An audit of oestradiol levels and implant frequency in women undergoing subcutaneous implant therapy

Hormone replacement therapy subcutaneous implants for refractory menopause symptoms; the patient's perspective

OBJECTIVE

For women with menopause symptoms refractory to standard hormone replacement therapy (HRT) preparations, HRT implants offer an alternative. The primary objective of this study was to evaluate women's perceptions regarding efficacy, tolerability, satisfaction and safety of implant therapy.

STUDY DESIGN

A single centre service evaluation study performed at Birmingham Women's & Children's Foundation Hospital Trust. An anonymised semi-structured survey link was posted to all women (n = 397) recorded to have received HRT implant(s) at a tertiary Menopause clinic (May 1982 and Dec 2018). Women attending clinic (June 2020 to Sept 2020) were opportunistically invited to complete a written version of the survey.

MAIN OUTCOME MEASURES

Data collected included demographics, medical and surgical history, therapy duration, type, indication and complications. Climacteric symptoms were assessed using the Greene Climacteric Scale.

RESULTS

Data was obtained for 119 women. The written survey yielded higher response rates (n = 73, 61.3%). Most respondents were 51-60 years old (n = 51 42.9%) and 87.4% (n = 104) were 'White British'. 70 women used estradiol only implants. 30.1%% (n = 34) of patients reported a low Greene Climacteric Scale score (0-5). Subgroup analysis showed prevalence of sexual dysfunction and vasomotor symptoms across ages. There was a lower prevalence of psychological symptoms amongst ≥51 year olds. High satisfaction rates were reported.

CONCLUSIONS

Data from a large cohort is presented. Good symptom control, satisfaction and long-term efficacy was demonstrated. This study supports the value of HRT implants for refractory menopause symptoms. A national database of implant users would be a useful tool to record satisfaction scores and adverse events.

Use of Testosterone in Postmenopausal Women

The role of testosterone in women and its potential as a therapeutic agent continue to attract controversy. The clinical trials of testosterone therapy for women primarily have focused on treatment of female sexual dysfunction, with the largest placebo-controlled studies being of transdermal testosterone in postmenopausal women. Based on the cumulative data from these studies, loss of sexual desire with associated personal distress currently is the only agreed-on indication for judicious testosterone supplementation for postmenopausal women. This article reviews the physiology of testosterone in women, summarizes the findings from observational studies and clinical trials, and considers indications for testosterone use.

Androgens in premenopausal women and women with premature ovarian insufficiency

Premature ovarian insufficiency (POI) results in both estrogen and testosterone insufficiency. Whether testosterone therapy may be of benefit for women with POI is uncertain. Presently, the only evidence-based indication for testosterone therapy for women is for the treatment of postmenopausal women with low sexual desire with associated personal distress. Consistent with this, available evidence does not support the prescription of testosterone to prevent cardiometabolic disease, bone loss, sarcopenia, or cognitive decline or to improve well-being and low mood in postmenopausal women. Data pertaining to the treatment of women with POI with testosterone are limited. This article reviews androgen physiology in premenopausal women and the impact of POI on circulating androgen concentrations, summarizes findings from observational studies and clinical trials of testosterone therapy in premenopausal women and women with POI, and concludes with recommendations regarding testosterone use in women with POI.

Oestrogens for treatment or prevention of pelvic organ prolapse in postmenopausal women

BACKGROUND

Pelvic organ prolapse is common and can be detected in up to 50% of parous women although many are asymptomatic. Oestrogen preparations are used to improve vaginal thinning (atrophy). It is possible that oestrogens, alone or in conjunction with other interventions, might prevent or assist in the management of pelvic organ prolapse, for example by improving the strength of weakened supporting structures.

OBJECTIVES

To determine the effects of oestrogens or drugs with oestrogenic effects alone, or in conjunction with other treatments, both for prevention and treatment of pelvic organ prolapse.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group Specialised Register of trials (searched 6 May 2010), MEDLINE (January 1950 to April 2010) as well as reference lists of relevant articles.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials that included the use of any oestrogens or drugs with oestrogenic (or anti-oestrogenic) actions for pelvic organ prolapse.

DATA COLLECTION AND ANALYSIS

Trials were assessed and data extracted independently by two review authors.

MAIN RESULTS

Three trials and one meta-analysis of adverse effects of a further three trials were identified. One trial did not provide useable data. Two trials included 148 women with prolapse, one included 58 postmenopausal women and the meta-analysis reported a mixed population (women with and without prolapse) of postmenopausal women (N=6984). The meta analysis and one other small trial investigated the effect of selective oestrogen receptor modulators (SERMs) for treatment or prevention of osteoporosis but also collected data of the effects on prolapse. Interventions included oestradiol, conjugated equine oestrogen and two (SERMs), raloxifene and tamoxifen. Only one small trial addressed the primary outcome (prolapse symptoms).One small treatment trial of oestradiol for three weeks before prolapse surgery found a reduced incidence of cystitis in the first four weeks after surgery but this unexpected finding needs to be confirmed in a larger trial.A meta-analysis of adverse effects of a SERM, raloxifene (used for treatment or prevention of osteoporosis in postmenopausal women) found a statistically significant reduction in the need for prolapse surgery at three year follow up (OR 0.50, 95% CI 0.31 to 0.81), but this was statistically significant only in women older than 60 years (OR 0.68, 95% CI 0.22 to 2.08) and the total number of women having prolapse surgery was small. A further small trial comparing conjugated equine oestrogen, raloxifene, tamoxifen and placebo in postmenopausal women having pelvic floor muscle training was too small to detect effects on prolapse outcomes.

AUTHORS' CONCLUSIONS

There was limited evidence from randomised controlled trials regarding the use of oestrogens for the prevention and management of pelvic organ prolapse. The use of local oestrogen in conjunction with pelvic floor muscle training before surgery may reduce the incidence of post-operative cystitis within four weeks after surgery. Oral raloxifene may reduce the need for pelvic organ prolapse surgery in women older than 60 years although this cannot be taken as an indication for practice.There is a need for rigorous randomised controlled trials with long term follow up to assess oestrogen preparations for prevention and management of pelvic organ prolapse, particularly as an adjunctive treatment for women using pessaries and also before and after prolapse surgery.

Oestradiol assays: fitness for purpose?

In this review we discuss the analytical inadequacies of oestradiol assays in relation to the clinical requirements for performing them, and make recommendations for their improvement. The measurement of oestradiol can be requested in a number of clinical scenarios (precocious puberty, infertility, assisted conception, hormone replacement therapy). The very wide dynamic range of oestradiol concentrations is a huge challenge for routine assays, which they are unlikely to meet on theoretical as well as practical grounds. The EQA performance of oestradiol assays in terms of trueness, comparability, recovery and analytical sensitivity leaves much to be desired and indicates that calibration is compromised by poor analytical specificity. To make oestradiol assays fit for purpose requires concerted action by all stakeholders to define analytical quality specifications for the various clinical scenarios involved, and then to encourage concerted action by the diagnostic industry to use the steroid reference measurement system to improve specificity, trueness and traceability.

Response Surface Methodology to Obtain β-Estradiol Biodegradable Microspheres for Long-Term Therapy of Osteoporosis

The purpose of this work was to evaluate the main and interaction effects of formulation factors on the drug encapsulation efficiency of beta-estradiol biodegradable microspheres by applying response surface methodology. A secondary purpose was to obtain an optimized formula for long-term therapy of osteoporosis. A three factor, three level Box-Behnken experimental design was used to get 15 experimental runs. The independent variables were drug/polymer ratio (X1), dispersing agent concentration (X2), and deaggregating agent concentration (X3). The dependent variables were percentage encapsulation efficiency (Y1), cumulative percent drug released (Y2), and percentage yield of the microspheres (Y3). The formulations were prepared by emulsion solvent evaporation technique using ethyl acetate as organic solvent. The optimized formulation was maximized for encapsulation efficiency and further characterized for the particle size distribution, scanning electron microscopy (SEM), X-ray diffraction (XRD), and Fourier transform infrared (FT-IR). The mathematical relationship obtained between X1, X2, X3, and Y1 was: Y1 = -129.85 + 29.35X1 + 129.99X2 + 64.82X3 - 3.2X1X2 - 0.29X1X3 - 35.83X2X3 - 2.05X(2)(1) - 13.23X(2)(2) - 5.92X(2)(3) (R2 = 0.99) The equation showed that X1, X2, and X3 affect Y1 positively but interaction between any two of these factors affects Y1 negatively. The most significant interaction was between X2 and X3. The finding indicated that controlled releases beta-estradiol biodegradable microspheres with high encapsulation efficiency and low pulsatile release can be prepared and the quantitative response surface methodology applied helped in understanding the effects and the interaction effects between the three factors applied.

Testosterone release rate and duration of action of testosterone pellet implants

OBJECTIVE

Testosterone pellets are a highly effective subdermal depot administered at regular intervals with the timing individualized depending upon return of the patient's characteristic androgen deficiency symptoms. Yet the in vivo testosterone release rate and effective duration of action of these pellets has been little studied systematically.

DESIGN

Analysis of prospectively collected data from three randomized controlled clinical trials. Collection of extruded pellets.

PATIENTS

Androgen-deficient men (n = 136) undergoing long-term androgen replacement therapy with a standard dose (800 mg) of testosterone pellets implanted subdermally at intervals from 5 to 7 months.

MEASUREMENTS

Testosterone release rate of pellets, consisting of pure crystalline testosterone without excipients, is estimated by measuring the dry weight lost by pellets (n = 179) over their time in situ. The effective duration of the standard regimen, and the influence of extrusion and patient or procedural characteristics on it, was estimated by timing of return for re-implantation due to recurrence of the patient's familiar androgen deficiency symptoms.

RESULTS

The loss of dry weight of intact (n = 112) pellets was strongly correlated with time in situ (r2 = 0.969) providing an estimate of daily testosterone release rate per 200 mg pellet of 1.34 +/- 0.02 mg/pellet/day (95% CI 1.30-1.37 mg/day) for the first 3 months. After 756 implantations of the standard dose, men return for re-implantation at 5.8 calendar months following no or only a single pellet extrusion, but the time to return was significantly shorter after multiple extrusions. No patient or procedural features influenced the timing of return. Among men with primary hypogonadism, increases in plasma LH and FSH were more sensitive than plasma total or free testosterone to changes in testosterone delivery following an extrusion.

CONCLUSION

Testosterone pellet implants release testosterone at a steady rate of 1.3 mg/200 mg implant/day (95% CI). The duration of action is about 6 months in an uncomplicated cycle with timing of return shortened by extrusions only in the 3.6% of procedures followed by multiple extrusions. No other patient or procedural features influenced duration of action. Among men with an intact hypothalamo-pituitary unit, plasma gonadotropins are more sensitive than blood total or free testosterone to reduced testosterone delivery following an extrusion.

Estrogen acutely inhibits ion transport by isolated stria vascularis

We investigated the nongenomic effects of female sex steroid hormones on the short circuit current (I(sc,probe)) across gerbil stria vascularis using the voltage-sensitive vibrating probe. The strial marginal cell epithelial layer produces I(sc,probe) by secreting K+ via I(Ks) channels in the apical membrane. Application of 17beta-estradiol (E2) caused a decrease of I(sc,probe) in a dose-dependent manner (10 nM-10 microM) within seconds. Tamoxifen, a competitive inhibitor of the intracellular estrogen receptor, did not change the inhibitory effect of E2. Activation of I(Ks) channels by 4,4'-diisothiocyanatostilbene-2,2'-disulfonic acid in the presence and absence of E2 was used to test the mechanism of action. The results were consistent with a direct inhibitory effect of E2 on the I(Ks) channels. By contrast, progesterone caused a transient increase of I(sc,probe). These results suggest that E2 decreases secretion of K+ by inhibition of I(Ks) channels via a nongenomic mechanism at concentrations near those occurring under some physiologic conditions while progesterone caused only transient effects on I(sc,probe).

Biodegradable progesterone microsphere delivery system for osteoporosis therapy

The purpose of this study was to formulate and characterize a controlled-release biodegradable delivery system of progesterone for the treatment or prevention of osteoporosis. Microspheres of progesterone were formulated using copolymers of poly(glycolic acid-co-dl-lactic acid) (PGLA 50/50 and PGLA 15/85) and poly(L-lactic acid) (L-PLA) of similar molecular weight by the emulsion solvent evaporation technique. The effects of process variables, such as volume fraction, polyvinyl alcohol (PVA) concentration, polymer composition, and stir speed during preparation, on the yield, encapsulation efficiency (EEF), particle size distribution, in vitro release profiles of progesterone, and surface morphology of progesterone microspheres were investigated. Increasing the volume fraction from 9% to 22% increased the EEF without significantly increasing the yield; however, the rate of progesterone release from the microspheres decreased. Increasing the PVA concentration from 1% to 5% had no significant influence on the EEF, but the rate of progesterone release from microspheres increased. Polymer composition had no significant effect on the EEF, but had a significant effect on the particle size distribution, surface morphology, and release rate of progesterone from the microspheres. Stir speed did not have a significant influence on the EEF; however, stir speed influenced particle size distribution and the rate of progesterone release from microspheres of the same sieve-size range. The results suggest that controlled release of progesterone is possible by varying the different process variables, and that PGLA 50/50 provided the slowest release of progesterone. This should provide a means of delivering progesterone for months for the treatment or prevention of osteoporosis in postmenopausal women.

An audit of oestrogen implant hormone replacement therapy

The aim of this review was to determine the factors that impact upon oestradiol levels in patients receiving oestradiol implants and to assess the relationship between symptom scores and oestradiol levels. In addition we sought to determine the incidence of tachyphylaxis (menopausal symptoms in spite of high oestradiol levels) among our patients, and to assess the degree of menstrual cycle control in the nonhysterectomized women receiving implant treatment. We undertook an audit of the medical records of 118 women who received 673 oestradiol implants (50 or 100 mg) over an 8-year period in the menopause clinics at Royal North Shore Hospital. Data on patient age, clinical diagnosis, symptom score, previous or subsequent hysterectomy, oestradiol implant dosage (50 mg or 100 mg), number of doses, oestradiol levels and concurrent testosterone implant insertion were recorded. We found that implant dosage (p<0.001) and implant number (p<0.001) were the factors that significantly impact upon oestradiol levels. Concomitant testosterone implant usage (p=0.74), patient age (p=0.14) and hysterectomy (p=0.57) did not have a statistically significant effect upon oestradiol levels. The incidence of tachyphylaxis was 1.7% (2 patients). There was no relationship between oestradiol levels and symptom scores (p=0.69). Oestradiol implant treatment, when administered on the basis of return of symptoms, without a strict target oestradiol level, results in a steady increase in baseline oestradiol levels. The dosage used and the number of implants received are important factors influencing oestradiol levels. The incidence of tachyphylaxis is low when patients are counselled regarding the lack of agreement between symptom scores and oestradiol levels.