs −0.33, P = 0.049) and W12 (−1.04 vs −0.66, P = 0.049); the other doses failed to achieve statistical significance. In nonhysterectomized women, endometrial thickness increased during treatment and normalized following progestin treatment at study completion. No endometrial hyperplasia was observed. Conclusions: Estetrol 15 mg is considered to be the minimum effective daily oral dose for treatment of vasomotor symptoms. Its current seemingly favorable safety profile is further to be confirmed in phase 3 clinical development. Video Summary:.
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TX-001HR is associated with a clinically meaningful effect on severity of moderate to severe vasomotor symptoms in the REPLENISH trial. ACTA ACUST UNITED AC 2021; 27:1236-1241. [PMID: 33110039 PMCID: PMC7587237 DOI: 10.1097/gme.0000000000001602] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Objective: The aim of the study was to evaluate the clinically meaningful effect of oral TX-001HR (17β-estradiol [E2]/progesterone [P4]) capsules on hot flushes severity (vasomotor symptoms [VMS] severity scale) using the patient-reported Clinical Global Impression (CGI). Methods: REPLENISH (NCT01942668) was a phase 3, randomized, double-blind, placebo-controlled, multicenter trial that evaluated TX-001HR in postmenopausal women (40-65 y) with a uterus. Those with frequent moderate to severe hot flushes (≥7/d or ≥50/wk) were randomized in a VMS substudy to daily E2/P4 (1/100, 0.5/100, 0.5/50, or 0.25/50 mg/mg), or placebo. Patients rated VMS severity from 1 (mild) to 3 (severe) and symptom improvements with the CGI. CGI results were an anchor in a nonparametric discriminant analysis to define clinically important differences (CIDs) and minimal CID in VMS severity at weeks 4 and 12. Results: In the VMS substudy (n = 726), determined CID and minimal CID severity thresholds were reductions of 0.525 and 0.350 points at week 4, respectively, and 0.775 and 0.225 points at week 12. Significantly more women taking the two highest E2/P4 doses (1/100 and 0.5/100) versus placebo met CID severity thresholds at weeks 4 (40% and 44% vs 17%; P < 0.05) and 12 (56% and 48% vs 29%; P < 0.05). Conclusion: REPLENISH trial data demonstrated that E2/P4 1/100 and 0.5/100 provided clinically meaningful improvements in hot flushes severity in postmenopausal women. In conjunction with previously demonstrated clinically meaningful VMS frequency improvements, these data support oral E2/P4 1/100 and 0.5/100 for postmenopausal women with a uterus seeking treatment for moderate to severe VMS.
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Sriprasert I, Hodis HN, Bernick B, Mirkin S, Mack WJ. Determinants of attained estradiol levels in response to oral estradiol plus progesterone therapy. Climacteric 2021; 24:194-199. [PMID: 33179515 PMCID: PMC7920923 DOI: 10.1080/13697137.2020.1838477] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 10/12/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVES Among postmenopausal women taking hormone therapy (HT), the estradiol (E2) dose and E2 levels were differentially associated with change in metabolic measures. We evaluated determinants of attained E2 levels in response to HT. METHODS Postmenopausal women from the REPLENISH trial tested four formulations of oral combined E2 and progesterone compared with placebo. Mixed-effects linear models assessed characteristics associated with E2 levels among women with ≥80% HT compliance, adjusted for E2 dose and baseline E2 level. RESULTS Among 1173 postmenopausal women with mean (standard deviation) age 55 (4.3) years and 5.2 (4.8) years since menopause, higher treated E2 levels were significantly related to younger age, more recent menopause, and current alcohol use, while lower E2 levels were related to current smoking. Both age and time since menopause were significantly inversely associated with E2 levels; time since menopause had a stronger association with E2 levels. In the final multivariable model, E2 levels were positively associated with current alcohol use, and inversely associated with time since menopause and current smoking. CONCLUSION Adjusting for E2 dose and baseline E2 level, on-trial E2 levels were significantly associated with time since menopause, current smoking, and current alcohol use. Practitioners should consider these factors in individual women to achieve a desirable E2 level during HT.
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Affiliation(s)
- I. Sriprasert
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - H. N. Hodis
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
- Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
- Atherosclerosis Research Unit, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | | | | | - W. J. Mack
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
- Atherosclerosis Research Unit, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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Endometrial safety and bleeding profile of a 17β-estradiol/progesterone oral softgel capsule (TX-001HR). ACTA ACUST UNITED AC 2020; 27:410-417. [PMID: 31913228 PMCID: PMC7147409 DOI: 10.1097/gme.0000000000001480] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Objective: The aim of the study was to evaluate the effect of a single-capsule 17β-estradiol/progesterone (E2/P4), TX-001HR, on endometrial safety, to report on amenorrhea and bleeding patterns of users, and to identify predictors of amenorrhea. Methods: The REPLENISH trial (NCT01942668) evaluated use of TX-001HR in menopausal women (40-65 y) with vasomotor symptoms (VMS) and a uterus. Women were randomized to daily E2/P4 (mg/mg: 1/100, 0.5/100, 0.5/50, or 0.25/50), or placebo for 12 months. Incidence rate of endometrial hyperplasia was calculated from endometrial biopsies conducted at screening and study completion. Women reported bleeding and spotting in daily diaries. The number of bleeding and/or spotting days and the proportion of women with no bleeding or amenorrhea were compared between treatment and placebo using the Fisher exact test. Predictors of cumulative amenorrhea were assessed by univariate analyses. Results: Women (n = 1,835) who took at least one study dose comprised the safety population; 1,255 had baseline and 12-month biopsies and comprised the endometrial safety population. Incidence of endometrial hyperplasia was ≤0.36% with any dose of TX-001HR after 1 year of use (one-sided upper 95% confidence interval ≤4%). Cumulative amenorrhea (no bleeding/spotting) rates increased over time and were relatively high from cycle 1 to 13 with TX-001HR (56%-73%; placebo 79%; P < 0.05 except with 0.25/50 dose). Few vaginal bleeding adverse events (1.0%-4.6% TX-001HR vs 0.7% placebo) were reported and discontinuations due to bleeding were low (0.4%-1.4% vs 0%). Cumulative amenorrhea was significantly more frequent in older women, those further from their last menstrual period, and those with lower baseline E2 concentrations (all; P < 0.01). Conclusions: All doses of TX-001HR provided endometrial protection and were associated with an improved bleeding profile over time; older age, further last menstrual period, or lower baseline E2 may predict amenorrhea with TX-001HR.
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22
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Woodis CB, Ghassemi E, McLendon AN. Bioidentical Oral 17β-Estradiol and Progesterone for the Treatment of Moderate to Severe Vasomotor Symptoms of Menopause. Ann Pharmacother 2020; 55:1153-1158. [PMID: 33345556 DOI: 10.1177/1060028020982611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To review the efficacy, safety, and available literature regarding the novel combination bioidentical product Bijuva, or 17β-estradiol/progesterone (17β-E/P), for the treatment of moderate to severe menopausal symptoms in cisgender females with an intact uterus. DATA SOURCES Literature searches of both PubMed (1966 to October 2020) and Google Scholar were conducted using search terms including bioidentical, estradiol, progesterone, menopause, E2/P4, TX-001HR, and Bijuva. STUDY SELECTION AND DATA EXTRACTION All articles with studies conducted in cisgender human females and in the English language were considered for review; 18 publications were included. DATA SYNTHESIS In 1 phase 3 clinical study, 17β-E/P was proven to be effective at reducing the frequency and severity of vasomotor symptoms (VMS) at 12 weeks compared with placebo, and no cases of endometrial hyperplasia were observed over the 52-week safety study period. Menopausal women with an intact uterus were included in the study population. RELEVANCE TO PATIENT CARE AND PRACTICE Concerns over content and safety of compounded bioidentical hormones have been raised by several professional societies. As women experience VMS of menopause, a desire for a Food and Drug Administration-regulated bioidentical combination product for the treatment of moderate to severe menopausal symptoms may be desirable. Given as a once-daily oral capsule at the dose of 1 mg estradiol/100 mg progesterone, 17β-E/P is approved for the treatment of VMS associated with menopause. CONCLUSIONS 17β-E/P is a novel bioidentical product that is the first of its kind in the treatment of moderate to severe menopausal symptoms.
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Affiliation(s)
- C Brock Woodis
- Campbell University College of Pharmacy and Health Sciences, Buies Creek, NC, USA.,Duke University Medical Center, Durham, NC, USA
| | - Emily Ghassemi
- Campbell University College of Pharmacy and Health Sciences, Buies Creek, NC, USA.,Southern Regional Area Health Education Center, Fayetteville, NC, USA
| | - Amber N McLendon
- Campbell University College of Pharmacy and Health Sciences, Buies Creek, NC, USA.,Glenaire, Inc, Cary, NC, USA
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Smith T, Sahni S, Thacker HL. Postmenopausal Hormone Therapy-Local and Systemic: A Pharmacologic Perspective. J Clin Pharmacol 2020; 60 Suppl 2:S74-S85. [PMID: 33274517 DOI: 10.1002/jcph.1740] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 08/19/2020] [Indexed: 12/16/2022]
Abstract
Every woman, if she lives long enough, will transition into menopause, and as the US population ages, women will be spending more time in a postmenopausal state than before. For postmenopausal women, the decision to initiate menopausal hormone therapy should be individualized. A thorough evaluation of the patient's cardiovascular, venous thromboembolic, cancer, and fracture risk should be considered along with the woman's quality of life. Hormone therapy exerts its therapeutic effects on vasomotor symptoms, the skeleton, and the genitourinary system independent of age since menopause and these benefits are lost once hormone therapy is stopped. Here we review the pharmacologic properties dose, formulation, mode of administration, timing of initiation, and duration of hormonal therapies in regard to optimizing benefit and minimizing risk to the patient. This discussion will focus on the effects of common hormonal therapies including estrogen (local and systemic), progesterone, estrogen receptor agonist/antagonist, and local dehydroepiandrosterone and include a brief review of compounded bioidentical hormone therapy.
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Affiliation(s)
- Taryn Smith
- OB-GYN and Women's Health Institute, Center for Specialized Women's Health, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Sabrina Sahni
- OB-GYN and Women's Health Institute, Department of OB-GYN, Cleveland Clinic Foundation, Weston, Florida, USA
| | - Holly L Thacker
- OB-GYN and Women's Health Institute, Center for Specialized Women's Health, Cleveland Clinic Foundation, Cleveland, Ohio, USA
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Abstract
One of the defining moments of the 80-year evolution of menopausal hormone therapy (MHT) was the 2002 reveal of the initial results of the combined hormone therapy arm of the Women's Health Initiative (WHI) clinical trial. The exodus from regulatory approved MHT was prompt and profound and accompanied by a rapid acceleration of the compounding pharmacy 'bioidentical' hormone therapy industry. Compounders had recruited prescribers and promoted compounded bioidentical hormone therapy (cBHT) well before the WHI, yet the startling results provided a catalyst that enabled a leap in production of compounded hormones that were variably regulated, basically unstudied, and inconsistently labeled. In this review, the story of the rise of cBHT and the regulatory double standard is eclipsed only by the 2020 findings and recommendations of the US National Academies of Science, Engineering, and Medicine. Their investigation, commissioned by the US Food and Drug Administration, was tasked to: provide an evidence-based summary of the clinical utility of cBHT; evaluate whether the evidence of safety and efficacy supports the use of cBHT; and identify patient populations that might need cBHT in lieu of an approved drug product. Their conclusions are consistent with sound science and their recommendations are in harmony with global menopause societies.
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Affiliation(s)
- C A Stuenkel
- University of California, San Diego, School of Medicine, La Jolla, CA, USA
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25
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Hipolito Rodrigues MA, Gompel A. Micronized progesterone, progestins, and menopause hormone therapy. Women Health 2020; 61:3-14. [DOI: 10.1080/03630242.2020.1824956] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
| | - Anne Gompel
- Department of Gynecology, Université Paris Descartes, Paris, France
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Effects of combined 17β-estradiol and progesterone on weight and blood pressure in postmenopausal women of the REPLENISH trial. ACTA ACUST UNITED AC 2020; 28:32-39. [PMID: 32932401 PMCID: PMC7769186 DOI: 10.1097/gme.0000000000001659] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Objective: To examine the impact of a single-capsule 17β-estradiol (E2)/progesterone (P4) on weight and blood pressure (BP) when treating moderate to severe vasomotor symptoms in postmenopausal women with a uterus. Methods: Healthy postmenopausal women with a uterus (aged 40-65, body mass index ≤34 kg/m2, BP ≤140/90 mm Hg) were randomized to daily E2/P4 (mg/mg; 1/100, 0.5/100, 0.5/50, 0.25/50) or placebo in the phase 3 REPLENISH trial (NCT01942668). Changes in weight and BP from baseline to month 12 were evaluated. Potentially clinically important changes were defined as increases or decreases from baseline in weight by ≥15% and ≥11.3 kg, systolic BP by ≥20 mm Hg (absolute value ≥160 or ≤90 mm Hg), and diastolic BP by ≥15 mm Hg (absolute value ≥90 or ≤60 mm Hg). Results: Overall mean changes in weight and BP from baseline to month 12 with E2/P4 were modest and generally not statistically or clinically significant versus placebo. Incidence of potentially clinically important changes was low for weight (E2/P4 vs placebo: 1.1-2.6% vs 2.2%), systolic BP (0.3-1.1% vs 1.1%), and diastolic BP (1.4-4.2% vs 3.2%). A small number of women had treatment-related, treatment-emergent adverse events of weight gain (1.4-2.6% vs 1.3%) or hypertension (0.2-1.2% vs 0%). Few women who discontinued E2/P4 had weight gain (1.6%) or hypertension (0.6%) as a primary reason. Efficacy profile on VMS was consistent with previous findings and not modified by body mass index. Conclusions: Twelve-month use of E2/P4 had no clinically meaningful impact on weight or BP in postmenopausal women of the REPLENISH study.
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Liu JH, Black DR, Larkin L, Graham S, Bernick B, Mirkin S. Breast effects of oral, combined 17β-estradiol, and progesterone capsules in menopausal women: a randomized controlled trial. ACTA ACUST UNITED AC 2020; 27:1388-1395. [PMID: 32842052 PMCID: PMC7709925 DOI: 10.1097/gme.0000000000001631] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Objective: To evaluate the effect of a single-capsule, bioidentical 17β-estradiol (E2) and progesterone (P4) hormone therapy on mammograms and breasts in postmenopausal women after 1 year of use. Methods: In the 12-month, phase 3, randomized, double-blind, placebo-controlled, multicenter REPLENISH trial, postmenopausal women (40-65 y) with moderate to severe vasomotor symptoms and a uterus were randomized to four active daily dose groups of E2/P4 (TX-001HR) or a placebo group. Mammograms were performed and read locally at screening (or ≤6 months before first dose) and at study end using BI-RADS classification. Incidence of abnormal mammograms and breast adverse events was evaluated. Results: All but 8 (0.4%) mammograms at screening were normal (BI-RADS 1 or 2). At 1 year, 39 (2.9%) of the 1,340 study-end mammograms were abnormal (BI-RADS 3 or 4); incidence was 1.7% to3.7% with active doses and 3.1% with placebo. Breast cancer incidence was 0.36% with active doses and 0% with placebo. Breast tenderness was reported at frequencies of 2.4% to 10.8% with active doses versus 0.7% with placebo, and led to eight study discontinuations (1.6% of discontinuations in active groups). Conclusions: In this phase 3 trial of a combined E2/P4, results of secondary outcomes suggest that E2/P4 may not be associated with increased risk of abnormal mammograms versus placebo, and the incidence of breast tenderness was low relative to most of the rates reported in other studies using hormone therapy.
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Affiliation(s)
- James H Liu
- University Hospitals Cleveland Medical Center, Cleveland, OH
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17β-estradiol/progesterone in a single, oral, softgel capsule (TX-001HR) significantly increased the number of vasomotor symptom-free days in the REPLENISH trial. ACTA ACUST UNITED AC 2020; 27:1382-1387. [PMID: 32740481 PMCID: PMC7709918 DOI: 10.1097/gme.0000000000001615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Objective: To examine responder rates and vasomotor symptom-free days with oral 17β-estradiol/progesterone (E2/P4; TX-001HR) versus placebo in the REPLENISH trial. Methods: REPLENISH (NCT01942668) was a phase 3, randomized, double-blind, placebo-controlled, multicenter trial, evaluating single, oral, softgel E2/P4 capsules in postmenopausal women (40-65 y) with a uterus and vasomotor symptoms (VMS). Women with moderate to severe hot flushes (≥7/d or ≥50/wk) were randomized (VMS substudy) to daily E2/P4 (mg/mg) of 1/100, 0.5/100, 0.5/50, 0.25/50, or placebo. Proportions of women with ≥50% or ≥75% reductions in moderate to severe VMS (responders), and those with no severe VMS as well as the weekly number of days without moderate to severe VMS with TX-001HR versus placebo were determined. Mixed model repeated measures was used to analyze data and Fisher exact test was employed to compare E2/P4 versus placebo. Results: Seven hundred twenty-six women were eligible for the VMS efficacy analysis (E2/P4 1/100 [n = 141], 0.5/100 [n = 149], 0.5/50 [n = 147], 0.25/50 [n = 154], or placebo [n = 135]). Significantly more women treated with all E2/P4 doses versus placebo were ≥50% responders and ≥75% responders at weeks 4 and 12 (P < 0.05) and also had significantly more days per week without moderate to severe VMS at week 12 (1.9-3.0 d for E2/P4 versus 1.3 d for placebo; P < 0.05). The proportion of women without severe hot flushes at week 12 was 43% to 56% for all E2/P4 doses versus 26% for placebo (P ≤ 0.01). Conclusions: Women treated with E2/P4 had a greater response to treatment with more VMS-free days than with placebo. The E2/P4 1/100 dose (Bijuva [E2 and P4] capsules) represents an oral treatment option for postmenopausal women with moderate to severe VMS and a uterus.
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29
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Sriprasert I, Hodis HN, Bernick B, Mirkin S, Mack WJ. Effects of Estradiol Dose and Serum Estradiol Levels on Metabolic Measures in Early and Late Postmenopausal Women in the REPLENISH Trial. J Womens Health (Larchmt) 2020; 29:1052-1058. [PMID: 32644875 DOI: 10.1089/jwh.2019.8238] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Background: To identify the association of estradiol (E2) dose and serum E2 levels with metabolic measures in early (<6 years) compared with late (≥10 years) postmenopausal women from the REPLENISH trial. Material and Methods: This is a post hoc analysis of a multicenter randomized clinical trial in the United States. Four doses of TX-001HR, an oral combination of E2 and progesterone (P4), and placebo were tested. This analysis included a total of 1,216 early and 297 late postmenopausal women. Linear mixed-effects models tested the association of E2 dose and serum E2 levels with changes in metabolic parameters; total cholesterol (TC), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), triglyceride (TG), and glucose (GLUC) levels from six visits over 12 months, adjusted for the serum P4 level. Results: A higher E2 dose was significantly associated with lower TC (p = 0.02) and LDL-C (p = 0.002) and higher HDL-C (p = 0.04) levels in early, but not late, postmenopause. With longer time since menopause, the inverse association of E2 dose with TC and LDL-C and positive association with HDL-C were attenuated (interaction p < 0.05). Higher serum E2 levels were significantly associated with lower TC (p = 0.004), LDL-C (p = 0.0001), and fasting blood GLUC (p = 0.003) and higher TG (p = 0.002) levels in early postmenopause. Conclusion: E2 dose differentially affects metabolic measures among early compared with late postmenopausal women. No significant main effect of the serum P4 level was found. As the metabolic parameters studied are risk factors for cardiovascular events, these results support the timing hypothesis of E2 therapy and its cardiovascular benefits.
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Affiliation(s)
- Intira Sriprasert
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA.,Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Howard N Hodis
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA.,Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA.,Atherosclerosis Research Unit, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | | | | | - Wendy J Mack
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA.,Atherosclerosis Research Unit, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
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30
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Gompel A. Progesterone and endometrial cancer. Best Pract Res Clin Obstet Gynaecol 2020; 69:95-107. [PMID: 32732107 DOI: 10.1016/j.bpobgyn.2020.05.003] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 04/06/2020] [Accepted: 05/06/2020] [Indexed: 12/19/2022]
Abstract
It is well established that unopposed estrogen, either endogenous or therapeutic, can induce endometrial hyperplasia and potentially endometrial cancer (EC). Anovulatory cycles, obesity, and insulin resistance are major risk factors for EC. Progestogen (progesterone and progestin), including levonorgestrel intrauterine device, are able to prevent or to treat hyperplasia, atypical hyperplasia, and even well-differentiated EC, as presented in this review. During menopausal hormone therapy, progestogens protect the endometrium against the proliferative effects of estrogens in women with a uterus. Whereas, recent epidemiologic data suggest that micronized progesterone (MP) is apparently safer for the breast, it could be less efficient than synthetic progestin on the endometrium. However, several studies from biopsies during treatment with MP do not show any increased risk of hyperplasia. Lack of compliance could explain the results on EC.
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Affiliation(s)
- Anne Gompel
- Université de Paris, Hôpitaux Universitaires Port Royal-Cochin, Gynécologie Endocrinienne, 123 bd du Port Royal, Paris, 75014, France.
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31
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Evaluation of clinical meaningfulness of estrogen plus progesterone oral capsule (TX-001HR) on moderate to severe vasomotor symptoms. Menopause 2020; 26:513-519. [PMID: 30516713 PMCID: PMC6493698 DOI: 10.1097/gme.0000000000001261] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Objective: The aim of this study was to determine the clinical meaningfulness of TX-001HR in reducing moderate to severe vasomotor symptoms (VMS) in menopausal women with a uterus. Methods: In the REPLENISH study (NCT01942668), women with moderate to severe hot flushes (≥7/d or ≥50/wk) were enrolled in a VMS substudy and randomized to four doses of daily TX-001HR (17β-estradiol/progesterone) or placebo. Participants assessed improvement of their VMS by the Clinical Global Impression and the Menopause-Specific Quality of Life (MENQOL) questionnaire, which were used to define clinical responders, clinically important differences (CIDs) or minimal CID (MCID) in VMS frequency. Response thresholds were determined by nonparametric discriminant analyses utilizing bootstrapping methods. Results: In the modified intent-to-treat VMS substudy population (n = 726), statistically significantly more Clinical Global Impression–based clinical responders were observed with TX-001HR than placebo for MCID (weekly reduction of ≥25 moderate to severe VMS: 82-88% vs 69%; all, P < 0.05) and CID (weekly reduction of ≥39 VMS: 68%-73% vs 52%; all, P < 0.05) at week 12. Week 4 results were similar. For Menopause Quality of Life–based analysis, significantly more clinical responders were observed with TX-001HR than placebo for MCID (weekly reduction of ≥34 VMS: 74%-81% vs 55%; all, P < 0.01) and CID (weekly reduction of ≥44 VMS: 61%-69% vs 42%; all, P < 0.01) at week 12. Conclusions: TX-001HR provided clinically meaningful improvements (as measured by 2 different methods), in addition to statistically significant reductions, in menopausal VMS frequency. TX-001HR may provide a new option, as a single oral capsule of estradiol and progesterone (identical to the hormones naturally occurring in women) for the treatment of moderate to severe VMS in menopausal women with a uterus.
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32
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Oral 17β-estradiol/progesterone (TX-001HR) and quality of life in postmenopausal women with vasomotor symptoms. Menopause 2020; 26:506-512. [PMID: 30489424 PMCID: PMC6493699 DOI: 10.1097/gme.0000000000001271] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Objective: The aim of the study was to describe the effects of TX-001HR (17β-estradiol [E2] and natural progesterone [P4] in a single oral capsule) on menopause-specific quality of life in women with moderate to severe vasomotor symptoms (VMS). Methods: The REPLENISH study (NCT01942668) was a phase 3, randomized, double-blind, placebo-controlled, multicenter trial which evaluated four E2/P4 doses in postmenopausal women with VMS and a uterus. Women with moderate to severe hot flushes (≥7/d or ≥50/wk) were included in a VMS substudy. Participants self-administered the Menopause-Specific Quality of Life (MENQOL) questionnaire. Baseline changes in MENQOL overall and domains were determined as well as correlations between changes in MENQOL scores and VMS frequency or severity. Results: In the VMS substudy, women treated with E2/P4 had significantly greater improvements from baseline in their MENQOL overall score at week 12, and months 6 and 12, compared with placebo (all, P < 0.05, except the lowest E2/P4 dose at months 6 and 12). Improvements from baseline for the MENQOL vasomotor domain score were significantly greater with TX-001HR doses versus placebo at all time points (all, P < 0.01). Changes in MENQOL vasomotor scores moderately correlated with changes in VMS frequency (r = 0.56, P < 0.0001) and severity (r = 0.55, P < 0.0001). Conclusion: In the REPLENISH trial, women with moderate to severe VMS treated with most E2/P4 doses reported significant improvements in quality of life from baseline to 12 weeks compared with placebo, which were maintained up to 12 months. TX-001HR, if approved, may provide the first oral hormone therapy formulation in a single capsule containing E2 and P4 for the treatment of VMS in postmenopausal women with a uterus.
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Relationship between vasomotor symptom improvements and quality of life and sleep outcomes in menopausal women treated with oral, combined 17β-estradiol/progesterone. Menopause 2020; 26:637-642. [PMID: 30601452 PMCID: PMC6553507 DOI: 10.1097/gme.0000000000001294] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Objective: To characterize the impact of TX-001HR on the relationship between vasomotor symptom (VMS) improvement and quality of life and sleep. Methods: REPLENISH (NCT01942668) was a phase 3, randomized, double-blind, placebo-controlled, multicenter trial, which evaluated four daily doses of 17β-estradiol and progesterone (E2/P4) combined in a single, oral, softgel capsule in postmenopausal women (40-65 years) with a uterus and moderate to severe VMS (≥7/day or ≥50/week). In post hoc analyses, growth models were used to examine relationships between linear changes in VMS frequency and severity over 12 weeks and changes from baseline in the Menopause-Specific Quality of Life (MENQOL; total score and VMS domain) and the Medical Outcomes Study-Sleep (total score, sleep problems indices I and II) questionnaire outcomes at 12 weeks with treatment compared with placebo. Results: Outcomes with all four E2/P4 doses were combined (n = 591) and compared with placebo (n = 135). In all 5 growth models, the effects of TX-001HR on MENQOL total score and vasomotor domain were significantly associated with changes in VMS frequency and severity observed over 12 weeks (all, P < 0.001). Treatment-mediated effects on MENQOL via VMS frequency and severity models were significant. Similar results were found with Medical Outcomes Study-Sleep total score and sleep problems indices. Conclusions: TX-001HR improvements in quality of life and sleep outcomes are associated with and may be mediated through improvements in VMS frequency and severity.
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Sriprasert I, Hodis HN, Bernick B, Mirkin S, Mack WJ. Association of oral estradiol dose/levels with coagulation measures in early/late postmenopausal women. Climacteric 2020; 23:273-278. [PMID: 31939316 DOI: 10.1080/13697137.2019.1703939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Objective: This study evaluated associations of estradiol (E2) dose and serum E2 levels with coagulation/anti-coagulation measures in early (<6 years) compared with late (≥10 years) postmenopausal women.Methods: Postmenopausal women from the REPLENISH trial tested four formulations of oral combined E2 and progesterone compared with placebo. Mixed-effects linear models tested the association of E2 dose and serum E2 levels with the prothrombin time (PT), the activated partial thromboplastin time (APTT), antithrombin (ATHRM), fibrinogen (FIBRINO), protein C (PROTC), and protein S (PROTS), assessed five times over 12 months.Results: Among 1215 early and 297 late postmenopausal women, the E2 dose was statistically significantly inversely associated with the APTT in early postmenopause, PROTC in late postmenopause, and with the PT, ATHRM, and PROTS in both groups. Serum E2 levels were statistically significantly inversely associated with the APTT, PROTS, and FIBRINO in early postmenopause, the PT in late postmenopause, and ATHRM and PROTC in both groups. With longer time since menopause, the inverse E2 dose effect and serum E2 effects became stronger.Conclusion: Increasing E2 dose and serum E2 levels were associated with changes in coagulation/anti-coagulation measures. The associations were stronger among women ≥10 years since menopause when initiating E2. The timing of E2 therapy, E2 dose, and serum E2 levels relative to time since menopause may modify the venous thromboembolism risk.
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Affiliation(s)
- I Sriprasert
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.,Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - H N Hodis
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.,Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.,Atherosclerosis Research Unit, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | | | - S Mirkin
- TherapeuticsMD, Boca Raton, FL, USA
| | - W J Mack
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.,Atherosclerosis Research Unit, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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Depypere H, Timmerman D, Donders G, Sieprath P, Ramael S, Combalbert J, Hoveyda HR, Fraser GL. Treatment of Menopausal Vasomotor Symptoms With Fezolinetant, a Neurokinin 3 Receptor Antagonist: A Phase 2a Trial. J Clin Endocrinol Metab 2019; 104:5893-5905. [PMID: 31415087 DOI: 10.1210/jc.2019-00677] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Accepted: 08/07/2019] [Indexed: 02/13/2023]
Abstract
CONTEXT The thermoregulatory center in the hypothalamus is stimulated by neurokinin 3 receptor (NK3R) activation and inhibited by estrogen-negative feedback. This balance is disrupted in menopause, producing vasomotor symptoms (VMSs). OBJECTIVE To evaluate safety and efficacy of the NK3R antagonist fezolinetant in menopausal VMSs. DESIGN Twelve-week, double-blind, randomized, placebo-controlled study. SETTING Eight Belgian centers from September 2015 to October 2016. PARTICIPANTS Generally healthy menopausal women aged 40 to 65 years with moderate/severe VMSs. INTERVENTIONS Subjects were randomized (1:1) to 90 mg of fezolinetant twice daily or placebo for 12 weeks. MAIN OUTCOME MEASURES Subjects captured VMS severity and frequency using an electronic diary. The primary outcome was change from baseline to week 12 in total VMS score with fezolinetant vs placebo. Secondary outcomes included timing of changes in frequency and severity of moderate/severe VMSs and quality-of-life assessments at weeks 4, 8, and 12. Pharmacodynamic and pharmacokinetic effects were assessed, as were safety and tolerability. RESULTS Of 122 subjects screened, 87 were randomized and 80 (92%) completed the study. At week 12, fezolinetant significantly reduced total VMS score vs placebo (-26.5 vs -12.2, P < 0.001) and decreased mean frequency of moderate/severe VMSs by five episodes per day vs placebo. Severity and frequency of moderate/severe VMSs were reduced from the first day of treatment. Improvements were achieved in all quality-of-life measures. Fezolinetant was well tolerated. The most common fezolinetant-related adverse event was gastrointestinal disorder (n = 6). CONCLUSIONS Fezolinetant rapidly and significantly reduced moderate/severe VMSs, supporting its potential as an effective nonhormonal treatment option for menopausal women.
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Affiliation(s)
- Herman Depypere
- Breast and Menopause Clinic, University Hospital, Ghent, Netherlands
| | - Dirk Timmerman
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
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Improvement in sleep outcomes with a 17β-estradiol-progesterone oral capsule (TX-001HR) for postmenopausal women. Menopause 2019; 26:622-628. [PMID: 30586005 PMCID: PMC6553506 DOI: 10.1097/gme.0000000000001278] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Objective: The aim of the study was to evaluate the effects of TX-001HR, a single-capsule 17β-estradiol–progesterone on sleep parameters in postmenopausal women with vasomotor symptoms (VMS) using the Medical Outcomes Study (MOS)-Sleep scale questionnaire in the REPLENISH trial. Methods: In the REPLENISH trial (NCT01942668), women were randomized to one of four doses of TX-001HR or placebo, and the 12-item MOS-Sleep questionnaire (secondary endpoint) was self-administered at baseline, week 12, and months 6 and 12. Changes from baseline in the MOS-Sleep total score and 7 subscale scores were analyzed for treatment groups versus placebo at all time points. Somnolence was also collected as an adverse event. Results: Women (mean age 55 y) were randomized to TX-001HR (estradiol/ progesterone [E2/P4] [mg/mg]) doses: 1/100 (n = 415), 0.5/100 (n = 424), 0.5/50 (n = 421), 0.25/50 (n = 424), or placebo (n = 151). TX-001HR significantly improved MOS-Sleep total score, Sleep Problems Index II subscale, and sleep disturbance subscale versus placebo at all time points, except with 0.25 mg E2/50 mg P4 at week 12. Differences in LS mean changes between TX-001HR and placebo for MOS-Sleep total scores ranged from −6.5 to −7.6 at 12 months (all; P ≤ 0.001). All doses of TX-001HR significantly improved the Sleep Problems Index I subscale at all time points. The sleep somnolence subscale significantly improved from baseline with 0.5 mg E2/100 mg P4 and 0.5 mg E2/50 mg P4 at month 12. The incidence of somnolence as a treatment-emergent adverse event ranged from 0.2% to 1.2% versus 0% with placebo. Conclusion: TX-001HR significantly improved MOS-Sleep parameters from baseline to week 12, which was sustained for up to 12 months, and was associated with a very low incidence of somnolence.
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Mueck AO, Ruan X. Will estradiol/progesterone capsules for oral use become the best choice for menopausal hormone therapy? Climacteric 2019; 22:535-537. [PMID: 31612748 DOI: 10.1080/13697137.2019.1663625] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- A O Mueck
- Department of Women's Health, University of Tuebingen , Tuebingen , Germany.,Department of Gynecological Endocrinology, Beijing Obstetrics and Gynecology Hospital, Capital Medical University , Beijing , China
| | - X Ruan
- Department of Women's Health, University of Tuebingen , Tuebingen , Germany.,Department of Gynecological Endocrinology, Beijing Obstetrics and Gynecology Hospital, Capital Medical University , Beijing , China
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Estradiol/Progesterone (Bijuva) for Menopausal Vasomotor Symptoms. JAMA 2019; 322:1206-1207. [PMID: 31550026 DOI: 10.1001/jama.2019.10692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Lobo RA, Kaunitz AM, Santoro N, Bernick B, Graham S, Mirkin S. Metabolic and cardiovascular effects of TX-001HR in menopausal women with vasomotor symptoms. Climacteric 2019; 22:610-616. [PMID: 31364889 DOI: 10.1080/13697137.2019.1640197] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Objective: This study aimed to evaluate the effects of TX-001HR (17β-estradiol [E2] and progesterone [P4] in a single oral capsule) on cardiometabolic markers and outcomes. Methods: Four E2/P4 doses (1 mg/100 mg, 0.5 mg/100 mg, 0.5 mg/50 mg, 0.25 mg/50 mg) were compared with placebo in menopausal women with vasomotor symptoms (VMS) and a uterus in the phase 3 REPLENISH (ClinicalTrials.gov, NCT01942668) trial. Changes in lipid and coagulation parameters and blood glucose from baseline at 6, 9, and 12 months as well as cardiovascular events are summarized. Results: A total of 1835 participants took ≥1 capsule of daily E2/P4; 1684 received E2/P4 and 151 received placebo. No clinically significant changes in lipid parameters, coagulation factors, or glucose were observed between treatment groups. Minimal increases of potential clinical importance were observed in total cholesterol, triglycerides, and glucose at month 12 with E2/P4 (1-4%, 6-11%, and 1%, respectively) and placebo (3%, 7%, and 2%, respectively). One episode of deep venous thrombosis and three cases of cardiovascular disease were observed, similar to expected rates of these events in the general population. Conclusions: In the REPLENISH trial, postmenopausal women with VMS treated with E2/P4 had no clinically meaningful effects on lipids, glucose, or coagulation parameters compared with placebo.
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Affiliation(s)
- R A Lobo
- Department of Obstetrics and Gynecology, Columbia University Medical Center , New York , NY , USA
| | - A M Kaunitz
- Department of Obstetrics and Gynecology, University of Florida College of Medicine-Jacksonville , Jacksonville , FL , USA
| | - N Santoro
- Department of Obstetrics and Gynecology, University of Colorado School of Medicine , Aurora , CO , USA
| | - B Bernick
- TherapeuticsMD , Boca Raton , FL , USA
| | - S Graham
- TherapeuticsMD , Boca Raton , FL , USA
| | - S Mirkin
- TherapeuticsMD , Boca Raton , FL , USA
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Archer DF, Bernick BA, Mirkin S. A combined, bioidentical, oral, 17β-estradiol and progesterone capsule for the treatment of moderate to severe vasomotor symptoms due to menopause. Expert Rev Clin Pharmacol 2019; 12:729-739. [DOI: 10.1080/17512433.2019.1637731] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- David F. Archer
- Clinical Research Center, Eastern Virginia Medical School, Norfolk, VA, USA
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Dodda BR, Bondi CD, Hasan M, Clafshenkel WP, Gallagher KM, Kotlarczyk MP, Sethi S, Buszko E, Latimer JJ, Cline JM, Witt-Enderby PA, Davis VL. Co-administering Melatonin With an Estradiol-Progesterone Menopausal Hormone Therapy Represses Mammary Cancer Development in a Mouse Model of HER2-Positive Breast Cancer. Front Oncol 2019; 9:525. [PMID: 31355130 PMCID: PMC6636553 DOI: 10.3389/fonc.2019.00525] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 05/30/2019] [Indexed: 12/20/2022] Open
Abstract
Melatonin has numerous anti-cancer properties reported to influence cancer initiation, promotion, and metastasis. With the need for effective hormone therapies (HT) to treat menopausal symptoms without increasing breast cancer risk, co-administration of nocturnal melatonin with a natural, low-dose HT was evaluated in mice that develop primary and metastatic mammary cancer. Individually, melatonin (MEL) and estradiol-progesterone therapy (EPT) did not significantly affect mammary cancer development through age 14 months, but, when combined, the melatonin-estradiol-progesterone therapy (MEPT) significantly repressed tumor formation. This repression was due to effects on tumor incidence, but not latency. These results demonstrate that melatonin and the HT cooperate to decrease the mammary cancer risk. Melatonin and EPT also cooperate to alter the balance of the progesterone receptor (PR) isoforms by significantly increasing PRA protein expression only in MEPT mammary glands. Melatonin significantly suppressed amphiregulin transcripts in MEL and MEPT mammary glands, suggesting that amphiregulin together with the higher PRA:PRB balance and other factors may contribute to reducing cancer development in MEPT mice. Melatonin supplementation influenced mammary morphology by increasing tertiary branching in the mouse mammary glands and differentiation in human mammary epithelial cell cultures. Uterine weight in the luteal phase was elevated after long-term exposure to EPT, but not to MEPT, indicating that melatonin supplementation may reduce estrogen-induced uterine stimulation. Melatonin supplementation significantly decreased the incidence of grossly-detected lung metastases in MEL mice, suggesting that melatonin delays the formation of metastatic lesions and/or decreases aggressiveness in this model of HER2+ breast cancer. Mammary tumor development was similar in EPT and MEPT mice until age 8.6 months, but after 8.6 months, only MEPT continued to suppress cancer development. These data suggest that melatonin supplementation has a negligible effect in young MEPT mice, but is required in older mice to inhibit tumor formation. Since melatonin binding was significantly decreased in older mammary glands, irrespective of treatment, melatonin supplementation may overcome reduced melatonin responsiveness in the aged MEPT mice. Since melatonin levels are known to decline near menopause, nocturnal melatonin supplementation may also be needed in aging women to cooperate with HT to decrease breast cancer risk.
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Affiliation(s)
- Balasunder R Dodda
- Graduate School of Pharmaceutical Sciences, Duquesne University, Pittsburgh, PA, United States
| | - Corry D Bondi
- Graduate School of Pharmaceutical Sciences, Duquesne University, Pittsburgh, PA, United States
| | - Mahmud Hasan
- Graduate School of Pharmaceutical Sciences, Duquesne University, Pittsburgh, PA, United States
| | - William P Clafshenkel
- Graduate School of Pharmaceutical Sciences, Duquesne University, Pittsburgh, PA, United States
| | - Katie M Gallagher
- Graduate School of Pharmaceutical Sciences, Duquesne University, Pittsburgh, PA, United States
| | - Mary P Kotlarczyk
- Graduate School of Pharmaceutical Sciences, Duquesne University, Pittsburgh, PA, United States
| | - Shalini Sethi
- Graduate School of Pharmaceutical Sciences, Duquesne University, Pittsburgh, PA, United States
| | - Ethan Buszko
- Graduate School of Pharmaceutical Sciences, Duquesne University, Pittsburgh, PA, United States
| | - Jean J Latimer
- UPMC Hillman Cancer Center, University of Pittsburgh, Pittsburgh, PA, United States
| | - J Mark Cline
- Department of Pathology, Wake Forest University School of Medicine, Winston-Salem, NC, United States
| | - Paula A Witt-Enderby
- Graduate School of Pharmaceutical Sciences, Duquesne University, Pittsburgh, PA, United States.,UPMC Hillman Cancer Center, University of Pittsburgh, Pittsburgh, PA, United States
| | - Vicki L Davis
- Graduate School of Pharmaceutical Sciences, Duquesne University, Pittsburgh, PA, United States
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Genazzani AR, Gaspard U, Foidart JM. Oral investigational drugs currently in phase I or phase II for the amelioration of menopausal symptoms. Expert Opin Investig Drugs 2019; 28:235-247. [DOI: 10.1080/13543784.2019.1572114] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Andrea R. Genazzani
- Division of Obstetrics and Gynecology, Department of Clinical and Experimental Medicine, University of Pisa,
Pisa, Italy
| | - Ulysse Gaspard
- Department of Obstetrics and Gynecology, University of Liège, Liège,
Belgium
| | - Jean-Michel Foidart
- Department of Obstetrics and Gynecology, University of Liège, Liège,
Belgium
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Estradiol and progesterone bioavailability for moderate to severe vasomotor symptom treatment and endometrial protection with the continuous-combined regimen of TX-001HR (oral estradiol and progesterone capsules). Menopause 2019; 26:720-727. [PMID: 30694918 PMCID: PMC6636803 DOI: 10.1097/gme.0000000000001306] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Objective: In the REPLENISH trial, women receiving TX-001HR—an oral, softgel capsule, combining 17β-estradiol (E2) and progesterone (E2 mg/P4 mg 1/100, 0.5/100), had significantly improved vasomotor symptoms, while having their endometrium protected from hyperplasia. The objective here was to describe P4 levels sufficient to counteract the potential endometrial effects of 1 or 0.5 mg oral E2 with TX-001HR. Methods: In REPLENISH (phase 3; NCT01942668), serum P4, E2, and estrone (E1) levels were characterized in postmenopausal women treated with TX-001HR (E2 mg/P4 mg: 1/100, 0.5/100, [0.5/50, 0.25/50 and placebo not reported here]) at baseline, week 12, and month 12 for P4, and at baseline, weeks 4 and 12, and months 6, 9, and 12 for E2 and E1. In a phase 1 study, pharmacokinetic parameters were assessed after 7 daily doses of oral E2 mg/P4 mg (1/100 and 0.5/100). Results: In REPLENISH (n = 1,835), mean P4 levels were 0.39 to 0.55 ng/mL with 100-mg P4 doses; E2 levels were 42.3 to 45.6 pg/mL and 23.0 to 27.4 pg/mL for the 1-mg and 0.5-mg E2 doses, respectively; E1 levels were 214 to 242 pg/mL and 114 to 129 pg/mL for the 1-mg and 0.5-mg E2 doses. In the phase 1 study (n = 40; day 7), mean Cavg for P4 was 0.66 ng/mL with 100-mg P4 doses; E2 was 38.1 pg/mL and 29.2 pg/mL for 1 mg and 0.5 mg E2, respectively; and E1 was 211 and 106 pg/mL for 1 mg and 0.5 mg E2. All three analytes reached steady state within 7 days; accumulation ratios were 1.36 to 1.94. Conclusions: P4 levels observed with TX-001HR were similar in the phase 1 and 3 studies, and were associated with no endometrial hyperplasia with either E2 daily dose over 1 year in the REPLENISH phase 3 study, which showed significant improvements in menopausal vasomotor symptoms.
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A 17β-Estradiol–Progesterone Oral Capsule for Vasomotor Symptoms in Postmenopausal Women: A Randomized Controlled Trial: Correction. Obstet Gynecol 2018; 132:786. [DOI: 10.1097/aog.0000000000002859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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45
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Abstract
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.
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Affiliation(s)
- S Mirkin
- a TherapeuticsMD , Boca Raton , FL , USA
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