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Danan ER, Sowerby C, Ullman KE, Ensrud K, Forte ML, Zerzan N, Anthony M, Kalinowski C, Abdi HI, Friedman JK, Landsteiner A, Greer N, Nardos R, Fok C, Dahm P, Butler M, Wilt TJ, Diem S. Hormonal Treatments and Vaginal Moisturizers for Genitourinary Syndrome of Menopause : A Systematic Review. Ann Intern Med 2024. [PMID: 39250810 DOI: 10.7326/annals-24-00610] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/11/2024] Open
Abstract
BACKGROUND Postmenopausal women commonly experience vulvovaginal, urinary, and sexual symptoms associated with genitourinary syndrome of menopause (GSM). PURPOSE To evaluate effectiveness and harms of vaginal estrogen, nonestrogen hormone therapies, and vaginal moisturizers for treatment of GSM symptoms. DATA SOURCES Medline, Embase, and CINAHL through 11 December 2023. STUDY SELECTION Randomized controlled trials (RCTs) of at least 8 weeks' duration enrolling postmenopausal women with at least 1 GSM symptom and reporting effectiveness or harms of hormonal interventions or vaginal moisturizers. DATA EXTRACTION Risk of bias and data extraction were performed by one reviewer and verified by a second reviewer. Certainty of evidence (COE) was assessed by one reviewer and verified by consensus. DATA SYNTHESIS From 11 993 citations, 46 RCTs evaluating vaginal estrogen (k = 22), nonestrogen hormones (k = 16), vaginal moisturizers (k = 4), or multiple interventions (k = 4) were identified. Variation in populations, interventions, comparators, and outcomes precluded meta-analysis. Compared with placebo or no treatment, vaginal estrogen may improve vulvovaginal dryness, dyspareunia, most bothersome symptom, and treatment satisfaction. Compared with placebo, vaginal dehydroepiandrosterone (DHEA) may improve dryness, dyspareunia, and distress, bother, or interference from genitourinary symptoms; oral ospemifene may improve dryness, dyspareunia, and treatment satisfaction; and vaginal moisturizers may improve dryness (all low COE). Vaginal testosterone, systemic DHEA, vaginal oxytocin, and oral raloxifene or bazedoxifene may provide no benefit (low COE) or had uncertain effects (very low COE). Although studies did not report frequent serious harms, reporting was limited by short-duration studies that were insufficiently powered to evaluate infrequent serious harms. LIMITATIONS Most studies were 12 weeks or less in duration and used heterogeneous GSM diagnostic criteria and outcome measures. Few studies enrolled women with a history of cancer. CONCLUSION Vaginal estrogen, vaginal DHEA, oral ospemifene, and vaginal moisturizers may improve some GSM symptoms in the short term. Few long-term data exist on efficacy, comparative effectiveness, tolerability, and safety of GSM treatments. PRIMARY FUNDING SOURCE Agency for Healthcare Research and Quality and Patient-Centered Outcomes Research Institute. (PROSPERO: CRD42023400684).
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Affiliation(s)
- Elisheva R Danan
- Center for Care Delivery & Outcomes Research, VA Health Care System, and Department of Medicine, University of Minnesota, Minneapolis, Minnesota (E.R.D., S.D.)
| | - Catherine Sowerby
- Center for Care Delivery & Outcomes Research, VA Health Care System, Minneapolis, Minnesota (C.S., K.E.U., N.Z., M.A., C.K., A.L., N.G.)
| | - Kristen E Ullman
- Center for Care Delivery & Outcomes Research, VA Health Care System, Minneapolis, Minnesota (C.S., K.E.U., N.Z., M.A., C.K., A.L., N.G.)
| | - Kristine Ensrud
- Center for Care Delivery & Outcomes Research, VA Health Care System; Department of Medicine, University of Minnesota; and Division of Epidemiology & Community Health, School of Public Health, University of Minnesota, Minneapolis, Minnesota (K.E.)
| | - Mary L Forte
- Division of Health Policy & Management, School of Public Health, University of Minnesota, Minneapolis, Minnesota (M.L.F., H.I.A., M.B.)
| | - Nicholas Zerzan
- Center for Care Delivery & Outcomes Research, VA Health Care System, Minneapolis, Minnesota (C.S., K.E.U., N.Z., M.A., C.K., A.L., N.G.)
| | - Maylen Anthony
- Center for Care Delivery & Outcomes Research, VA Health Care System, Minneapolis, Minnesota (C.S., K.E.U., N.Z., M.A., C.K., A.L., N.G.)
| | - Caleb Kalinowski
- Center for Care Delivery & Outcomes Research, VA Health Care System, Minneapolis, Minnesota (C.S., K.E.U., N.Z., M.A., C.K., A.L., N.G.)
| | - Hamdi I Abdi
- Division of Health Policy & Management, School of Public Health, University of Minnesota, Minneapolis, Minnesota (M.L.F., H.I.A., M.B.)
| | - Jessica K Friedman
- VA Center for the Study of Healthcare Innovation, Implementation, and Policy, Los Angeles, California (J.K.F.)
| | - Adrienne Landsteiner
- Center for Care Delivery & Outcomes Research, VA Health Care System, Minneapolis, Minnesota (C.S., K.E.U., N.Z., M.A., C.K., A.L., N.G.)
| | - Nancy Greer
- Center for Care Delivery & Outcomes Research, VA Health Care System, Minneapolis, Minnesota (C.S., K.E.U., N.Z., M.A., C.K., A.L., N.G.)
| | - Rahel Nardos
- Department of Obstetrics, Gynecology and Women's Health, University of Minnesota, Minneapolis, Minnesota (R.N.)
| | - Cynthia Fok
- Department of Urology, University of Minnesota, Minneapolis, Minnesota (C.F.)
| | - Philipp Dahm
- Urology Section, VA Health Care System, and Department of Urology, University of Minnesota, Minneapolis, Minnesota (P.D.)
| | - Mary Butler
- Division of Health Policy & Management, School of Public Health, University of Minnesota, Minneapolis, Minnesota (M.L.F., H.I.A., M.B.)
| | - Timothy J Wilt
- Center for Care Delivery & Outcomes Research, VA Health Care System; Department of Medicine, University of Minnesota; and Division of Health Policy & Management, School of Public Health, University of Minnesota, Minneapolis, Minnesota (T.J.W.)
| | - Susan Diem
- Center for Care Delivery & Outcomes Research, VA Health Care System, and Department of Medicine, University of Minnesota, Minneapolis, Minnesota (E.R.D., S.D.)
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Tang X, Qin H, Yang J, Zhang X. Transdermal Delivery of Estradiol Simultaneously Possessing Rapid Release and Sustained Release Effect. AAPS PharmSciTech 2023; 24:145. [PMID: 37353673 DOI: 10.1208/s12249-023-02604-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 05/30/2023] [Indexed: 06/25/2023] Open
Abstract
Dissolving microneedle (DMN) has been researched as a drug delivery technology that improves drug molecule transportation through the skin with little discomfort. However, the sluggish drug absorption, poor skin dissolution, and lengthy time lags of DMN have limited its potential uses. The aim of this study was to design a novel DMN system for the administration of the poorly water-soluble drug, estradiol (E2), with fast skin penetration and a stable release rate for a long time. DMN containing E2 emulsion (E2-EM-DMN) and traditional DMN (T-DMN) were prepared. Rat skin was used for penetration test and guinea pig skin was used for skin irritation experiment. The drug release profiles and stability properties of these two kinds of DMNs were also investigated. High performance liquid chromatography was employed to determine the E2 content in DMN. The E2 concentration in rat plasma was achieved by a newly developed liquid chromatography-mass spectrometry method that was fast, reproducible, and specific. The height of E2-EM-DMN and T-DMN was 600 μm. The drug loading of the E2-EM-DMN and T-DMN was 667.30 ± 7.21 μg/patch and 672.56 ± 6.98 μg/patch. E2-EM-DMN possessed enough mechanical strength to penetrate the skin and caused no irritation to the skin. E2-EM-DMN could release the drug more rapidly and more continuously than T-DMN. E2-EM-DMN had good pharmaceutical stability. In summary, the E2-EM-DMN showed reliable quality and superior release performance. Emulsion-embedded DMN is an ideal transdermal delivery system for drugs.
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Affiliation(s)
- XiaoFei Tang
- School of Pharmacy, Lanzhou University, No.199, Donggang West Road, Lanzhou, 730000, China
| | - Huaiying Qin
- School of Pharmacy, Lanzhou University, No.199, Donggang West Road, Lanzhou, 730000, China
| | - Jianhua Yang
- School of Pharmacy, Lanzhou University, No.199, Donggang West Road, Lanzhou, 730000, China
| | - XiaoYun Zhang
- School of Pharmacy, Lanzhou University, No.199, Donggang West Road, Lanzhou, 730000, China.
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Lázaro-Carrasco de la Fuente J, Cuerva González M, González Rodríguez S, Delgado Marín JL, Cuevas Castillo C, Nieto Magro C. Early Effect of 0.005% Estriol Vaginal Gel on Symptoms and Signs of Vulvovaginal Atrophy. J Menopausal Med 2022; 28:60-69. [PMID: 36070871 PMCID: PMC9452593 DOI: 10.6118/jmm.21038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 04/15/2022] [Accepted: 06/27/2022] [Indexed: 11/05/2022] Open
Affiliation(s)
| | - Marcos Cuerva González
- Department of Obstetrics and Gynecology, San Francisco de Asís University Hospital, La Paz University Hospital, and Alfonso X El Sabio University, Madrid, Spain
| | | | - Juan Luis Delgado Marín
- Department of Obstetrics and Gynecology, Virgen de la Arrixaca University Clinical Hospital, University of Murcia, Murcia, Spain
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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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Liu JH, Bernick B, Mirkin S. Estradiol softgel inserts for the treatment of VVA symptoms: an expert opinion. Expert Opin Drug Deliv 2020; 17:1573-1581. [PMID: 32877254 DOI: 10.1080/17425247.2020.1810662] [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: 12/23/2022]
Abstract
INTRODUCTION Vulvar and vaginal atrophy (VVA) affects up to two thirds of postmenopausal women, with symptoms of vaginal dryness, dyspareunia, and vulvar/vaginal irritation. Despite the availability of various treatments, women express dissatisfaction with their options. An estradiol (E2; 4-µg and 10-µg) softgel vaginal insert was approved by the Food and Drug Administration (FDA) to treat moderate to severe dyspareunia, a symptom of VVA, due to menopause. These inserts were designed to treat VVA effectively and safely while avoiding some of the drawbacks of other administration methods. AREAS COVERED This article reviews the physical characteristics and pharmacokinetic data of the E2 softgel vaginal insert. Primary and secondary efficacy endpoints and safety data are reviewed from the pivotal REJOICE trial (NCT02253173), and substudies that explore response rates, changes in vaginal epithelium by visual assessment, efficacy in patient subgroups, effects on sexual function, and patient satisfaction compared with other treatments. EXPERT OPINION The E2 insert shows that vaginal drug delivery is an optimal route of administration for locally treating VVA. This E2 softgel vaginal insert is a safe and effective treatment for symptoms of postmenopausal VVA. The E2 insert's pharmacokinetic characteristics are related to its unique formulation, rapid dissolution, and minimal systemic absorption. ABBREVIATIONS AE: adverse event; AUC: area under the concentration-time curve; BMI: body mass index; Cavg: average concentration; CI: confidence interval; Cmax: maximum concentration; Cmin: minimum concentration; E2: estradiol; FDA: Food and Drug Administration; FSFI: Female Sexual Function Index; GSM: genitourinary symptoms of menopause: MBS: most bothersome symptom; NAMS: North American Menopause Society; OR: odds ratio; PI: pulsatility index; PK: pharmacokinetic; REVIVE: Real Women's Views of treatment options for menopausal Vaginal changEs; RI: resistance index; ROC: receiver operating characteristic; TEAE: treatment-emergent adverse event; tmax: time to maximum concentration; VVA: vulvar and vaginal atrophy.
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Affiliation(s)
- James H Liu
- Department of Obstetrics and Gynecology, University Hospitals Cleveland Medical Center , Cleveland, OH, USA
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Petrine JCP, Del Bianco-Borges B. The influence of phytoestrogens on different physiological and pathological processes: An overview. Phytother Res 2020; 35:180-197. [PMID: 32780464 DOI: 10.1002/ptr.6816] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 06/01/2020] [Accepted: 07/02/2020] [Indexed: 02/06/2023]
Abstract
Functional foods have nutritional properties and organic functions, which are beneficial to health. Certain types of functional food components are so-called phytoestrogens, non-steroidal compounds derived from the metabolism of precursors contained in plants, which originate secondary metabotypes known to induce biological responses and by mimicry or modulating the action of endogenous estrogen. These molecules are involved in several physiological and pathological processes related to reproduction, bone remodeling, skin, cardiovascular, nervous, immune systems, and metabolism. This review aimed to present an overview of phytoestrogens regarding their chemical structure, actions, and effects in the organism given several pathologies. Several studies have demonstrated beneficial phytoestrogen actions, such as lipid profile improvement, cognitive function, menopause, oxidative stress, among others. Phytoestrogens effects are not completely elucidated, being necessary future research to understand the exact action mechanisms, whether they are via estrogen receptor or whether other hidden mechanisms produce these effects. Thus, this review makes a general approach to the phytoestrogen actions, beneficial effects, risk and limitations. However, the complexities of biological effects after ingestion of phytoestrogens and the differences in their metabolism and bioavailability indicate that interpretation of either risk or benefits needs to be made with caution.
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Affiliation(s)
- Jéssica C P Petrine
- Departamento de Ciências da Saúde, Universidade Federal de Lavras, Lavras, Brasil
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