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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; 27:340-350. [PMID: 38978340 DOI: 10.1080/13697137.2024.2368486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 05/28/2024] [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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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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Hull L, Stuckey BGA, Hartman K, Zack N, Friend DR. Evaluation of 28-day estradiol and progesterone vaginal rings in a phase 1 clinical pharmacokinetic study. Menopause 2023; 30:427-436. [PMID: 36727806 DOI: 10.1097/gme.0000000000002148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The aim of this work is to develop a combination of 17β-estradiol (E2) and progesterone (P4) in a single-dose intravaginal ring (IVR) for the treatment of vasomotor symptoms (VMS) and genitourinary syndrome of menopause while providing endometrial protection. The objective of this study was to evaluate DARE-HRT1, a 28-day IVR that continuously delivers E2 and P4, in a phase 1 clinical trial to assess its pharmacokinetics. METHODS This was an open-label, three-arm (group) study. Thirty-two (32) healthy postmenopausal women were recruited at two Australian sites. The average age was 57.2 years (47-69 y). The first arm received one ring for 28 days designed to release E2 at a rate of 80 μg/d and P4 at 4 mg/d (80/4 IVR); the second arm received a ring releasing E2 at 160 μg/d and P4 at 8 mg/d (160/8 IVR). The third arm received oral Estrofem (1 mg E2) and Prometrium (100 mg P4) both daily for 29 days. Blood samples were taken predose then intensively over the first day (day 1) and periodically thereafter over the remaining 27 days. After removal of the rings on the morning of day 29, intensive samples were collected. Similar procedures were conducted with women enrolled in the oral group. The plasma samples were analyzed for E2, estrone (E1), and P4 using validated bioanalytical methods. RESULTS The baseline-adjusted steady-state plasma levels of E2 and P4 from 80/4 IVR were 20.4 ± 17.1 pg/mL and 1.32 ± 0.19 ng/mL (n = 10), respectively. The baseline-adjusted steady-state plasma levels of E2 and P4 from 160/8 IVR were 30.9 ± 8.7 pg/mL and 2.08 ± 0.50 ng/mL (n = 10), respectively. The baseline-adjusted average plasma concentrations of E2 and P4 at day 29 of the oral group were 35.4 ± 11.2 pg/mL and 0.79 ± 0.72 ng/mL (n = 11), respectively. The baseline-adjusted steady state of E1 from the 80/4 IVR and the 160/8 IVR were 22.1 ± 16.6 pg/mL (n = 10) and 25.2 ± 12.3 pg/mL (n = 10), respectively. The baseline-adjusted concentration of E1 in the oral arm was 209 ± 67.7 ng/mL (n = 11). The IVR were well tolerated, and no serious adverse events were reported. CONCLUSIONS The 80/4 IVR and 160/8 IVR gave similar steady-state concentrations of E2 as seen with drug products approved by the US Food and Drug Administration for treatment of VMS and genitourinary symptoms of menopause. The E2 concentrations of this study support the potential of DARE-HRT1, a promising new option for hormone therapy for treatment of VMS and vaginal symptoms associated with menopause.
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Affiliation(s)
- Louise Hull
- From the PARC Clinical Research, University of Adelaide, Adelaide, Australia
| | - Bronwyn G A Stuckey
- Keogh Institute for Medical Research, Department of Endocrinology and Diabetes, Sir Charles Gairdner Hospital, University of Western Australia, Nedlands, Australia
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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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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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