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Bounous VE, Cipullo I, D'Alonzo M, Martella S, Franchi D, Villa P, Biglia N, Ferrero A. A prospective, multicenter, randomized, double-blind placebo-controlled trial on purified and specific Cytoplasmic pollen extract for hot flashes in breast cancer survivors. Gynecol Endocrinol 2024; 40:2334796. [PMID: 38760920 DOI: 10.1080/09513590.2024.2334796] [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] [Received: 11/23/2023] [Accepted: 03/11/2024] [Indexed: 05/20/2024] Open
Abstract
OBJECTIVE evaluate the efficacy and tolerability of PureCyTonin against hot flashes (HF) in breast cancer survivors (BCS). METHODS a prospective, multicenter, randomized, double-blind placebo-controlled trial was conducted in Italy. INTERVENTIONS administration of PureCyTonin or placebo, for 3 months. Effectiveness was investigated through the compilation of a daily diary for HF and of validated questionnaires (Menopause Rating Scale (MRS), Pittsburgh Sleep Quality Index (PSQI), Visual Analogical Scales (VAS) for HF, sweating, irritability, fatigue, sleep, quality of life), carried out before starting the treatment (T0), after 1 month (T1) and after 3 months (T2). Any side effects and HF diary were recorded at each visit. RESULTS 19 women were randomized to receive PureCyTonin and 20 to placebo. At T2 compared to T0, in the PureCyTonin group, we found a reduction in the number of HF (p = 0.02) measured by daily diary. An improvement in the subjective perception of women regarding HF intensity (p = 0.04), sweat nuisance (p = 0.02), irritability (p = 0.03) and fatigue (p = 0.04) was observed through VAS scale measurement at T2 compared to T0.The total MRS score was significantly better in the PureCyTonin group at T1 (p = 0.03) compared to T0. CONCLUSIONS PureCyTonin significantly reduces HF number after 3 months of therapy in BCS and it is well-tolerated.
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Affiliation(s)
- Valentina Elisabetta Bounous
- Gynecology and Obstetrics Unit, Umberto I Hospital of Turin, Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Isabella Cipullo
- Gynecology and Obstetrics Unit, Umberto I Hospital of Turin, Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Marta D'Alonzo
- Gynecology and Obstetrics Unit, Umberto I Hospital of Turin, Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Silvia Martella
- Unit of Preventive Gynecology, IRCCS European Institute of Oncology, Milan, Italy
| | - Dorella Franchi
- Unit of Preventive Gynecology, IRCCS European Institute of Oncology, Milan, Italy
| | - Paola Villa
- Department of Woman and Child Health and Public Health, Child Health Area, Sacred Heart Catholic University, Rome, Italy
| | - Nicoletta Biglia
- Gynecology and Obstetrics Unit, Umberto I Hospital of Turin, Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Annamaria Ferrero
- Gynecology and Obstetrics Unit, Umberto I Hospital of Turin, Department of Surgical Sciences, University of Turin, Turin, Italy
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Fidecicchi T, Giannini A, Chedraui P, Luisi S, Battipaglia C, Genazzani AR, Genazzani AD, Simoncini T. Neuroendocrine mechanisms of mood disorders during menopause transition: A narrative review and future perspectives. Maturitas 2024; 188:108087. [PMID: 39111089 DOI: 10.1016/j.maturitas.2024.108087] [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: 04/10/2024] [Revised: 07/29/2024] [Accepted: 07/31/2024] [Indexed: 09/01/2024]
Abstract
The menopause transition is an important period in a woman's life, during which she is at an increased risk of mood disorders. Estrogen and progesterone fluctuations during the menopausal transition and very low levels of estradiol after menopause have a profound effect on the central nervous system (CNS), causing an imbalance between excitatory and inhibitory inputs. Changes in neurotransmission and neuronal interactions that occur with estradiol withdrawal disrupt the normal neurological balance and may be associated with menopausal symptoms. Hot flushes, depressed mood and anxiety are all symptoms of menopause that are a consequence of the complex changes that occur in the CNS, involving many signaling pathways and neurotransmitters (i.e. γ-aminobutyric acid, serotonin, dopamine), neurosteroids (i.e. allopregnanolone), and neuropeptides (i.e. kisspeptin, neurokinin B). All these pathways are closely linked, and the complex interactions that exist are not yet fully understood. This review summarizes the neuroendocrine changes in the CNS during the menopausal transition, with particular emphasis on those that underlie mood changes.
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Affiliation(s)
- Tiziana Fidecicchi
- Department of Clinical and Experimental Medicine, Division of Gynecology and Obstetrics, University of Pisa, Via Roma 67, 56126 Pisa, PI, Italy
| | - Andrea Giannini
- Department of Clinical and Experimental Medicine, Division of Gynecology and Obstetrics, University of Pisa, Via Roma 67, 56126 Pisa, PI, Italy.
| | - Peter Chedraui
- Escuela de Posgrado en Salud, Universidad Espíritu Santo, Av. Samborondón 5, Samborondón 092301, Ecuador
| | - Stefano Luisi
- Department of Clinical and Experimental Medicine, Division of Gynecology and Obstetrics, University of Pisa, Via Roma 67, 56126 Pisa, PI, Italy.
| | - Christian Battipaglia
- Gynecological Endocrinology Center, Department of Obstetrics and Gynecology, University of Modena and Reggio Emilia, Largo del Pozzo, 71, 41125 Modena, MO, Italy.
| | - Andrea R Genazzani
- Department of Clinical and Experimental Medicine, Division of Gynecology and Obstetrics, University of Pisa, Via Roma 67, 56126 Pisa, PI, Italy
| | - Alessandro D Genazzani
- Gynecological Endocrinology Center, Department of Obstetrics and Gynecology, University of Modena and Reggio Emilia, Largo del Pozzo, 71, 41125 Modena, MO, Italy
| | - Tommaso Simoncini
- Department of Clinical and Experimental Medicine, Division of Gynecology and Obstetrics, University of Pisa, Via Roma 67, 56126 Pisa, PI, Italy.
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Pinkerton JV, Simon JA, Joffe H, Maki PM, Nappi RE, Panay N, Soares CN, Thurston RC, Caetano C, Haberland C, Haseli Mashhadi N, Krahn U, Mellinger U, Parke S, Seitz C, Zuurman L. Elinzanetant for the Treatment of Vasomotor Symptoms Associated With Menopause: OASIS 1 and 2 Randomized Clinical Trials. JAMA 2024:2822766. [PMID: 39172446 PMCID: PMC11342219 DOI: 10.1001/jama.2024.14618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Accepted: 07/08/2024] [Indexed: 08/23/2024]
Abstract
Importance Safe and effective nonhormonal treatments for menopausal vasomotor symptoms (VMS) are needed. Objective To evaluate the efficacy and safety of elinzanetant, a selective neurokinin-1,3 receptor antagonist, for the treatment of moderate to severe menopausal vasomotor symptoms. Design, Setting, and Participants Two randomized double-blind phase 3 trials (OASIS 1 and 2) included postmenopausal participants aged 40 to 65 years experiencing moderate to severe vasomotor symptoms (OASIS 1: 77 sites in the US, Europe, and Israel from August 27, 2021, to November 27, 2023, and OASIS 2: 77 sites in the US, Canada, and Europe from October 29, 2021, to October 10, 2023). Intervention Once daily oral elinzanetant, 120 mg, for 26 weeks or matching placebo for 12 weeks followed by elinzanetant, 120 mg, for 14 weeks. Main Outcomes and Measures Primary end points included mean change in frequency and severity of moderate to severe vasomotor symptoms from baseline to weeks 4 and 12, measured by the electronic hot flash daily diary. Secondary end points included Patient-Reported Outcomes Measurement Information System Sleep Disturbance Short Form 8b total T score and Menopause-Specific Quality of Life questionnaire total score from baseline to week 12. Results Eligible participants (mean [SD] age, OASIS 1: 54.6 [4.9] years; OASIS 2: 54.6 [4.8] years) were randomized to elinzanetant (OASIS 1: n = 199; OASIS 2: n = 200) or placebo (OASIS 1: n = 197; OASIS 2: n = 200). A total of 309 (78.0%) and 324 (81.0%) completed OASIS 1 and 2, respectively. For the elinzanetant and placebo groups, the baseline mean (SD) VMS per 24 hours were 13.4 (6.6) vs 14.3 (13.9) (OASIS 1) and 14.7 (11.1) v 16.2 (11.2) (OASIS 2). Baseline VMS severity was 2.6 (0.2) vs 2.5 (0.2) (OASIS 1) and 2.5 (0.2) vs 2.5 (0.2) (OASIS 2). Elinzanetant significantly reduced VMS frequency at week 4 (OASIS 1: -3.3 [95% CI, -4.5 to -2.1], P < .001; OASIS 2: -3.0 [95% CI, -4.4 to -1.7], P < .001) and at week 12 (OASIS 1: -3.2 [95% CI, -4.8 to -1.6], P < .001; OASIS 2: -3.2 [95% CI, -4.6 to -1.9], P < .001). Elinzanetant also improved VMS severity at week 4 (OASIS 1: -0.3 [95% CI, -0.4 to -0.2], P < .001; OASIS 2: -0.2 [95 CI, -0.3 to -0.1], P < .001) and week 12 (OASIS 1: -0.4 [95% CI, -0.5 to -0.3], P < .001; OASIS 2: -0.3 [95% CI, -0.4 to -0.1], P < .001). Elinzanetant improved sleep disturbances and menopause-related quality of life at week 12, and the safety profile was favorable. Conclusions and Relevance Elinzanetant was well tolerated and efficacious for moderate to severe menopausal VMS. Trial Registration ClinicalTrials.gov Identifier: OASIS 1: NCT05042362, OASIS 2: NCT05099159.
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Affiliation(s)
- JoAnn V. Pinkerton
- Department of Obstetrics and Gynecology, Division Midlife Health, University of Virginia Health, Charlottesville
| | - James A. Simon
- IntimMedicine Specialists, George Washington University, Washington, DC
| | - Hadine Joffe
- Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Pauline M. Maki
- Department of Psychiatry, Psychology, and OB/GYN, University of Illinois at Chicago
| | - Rossella E. Nappi
- Department of Clinical, Surgical, Diagnostic, and Pediatric Sciences, University of Pavia, Pavia, Italy
- Research Center for Reproductive Medicine, Gynecological Endocrinology, and Menopause, IRCCS San Matteo Foundation, Pavia, Italy
| | - Nick Panay
- Queen Charlotte’s and Chelsea Hospital, Imperial College London, London, United Kingdom
| | - Claudio N. Soares
- Department of Psychiatry, Queen’s University School of Medicine, Kingston, Ontario, Canada
| | - Rebecca C. Thurston
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | | | | | | | | | | | | | - Christian Seitz
- Bayer AG, Berlin, Germany
- Charité–Universitätsmedizin Berlin, Germany
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Douxfils J, Beaudart C, Dogné JM. Letter to the Editor. Menopause 2024; 31:734-735. [PMID: 39058234 DOI: 10.1097/gme.0000000000002404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2024]
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Maki PM, Panay N, Simon JA. Sleep disturbance associated with the menopause. Menopause 2024; 31:724-733. [PMID: 38916279 DOI: 10.1097/gme.0000000000002386] [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: 06/26/2024]
Abstract
IMPORTANCE AND OBJECTIVES Sleep disturbance is one of the most common and debilitating symptoms experienced by women during the menopause transition. However, there are currently no therapies specifically approved for sleep disturbance associated with the menopause. Here, we consider how to characterize sleep disturbance associated with the menopause and discuss its etiology, including the latest advances in our understanding of the neuronal circuits that regulate reproduction, body temperature, sleep, and mood; and reflect on its impact on women's health and well-being. We also examine the current treatment landscape and look to the future of treatment for this condition. METHODS We conducted a review of the literature and combined this with discussion with experts in the fields of sleep and menopause as well as experiences from our own clinical practices. DISCUSSION AND CONCLUSIONS Sleep disturbance associated with the menopause is characterized by frequent night-time awakenings and increased awake time after sleep onset. Its impacts are wide-ranging, negatively affecting health as well as personal and social relationships, productivity, and work performance. There is currently an unmet need for effective, safe, and well-tolerated treatments to address this important symptom, and wider recognition of the association between sleep disturbances and the menopause is needed. Sleep disturbances associated with the menopause can result from hormone changes as well as vasomotor and mood symptoms. Growing research has contributed to our knowledge of the role of hypothalamic estrogen-sensitive kisspeptin/neurokinin B/dynorphin neurons. These neurons are thought to integrate the gonadotropin-releasing hormone pathway and the pathways responsible for the homeostatic control of body temperature and the circadian regulation of sleep-wake cycles. Understanding these neurons offers the potential to create treatments that target a key cause of sleep disturbance associated with the menopause. Further research to understand their etiology and characterize the neuronal circuits responsible could benefit the development of these targeted treatment approaches.
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Affiliation(s)
| | - Nick Panay
- Queen Charlotte's & Chelsea Hospital, Imperial College London, United Kingdom
| | - James A Simon
- George Washington University, IntimMedicine Specialists, Washington, DC
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Pinkerton JV, Simon J, Panay N, Seitz C, Parke S, Caetano C, Mellinger U, Haseli Mashhadi N, Haberland C, Atanackovic G, Holz C, Mao G, Morrison M, Nisius S, Schaefers M, Zuurman L. Design of OASIS 1 and 2: phase 3 clinical trials assessing the efficacy and safety of elinzanetant for the treatment of vasomotor symptoms associated with menopause. Menopause 2024; 31:522-529. [PMID: 38564691 DOI: 10.1097/gme.0000000000002350] [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: 04/04/2024]
Abstract
OBJECTIVE Elinzanetant is a selective neurokinin-1,3 receptor antagonist in development for the treatment of vasomotor symptoms (VMS) associated with menopause. The pivotal, double-blind, randomized, placebo-controlled phase 3 studies Overall Assessment of efficacy and Safety of elinzanetant In patients with vasomotor Symptoms (OASIS) 1 and 2 will assess the efficacy and safety of elinzanetant in women with VMS. METHODS The OASIS 1 and 2 pivotal studies are designed in accordance with regulatory guidance. Postmenopausal women with moderate/severe VMS are randomized to receive 120 mg elinzanetant or placebo once daily for 12 weeks, followed by a 14-week active treatment extension. Primary endpoints are the mean change in frequency and severity of moderate/severe VMS from baseline to weeks 4 and 12. Key secondary endpoints will assess the onset of action and effects on sleep disturbance and menopause-related quality of life. Primary and key secondary endpoints will be analyzed using a mixed model with repeated measures. Feedback from postmenopausal women with VMS was used during protocol development. RESULTS Women confirmed the relevance of endpoints that assess the impact of VMS, sleep disturbance, and mood changes, and the need for new nonhormone treatments. Educational materials around study design, conduct and expected assessments and procedures were developed based on questions and concerns raised by women. CONCLUSIONS The OASIS 1 and 2 pivotal phase 3 studies will enable assessment of the efficacy and safety of elinzanetant as a treatment for VMS, together with its effect on sleep disturbances, depressive symptoms, and menopause-related quality of life. Feedback from postmenopausal women with VMS was used to maximize patient centricity in the trials.
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Affiliation(s)
- JoAnn V Pinkerton
- From the Department of Obstetrics and Gynecology, UVA Health, University of Virginia, Charlottesville, VA
| | - James Simon
- IntimMedicine Specialists, George Washington University, Washington, DC
| | - Nick Panay
- Queen Charlotte's and Chelsea Hospital, Imperial College, London, United Kingdom
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Elnaga AAA, Alsaied MA, Elettreby AM, Ramadan A. Effectiveness and safety of fezolinetant in alleviating vasomotor symptoms linked to Menopause.: A systematic review and Meta-Analysis. Eur J Obstet Gynecol Reprod Biol 2024; 297:142-152. [PMID: 38640780 DOI: 10.1016/j.ejogrb.2024.04.017] [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: 01/03/2024] [Revised: 04/10/2024] [Accepted: 04/12/2024] [Indexed: 04/21/2024]
Abstract
BACKGROUND & OBJECTIVE Vasomotor symptoms (VMS) are the most common symptoms during menopause including hot flushes and night sweats. They are highly disruptive to the quality of life. Fezolinetant is an FDA-approved non-hormonal selective neurokinin3 receptor antagonist for the treatment of VMS. In this study, we aim to assess the efficacy and safety of fezolinetant for VMS associated with menopause. METHODS Databases were searched until September 2023 for relevant studies comparing fezolinetant against placebo. Data was extracted into an online form and analyzed using RevMan (Version 5.4.1). The GRADE approach was conducted to evaluate the quality of evidence regarding efficacy outcomes. We included randomized controlled trials (RCTs) comparing fezolinetant to placebo in postmenopausal women experiencing VMS. Exclusion criteria comprised studies involving participants with contraindications to fezolinetant or those evaluating its efficacy for indications other than VMS associated with menopause. RESULTS Six studies were included in this study involving 3301 patients. Compared to placebo, fezolinetant reduced the frequency of VMS episodes from baseline (SMD = -0.64, 95 % CI [-0.77, -0.5]) and (SMD = -0.63, 95 % CI [-0.72, -0.53] at weeks 4 and 12 respectively. Additionally, fezolinetant reduced VMS severity score (SMD = -0.59, 95 %CI [-0.77, -0.42]) and (SMD = -0.4, 95 % CI [-0.54, -0.27]) at weeks 4 at 12 respectively. These reductions were positively reflected on Menopause specific quality of life score (SMD = -0.46, 95 %CI [-57, -0.34]), (SMD = -0.37, 95 %CI [-0.48, -0.25]) at weeks 4 and 12 respectively. Regarding safety analysis, fezolinetant showed increased risk for drug-related TEAEs (RR = 1.47, 95 %CI [1.06,2.04]), serious TEAEs (RR = 1.67, 95 %CI [1.09,2.55]), fatigue (RR = 4.05, 95 %CI [1.27,12.88]), arthralgia (RR = 2.83, 95 %CI [1.02,7.8]) and ALT or AST > 3 times (RR = 2, 95 %CI [1.12,3.57]), with no other statistically significant difference regarding other safety terms. CONCLUSION Fezolinetant has demonstrated efficacy in reducing the frequency and severity of VMS in postmenopausal women, leading to an improvement in their quality of life. These findings suggest that Fezolinetant may serve as a viable alternative to hormonal therapy for managing VMS.
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Affiliation(s)
| | | | | | - Alaa Ramadan
- Faculty of Medicine, South Valley University, Qena, Egypt.
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Chavez MP, Pasqualotto E, Ferreira ROM, Hohl A, de Moraes FCA, Schmidt PHS, Rodrigues ALSDO, de Sa JR. Fezolinetant for the treatment of vasomotor symptoms associated with menopause: a meta-analysis. Climacteric 2024; 27:245-254. [PMID: 38619017 DOI: 10.1080/13697137.2024.2334083] [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: 11/21/2023] [Accepted: 03/18/2024] [Indexed: 04/16/2024]
Abstract
This systematic review and meta-analysis investigated the efficacy and safety of fezolinetant for the treatment of moderate-to-severe vasomotor symptoms (VMS) associated with menopause. PubMed, Cochrane Library, Embase and Web of Science were searched for randomized controlled trials (RCTs) published from inception to June 2023, comparing fezolinetant to placebo in postmenopausal women suffering from moderate-to-severe VMS. The mean difference and risk ratio were calculated for continuous and binary outcomes, respectively. R software was used for the statistical analysis, and RoB-2 (Cochrane) to assess the risk of bias. We performed subgroup analysis based on different dosing regimens. Five RCTs comprising 3302 patients were included. Compared with placebo, at 12-week follow-up, fezolinetant significantly reduced the daily frequency of moderate-to-severe VMS (weighted mean difference [WMD] - 2.36; 95% confidence interval [CI] - 2.92, -1.81) and daily severity of moderate-to-severe VMS (WMD -0.22; 95% CI -0.31, -0.13). Also, fezolinetant significantly improved the quality of life (WMD -0.42; 95% CI -0.58, -0.26) and sleep disturbance (WMD -1.10; 95% CI -1.96, -0.24). There were no significant differences between groups in adverse events. These findings support the efficacy and safety of fezolinetant for the treatment of VMS related to menopause.
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Affiliation(s)
| | - Eric Pasqualotto
- Division of Medicine, Federal University of Santa Catarina, Florianópolis, Brazil
| | | | - Alexandre Hohl
- Division of Endocrinology, Federal University of Santa Catarina, Florianópolis, Brazil
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Hager M, Goldstein T, Fitz V, Ott J. Elinzanetant, a new combined neurokinin-1/-3 receptor antagonist for the treatment of postmenopausal vasomotor symptoms. Expert Opin Pharmacother 2024; 25:783-789. [PMID: 38869992 DOI: 10.1080/14656566.2024.2358131] [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: 04/18/2024] [Accepted: 05/17/2024] [Indexed: 06/15/2024]
Abstract
INTRODUCTION In many postmenopausal women, quality of life is decreased due to vasomotor symptoms. Efficient and well-tolerated non-hormonal treatment options are needed. AREAS COVERED The present review summarizes what is known about the etiology of postmenopausal vasomotor symptoms as a rationale for the mechanism of action of Elinzanetant, a new neurokinin (NK)-1/-3 receptor antagonist, as well as its efficacy and side effect profile. EXPERT OPINION Elinzanetant likely exerts an antagonistic effect on the NK-3 receptor in the preoptic thermoregulatory zone, but also an additional antagonistic effect on the NK-1 receptor possibly leading to a reduction in vasodilatation and heat-sensing neuro-activity. Elinzanetant's reported peak drug concentrations are reached within one hour and the terminal elimination half-life is approximately 15 hours. Two phase IIb clinical trials evaluated the safety profile and efficacy of several doses. There were no serious adverse events, which also included a lack of evidence of drug-related hepatotoxicity. Overall, Elinzanetant seems to be well-tolerated. In the SWITCH-1 study, the 120 mg/day and 160 mg/day regimen showed good efficacy for the treatment of vasomotor symptoms and led to significant improvements in quality of life. Thus, 120 mg oral Elinzanetant/day was used in phase III trials, whose results have not yet been published.
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Affiliation(s)
- Marlene Hager
- Clinical Division of Gynecological Endocrinology and Reproductive Medicine, Department of Obstetrics and Gynecology, Medical University of Vienna, Vienna, Austria
| | - Tal Goldstein
- Clinical Division of Gynecological Endocrinology and Reproductive Medicine, Department of Obstetrics and Gynecology, Medical University of Vienna, Vienna, Austria
| | - Victoria Fitz
- Division of Reproductive Endocrinology and Infertility, Department of OB/GYN, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Johannes Ott
- Clinical Division of Gynecological Endocrinology and Reproductive Medicine, Department of Obstetrics and Gynecology, Medical University of Vienna, Vienna, Austria
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Cieri-Hutcherson NE, Marji EK, Hutcherson TC. Systematic review of neurokinin-3 receptor antagonists for the management of vasomotor symptoms of menopause. Menopause 2024; 31:342-354. [PMID: 38471077 DOI: 10.1097/gme.0000000000002328] [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: 03/14/2024]
Abstract
IMPORTANCE Vasomotor symptoms (VMS) affect many postmenopausal persons and impact sleep and quality of life. OBJECTIVE This systematic review examines the literature describing the safety and efficacy of neurokinin-3 receptor antagonists approved and in development for postmenopausal persons with VMS. EVIDENCE REVIEW A search of MEDLINE, EMBASE, and International Pharmaceutical Abstracts was conducted using the search terms and permutations of neurokinin-3 receptor antagonist, elinzanetant, fezolinetant, and osanetant. Inclusion criteria of reporting on efficacy or safety of fezolinetant, elinzanetant, or osanetant; studies in participants identifying as female; full record in English; and primary literature were applied. Abstract-only records were excluded. Extracted data were synthesized to allow comparison of reported study characteristics, efficacy outcomes, and safety events. Eligible records were evaluated for risk of bias via the Cochrane Risk of Bias 2 tool for randomized studies and the Grading of Recommendations Assessment, Development and Evaluation system was used. This study was neither funded nor registered. FINDINGS The search returned 191 records; 186 were screened after deduplication. Inclusion criteria were met by six randomized controlled trials (RCT), four reported on fezolinetant, and two reported on elinzanetant. One record was a post hoc analysis of a fezolinetant RCT. An additional study was identified outside the database search. Three fezolinetant RCT demonstrated a reduction in VMS frequency/severity, improvement in Menopause-Specific Quality of Life scores, and improvement in sleep quality at weeks 4 and 12 compared with placebo without serious adverse events. The two RCT on elinzanetant also showed improvements in VMS frequency and severity. All eight records evaluated safety through treatment-emergent adverse events; the most common adverse events were COVID-19, headache, somnolence, and gastrointestinal. Each record evaluated had a low risk of bias. There is a strong certainty of evidence as per the Grading of Recommendations Assessment, Development and Evaluation system. CONCLUSIONS AND RELEVANCE Because of the high-quality evidence supporting the efficacy of fezolinetant and elinzanetant, these agents may be an effective option with mild adverse events for women seeking nonhormone treatment of VMS.
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11
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Patel B, Koysombat K, Mills EG, Tsoutsouki J, Comninos AN, Abbara A, Dhillo WS. The Emerging Therapeutic Potential of Kisspeptin and Neurokinin B. Endocr Rev 2024; 45:30-68. [PMID: 37467734 PMCID: PMC10765167 DOI: 10.1210/endrev/bnad023] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 06/13/2023] [Accepted: 07/11/2023] [Indexed: 07/21/2023]
Abstract
Kisspeptin (KP) and neurokinin B (NKB) are neuropeptides that govern the reproductive endocrine axis through regulating hypothalamic gonadotropin-releasing hormone (GnRH) neuronal activity and pulsatile GnRH secretion. Their critical role in reproductive health was first identified after inactivating variants in genes encoding for KP or NKB signaling were shown to result in congenital hypogonadotropic hypogonadism and a failure of pubertal development. Over the past 2 decades since their discovery, a wealth of evidence from both basic and translational research has laid the foundation for potential therapeutic applications. Beyond KP's function in the hypothalamus, it is also expressed in the placenta, liver, pancreas, adipose tissue, bone, and limbic regions, giving rise to several avenues of research for use in the diagnosis and treatment of pregnancy, metabolic, liver, bone, and behavioral disorders. The role played by NKB in stimulating the hypothalamic thermoregulatory center to mediate menopausal hot flashes has led to the development of medications that antagonize its action as a novel nonsteroidal therapeutic agent for this indication. Furthermore, the ability of NKB antagonism to partially suppress (but not abolish) the reproductive endocrine axis has supported its potential use for the treatment of various reproductive disorders including polycystic ovary syndrome, uterine fibroids, and endometriosis. This review will provide a comprehensive up-to-date overview of the preclinical and clinical data that have paved the way for the development of diagnostic and therapeutic applications of KP and NKB.
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Affiliation(s)
- Bijal Patel
- Section of Investigative Medicine, Department of Metabolism, Digestion and Reproduction, Imperial College School of Medicine, Imperial College London, London, W12 0NN, UK
| | - Kanyada Koysombat
- Section of Investigative Medicine, Department of Metabolism, Digestion and Reproduction, Imperial College School of Medicine, Imperial College London, London, W12 0NN, UK
- Department of Diabetes and Endocrinology, Imperial College Healthcare NHS Trust, 72 Du Cane Rd, London, W12 0HS, UK
| | - Edouard G Mills
- Section of Investigative Medicine, Department of Metabolism, Digestion and Reproduction, Imperial College School of Medicine, Imperial College London, London, W12 0NN, UK
- Department of Diabetes and Endocrinology, Imperial College Healthcare NHS Trust, 72 Du Cane Rd, London, W12 0HS, UK
| | - Jovanna Tsoutsouki
- Section of Investigative Medicine, Department of Metabolism, Digestion and Reproduction, Imperial College School of Medicine, Imperial College London, London, W12 0NN, UK
| | - Alexander N Comninos
- Section of Investigative Medicine, Department of Metabolism, Digestion and Reproduction, Imperial College School of Medicine, Imperial College London, London, W12 0NN, UK
- Department of Diabetes and Endocrinology, Imperial College Healthcare NHS Trust, 72 Du Cane Rd, London, W12 0HS, UK
| | - Ali Abbara
- Section of Investigative Medicine, Department of Metabolism, Digestion and Reproduction, Imperial College School of Medicine, Imperial College London, London, W12 0NN, UK
- Department of Diabetes and Endocrinology, Imperial College Healthcare NHS Trust, 72 Du Cane Rd, London, W12 0HS, UK
| | - Waljit S Dhillo
- Section of Investigative Medicine, Department of Metabolism, Digestion and Reproduction, Imperial College School of Medicine, Imperial College London, London, W12 0NN, UK
- Department of Diabetes and Endocrinology, Imperial College Healthcare NHS Trust, 72 Du Cane Rd, London, W12 0HS, UK
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Koysombat K, McGown P, Nyunt S, Abbara A, Dhillo WS. New advances in menopause symptom management. Best Pract Res Clin Endocrinol Metab 2024; 38:101774. [PMID: 37076317 DOI: 10.1016/j.beem.2023.101774] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/21/2023]
Abstract
Vasomotor symptoms (VMS) are characteristic of menopause experienced by over 75% of postmenopausal women with significant health and socioeconomic implications. Although the average duration of symptoms is seven years, 10% of women experience symptoms for more than a decade. Although menopausal hormone therapy (MHT) remains an efficacious and cost-effective treatment, its use may not be suitable in all women, such as those at an increased risk of breast cancer or gynaecological malignancy. The neurokinin B (NKB) signaling pathway, together with its intricate connection to the median preoptic nucleus (MnPO), has been postulated to provide integrated reproductive and thermoregulatory responses, with a central role in mediating postmenopausal VMS. This review describes the physiological hypothalamo-pituitary-ovary (HPO) axis, and subsequently the neuroendocrine changes that occur with menopause using evidence derived from animal and human studies. Finally, data from the latest clinical trials using novel therapeutic agents that antagonise NKB signaling are reviewed.
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Affiliation(s)
- Kanyada Koysombat
- Section of Investigative Medicine, Imperial College London, London, United Kingdom; Department of Endocrinology, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Patrick McGown
- Section of Investigative Medicine, Imperial College London, London, United Kingdom
| | - Sandhi Nyunt
- Section of Investigative Medicine, Imperial College London, London, United Kingdom; Department of Endocrinology, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Ali Abbara
- Section of Investigative Medicine, Imperial College London, London, United Kingdom; Department of Endocrinology, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Waljit S Dhillo
- Section of Investigative Medicine, Imperial College London, London, United Kingdom; Department of Endocrinology, Imperial College Healthcare NHS Trust, London, United Kingdom.
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Sassarini J, Anderson RA. Elinzanetant: a phase III therapy for postmenopausal patients with vasomotor symptoms. Expert Opin Investig Drugs 2024; 33:19-26. [PMID: 38224099 DOI: 10.1080/13543784.2024.2305122] [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: 10/19/2023] [Accepted: 01/10/2024] [Indexed: 01/16/2024]
Abstract
INTRODUCTION Menopausal vasomotor symptoms (VMS) are experienced by most women and are often debilitating and can last for years. While hormone replacement therapy is effective, it carries risks that have impacted its wider use, and it can be contraindicated. There is a large unmet need for a safe, effective non-hormonal therapy. AREAS COVERED The importance of the neurokinin (NK) system in the hypothalamic regulation of the vasomotor center has become clear. NK antagonists, previously developed for other indications, have therefore been investigated for the treatment of VMS. Elinzanetant is a potent antagonist at both NK1 (endogenous ligand Substance P) and NK3 (neurokinin B) receptors, whereas other related drugs in development are selective NK3 antagonists. Elinzanetant has been investigated in 2 Phase II trials for menopausal VMS, demonstrating rapid onset and dose-dependant efficacy for the relief of VMS and improvement in quality of life for up to 12 weeks. Phase III trials are underway in women both with physiological menopause and after treatment for breast cancer. EXPERT OPINION Elinzanetant is a very promising non-hormonal approach to a highly prevalent symptom constellation, with rapid onset and high efficacy. Wider indications are being explored in current Phase III trials.
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Affiliation(s)
- Jenifer Sassarini
- School of Medicine, Dentistry & Nursing, University of Glasgow, Glasgow, UK
| | - Richard A Anderson
- Centre for Reproductive Health, Institute for Repair and Regeneration, University of Edinburgh, Edinburgh, UK
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Servayge J, Verduyn AC, Page A, Lagaert L, Tjalma WAA. Clinical guidelines for managing menopausal symptoms in women with (a history of) breast cancer. Facts Views Vis Obgyn 2023; 15:297-308. [PMID: 37963326 PMCID: PMC10832648 DOI: 10.52054/fvvo.15.4.102] [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: 11/16/2023] Open
Abstract
Background One in eight women will be diagnosed with breast cancer. At the time of diagnosis, 75% of patients are postmenopausal. Many will receive anti-hormone therapy, which often induces menopausal symptoms. Premenopausal breast cancer patients frequently become postmenopausal as a result of the treatment and often experience menopausal symptoms. The increased incidence of breast cancer, combined with longer survival, has led to an increase in the number of women experiencing menopausal symptoms. Therefore, the management of menopausal symptoms in women with a history or current breast cancer is a relevant and common clinical problem. Objectives To provide a clinically useful overview of the steps in the management of menopausal symptoms in women with (a history of) breast cancer. Materials and Methods A comprehensive literature review was conducted by authors JS and WT using the PubMed and Medline databases. Abstracts were critically appraised and, where appropriate, the full text was analysed. Main Outcome Measures Not applicable. Results Depending on the condition, either meta-analyses, randomised controlled trials or retrospective cohorts were identified. No evidence was found for some proposed treatments. Conclusions Menopausal symptoms in women with (a history of) breast cancer require a patient-tailored approach. Shared decision making is paramount and adequate up-to-date knowledge can help the breast cancer specialist to advise and guide patients accordingly. What is new? A comprehensive, clinically-based overview of evidence-based treatment options for menopausal symptoms in women with (a history of) breast cancer.
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Ruth KS, Beaumont RN, Locke JM, Tyrrell J, Crandall CJ, Hawkes G, Frayling TM, Prague JK, Patel KA, Wood AR, Weedon MN, Murray A. Insights into the genetics of menopausal vasomotor symptoms: genome-wide analyses of routinely-collected primary care health records. BMC Med Genomics 2023; 16:231. [PMID: 37784116 PMCID: PMC10546673 DOI: 10.1186/s12920-023-01658-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 09/08/2023] [Indexed: 10/04/2023] Open
Abstract
BACKGROUND Vasomotor symptoms (VMS) can often significantly impact women's quality of life at menopause. In vivo studies have shown that increased neurokinin B (NKB) / neurokinin 3 receptor (NK3R) signalling contributes to VMS, with previous genetic studies implicating the TACR3 gene locus that encodes NK3R. Large-scale genomic analyses offer the possibility of biological insights but few such studies have collected data on VMS, while proxy phenotypes such as hormone replacement therapy (HRT) use are likely to be affected by changes in clinical practice. We investigated the genetic basis of VMS by analysing routinely-collected health records. METHODS We performed a GWAS of VMS derived from linked primary-care records and cross-sectional self-reported HRT use in up to 153,152 women from UK Biobank, a population-based cohort. In a subset of this cohort (n = 39,356), we analysed exome-sequencing data to test the association with VMS of rare deleterious genetic variants. Finally, we used Mendelian randomisation analysis to investigate the reasons for HRT use over time. RESULTS Our GWAS of health-records derived VMS identified a genetic signal near TACR3 associated with a lower risk of VMS (OR=0.76 (95% CI 0.72,0.80) per A allele, P=3.7x10-27), which was consistent with previous studies, validating this approach. Conditional analyses demonstrated independence of genetic signals for puberty timing and VMS at the TACR3 locus, including a rare variant predicted to reduce functional NK3R levels that was associated with later menarche (P = 5 × 10-9) but showed no association with VMS (P = 0.6). Younger menopause age was causally-associated with greater HRT use before 2002 but not after. CONCLUSIONS We provide support for TACR3 in the genetic basis of VMS but unexpectedly find that rare genomic variants predicted to lower NK3R levels did not modify VMS, despite the proven efficacy of NK3R antagonists. Using genomics we demonstrate changes in genetic associations with HRT use over time, arising from a change in clinical practice since the early 2000s, which is likely to reflect a switch from preventing post-menopausal complications in women with earlier menopause to primarily treating VMS. Our study demonstrates that integrating routinely-collected primary care health records and genomic data offers great potential for exploring the genetic basis of symptoms.
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Affiliation(s)
- Katherine S Ruth
- Genetics of Complex Traits, University of Exeter Medical School, University of Exeter, Exeter, EX2 5DW, UK.
| | - Robin N Beaumont
- Genetics of Complex Traits, University of Exeter Medical School, University of Exeter, Exeter, EX2 5DW, UK
| | - Jonathan M Locke
- Genetics of Complex Traits, University of Exeter Medical School, University of Exeter, Exeter, EX2 5DW, UK
| | - Jessica Tyrrell
- Genetics of Complex Traits, University of Exeter Medical School, University of Exeter, Exeter, EX2 5DW, UK
| | - Carolyn J Crandall
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at University of California, Los Angeles, CA, 90024, USA
| | - Gareth Hawkes
- Genetics of Complex Traits, University of Exeter Medical School, University of Exeter, Exeter, EX2 5DW, UK
| | - Timothy M Frayling
- Genetics of Complex Traits, University of Exeter Medical School, University of Exeter, Exeter, EX2 5DW, UK
| | - Julia K Prague
- Exeter Centre of Excellence for Diabetes Research, University of Exeter, Exeter, EX2 5DW, UK
- Macleod Diabetes and Endocrinology Centre, Royal Devon and Exeter National Health Service Foundation Trust, Exeter, EX2 5DW, UK
| | - Kashyap A Patel
- Exeter Centre of Excellence for Diabetes Research, University of Exeter, Exeter, EX2 5DW, UK
- Macleod Diabetes and Endocrinology Centre, Royal Devon and Exeter National Health Service Foundation Trust, Exeter, EX2 5DW, UK
| | - Andrew R Wood
- Genetics of Complex Traits, University of Exeter Medical School, University of Exeter, Exeter, EX2 5DW, UK
| | - Michael N Weedon
- Genetics of Complex Traits, University of Exeter Medical School, University of Exeter, Exeter, EX2 5DW, UK
| | - Anna Murray
- Genetics of Complex Traits, University of Exeter Medical School, University of Exeter, Exeter, EX2 5DW, UK
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Davis SR, Pinkerton J, Santoro N, Simoncini T. Menopause-Biology, consequences, supportive care, and therapeutic options. Cell 2023; 186:4038-4058. [PMID: 37678251 DOI: 10.1016/j.cell.2023.08.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Revised: 07/06/2023] [Accepted: 08/15/2023] [Indexed: 09/09/2023]
Abstract
Menopause is the cessation of ovarian function, with loss of reproductive hormone production and irreversible loss of fertility. It is a natural part of reproductive aging. The physiology of the menopause is complex and incompletely understood. Globally, menopause occurs around the age of 49 years, with geographic and ethnic variation. The hormonal changes of the menopause transition may result in both symptoms and long-term systemic effects, predominantly adverse effects on cardiometabolic and musculoskeletal health. The most effective treatment for bothersome menopausal symptoms is evidence-based, menopausal hormone therapy (MHT), which reduces bone loss and may have cardiometabolic benefits. Evidence-based non-hormonal interventions are also available for symptom relief. Treatment should be individualized with shared decision-making. Most MHT regimens are not regulator approved for perimenopausal women. Studies that include perimenopausal women are needed to determine the efficacy and safety of treatment options. Further research is crucial to improve menopause care, along with research to guide policy and clinical practice.
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Affiliation(s)
- Susan R Davis
- Women's Health Research Program, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC 3004, Australia; Department of Endocrinology and Diabetes, Alfred Health, Commercial Rd., Melbourne, VIC 3004, Australia.
| | - JoAnn Pinkerton
- Department of Obstetrics and Gynecology, Division of Midlife Health, The University of Virginia Health System, Charlottesville, VA, USA
| | | | - Tommaso Simoncini
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
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David PS, Sobel T, Sahni S, Mehta J, Kling JM. Menopausal Hormone Therapy in Older Women: Examining the Current Balance of Evidence. Drugs Aging 2023:10.1007/s40266-023-01043-3. [PMID: 37344689 DOI: 10.1007/s40266-023-01043-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/06/2023] [Indexed: 06/23/2023]
Abstract
Menopause occurs in all women. During the menopause transition, 80% of women experience vasomotor symptoms that can last an average of 7-10 years or longer, sometimes into the seventh and eighth decades of life. Understanding how to manage vasomotor symptoms (VMS) in older menopausal women is important since these symptoms can negatively impact quality of life. This review provides a practical guide on how to approach VMS treatment either with menopausal hormone therapy or non-hormone options. When initiating, as well as continuing hormone therapy, the factors clinicians should consider as they weigh risks and benefits include assessing a woman's risks related to cardiovascular disease, breast cancer, and osteoporosis. Utilizing a shared decision-making approach in regard to menopausal symptom management should aim to support women and help them maintain health and quality of life.
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Affiliation(s)
- Paru S David
- Division of Women's Health, Department of Internal Medicine, Mayo Clinic, Scottsdale, AZ, USA.
| | - Talia Sobel
- Division of Women's Health, Department of Internal Medicine, Mayo Clinic, Scottsdale, AZ, USA
| | - Sabrina Sahni
- Division of Hematology/Oncology, Department of Internal Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Jaya Mehta
- Primary Care Institute, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, PA, USA
| | - Juliana M Kling
- Mayo Clinic Women's Health, Rochester, MN, USA
- Division of Women's Health, Department of Internal Medicine, Mayo Clinic, Scottsdale, AZ, USA
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Hassan F, Saleem A, Samuel SS, Sarfraz Z, Sarfraz A, Sarfraz M, Kc M. Neurokinin 1/3 receptor antagonists for menopausal women: A current systematic review and insights into the investigational non-hormonal therapy. Medicine (Baltimore) 2023; 102:e33978. [PMID: 37335635 DOI: 10.1097/md.0000000000033978] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/21/2023] Open
Abstract
BACKGROUND Over 75% of menopausal women experience vasomotor symptoms (VMS), such as night sweats and hot flashes. Despite the prevalence of these symptoms, there is limited data on non-hormonal therapies to alleviate them. METHODS PubMed, Cochrane, Scopus, Ovid, Web of Science, and ClinicalTrials.Gov were searched for relevant studies. The search was performed using the following keywords, which were customized to suit the specific databases/registers: menopause, women, neurokinin 3, and/or Fezolinetant. The search was conducted until December 20, 2022. This systematic review was conducted in compliance with the PRISMA Statement 2020 guidelines. RESULTS A total of 326 records were found, with 10 studies (enrolling 1993 women) selected for inclusion. The women received 40-mg doses of NK1/3 receptor antagonists twice daily, with follow-ups at 1 to 3 weeks. Moderately strong evidence was found suggesting that NK1/3 receptor antagonists can help limit the frequency and severity of hot flashes in menopausal women. CONCLUSION While the results should be interpreted with caution until further clinical trials validate the efficacy and safety of NK1/3 receptor antagonists among menopausal women, these findings suggest that they are promising targets for future pharmacological and clinical studies in addressing vasomotor symptoms.
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Affiliation(s)
| | - Anam Saleem
- Punjab Medical College, Faisalabad, Pakistan
| | | | | | | | | | - Manish Kc
- KIST Medical College, Lalitpur, Nepal
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Abstract
OBJECTIVE To update the evidence-based Nonhormonal Management of Menopause-Associated Vasomotor Symptoms: 2015 Position Statement of The North American Menopause Society. METHODS An advisory panel of clinicians and research experts in women's health were selected to review and evaluate the literature published since the Nonhormonal Management of Menopause-Associated Vasomotor Symptoms: 2015 Position Statement of The North American Menopause Society. Topics were divided into five sections for ease of review: lifestyle; mind-body techniques; prescription therapies; dietary supplements; and acupuncture, other treatments, and technologies. The panel assessed the most current and available literature to determine whether to recommend or not recommend use based on these levels of evidence: Level I, good and consistent scientific evidence; Level II, limited or inconsistent scientific evidence, and Level III, consensus and expert opinion. RESULTS Evidence-based review of the literature resulted in several nonhormone options for the treatment of vasomotor symptoms. Recommended: Cognitive-behavioral therapy, clinical hypnosis, selective serotonin reuptake inhibitors/serotonin-norepinephrine reuptake inhibitors, gabapentin, fezolinetant (Level I); oxybutynin (Levels I-II); weight loss, stellate ganglion block (Levels II-III). Not recommended: Paced respiration (Level I); supplements/herbal remedies (Levels I-II); cooling techniques, avoiding triggers, exercise, yoga, mindfulness-based intervention, relaxation, suvorexant, soy foods and soy extracts, soy metabolite equol, cannabinoids, acupuncture, calibration of neural oscillations (Level II); chiropractic interventions, clonidine; (Levels I-III); dietary modification and pregabalin (Level III). CONCLUSION Hormone therapy remains the most effective treatment for vasomotor symptoms and should be considered in menopausal women within 10 years of their final menstrual periods. For women who are not good candidates for hormone therapy because of contraindications (eg, estrogen-dependent cancers or cardiovascular disease) or personal preference, it is important for healthcare professionals to be well informed about nonhormone treatment options for reducing vasomotor symptoms that are supported by the evidence.
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20
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Lederman S, Ottery FD, Cano A, Santoro N, Shapiro M, Stute P, Thurston RC, English M, Franklin C, Lee M, Neal-Perry G. Fezolinetant for treatment of moderate-to-severe vasomotor symptoms associated with menopause (SKYLIGHT 1): a phase 3 randomised controlled study. Lancet 2023; 401:1091-1102. [PMID: 36924778 DOI: 10.1016/s0140-6736(23)00085-5] [Citation(s) in RCA: 58] [Impact Index Per Article: 58.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 12/15/2022] [Accepted: 01/05/2023] [Indexed: 03/16/2023]
Abstract
BACKGROUND Neurokinin 3 receptor antagonists are potential non-hormonal therapies for the treatment of vasomotor symptoms in menopausal women as options are scarce for those who cannot or do not want to take hormone therapy. Fezolinetant is one of the first non-hormonal neurokinin 3 receptor antagonists in development for the treatment of vasomotor symptoms due to menopause. This study investigated the safety and efficacy of fezolinetant for the treatment of moderate-to-severe vasomotor symptoms associated with menopause. METHODS SKYLIGHT 1 is a randomised, double-blind, placebo-controlled, 12-week, phase 3 trial with a 40-week active treatment extension. This trial was done at 97 facilities across the USA, Canada, Czech Republic, Hungary, Poland, Spain, and the UK. Women aged 40-65 years with an average of seven or more moderate-to-severe hot flashes per day were randomly assigned (1:1:1) to once-daily exact-matched placebo, fezolinetant 30 mg, or fezolinetant 45 mg. Randomisation was done using a web-based interactive response system and investigators, project team members, clinical staff, and participants were masked to treatment assignment. Coprimary endpoints were mean change in frequency and severity of vasomotor symptoms from baseline to weeks 4 and 12. The efficacy and safety analyses comprised all randomly assigned participants who received at least one dose of study drug. This trial is registered with ClinicalTrials.gov (NCT04003155) and is completed. FINDINGS Between July 11, 2019, and Aug 11, 2021, 2205 women were recruited of whom 175 were assigned to placebo, 176 to fezolinetant 30 mg, and 176 to fezolinetant 45 mg (175 in the placebo group, 174 in the fezolinetant 30 mg group, and 173 in the fezolinetant 45 mg received at least one dose [safety analysis set]). One participant randomly assigned to fezolinetant 45 mg received fezolinetant 30 mg in error, so the efficacy analysis set (full analysis set) consisted of 173 in the fezolinetant 30 mg group and 174 in the fezolinetant 45 mg group. 23 participants in the placebo group, 31 in the fezolinetant 30 mg group, and 13 in the fezolinetant 45 mg group discontinued treatment before week 12, mostly due to adverse events or participant withdrawal. Compared with placebo, fezolinetant 30 mg and fezolinetant 45 mg significantly reduced the frequency of vasomotor symptoms at week 4 (difference in change in least squares mean -1·87 [SE 0·42; p<0·001], -2·07 [SE 0·42; p<0·001]) and week 12 (-2·39 [SE 0·44; p<0·001], -2·55 [SE 0·43; p<0·001]). Compared with placebo, fezolinetant 30 mg and 45 mg significantly reduced the severity of vasomotor symptoms at week 4 (-0·15 [0·06; p=0·012], -0·19 [0·06; p=0·002]) and week 12 (-0·24 [0·08; p=0·002], -0·20 [0·08; p=0·007]). Improvements in frequency and severity of vasomotor symptoms were observed after 1 week and maintained over 52 weeks. During the first 12 weeks, treatment-emergent adverse events occurred in 65 (37%) of 174 women in the fezolinetant 30 mg group, 75 (43%) of 173 in the fezolinetant 45 mg group, and 78 (45%) of 175 in the placebo group. The incidence of liver enzyme elevations was low (placebo n=1; fezolinetant 30 mg n=2; fezolinetant 45 mg n=0) and these events were generally asymptomatic, transient, and resolved while on treatment or after treatment discontinuation. INTERPRETATION Data support the clinical use of fezolinetant as a non-hormonal treatment for vasomotor symptoms associated with menopause. The study was placebo-controlled for 12 weeks followed by a 40-week blinded extension to assess the maintenance of effect. Furthermore, the population studied was diverse and representative of the potential target population for fezolinetant therapy. Further characterisation of the benefit of fezolinetant on quality of life, including on symptoms of mood and sexual wellbeing, merits investigation. FUNDING Astellas Pharma.
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Affiliation(s)
| | | | - Antonio Cano
- Department of Paediatrics, Obstetrics and Gynaecology, University of Valencia, Valencia, Spain
| | - Nanette Santoro
- Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Marla Shapiro
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Petra Stute
- University Clinic for Gynecology, Inselspital, Bern, Switzerland
| | - Rebecca C Thurston
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Marci English
- Astellas Pharma Global Development, Northbrook, IL, USA
| | | | - Misun Lee
- Astellas Pharma Global Development, Northbrook, IL, USA
| | - Genevieve Neal-Perry
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, NC, USA.
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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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22
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Khan SJ, Kapoor E, Faubion SS, Kling JM. Vasomotor Symptoms During Menopause: A Practical Guide on Current Treatments and Future Perspectives. Int J Womens Health 2023; 15:273-287. [PMID: 36820056 PMCID: PMC9938702 DOI: 10.2147/ijwh.s365808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 01/18/2023] [Indexed: 02/16/2023] Open
Abstract
Vasomotor symptoms affect as many as 80% of midlife women, but only about one in four women receive treatment due to many factors. Menopausal hormone therapy remains the most effective treatment for vasomotor symptoms, and current professional guidelines conclude that the benefits of treatment typically outweigh the risks for healthy, symptomatic women under age 60 years and those within 10 years from their final menstrual period. For women with medical comorbidities, an individualized approach to treatment is recommended. For women who cannot use or choose not to use menopausal hormone therapy, there are many evidence-based non-hormonal options available including pharmacologic therapies. This review aims to summarize treatment options for bothersome vasomotor symptoms to guide clinicians caring for midlife women.
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Affiliation(s)
- Saira J Khan
- Department of Internal Medicine, Mayo Clinic, Phoenix, AZ, USA
| | - Ekta Kapoor
- Mayo Clinic Women’s Health, Rochester, MN, USA,Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA,Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Stephanie S Faubion
- Mayo Clinic Women’s Health, Rochester, MN, USA,Division of General Internal Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Juliana M Kling
- Mayo Clinic Women’s Health, Rochester, MN, USA,Division of Women’s Health Internal Medicine, Mayo Clinic, Scottsdale, AZ, USA,Correspondence: Juliana M Kling, Division of Women’s Health Internal Medicine, Mayo Clinic, 13737 N 92 23 nd St, Scottsdale, AZ, 85260, USA, Tel +1-480-614-6001, Fax +1-480-614-6021, Email
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Conklin M, Santoro N. Neurokinin receptor antagonists as potential non-hormonal treatments for vasomotor symptoms of menopause. Ther Adv Reprod Health 2023; 17:26334941231177611. [PMID: 37388717 PMCID: PMC10302519 DOI: 10.1177/26334941231177611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 05/05/2023] [Indexed: 07/01/2023] Open
Abstract
Vasomotor symptoms of menopause (VMS), otherwise known as hot flashes, can significantly impact women's quality of life. Up to 87% of women report hot flashes during or after their menopause transition, and can last for a median duration of 7.4 years. The current mainstay of treatment and the most effective treatment for VMS is hormone therapy with estrogen. However, hormone therapy is not without risk, and the discovery of an effective nonhormonal treatment option with neurokinin B receptor antagonists for VMS provides an encouraging and potentially practice-changing treatment option for all women. This review will discuss the pathophysiology and mechanism of action, as well as review the current compounds in development targeting the neurokinin receptors.
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Affiliation(s)
- Melissa Conklin
- Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, CO, USA
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Mills EG, Dhillo WS. Invited review: Translating kisspeptin and neurokinin B biology into new therapies for reproductive health. J Neuroendocrinol 2022; 34:e13201. [PMID: 36262016 PMCID: PMC9788075 DOI: 10.1111/jne.13201] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 07/26/2022] [Accepted: 09/06/2022] [Indexed: 12/30/2022]
Abstract
The reproductive neuropeptide kisspeptin has emerged as the master regulator of mammalian reproduction due to its key roles in the initiation of puberty and the control of fertility. Alongside the tachykinin neurokinin B and the endogenous opioid dynorphin, these peptides are central to the hormonal control of reproduction. Building on the expanding body of experimental animal models, interest has flourished with human studies revealing that kisspeptin administration stimulates physiological reproductive hormone secretion in both healthy men and women, as well as patients with common reproductive disorders. In addition, emerging therapeutic roles based on neurokinin B for the management of menopausal flushing, endometriosis and uterine fibroids are increasingly recognised. In this review, we focus on kisspeptin and neurokinin B and their potential application as novel clinical strategies for the management of reproductive disorders.
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Affiliation(s)
- Edouard G. Mills
- Section of Endocrinology and Investigative MedicineImperial College LondonLondonUK
- Department of EndocrinologyImperial College Healthcare NHS TrustLondonUK
| | - Waljit S. Dhillo
- Section of Endocrinology and Investigative MedicineImperial College LondonLondonUK
- Department of EndocrinologyImperial College Healthcare NHS TrustLondonUK
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Abstract
Every woman who lives past midlife will experience menopause, which, by definition, is complete cessation of ovarian function. This process might occur spontaneously (natural menopause) or be iatrogenic (secondary menopause), and can be further classified as 'early' if it occurs before the age of 45 years and 'premature' if it occurs before the age of 40 years. Globally, the mean age of natural menopause is 48.8 years, with remarkably little geographic variation. A woman's age at menopause influences health outcomes in later life. Early menopause is associated with a reduced risk of breast cancer, but increased risks of premature osteoporosis, cardiovascular disease and premature death. The cardinal symptoms of menopause, and adverse health sequelae, are due to loss of ovarian oestrogen production. Consequently, menopausal hormone therapy (MHT) that includes oestrogen or an oestrogenic compound ameliorates menopausal symptoms, while preventing menopause-associated bone loss and cardiometabolic changes. Importantly, comprehensive care of postmenopausal women involves lifestyle optimization (attention to nutrition and physical activity, reducing alcohol consumption and not smoking) and treating other established chronic disease risk factors. This Review offers a commentary specifically on the contemporary use of MHT and novel pharmaceutical alternatives to manage menopausal symptoms.
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Affiliation(s)
- Susan R Davis
- Women's Health Research Program, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia.
- Department of Endocrinology and Diabetes, Alfred Hospital, Melbourne, VIC, Australia.
| | - Rodney J Baber
- Department of Obstetrics and Gynaecology, University of Sydney, Sydney, NSW, Australia
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26
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Anderson RA, Millar RP. The roles of kisspeptin and neurokinin B in GnRH pulse generation in humans, and their potential clinical application. J Neuroendocrinol 2022; 34:e13081. [PMID: 34962670 DOI: 10.1111/jne.13081] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 11/22/2021] [Accepted: 12/14/2021] [Indexed: 12/22/2022]
Abstract
The delivery of gonadotropin-releasing hormone (GnRH) in a pulsatile mode to the gonadotropes has long been known to be essential for normal reproductive function. There have been numerous studies aimed at dissecting out the mechanisms underlying GnRH pulse generation. The discovery of kisspeptin as an upstream regulator of GnRH attracted the possibility that pulsatile kisspeptin governed the pulsatile secretion of GnRH. Subsequent studies have shown the importance of the neurokinin B (NKB) system in modulating kisspeptin secretion and this GnRH. A number of studies in laboratory rodents have supported this notion. By contrast, we present data from clinical studies in men and women, in a range of contexts, showing that continuous infusion of kisspeptin 10 at receptor-saturating levels gives rise to an increase in luteinizing hormone (LH) (GnRH) pulse frequency. This has been demonstrated in normal healthy and hypogonadal men, in normal women during the mid-cycle LH surge, in men and women with mutations in the genes encoding NKB or its receptor, neurokinin 3 receptor (NK3R), in women with polycystic ovary syndrome treated with NK3R antagonist, and in women treated with NK3R antagonist during the LH surge. These finds indicate that pulsatile secretion and action of kisspeptin on GnRH neurons is not required for the generation of LH (GnRH) pulses in humans. We also report that there is an absence of desensitization in humans exposed to continuous infusion of kisspeptin-10 at receptor-saturating concentrations over 22 h and briefly review GnRH, kisspeptin and NKB analogs and their clinical application.
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Affiliation(s)
- Richard A Anderson
- MRC Centre for Reproductive Health, Queens Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | - Robert P Millar
- Department of Immunology, Faculty of Health Sciences, Centre for Neuroendocrinology, University of Pretoria, Pretoria, South Africa
- Department of Integrative Biomedical Sciences, Faculty of Health Sciences, Institute of Infectious Disease and Molecular Medicine, Observatory, South Africa
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Sahni S, Lobo-Romero A, Smith T. Contemporary Non-hormonal Therapies for the Management of Vasomotor Symptoms Associated with Menopause: A Literature Review. TOUCHREVIEWS IN ENDOCRINOLOGY 2022; 17:133-137. [PMID: 35118459 DOI: 10.17925/ee.2021.17.2.133] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 06/28/2021] [Indexed: 11/24/2022]
Abstract
Nearly 75% of all menopausal women experience bothersome vasomotor symptoms including hot flushes and night sweats. Yet vasomotor symptoms continue to be an undertreated and underdiagnosed symptom of menopause which can negatively affect a woman's overall quality of life. While hormone therapy has been widely utilized to ameliorate hot flushes, not all women are candidates for use, especially those with increased risk of cardiovascular disease, thromboembolic disease, and/or women at an increased risk of certain hormone-dependent cancers. The current literature provides strong evidence for non-hormonal therapies in women who experience vasomotor symptoms. This article reviews the evidence for the use of non-hormonal pharmacologic therapies for the treatment of menopausal symptoms including antidepressants, gabapentinoids, clonidine and anticholinergics. We also review data on emerging therapies including the latest evidence on neurokinin-1 and -3 antagonists. These therapies should be considered when hormonal options are contraindicated and/or not preferred by the patient. While there are many options available, clinicians should individualize therapy based on the patient's needs and goals while mitigating bothersome side effects.
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Affiliation(s)
- Sabrina Sahni
- Division of General Internal Medicine, Jacoby Center for Breast Health, Mayo Clinic, Jacksonville, FL, USA
| | - Angie Lobo-Romero
- Division of General Internal Medicine, Women's Health, Mayo Clinic Rochester, MN, USA
| | - Taryn Smith
- Division of General Internal Medicine, Women's Health, Mayo Clinic, Jacksonville, FL, USA
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McCarthy EA, Dischino D, Maguire C, Leon S, Talbi R, Cheung E, Schteingart CD, Rivière PJM, Reed SD, Steiner RA, Navarro VM. Inhibiting Kiss1 Neurons With Kappa Opioid Receptor Agonists to Treat Polycystic Ovary Syndrome and Vasomotor Symptoms. J Clin Endocrinol Metab 2022; 107:e328-e347. [PMID: 34387319 PMCID: PMC8684497 DOI: 10.1210/clinem/dgab602] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT Recent evidence suggests that vasomotor symptoms (VMS) or hot flashes in the postmenopausal reproductive state and polycystic ovary syndrome (PCOS) in the premenopausal reproductive state emanate from the hyperactivity of Kiss1 neurons in the hypothalamic infundibular/arcuate nucleus (KNDy neurons). OBJECTIVE We demonstrate in 2 murine models simulating menopause and PCOS that a peripherally restricted kappa receptor agonist (PRKA) inhibits hyperactive KNDy neurons (accessible from outside the blood-brain barrier) and impedes their downstream effects. DESIGN Case/control. SETTING Academic medical center. PARTICIPANTS Mice. INTERVENTIONS Administration of peripherally restricted kappa receptor agonists and frequent blood sampling to determine hormone release and body temperature. MAIN OUTCOME MEASURES LH pulse parameters and body temperature. RESULTS First, chronic administration of a PRKA to bilaterally ovariectomized mice with experimentally induced hyperactivity of KNDy neurons reduces the animals' elevated body temperature, mean plasma LH level, and mean peak LH per pulse. Second, chronic administration of a PRKA to a murine model of PCOS, having elevated plasma testosterone levels and irregular ovarian cycles, suppresses circulating levels of LH and testosterone and restores normal ovarian cyclicity. CONCLUSION The inhibition of kisspeptin neuronal activity by activation of kappa receptors shows promise as a novel therapeutic approach to treat both VMS and PCOS in humans.
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Affiliation(s)
- Elizabeth A McCarthy
- Department of Medicine, Harvard Medical School, Boston, MA 02115, USA
- Department of Medicine, Division of Endocrinology, Diabetes and Hypertension, Brigham and Women’s Hospital, Boston, MA 02115, USA
| | - Daniel Dischino
- Department of Medicine, Harvard Medical School, Boston, MA 02115, USA
| | - Caroline Maguire
- Department of Medicine, Harvard Medical School, Boston, MA 02115, USA
| | - Silvia Leon
- Department of Medicine, Harvard Medical School, Boston, MA 02115, USA
- Department of Medicine, Division of Endocrinology, Diabetes and Hypertension, Brigham and Women’s Hospital, Boston, MA 02115, USA
| | - Rajae Talbi
- Department of Medicine, Harvard Medical School, Boston, MA 02115, USA
- Department of Medicine, Division of Endocrinology, Diabetes and Hypertension, Brigham and Women’s Hospital, Boston, MA 02115, USA
| | - Eugene Cheung
- Department of Medicine, Harvard Medical School, Boston, MA 02115, USA
- Department of Medicine, Division of Endocrinology, Diabetes and Hypertension, Brigham and Women’s Hospital, Boston, MA 02115, USA
| | | | | | - Susan D Reed
- Department of Obstetrics & Gynecology, University of Washington, Seattle, WA 98195, USA
| | - Robert A Steiner
- Department of Obstetrics & Gynecology, University of Washington, Seattle, WA 98195, USA
- Department of Physiology & Biophysics, University of Washington, Seattle, WA 98195, USA
| | - Victor M Navarro
- Department of Medicine, Harvard Medical School, Boston, MA 02115, USA
- Department of Medicine, Division of Endocrinology, Diabetes and Hypertension, Brigham and Women’s Hospital, Boston, MA 02115, USA
- Harvard Program in Neuroscience, Boston, MA 02115, USA
- Correspondence: Victor M. Navarro PhD, Brigham and Women’s Hospital, Division of Endocrinology, Diabetes and Hypertension, 221 Longwood Ave, Boston, MA 02115, USA.
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Djapardy V, Panay N. Alternative and non-hormonal treatments to symptoms of menopause. Best Pract Res Clin Obstet Gynaecol 2021; 81:45-60. [PMID: 34952794 DOI: 10.1016/j.bpobgyn.2021.09.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Accepted: 09/27/2021] [Indexed: 11/16/2022]
Abstract
Ovarian function can start to decline a few years before the eventual cessation of the menstrual cycle. The average age of menopause in the UK is 51 years, and it is a retrospective diagnosis after 12 months of amenorrhoea. Women can experience many symptoms such as vasomotor and vulvovaginal symptoms that impact them physically, psychologically, sexually and thus their overall wellbeing. Women may have medical contraindications to hormonal therapy or may prefer non-hormonal or alternative treatments. This review looks at the evidence, efficacy, and safety of a range of complementary or alternative treatments and non-hormonal pharmacological treatments for the treatment of vasomotor symptoms and vulvovaginal atrophy of menopause.
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Affiliation(s)
- Veronica Djapardy
- Queen Charlotte's & Chelsea Hospital, Imperial College Healthcare NHS Trust, London, UK.
| | - Nicholas Panay
- Queen Charlotte's & Chelsea Hospital, Imperial College Healthcare NHS Trust, London, UK
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Patel B, S Dhillo W. Menopause review: Emerging treatments for menopausal symptoms. Best Pract Res Clin Obstet Gynaecol 2021; 81:134-144. [PMID: 34965909 DOI: 10.1016/j.bpobgyn.2021.10.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 10/11/2021] [Accepted: 10/25/2021] [Indexed: 12/15/2022]
Abstract
Vasomotor symptoms (VMS) affect 2 out of 3 women during menopause and are highly disruptive and intolerable. They exert a negative impact on a woman's physical and mental well-being and are considered a high clinical priority requiring effective treatment. Although hormone therapy remains the gold-standard treatment for hot flushes, it is associated with several side effects and contraindications. Furthermore, alternative treatments for VMS are currently less efficacious and have limited availability; therefore, a new medication to treat VMS would benefit millions of women worldwide. Neurokinin 3 receptor (NK3R) antagonists have recently been developed as novel therapeutic agents for the amelioration of VMS through their action on NK3 receptors within the hypothalamus and consequent regulation of the thermoregulatory centre. So far, three NK3R antagonists have been studied in menopausal women, which have demonstrated significant reductions in VMS frequency and severity and have shown their ability to transform patients' quality of life.
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Affiliation(s)
- Bijal Patel
- Department of Metabolism, Digestion and Reproduction, 6th Floor Commonwealth Building, Imperial College London, Hammersmith Hospital, 150 Du Cane Road, W12 0NN, London, UK.
| | - Waljit S Dhillo
- Department of Metabolism, Digestion and Reproduction, 6th Floor Commonwealth Building, Imperial College London, Hammersmith Hospital, 150 Du Cane Road, W12 0NN, London, UK.
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Flores VA, Pal L, Manson JE. Hormone Therapy in Menopause: Concepts, Controversies, and Approach to Treatment. Endocr Rev 2021; 42:720-752. [PMID: 33858012 DOI: 10.1210/endrev/bnab011] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Indexed: 12/22/2022]
Abstract
Hormone therapy (HT) is an effective treatment for menopausal symptoms, including vasomotor symptoms and genitourinary syndrome of menopause. Randomized trials also demonstrate positive effects on bone health, and age-stratified analyses indicate more favorable effects on coronary heart disease and all-cause mortality in younger women (close proximity to menopause) than in women more than a decade past menopause. In the absence of contraindications or other major comorbidities, recently menopausal women with moderate or severe symptoms are appropriate candidates for HT. The Women's Health Initiative (WHI) hormone therapy trials-estrogen and progestin trial and the estrogen-alone trial-clarified the benefits and risks of HT, including how the results differed by age. A key lesson from the WHI trials, which was unfortunately lost in the posttrial cacophony, was that the risk:benefit ratio and safety profile of HT differed markedly by clinical characteristics of the participants, especially age, time since menopause, and comorbidity status. In the present review of the WHI and other recent HT trials, we aim to provide readers with an improved understanding of the importance of the timing of HT initiation, type and route of administration, and of patient-specific considerations that should be weighed when prescribing HT.
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Affiliation(s)
- Valerie A Flores
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut, USA
| | - Lubna Pal
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut, USA
| | - JoAnn E Manson
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Yuksel N, Evaniuk D, Huang L, Malhotra U, Blake J, Wolfman W, Fortier M. Guideline No. 422a: Menopause: Vasomotor Symptoms, Prescription Therapeutic Agents, Complementary and Alternative Medicine, Nutrition, and Lifestyle. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2021; 43:1188-1204.e1. [PMID: 34390867 DOI: 10.1016/j.jogc.2021.08.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Provide strategies for improving the care of perimenopausal and postmenopausal women based on the most recent published evidence. TARGET POPULATION Perimenopausal and postmenopausal women. BENEFITS, HARMS, AND COSTS Target population will benefit from the most recent published scientific evidence provided via the information from their health care provider. No harms or costs are involved with this information since women will have the opportunity to choose among the different therapeutic options for the management of the symptoms and morbidities associated with menopause, including the option to choose no treatment. EVIDENCE Databases consulted were PubMed, MEDLINE, and the Cochrane Library for the years 2002-2020, and MeSH search terms were specific for each topic developed through the 7 chapters. VALIDATION METHODS The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations). INTENDED AUDIENCE: physicians, including gynaecologists, obstetricians, family physicians, internists, emergency medicine specialists; nurses, including registered nurses and nurse practitioners; pharmacists; medical trainees, including medical students, residents, fellows; and other providers of health care for the target population. SUMMARY STATEMENTS RECOMMENDATIONS.
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Menown SJ, Tello JA. Neurokinin 3 Receptor Antagonists Compared With Serotonin Norepinephrine Reuptake Inhibitors for Non-Hormonal Treatment of Menopausal Hot Flushes: A Systematic Qualitative Review. Adv Ther 2021; 38:5025-5045. [PMID: 34514552 PMCID: PMC8478773 DOI: 10.1007/s12325-021-01900-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 08/19/2021] [Indexed: 11/30/2022]
Abstract
Introduction Hot flushes/flashes (HFs) or other vasomotor symptoms affect between 45 and 97% of women during menopause. Hormone replacement therapy (HRT) is effective at alleviating menopausal symptoms, but some women cannot or prefer not to take HRT. Since current non-hormonal options have suboptimal efficacy/tolerability, there is a pressing need for an effective, well-tolerated alternative. The neurokinin 3 receptor (NK3R) has recently been implicated in the generation of menopausal HFs and represents a novel therapeutic target to ameliorate HF symptoms. This review aims to assess if NK3R antagonists (NK3Ras) are more effective than Serotonin Norepinephrine Reuptake Inhibitors (SNRIs)—currently a common choice for non-hormonal treatment of menopausal HFs. Methods Studies were identified after systematically searching Ovid MEDLINE and EMBASE databases based on PRISMA guidelines. Trial quality and bias were assessed. Key efficacy outcomes (HF frequency, HF severity and number of night-time awakenings/night-sweats) and selected safety outcomes were extracted and analysed. Results Seven SNRI and four NK3Ra placebo-controlled randomised trials (plus four follow-up reports) were included in this review. NK3Ra administration resulted in a larger reduction from baseline in HF frequency, HF severity and night-sweats compared to SNRIs. Five of seven SNRI trials showed a reduction in HF frequency that was statistically significant (by 48–67% from baseline at weeks 8 or 12) whereas all NK3Ra trials showed a statistically significant reduction in HF frequency (by 62–93% from baseline at weeks 2, 4 or 12). While SNRI trials reported poor tolerability, particularly nausea, NK3Ra trials reported good tolerability overall, although two trials reported elevation in transaminases. Conclusion NK3Ras trials show encouraging efficacy and tolerability/safety. Completion of phase 3 NK3Ra trials are required to confirm efficacy and uphold safety/tolerability data but phase 2 results suggest that NK3Ras are more effective than SNRIs for non-hormonal treatment of menopausal HFs.
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Affiliation(s)
- Sara J. Menown
- School of Medicine, University of St Andrews, Medical and Biological Sciences Building, North Haugh, St Andrews, KY16 9TF UK
- Present Address: School of Medicine, Dentistry and Nursing, College of Medical, Veterinary & Life Sciences, University of Glasgow, Glasgow, Scotland
| | - Javier A. Tello
- School of Medicine, University of St Andrews, Medical and Biological Sciences Building, North Haugh, St Andrews, KY16 9TF UK
- Biomedical Research Complex, University of St Andrews, North Haugh, St Andrews, KY16 9TZ UK
- Centre for Biophotonics, University of St Andrews, North Haugh, St Andrews, KY16 9SS UK
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Yuksel N, Evaniuk D, Huang L, Malhotra U, Blake J, Wolfman W, Fortier M. Directive clinique n o 422a : Ménopause : symptômes vasomoteurs, agents thérapeutiques d'ordonnance, médecines douces et complémentaires, nutrition et mode de vie. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2021; 43:1205-1223.e1. [PMID: 34649685 DOI: 10.1016/j.jogc.2021.08.006] [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: 10/20/2022]
Abstract
OBJECTIF Proposer des stratégies pour améliorer les soins aux femmes ménopausées ou en périménopause d'après les plus récentes données probantes publiées. POPULATION CIBLE Femmes ménopausées ou en périménopause. BéNéFICES, RISQUES ET COûTS: La population cible bénéficiera des plus récentes données scientifiques publiées que leur communiqueront les fournisseurs de soins de santé. Aucun coût ni préjudice ne sont associés à cette information, car les femmes seront libres de choisir parmi les différentes options thérapeutiques offertes pour la prise en charge des symptômes et morbidités associés à la ménopause, y compris l'abstention thérapeutique. DONNéES PROBANTES: Les auteurs ont interrogé les bases de données PubMed, Medline et Cochrane Library pour extraire des articles publiés entre 2002 et 2020 en utilisant des termes MeSH spécifiques à chacun des sujets abordés dans les 7 chapitres. MéTHODES DE VALIDATION: Les auteurs ont évalué la qualité des données probantes et la force des recommandations en utilisant le cadre méthodologique d'évaluation, de développement et d'évaluation (GRADE). Voir l'annexe A en ligne (tableau A1 pour les définitions et tableau A2 pour l'interprétation des recommandations fortes et faibles). PROFESSIONNELS CONCERNéS: médecins, y compris gynécologues, obstétriciens, médecins de famille, internistes, urgentologues; infirmières, y compris infirmières autorisées et infirmières praticiennes; pharmaciens; stagiaires, y compris étudiants en médecine, résidents, moniteurs cliniques; et autres fournisseurs de soins auprès de la population cible. DÉCLARATIONS SOMMAIRES: RECOMMANDATIONS.
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Hypothalamic neurokinin signalling and its application in reproductive medicine. Pharmacol Ther 2021; 230:107960. [PMID: 34273412 DOI: 10.1016/j.pharmthera.2021.107960] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 07/06/2021] [Accepted: 07/08/2021] [Indexed: 12/29/2022]
Abstract
The discovery of the essential requirement for kisspeptin and subsequently neurokinin B signalling for human reproductive function has sparked renewed interest in the neuroendocrinology of reproduction. A key discovery has been a population of cells co-expressing both these neuropeptides and dynorphin in the hypothalamus, directly regulating gonadotropin hormone releasing hormone (GnRH) secretion and thus pituitary secretion of gonadotropins. These neurons also project to the vasomotor centre, and their overactivity in estrogen deficiency results in the common and debilitating hot flushes of the menopause. Several antagonists to the neurokinin 3 receptor, for which neurokinin B is the endogenous ligand, have been developed, and are entering clinical studies in human reproductive function and clinical trials. Even single doses can elicit marked declines in testosterone levels in men, and their use has elicited evidence of the regulation of ovarian follicle growth in women. The most advanced indication is the treatment of menopausal vasomotor symptoms, where these drugs show remarkable results in both the degree and speed of symptom control. A range of other reproductive indications are starting to be explored, notably in polycystic ovary syndrome, the most common endocrinopathy in women.
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Pawsey S, Mills EG, Ballantyne E, Donaldson K, Kerr M, Trower M, Dhillo WS. Elinzanetant (NT-814), a Neurokinin 1,3 Receptor Antagonist, Reduces Estradiol and Progesterone in Healthy Women. J Clin Endocrinol Metab 2021; 106:e3221-e3234. [PMID: 33624806 PMCID: PMC8277204 DOI: 10.1210/clinem/dgab108] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Indexed: 12/30/2022]
Abstract
CONTEXT The ideal therapy for endometriosis (EM) and uterine fibroids (UFs) would suppress estrogenic drive to the endometrium and myometrium, while minimizing vasomotor symptoms and bone loss associated with current treatments. An integrated neurokinin-kisspeptin system involving substance P and neurokinin B acting at the neurokinin (NK) receptors 1 and 3, respectively, modulates reproductive hormone secretion and represents a therapeutic target. OBJECTIVE This work aimed to assess the effects of the novel NK1,3 antagonist elinzanetant on reproductive hormone levels in healthy women. METHODS A randomized, single-blinded, placebo-controlled study was conducted in 33 women who attended for 2 consecutive menstrual cycles. In each cycle blood samples were taken on days 3 or 4, 9 or 10, 15 or 16, and 21 or 22 to measure serum reproductive hormones. In cycle 2, women were randomly assigned to receive once-daily oral elinzanetant 40, 80, 120 mg, or placebo (N = 8 or 9 per group). RESULTS Elinzanetant dose-dependently lowered serum luteinizing hormone, estradiol (120 mg median change across cycle: -141.4 pmol/L, P = .038), and luteal-phase progesterone (120 mg change from baseline on day 21 or 22: -19.400 nmol/L, P = .046). Elinzanetant 120 mg prolonged the cycle length by median of 7.0 days (P = .023). Elinzanetant reduced the proportion of women with a luteal-phase serum progesterone concentration greater than 30 nmol/L (a concentration consistent with ovulation) in a dose-related manner in cycle 2 (P = .002). Treatment did not produce vasomotor symptoms. CONCLUSION NK1,3 receptor antagonism with elinzanetant dose-dependently suppressed the reproductive axis in healthy women, with the 120-mg dose lowering estradiol to potentially ideal levels for UFs and EM. As such, elinzanetant may represent a novel therapy to manipulate reproductive hormone levels in women with hormone-driven disorders.
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Affiliation(s)
- Steve Pawsey
- NeRRe Therapeutics Limited, Stevenage, SG1 2FX, UK
| | - Edouard Gregory Mills
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, W12 ONN, UK
| | | | | | - Mary Kerr
- NeRRe Therapeutics Limited, Stevenage, SG1 2FX, UK
| | - Mike Trower
- NeRRe Therapeutics Limited, Stevenage, SG1 2FX, UK
| | - Waljit Singh Dhillo
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, W12 ONN, UK
- Imperial Consultants, Imperial College London, London, SW7 2PG, UK
- Correspondence: Waljit S. Dhillo, PhD, MBBS, Section of Endocrinology and Investigative Medicine, Imperial College London, 6th Fl, Commonwealth Bldg, Hammersmith Hospital, Du Cane Rd, London W12 ONN, UK.
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Depypere H, Lademacher C, Siddiqui E, Fraser GL. Fezolinetant in the treatment of vasomotor symptoms associated with menopause. Expert Opin Investig Drugs 2021; 30:681-694. [PMID: 33724119 DOI: 10.1080/13543784.2021.1893305] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Introduction: Although international clinical practice guidelines recognize a continued role for menopausal hormone therapy (HT), particularly for symptomatic women <60 years of age or within 10 years of menopause, safety and tolerability concerns have discouraged HT use due to potential links with a perceived increased risk of hormone-dependent cancers, and an established risk of stroke and venous thromboembolism. There is therefore a need for safe, effective non-hormonal therapy for relief of menopausal vasomotor symptoms (VMS).Areas covered: This narrative review summarizes the dataset accrued for fezolinetant, a neurokinin-3 receptor (NK3R) antagonist in clinical development for menopause-associated VMS.Expert opinion: Altered signaling in neuroendocrine circuits at menopause leads to VMS wherein NK3R activity plays a key role to modulate the thermoregulatory center in a manner conducive to triggering the 'hot flash' response. Thus, a new generation of NK3R antagonists has entered clinical development to specifically target the mechanistic basis of VMS. Fezolinetant is the most advanced NK3R antagonist in terms of stage of clinical development. Results to date have demonstrated rapid and substantial reduction in VMS frequency and severity and associated improvements in health-related quality of life. NK3R antagonists offer a non-hormonal alternative to HT for the treatment of menopause-related VMS.
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Affiliation(s)
- Herman Depypere
- Breast and Menopause Clinic, University Hospital, Ghent, Belgium
| | | | - Emad Siddiqui
- Medical Affairs, Astellas Pharma Medical and Development, Chertsey, UK
| | - Graeme L Fraser
- Former Chief Scientific Officer of Ogeda SA, Gosselies, Belgium and Consultant for Astellas Pharma Inc
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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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Kauffman RP, Young C, Castracane VD. Perils of prolonged ovarian suppression and hypoestrogenism in the treatment of breast cancer: Is the risk of treatment worse than the risk of recurrence? Mol Cell Endocrinol 2021; 525:111181. [PMID: 33529690 DOI: 10.1016/j.mce.2021.111181] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 01/04/2021] [Accepted: 01/21/2021] [Indexed: 01/18/2023]
Abstract
Premenopausal breast cancer is usually estrogen receptor positive, and hence, prolonged ovarian suppression by medical or surgical means to prevent recurrence has become standard of management to improve disease-free survival. Ten-year adjuvant tamoxifen therapy is associated with 3.5% fewer recurrences compared to five years. The SOFT trial demonstrated small but statistically significant incremental improvements in long-term disease-free survival by the addition of gonadotropin-releasing hormone analog treatment (triptorelin) to an aromatase inhibitor (exemestane). Profound hypoestrogenism in the premenopausal age group may not be well tolerated due to a host of bothersome side effects (primarily vasomotor symptoms, musculoskeletal complaints, genitourinary syndrome of menopause, and mood disorders). Prolonged hypoestrogenism in younger women is associated with premature development of cardiovascular disease, bone loss, cognitive decline, and all-cause mortality. This paper explores multi-system consequences of prolonged hypoestrogenism in premenopausal women derived from studies of women with and without breast cancer. Pretreatment counseling in estrogen receptor positive breast cancer should emphasize the benefit of prolonged estrogen suppression on breast cancer recurrence and established risks of lifelong hypoestrogenism on quality of life and all-cause mortality. Future genomic research may help identify the best candidates for extended ovarian suppression to avoid treating many women when only a minority benefit.
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Affiliation(s)
- Robert P Kauffman
- Department of Obstetrics and Gynecology, Texas Tech University Health Sciences Center, School of Medicine, 1400 S. Coulter Rd, Amarillo, TX, 79106, USA.
| | - Christina Young
- Department of Obstetrics and Gynecology, Texas Tech University Health Sciences Center, School of Medicine, 1400 S. Coulter Rd, Amarillo, TX, 79106, USA
| | - V Daniel Castracane
- Department of Obstetrics and Gynecology, Texas Tech University Health Sciences Center, School of Medicine, 1400 S. Coulter Rd, Amarillo, TX, 79106, USA
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Prague JK. Neurokinin 3 receptor antagonists - prime time? Climacteric 2021; 24:25-31. [PMID: 33135940 DOI: 10.1080/13697137.2020.1834530] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 09/26/2020] [Accepted: 09/30/2020] [Indexed: 02/08/2023]
Abstract
Vasomotor symptoms (hot flushes, flashes, night sweats) occur in the majority of menopausal women, and are reported as being of the highest symptom priority as they often persist over many years and can be highly disruptive. Hormone therapy is the most effective available treatment but is not without risk if taken long term, and is sometimes contraindicated; for example, in women with a personal or family history of breast cancer, which is the most common female cancer worldwide. Other treatment alternatives are not as efficacious, can cause side effects, and/or are not widely available. A new, effective, targeted treatment could therefore benefit millions of women worldwide. This became possible to investigate after accumulated evidence from both animal and human models implicated heightened signaling of a hypothalamic neuropeptide together with its receptor (neurokinin B/NK3R) in the etiology of sex-steroid-deficient vasomotor symptoms. Four clinical trials of three chemically distinct oral NK3R antagonists for the treatment of menopausal flushes have since completed and published, which consistently demonstrate efficacy and tolerability of these agents. These suggest great promise to change practice in the future if ongoing further larger-scale studies of longer duration confirm the same; as, estrogen exposure will no longer be required to effectively and safely treat vasomotor symptoms.
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Affiliation(s)
- J K Prague
- Macleod Diabetes and Endocrine Centre, Royal Devon and Exeter Hospital, Exeter, UK
- College of Medicine and Health, University of Exeter, Exeter, UK
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Abbara A, Phylactou M, Dhillo WS. Commentary on "Pharmacodynamic Activity of the Novel Neurokinin-3 Receptor Antagonist SJX-653 in Healthy Men". J Clin Endocrinol Metab 2021; 106:e1028-e1030. [PMID: 33119077 DOI: 10.1210/clinem/dgaa783] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Indexed: 11/19/2022]
Affiliation(s)
- Ali Abbara
- Section of Endocrinology and Investigative Medicine, Imperial College London, Hammersmith Hospital, London, UK
| | - Maria Phylactou
- Section of Endocrinology and Investigative Medicine, Imperial College London, Hammersmith Hospital, London, UK
| | - Waljit S Dhillo
- Section of Endocrinology and Investigative Medicine, Imperial College London, Hammersmith Hospital, London, UK
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Modi M, Dhillo WS. The neuroendocrinology of the preoptic area in menopause: Symptoms and therapeutic strategies. HANDBOOK OF CLINICAL NEUROLOGY 2021; 179:455-460. [PMID: 34225982 DOI: 10.1016/b978-0-12-819975-6.00029-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The preoptic area of the hypothalamus is the central hub of thermoregulation in mammals, coordinating autonomic heat-effector pathways in response to sensory information from the ambient and internal environment. This aims to maintain temperature homeostasis at a predetermined thermoregulatory set-point. However, hormonal and neuronal changes during the menopause, including estrogen deficiency, disrupt these normal thermoregulatory responses. This results in abnormal activation of heat dissipation effectors, manifesting clinically as hot flush symptoms. Neurokinin B (NKB) signaling via the neurokinin-3 receptor (NK3R) within the preoptic area is thought to play an important role in the pathophysiology of hot flushes. Therefore attenuation of the NKB/NK3R signaling pathway has garnered much interest as a novel therapeutic target for the amelioration of menopausal hot flushes. Recent clinical trials have demonstrated that NK3R antagonists can produce rapid and sustained improvements in hot flush frequency, severity, and quality of life, without the need for estrogen exposure. Therefore NK3R antagonists are fast emerging as a safe and efficacious alternative to hormone replacement therapy, the current gold standard of treatment.
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Affiliation(s)
- Manish Modi
- Section of Endocrinology and Investigative Medicine, Imperial College London, London, United Kingdom
| | - Waljit Singh Dhillo
- Section of Endocrinology and Investigative Medicine, Imperial College London, London, United Kingdom.
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Anderson RA, Cormier J, Thieroff-Ekerdt R, Boyce M, van den Berg F, Grau D, Turnquist D, Corzo D, Graham P. Pharmacodynamic Activity of the Novel Neurokinin-3 Receptor Antagonist SJX-653 in Healthy Men. J Clin Endocrinol Metab 2020; 105:5908704. [PMID: 32946574 PMCID: PMC7571451 DOI: 10.1210/clinem/dgaa657] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 09/17/2020] [Indexed: 11/19/2022]
Abstract
CONTEXT SJX-653 is a novel neurokinin 3 receptor (NK3R) antagonist. The NK3 pathway is a central regulator of gonadotropin releasing hormone (GnRH) secretion and has also been implicated in the generation of hot flashes. Therefore, decreases of luteinizing hormone (LH) and testosterone in men serve as sensitive pharmacodynamic (PD) markers of central NK3 antagonism. OBJECTIVE To characterize the safety, tolerability, pharmacokinetics, and pharmacodynamic activity of SJX-653 in healthy men. DESIGN A randomized, placebo-controlled, double-blind, single ascending dose study. SETTING Phase 1 unit. PATIENTS OR OTHER PARTICIPANTS Seven cohorts of 6 healthy men 18-45 years of age (4:2 randomization to SJX-653/placebo per cohort). INTERVENTION(S) Single oral doses of 0.5-90 mg SJX-653. MAIN OUTCOME MEASURE(S) Safety assessments and serial pharmacokinetic (PK)/PD measurements. RESULTS SJX-653 was well tolerated at all dose levels. Cmax and AUC0-24 increased in a dose-proportional manner. The terminal elimination half-life ranged between 9.8 and 12.5 hours independent of dose. A statistically significant, dose-dependent, reversible reduction of LH and testosterone was observed with near maximal effect after 15 mg and little to no effect at 4.5 mg. Maximal LH reduction was 70 ± 7% (mean ± sd) at 6 hours after 30 mg SJX-653 versus 10 ± 43% for placebo (P = 0.0006); maximal T reduction was of 68 ± 5% at 8 hours after 60 mg SJX-653 versus 18 ± 11% for placebo (P < 0.0001). The plasma IC50 for LH reduction was 33 ng/mL. CONCLUSIONS These data demonstrate clinical proof-of-mechanism for SJX-653 as a potent centrally-acting NK3R antagonist.
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Affiliation(s)
- Richard A Anderson
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, UK
- Correspondence and Reprint Requests: Professor RA Anderson, MRC Centre for Reproductive Health, The Queen’s Medical Research Institute, University of Edinburgh, 47 Little France Crescent, Edinburgh EH16 4TJ, UK. E-mail:
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Faubion SS, King A, Kattah AG, Kuhle CL, Sood R, Kling JM, Mara KC, Kapoor E. Hypertensive disorders of pregnancy and menopausal symptoms: a cross-sectional study from the data registry on experiences of aging, menopause, and sexuality. Menopause 2020; 28:25-31. [PMID: 32810078 PMCID: PMC7769885 DOI: 10.1097/gme.0000000000001638] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Hypertensive disorders of pregnancy and menopausal symptoms, specifically vasomotor symptoms, have both been associated with cardiovascular disease risk in women. However, data are sparse on the association between these two female-specific cardiovascular risk factors. This study was conducted to investigate the association between a history of a hypertensive disorder of pregnancy and menopausal symptoms. METHODS This was a cross-sectional study of women aged 40 to 65 years seen for specialty consultation in women's health clinics at Mayo Clinic Rochester, MN and Scottsdale, AZ, between May, 2015 and September, 2019. A self-reported history of hypertensive disorders of pregnancy served as the independent variable, and menopause symptoms as assessed by the Menopause Rating Scale were the primary outcome measure. RESULTS Of 2,684 women included in the analysis, 180 had a self-reported history of a hypertensive disorder of pregnancy. The total menopausal symptom scores as well as somatic and psychological domain scores were higher in women with a history of a hypertensive disorder of pregnancy compared to women without a history of a hypertensive disorder of pregnancy or to women without a pregnancy. On multivariable analysis, women with a hypertensive disorder of pregnancy using hormone therapy had significantly higher total menopause symptom scores than women with no such history. CONCLUSIONS In this large cross-sectional study, a history of hypertensive disorders of pregnancy was associated with more bothersome menopausal symptoms. Additional study is needed to determine the strength of this association, underlying mechanisms of the association, and clinical implications for cardiovascular risk prediction in women.
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Affiliation(s)
- Stephanie S. Faubion
- Center for Women’s Health, Mayo Clinic, Rochester, MN
- Division of General Internal Medicine, Mayo Clinic, Jacksonville, FL
| | - Amanda King
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN
| | - Andrea G. Kattah
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | - Carol L. Kuhle
- Center for Women’s Health, Mayo Clinic, Rochester, MN
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN
| | - Richa Sood
- Center for Women’s Health, Mayo Clinic, Rochester, MN
- Division of General Internal Medicine, Mayo Clinic, Jacksonville, FL
| | - Juliana M. Kling
- Division of Women’s Health Internal Medicine, Mayo Clinic, Scottsdale, AZ
| | - Kristin C. Mara
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | - Ekta Kapoor
- Center for Women’s Health, Mayo Clinic, Rochester, MN
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN
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To the Editor:. Menopause 2020; 27:1996-1997. [DOI: 10.1097/gme.0000000000001619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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