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Othman ER, Al-Hendy A, Mostafa R, Lambalk CB, Mijatovic V. Oral GnRH Antagonists in Combination with Estradiol and Norethindrone Acetate for Pain Relief Associated with Endometriosis: A Review of Evidence of a Novel Class of Hormonal Agents. Int J Womens Health 2024; 16:309-321. [PMID: 38435758 PMCID: PMC10908275 DOI: 10.2147/ijwh.s442357] [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: 09/27/2023] [Accepted: 01/22/2024] [Indexed: 03/05/2024] Open
Abstract
Current medical treatment options for endometriosis associated pains are inadequate. Evidence on effects of nonsteroidal anti-inflammatory drugs is scarce. Around one third of patients are not responsive to oral contraceptives or progestins due to progesterone resistance. Gonadotropin-releasing hormone (GnRH) agonists can only be used for a short duration because of associated side effects. Oral GnRH antagonists, including elagolix, relugolix, and linzagolix allow oral administration, induce dose dependent reduction of estradiol levels, do not cause initial flare up of endometriosis symptoms, and allow the fast return of ovarian function and menstruation after discontinuation. Elagolix at a low dose of 150 mg once daily, or the higher dose of 200 mg twice daily, significantly increased the proportion of women achieving clinically meaningful decline of dysmenorrhea, noncyclic pelvic pain, and dyspareunia. Relugolix at an oral dose of 40 mg/day results in improvement in different forms of endometriosis related pelvic pain, with an efficacy and side effect profile similar to that of GnRH agonists. Adding 1 mg of estradiol and 0.5 mg of norethindrone to 40 mg of relugolix (relugolix combination therapy) allows extension of treatment to 24 weeks with maintained efficacy and an improved side effect profile. Linzagolix, in a dose of 75 mg/day, can be used alone to treat endometriosis associated pain. For severe pelvic pain and dyspareunia, linzagolix can be used in a high dose of 200 mg/day with hormonal add-back therapy to preserve bone health.
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Affiliation(s)
- Essam R Othman
- OB-GYN Department, Assiut University, Assiut, 71515, Egypt
- Academic Endometriosis Center, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Ayman Al-Hendy
- Department of Obstetrics and Gynecology, University of Chicago, Chicago, IL, 60637, USA
| | - Radwa Mostafa
- OB-GYN Department, Assiut University, Assiut, 71515, Egypt
| | - Cornelis B Lambalk
- Academic Endometriosis Center, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Velja Mijatovic
- Academic Endometriosis Center, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
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2
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Marla S, Mortlock S, Heinosalo T, Poutanen M, Montgomery GW, McKinnon BD. Gene expression profiles separate endometriosis lesion subtypes and indicate a sensitivity of endometrioma to estrogen suppressive treatments through elevated ESR2 expression. BMC Med 2023; 21:460. [PMID: 37996888 PMCID: PMC10666321 DOI: 10.1186/s12916-023-03166-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 11/09/2023] [Indexed: 11/25/2023] Open
Abstract
BACKGROUND Endometriosis is a common, gynaecological disease characterised by the presence of endometrial-like cells growing outside the uterus. Lesions appear at multiple locations, present with variation in appearance, size and depth of invasion. Despite hormones being the recommended first-line treatment, their efficacy, success and side effects vary widely amongst study populations. Current, hormonal medication for endometriosis is designed to suppress systemic oestrogen. Whether these hormones can influence the lesions themselves is not yet clear. Evidence of hormone receptor expression in endometriotic lesions and their ability to respond is conflicting. A variation in their expression, activation of transcriptional co-regulators and the potential to respond may contribute to their variation in patient outcomes. Identifying patients who would benefit from hormonal treatments remain an important goal in endometriosis research. METHODS Using gene expression data from endometriosis lesions including endometrioma (OMA, n = 28), superficial peritoneal lesions (SUP, n = 72) and deeply infiltrating lesions (DIE, n = 78), we performed principal component analysis, differential gene expression and gene correlation analyses to assess the impact of menstrual stage, lesion subtype and hormonal treatment on the gene expression. RESULTS The gene expression profiles did not vary based on menstrual stage, but could distinguish lesion subtypes with OMA significantly differentiating from both SUP and DIE. Additionally, the effect of oestrogen suppression medication altered the gene expression profile in OMA, while such effect was not observed in SUP or DIE. Analysis of the target receptors for hormonal medication indicated ESR2 was differentially expressed in OMA and that genes that correlated with ESR2 varied significantly between medicated and non-medicated OMA samples. CONCLUSIONS Our results demonstrate of the different lesion types OMA present with strongest response to hormonal treatment directly through ESR2. The data suggests that there may be the potential to target treatment options to individual patients based on pre-surgical diagnoses.
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Affiliation(s)
- Sushma Marla
- Institute for Molecular Bioscience, The University of Queensland, Carmody Rd, Brisbane, QLD, 4067, Australia
| | - Sally Mortlock
- Institute for Molecular Bioscience, The University of Queensland, Carmody Rd, Brisbane, QLD, 4067, Australia
| | - Taija Heinosalo
- Institute of Biomedicine, Research Centre for Integrative Physiology and Pharmacology, University of Turku, Turku, 20014, Finland
| | - Matti Poutanen
- Institute of Biomedicine, Research Centre for Integrative Physiology and Pharmacology, University of Turku, Turku, 20014, Finland
- Turku Center for Disease Modelling, University of Turku, 20014, Turku, Finland
| | - Grant W Montgomery
- Institute for Molecular Bioscience, The University of Queensland, Carmody Rd, Brisbane, QLD, 4067, Australia
| | - Brett David McKinnon
- Institute for Molecular Bioscience, The University of Queensland, Carmody Rd, Brisbane, QLD, 4067, Australia.
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Shi J, Tan X, Feng G, Zhuo Y, Jiang Z, Banda S, Wang L, Zheng W, Chen L, Yu D, Guo C. Research advances in drug therapy of endometriosis. Front Pharmacol 2023; 14:1199010. [PMID: 37416064 PMCID: PMC10320007 DOI: 10.3389/fphar.2023.1199010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Accepted: 06/13/2023] [Indexed: 07/08/2023] Open
Abstract
Endometriosis is one of the most common benign gynecological disorders in reproductive-aged women. The major symptoms are chronic pelvic pain and infertility. Despite its profound impact on women's health and quality of life, its pathogenesis has not been fully elucidated, it cannot be cured and the long-term use of drugs yields severe side effects and hinders fertility. This review aims to present the advances in pathogenesis and the newly reported lead compounds and drugs managing endometriosis. This paper investigated Genetic changes, estrogen-dependent inflammation induction, progesterone resistance, imbalance in proliferation and apoptosis, angiogenesis, lymphangiogenesis and neurogenesis, and tissue remodeling in its pathogenesis; and explored the pharmacological mechanisms, constitutive relationships, and application prospects of each compound in the text. To date, Resveratrol, Bay1316957, and bardoxifene were effective against lesions and pain in controlled animal studies. In clinical trials, Quinagolide showed no statistical difference with the placebo group; the results of phase II clinical trial of the IL-33 antibody have not been announced yet; clinical trial stage III of vilaprisan was suspended due to drug toxicity. Elagolix was approved for the treatment of endometriosis-related pain, but clinical studies of Elagolix for the pretreatment of patients with endometriosis to before In vitro fertilization treatment have not been fulfilled. The results of a clinical study of Linzagolix in patients with moderate to severe endometriosis-related pain have not been disclosed yet. Letrozole improved the fertility of patients with mild endometriosis. For endometriosis patients with infertility, oral GnRH antagonists and aromatase inhibitors are promising drugs, especially Elagolix and Letrozole.
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Affiliation(s)
- Jianyou Shi
- Department of Pharmacy, Sichuan Academy of Medical Sciences and Sichuan Provincial People’s Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- Personalized Drug Therapy Key Laboratory of Sichuan Province, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Xin Tan
- Department of Pharmacy, Sichuan Academy of Medical Sciences and Sichuan Provincial People’s Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- Personalized Drug Therapy Key Laboratory of Sichuan Province, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Guimei Feng
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China
- Chinese Academy of Sciences Sichuan Translational Medicine Research Hospital, Chengdu, China
| | - Yuan Zhuo
- Pharmacy College, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Zhongliang Jiang
- Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Srikanth Banda
- Department of Chemistry and Biochemisty, Florida International University, Miami, FL, United States
| | - Lin Wang
- College of Food and Bioengineering, Xihua University, Chengdu, China
| | - Wei Zheng
- Pharmacy College, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Lu Chen
- Department of Pharmacy, Sichuan Academy of Medical Sciences and Sichuan Provincial People’s Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- Personalized Drug Therapy Key Laboratory of Sichuan Province, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Dongke Yu
- Department of Pharmacy, Sichuan Academy of Medical Sciences and Sichuan Provincial People’s Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- Personalized Drug Therapy Key Laboratory of Sichuan Province, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Chun Guo
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China
- Chinese Academy of Sciences Sichuan Translational Medicine Research Hospital, Chengdu, China
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Teworte S, Luciani P. Endometriosis, the Silent Disease: Molecular Targets, Active Principles, and Drug Delivery Systems. Helv Chim Acta 2022. [DOI: 10.1002/hlca.202200132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Sarah Teworte
- Department of Chemistry Biochemistry and Pharmaceutical Sciences University of Bern Freiestrasse 3 CH-3012 Bern Switzerland
| | - Paola Luciani
- Department of Chemistry Biochemistry and Pharmaceutical Sciences University of Bern Freiestrasse 3 CH-3012 Bern Switzerland
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Dolmans MM, Donnez J. Emerging Drug Targets for Endometriosis. Biomolecules 2022; 12:biom12111654. [PMID: 36359004 PMCID: PMC9687824 DOI: 10.3390/biom12111654] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 10/27/2022] [Accepted: 10/27/2022] [Indexed: 11/09/2022] Open
Abstract
Endometriosis is a chronic inflammatory disease causing distressing symptoms and requiring a life-long management strategy. The objective of this review is to evaluate endometriosis-related pathways and identify novel therapies to treat it. We focused on the crucial role of inflammation and inflammatory molecules in order to define new perspectives for non-hormonal treatment of the disease by targeting inflammation, nuclear factor kappa B and cytokines, or reactive oxygen species, apoptotic and autophagic pathways, regulators of epithelial-mesenchymal transition, and angiogenesis and neuroangiogenesis. Novel non-steroidal therapies targeting these pathways for endometriosis were explored, but multiple challenges remain. While numerous agents have been investigated in preclinical trials, few have reached the clinical testing stage because of use of inappropriate animal models, with no proper study design or reporting of preclinical strategies. Targeting estrogens is still the best way to control endometriosis progression and inflammation.
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Affiliation(s)
- Marie-Madeleine Dolmans
- Gynecology Department, Cliniques Universitaires St-Luc, Avenue Hippocrate 10, 1200 Brussels, Belgium
- Gynecology Research Laboratory, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Avenue Mounier 52, bte B1.52.02, 1200 Brussels, Belgium
| | - Jacques Donnez
- Department of Gynaecology, Université Catholique de Louvain, 1200 Brussels, Belgium
- Société de Recherche pour l’Infertilité (SRI), 143 Avenue Grandchamp, 1150 Brussels, Belgium
- Correspondence:
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Zou F, Wang Y, Yu D, Liu C, Lu J, Zhao M, Ma M, Wang W, Jiang W, Gao Y, Zhang R, Zhang J, Ye L, Tian J. Discovery of the thieno[2,3-d]pyrimidine-2,4-dione derivative 21a: A potent and orally bioavailable gonadotropin-releasing hormone receptor antagonist. Eur J Med Chem 2022; 242:114679. [PMID: 35998545 DOI: 10.1016/j.ejmech.2022.114679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Revised: 08/05/2022] [Accepted: 08/10/2022] [Indexed: 11/26/2022]
Abstract
The gonadotropin releasing hormone receptor (GnRH-R) is a G protein-coupled receptor (GPCR) belonging to the rhodopsin family. GnRH-R antagonists suppress testosterone to castrate level more rapidly than gonadotropin releasing hormone agonists but lack the flare phenomenon often seen during the early period of GnRH-R agonist treatment. Recently orgovyx (relugolix) was approved as the first oral GnRH-R antagonist for the treatment of advanced prostate cancer. However, orgovyx has demonstrated poor pharmacokinetic profile with low oral bioavailability and high efflux. Here, we rationally designed and synthesized a series of derivatives (13a-m, 21a-i) through the modification and structure-activity relationship study of relugolix, which led to the discovery of 21a as a highly potent GnRH-R antagonist (IC50 = 2.18 nM) with improved membrane permeability (Papp, A-B = 0.98 × 10-6 cm/s) and oral bioavailability (F % = 44.7). Compound 21a showed high binding affinity (IC50 = 0.57 nM) and potent in vitro antagonistic activity (IC50 = 2.18 nM) at GnRH-R. 21a was well tolerated and efficacious in preclinical studies to suppress blood testosterone levels, which merits further investigation as a candidate novel GnRH-R antagonist for clinical studies.
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Affiliation(s)
- Fangxia Zou
- School of Pharmacy, Key Laboratory of Molecular Pharmacology and Drug Evaluation (Yantai University), Ministry of Education, Collaborative Innovation Center of Advanced Drug Delivery System and Biotech Drugs in Universities of Shandong, Yantai University, Yantai, 264005, PR China
| | - Yao Wang
- School of Pharmacy, Key Laboratory of Molecular Pharmacology and Drug Evaluation (Yantai University), Ministry of Education, Collaborative Innovation Center of Advanced Drug Delivery System and Biotech Drugs in Universities of Shandong, Yantai University, Yantai, 264005, PR China
| | - Dawei Yu
- Medicinal Chemistry Research Department, R & D Center (Luye Pharma Group Ltd.), Yantai, 264003, PR China
| | - Chunjiao Liu
- School of Pharmacy, Key Laboratory of Molecular Pharmacology and Drug Evaluation (Yantai University), Ministry of Education, Collaborative Innovation Center of Advanced Drug Delivery System and Biotech Drugs in Universities of Shandong, Yantai University, Yantai, 264005, PR China
| | - Jing Lu
- School of Pharmacy, Key Laboratory of Molecular Pharmacology and Drug Evaluation (Yantai University), Ministry of Education, Collaborative Innovation Center of Advanced Drug Delivery System and Biotech Drugs in Universities of Shandong, Yantai University, Yantai, 264005, PR China
| | - Min Zhao
- School of Pharmacy, Key Laboratory of Molecular Pharmacology and Drug Evaluation (Yantai University), Ministry of Education, Collaborative Innovation Center of Advanced Drug Delivery System and Biotech Drugs in Universities of Shandong, Yantai University, Yantai, 264005, PR China
| | - Mingxu Ma
- School of Pharmacy, Key Laboratory of Molecular Pharmacology and Drug Evaluation (Yantai University), Ministry of Education, Collaborative Innovation Center of Advanced Drug Delivery System and Biotech Drugs in Universities of Shandong, Yantai University, Yantai, 264005, PR China
| | - Wenyan Wang
- School of Pharmacy, Key Laboratory of Molecular Pharmacology and Drug Evaluation (Yantai University), Ministry of Education, Collaborative Innovation Center of Advanced Drug Delivery System and Biotech Drugs in Universities of Shandong, Yantai University, Yantai, 264005, PR China
| | - Wanglin Jiang
- School of Public Health and Management, Binzhou Medical University, Yantai, PR China
| | - Yonglin Gao
- School of Pharmacy, Key Laboratory of Molecular Pharmacology and Drug Evaluation (Yantai University), Ministry of Education, Collaborative Innovation Center of Advanced Drug Delivery System and Biotech Drugs in Universities of Shandong, Yantai University, Yantai, 264005, PR China
| | - Rui Zhang
- Medicinal Chemistry Research Department, R & D Center (Luye Pharma Group Ltd.), Yantai, 264003, PR China
| | - Jianzhao Zhang
- College of Life Sciences, Yantai University, Yantai, Shangdong, 264005, PR China.
| | - Liang Ye
- School of Public Health and Management, Binzhou Medical University, Yantai, PR China.
| | - Jingwei Tian
- School of Pharmacy, Key Laboratory of Molecular Pharmacology and Drug Evaluation (Yantai University), Ministry of Education, Collaborative Innovation Center of Advanced Drug Delivery System and Biotech Drugs in Universities of Shandong, Yantai University, Yantai, 264005, PR China.
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7
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Beck D, Winzenborg I, Liu M, Degner J, Mostafa NM, Noertersheuser P, Shebley M. Population Pharmacokinetics of Elagolix in Combination with Low-Dose Estradiol/Norethindrone Acetate in Women with Uterine Fibroids. Clin Pharmacokinet 2021; 61:577-587. [PMID: 34878624 PMCID: PMC8975762 DOI: 10.1007/s40262-021-01096-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/16/2021] [Indexed: 11/27/2022]
Abstract
Background and Objectives Elagolix is an orally active, gonadotropin-releasing hormone receptor antagonist approved for the management of endometriosis-associated pain and heavy menstrual bleeding associated with uterine fibroids. Elagolix population pharmacokinetics and factors affecting elagolix exposure in healthy women and women with endometriosis have been reported previously. The purpose of this study was to extend the population pharmacokinetics model with additional modifications to incorporate data from phase III studies of elagolix with hormonal add-back therapy in women with uterine fibroids. Methods Data from 13 clinical studies (a total of 2168 women) consisting of six phase I studies in healthy premenopausal women, four phase III studies in premenopausal women with endometriosis, and three phase III studies in premenopausal women with uterine fibroids were analyzed using a non-linear mixed-effects modeling approach. Results Elagolix population pharmacokinetics was best described by a two-compartment model with first-order absorption, lag time in absorption, and first-order elimination. Out of the covariates tested on elagolix apparent clearance, apparent volume of distribution, and/or relative bioavailability, only organic anion transporting polypeptide 1B1 genotype status and body weight had a statistically significant but no clinically meaningful effect on elagolix relative bioavailability and apparent volume of distribution, respectively. There were no clinically meaningful differences in elagolix population pharmacokinetics in healthy women or women with endometriosis or uterine fibroids. Conclusions Elagolix population pharmacokinetics modeling did not reveal any patient-related factors or clinical parameters that would require dose adjustments for the approved dosage of 300 mg twice daily with estradiol 1 mg /norethindrone acetate 0.5 mg daily, in women with heavy menstrual bleeding associated with uterine fibroids. Clinical Trial Registration ClinicalTrials.gov identifiers: NCT01620528 (EM-1), NCT01760954 (EM-1-Extend), NCT01931670 (EM-2), NCT02143713 (EM-2-Extend), NCT02654054 (UF-1), NCT02691494 (UF-2), NCT0295494 (UF-Extend). Supplementary Information The online version contains supplementary material available at 10.1007/s40262-021-01096-w.
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Affiliation(s)
- Denise Beck
- Clinical Pharmacology and Pharmacometrics, AbbVie Deutschland GmbH & Co. KG, Ludwigshafen am Rhein, Germany
| | - Insa Winzenborg
- Clinical Pharmacology and Pharmacometrics, AbbVie Deutschland GmbH & Co. KG, Ludwigshafen am Rhein, Germany
| | - Mohan Liu
- Pharmacogenetics, AbbVie, North Chicago, IL, USA
| | - Jacob Degner
- Genomics Research Center, AbbVie, North Chicago, IL, USA
| | - Nael M Mostafa
- Clinical Pharmacology and Pharmacometrics, AbbVie, 1 North Waukegan Road, Bldg. AP31-3, North Chicago, IL, 60064, USA
| | - Peter Noertersheuser
- Clinical Pharmacology and Pharmacometrics, AbbVie Deutschland GmbH & Co. KG, Ludwigshafen am Rhein, Germany
| | - Mohamad Shebley
- Clinical Pharmacology and Pharmacometrics, AbbVie, 1 North Waukegan Road, Bldg. AP31-3, North Chicago, IL, 60064, USA.
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8
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Salliss ME, Farland LV, Mahnert ND, Herbst-Kralovetz MM. The role of gut and genital microbiota and the estrobolome in endometriosis, infertility and chronic pelvic pain. Hum Reprod Update 2021; 28:92-131. [PMID: 34718567 DOI: 10.1093/humupd/dmab035] [Citation(s) in RCA: 75] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 08/25/2021] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Endometriosis is a chronic, burdensome condition that is historically understudied. Consequently, there is a lack of understanding of the etiology of the disease and its associated symptoms, including infertility and chronic pelvic pain (CPP). Endometriosis development is influenced by estrogen metabolism and inflammation, which are modulated by several factors including the microbiome and the estrobolome (the collection of genes encoding estrogen-metabolizing enzymes in the gut microbiome). Therefore, there is increasing interest in understanding the role of microbiota in endometriosis etiology. OBJECTIVE AND RATIONALE To date, there is no cure for endometriosis and treatment options often are ineffective. This manuscript will review the potential relationship between the microbiome and endometriosis, infertility and CPP and highlight the available data on the microbiome in relation to endometriosis and its related symptoms. The overarching goal of this manuscript is to inform future microbiome research that will lead to a deeper understanding of the etiology of the disease and possible diagnostic modalities and treatments. The potential impact of the microbiome on estrogen regulation modulated by the estrobolome, as well as inflammation and other endometriosis-promoting mechanisms within the genital tract, will be reviewed. The methodological limitations of microbiome-related studies will be critically assessed to provide improved guidelines for future microbiome and clinical studies. SEARCH METHODS PubMed databases were searched using the following keywords: endometriosis AND microbiome, infertility AND microbiome, pelvic pain AND microbiome, IVF (in-vitro fertilization) AND microbiome, endometriosis AND infertility. Clinical and preclinical animal trials that were eligible for review, and related to microbiome and endometriosis, infertility or CPP were included. All available manuscripts were published in 2002-2021. OUTCOMES In total, 28 clinical and 6 animal studies were included in the review. In both human and animal studies, bacteria were enriched in endometriosis groups, although there was no clear consensus on specific microbiota compositions that were associated with endometriosis, and no studies included infertility or CPP with endometriosis. However, bacterial vaginosis-associated bacteria and Lactobacillus depletion in the cervicovaginal microbiome were associated with endometriosis and infertility in the majority (23/28) of studies. Interpretation of endometrial studies is limited owing to a variety of methodological factors, discussed in this review. In addition, metadata outlining antibiotic usage, age, race/ethnicity, menopausal status and timing of sample collection in relation to diagnosis of endometriosis was not consistently reported. Animal studies (6/6) support a bidirectional relationship between the gut microbiota and endometriosis onset and progression. WIDER IMPLICATIONS There is evidence that a dysbiotic gut or genital microbiota is associated with multiple gynecologic conditions, with mounting data supporting an association between the microbiome and endometriosis and infertility. These microbiomes likely play a role in the gut-brain axis, which further supports a putative association with the spectrum of symptoms associated with endometriosis, including infertility and CPP. Collectively, this review highlights the demand for more rigorous and transparent methodology and controls, consistency across the field, and inclusion of key demographic and clinical characteristics of disease and comparison participants. Rigorous study designs will allow for a better understanding of the potential role of the microbiome in endometriosis etiology and the relationship to other disorders of the female reproductive tract.
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Affiliation(s)
- Mary E Salliss
- Department of Obstetrics and Gynecology, University of Arizona-College of Medicine, Phoenix, AZ, USA.,Department of Biology and Biochemistry, Bath University, Bath, UK
| | - Leslie V Farland
- Department of Epidemiology and Biostatistics, Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, AZ, USA.,Department of Obstetrics and Gynecology, University of Arizona-College of Medicine Tucson, Tucson, AZ, USA
| | - Nichole D Mahnert
- Department of Obstetrics and Gynecology, University of Arizona-College of Medicine, Phoenix, AZ, USA.,Department of Obstetrics and Gynecology, Banner-University Medical Center Phoenix, Phoenix, AZ, USA
| | - Melissa M Herbst-Kralovetz
- Department of Obstetrics and Gynecology, University of Arizona-College of Medicine, Phoenix, AZ, USA.,Department of Basic Medical Sciences, University of Arizona-College of Medicine, Phoenix, AZ, USA
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GnRH Antagonists with or without Add-Back Therapy: A New Alternative in the Management of Endometriosis? Int J Mol Sci 2021; 22:ijms222111342. [PMID: 34768770 PMCID: PMC8583814 DOI: 10.3390/ijms222111342] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 10/15/2021] [Accepted: 10/19/2021] [Indexed: 12/15/2022] Open
Abstract
To evaluate the effectiveness of a new class of medical drugs, namely oral gonadotropin-releasing hormone (GnRH) antagonists, in the management of premenopausal women with endometriosis-associated pelvic pain. We reviewed the most relevant papers (n = 27) on the efficacy of new medical alternatives (oral GnRH antagonists) as therapy for endometriosis. We first briefly summarized the concept of progesterone resistance and established that oral contraceptives and progestogens work well in two-thirds of women suffering from endometriosis. Since clinical evidence shows that estrogens play a critical role in the pathogenesis of the disease, lowering their levels with oral GnRH antagonists may well prove effective, especially in women who fail to respond to progestogens. There is a need for reliable long-term oral treatment capable of managing endometriosis symptoms, taking into consideration both the main symptoms and phenotype of the disease. Published studies reviewed and discussed here confirm the efficacy of GnRH antagonists. There is a place for GnRH antagonists in the management of symptomatic endometriosis. Novel algorithms that take into account the different phenotypes are proposed.
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Sukhikh GT, Adamyan LV, Dubrovina SO, Baranov II, Bezhenar VF, Kozachenko AV, Radzinsky VE, Orazov MR, Yarmolinskaya MI, Olofsson JI. Prolonged cyclical and continuous regimens of dydrogesterone are effective for reducing chronic pelvic pain in women with endometriosis: results of the ORCHIDEA study. Fertil Steril 2021; 116:1568-1577. [PMID: 34465452 DOI: 10.1016/j.fertnstert.2021.07.1194] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 07/14/2021] [Accepted: 07/16/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To compare the effectiveness of two different treatment regimens of dydrogesterone in the management of endometriosis-related chronic pelvic pain. DESIGN Observational, prospective cohort study over six months. SETTING Twenty gynecology clinics in the Russian Federation. PATIENT(S) Three hundred fifty women from 18 to 45 years of age with endometriosis and chronic pelvic pain with or without dysmenorrhea. INTERVENTION(S) Dydrogesterone 10 mg 2 or 3 times daily, either between the 5th and 25th days of the menstrual cycle (prolonged cyclical treatment regimen) or continuously (continuous treatment regimen). For all patients, the data cutoff was at six months of treatment. MAIN OUTCOME MEASURE(S) Intensity of chronic pelvic pain on the 11-point numerical rating scale (after 6 months). RESULT(S) A marked reduction in chronic pelvic pain was observed with both the prolonged cyclical and continuous treatment regimens (mean ± standard deviation change from baseline -3.3 ± 2.2 and -3.0 ± 2.2, respectively), with no significant difference between the two groups. With both regimens, patients experienced significant improvements in the intensity of chronic pelvic pain, number of days in which analgesics were required, severity of dysmenorrhea, sexual well-being, and health-related quality-of-life parameters. A favorable safety profile of dydrogesterone was confirmed, and no serious adverse drug reactions were reported during the study. CONCLUSION(S) Prolonged cyclical and continuous treatment regimens of dydrogesterone therapy both demonstrated a pronounced and similar reduction in the severity of chronic pelvic pain and dysmenorrhea and led to marked improvements in all study parameters related to quality of life and sexual well-being. REGISTRATION NUMBER NCT03690765.
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Affiliation(s)
- Gennady T Sukhikh
- National Medical Research Center for Obstetrics, Gynecology and Perinatology, Moscow, Russian Federation
| | - Leila V Adamyan
- National Medical Research Center for Obstetrics, Gynecology and Perinatology, Moscow, Russian Federation; Department of Obstetrics and Gynecology, First Moscow State Medical University, Moscow, Russian Federation
| | - Svetlana O Dubrovina
- Scientific Research Institute of Obstetrics and Pediatrics, Rostov State Medical University, Rostov-on-Don, Russian Federation
| | - Igor I Baranov
- National Medical Research Center for Obstetrics, Gynecology and Perinatology, Moscow, Russian Federation
| | - Vitaly F Bezhenar
- Department of Obstetrics and Neonatology, Department of Obstetrics, Gynecology and Reproduction, Pavlov First Saint Petersburg State Medical University, Saint Petersburg, Russian Federation
| | - Andrey V Kozachenko
- National Medical Research Center for Obstetrics, Gynecology and Perinatology, Moscow, Russian Federation
| | - Viktor E Radzinsky
- Department of Obstetrics and Gynecology, Medical Institute of Peoples' Friendship University of Russia, Ministry of Education of Russia, Moscow, Russian Federation
| | - Mekan R Orazov
- Department of Obstetrics and Gynecology, Medical Institute of Peoples' Friendship University of Russia, Ministry of Education of Russia, Moscow, Russian Federation
| | - Maria I Yarmolinskaya
- Department of Gynecology and Endocrinology, Scientific Research Institute of Obstetrics, Gynecology and Reproduction named after D.O. Ott, Saint Petersburg, Russian Federation; Department of Obstetrics and Gynecology, North-Western State Medical University named after I.I. Mechnikov, Saint Petersburg, Russian Federation
| | - Jan I Olofsson
- Global Medical Affairs, Established Pharmaceuticals Division, Abbott Product Operations AG, Allschwil, Switzerland; Division of Obstetrics and Gynecology, Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.
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11
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Sasamori Y, Takehara K, Terashima T, Onodera T, Yatsuki K, Nakagawa I, Takahashi Y, Nishida H, Ichinose T, Hiraike H, Nagasaka K. A case of adenomyosis with leiomyoma that was effectively treated with relugolix and kamishoyosan add-on therapy. BMC Womens Health 2021; 21:306. [PMID: 34412607 PMCID: PMC8375059 DOI: 10.1186/s12905-021-01442-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Accepted: 08/02/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Recently, relugolix, an oral gonadotropin-releasing hormone receptor antagonist, has been considered an effective therapy for leiomyoma based on a phase 3 study in Japanese women. Leiomyoma combined with severe adenomyosis occasionally occurs in perimenopausal women; however, little information on the effectiveness of relugolix against severe adenomyosis exists. CASE PRESENTATION A 49-year-old woman was referred to our hospital with acute lower abdominal pain and abnormal uterine bleeding. Magnetic resonance imaging revealed multiple leiomyomas with diffuse adenomyosis. Left hydrosalpinx was also observed. The patient refused surgical treatment and preferred oral relugolix. Since she experienced a hot flush and headache induced by relugolix, a traditional Japanese Kampo, kamishoyosan, was added to improve the side effects of relugolix. The patient was asymptomatic at the time of this report and experienced a significant shrinkage in uterine volume. Ultimately, she avoided hysterectomy as desired. CONCLUSIONS To our knowledge, this is the first report of co-occurring adenomyosis and leiomyoma, which was effectively treated with relugolix. Although the management of adverse side effects, including hot flush and headache by relugolix, has recently attracted attention and controversy, relugolix add-on therapy with kamishoyosan may help treat menopausal symptoms.
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Affiliation(s)
- Yukifumi Sasamori
- Department of Obstetrics and Gynecology, Teikyo University School of Medicine, Tokyo , Japan
| | - Kohei Takehara
- Department of Obstetrics and Gynecology, Teikyo University School of Medicine, Tokyo , Japan
| | - Tsuyoshi Terashima
- Department of Obstetrics and Gynecology, Teikyo University School of Medicine, Tokyo , Japan
| | - Takako Onodera
- Department of Obstetrics and Gynecology, Teikyo University School of Medicine, Tokyo , Japan
| | - Keita Yatsuki
- Department of Obstetrics and Gynecology, Teikyo University School of Medicine, Tokyo , Japan
| | - Ippei Nakagawa
- Department of Obstetrics and Gynecology, Teikyo University School of Medicine, Tokyo , Japan
| | - Yuko Takahashi
- Department of Obstetrics and Gynecology, Teikyo University School of Medicine, Tokyo , Japan
| | - Haruka Nishida
- Department of Obstetrics and Gynecology, Teikyo University School of Medicine, Tokyo , Japan
| | - Takayuki Ichinose
- Department of Obstetrics and Gynecology, Teikyo University School of Medicine, Tokyo , Japan
| | - Haruko Hiraike
- Department of Obstetrics and Gynecology, Teikyo University School of Medicine, Tokyo , Japan
| | - Kazunori Nagasaka
- Department of Obstetrics and Gynecology, Teikyo University School of Medicine, Tokyo , Japan.
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12
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Ali M, A R S, Al Hendy A. Elagolix in the treatment of heavy menstrual bleeding associated with uterine fibroids in premenopausal women. Expert Rev Clin Pharmacol 2021; 14:427-437. [PMID: 33682578 DOI: 10.1080/17512433.2021.1900726] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Uterine fibroids (UFs) are the most common benign tumor arising from myometrium of reproductive age women, with significant financial burden estimated in hundreds of billions of dollars. Unfortunately, there are limitations in available long-term treatment options. Thus, there is a large unmet need in the UF space for noninvasive therapeutics. AREAS COVERED Authors reviewed the literature available for elagolix; an orally bioavailable, second-generation, non-peptide gonadotropin-releasing hormone (GnRH) antagonist recently approved by the US Food and Drug Administration (FDA) in combination with estradiol/norethindrone acetate for the management of heavy menstrual bleeding associated with UFs in premenopausal women. EXPERT OPINION The utility of new-generation oral GnRH-antagonists, such as elagolix, relugolix and linzagolix, is offering a new potential opportunity for the future therapy of UFs: elagolix has been the most studied drug of this class for treating benign gynecological diseases, including endometriosis and UFs, for which it has been US FDA-approved in 2018 and 2020, respectively.
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Affiliation(s)
- Mohamed Ali
- Clinical Pharmacy, Faculty of Pharmacy, Ain Shams University, Cairo, Egypt
| | - Sara A R
- Al-Galaa Military Hospital, Cairo, Egypt, Drug Research Center (DRC), Cairo, Egypt
| | - Ayman Al Hendy
- Department of Obstetrics and Gynecology, University of Chicago, Chicago, IL, USA
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13
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Endometriosis and Medical Therapy: From Progestogens to Progesterone Resistance to GnRH Antagonists: A Review. J Clin Med 2021; 10:jcm10051085. [PMID: 33807739 PMCID: PMC7961981 DOI: 10.3390/jcm10051085] [Citation(s) in RCA: 70] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 02/20/2021] [Accepted: 02/26/2021] [Indexed: 02/07/2023] Open
Abstract
Background: The first objective of this review was to present, based on recent literature, the most frequently applied medical options (oral contraceptive pills (OCPs) and progestogens) for the management of symptomatic endometriosis, and evaluate their effectiveness in treating premenopausal women with endometriosis-associated pelvic pain, dysmenorrhea, non-menstrual pelvic pain and dyspareunia. The second objective was to review the concept of progesterone resistance and newly available treatment options. Methods: We reviewed the most relevant papers (n = 73) on the efficacy of OCPs and progestogens as medical therapy for endometriosis, as well as those on progesterone resistance and new medical alternatives (oral gonadotropin-releasing hormone (GnRH) antagonist). Eleven papers, essentially reviews, were selected and scrutinized from among 94 papers discussing the concept of progesterone resistance. Results: Having reviewed the most significant papers, we can confirm that OCPs and progestogens are effective in two-thirds of women suffering from endometriosis, but that other options are required in case of failure (in one-third of women due to progesterone resistance) or intolerance to these compounds. It is clear that there is a need for effective long-term oral treatment capable of managing endometriosis symptoms, while mitigating the impact of side effects. Biochemical, histological and clinical evidence show that estrogens play a critical role in the pathogenesis of endometriosis, so lowering levels of circulating estrogens should be considered an effective medical approach. The efficacy of three oral GnRH antagonists is discussed on the basis of published studies. Conclusion: There is a place for GnRH antagonists in the management of symptomatic endometriosis and clinical trials should be conducted, taking into account the different phenotypes in order to propose novel algorithms.
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14
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Panknin O, Wagenfeld A, Bone W, Bender E, Nowak-Reppel K, Fernández-Montalván AE, Nubbemeyer R, Bäurle S, Ring S, Schmees N, Prien O, Schäfer M, Friedrich C, Zollner TM, Steinmeyer A, Mueller T, Langer G. Discovery and Characterization of BAY 1214784, an Orally Available Spiroindoline Derivative Acting as a Potent and Selective Antagonist of the Human Gonadotropin-Releasing Hormone Receptor as Proven in a First-In-Human Study in Postmenopausal Women. J Med Chem 2020; 63:11854-11881. [PMID: 32960053 DOI: 10.1021/acs.jmedchem.0c01076] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The growth of uterine fibroids is sex hormone-dependent and commonly associated with highly incapacitating symptoms. Most treatment options consist of the control of these hormonal effects, ultimately blocking proliferative estrogen signaling (i.e., oral contraceptives/antagonization of human gonadotropin-releasing hormone receptor [hGnRH-R] activity). Full hGnRH-R blockade, however, results in menopausal symptoms and affects bone mineralization, thus limiting treatment duration or demanding estrogen add-back approaches. To overcome such issues, we aimed to identify novel, small-molecule hGnRH-R antagonists. This led to the discovery of compound BAY 1214784, an orally available, potent, and selective hGnRH-R antagonist. Altering the geminal dimethylindoline core of the initial hit compound to a spiroindoline system significantly improved GnRH-R antagonist potencies across several species, mandatory for a successful compound optimization in vivo. In a first-in-human study in postmenopausal women, once daily treatment with BAY 1214784 effectively lowered plasma luteinizing hormone levels by up to 49%, at the same time being associated with low pharmacokinetic variability and good tolerability.
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Affiliation(s)
- Olaf Panknin
- Research & Development, Pharmaceuticals, Bayer AG, Müllerstrasse 170, 13342 Berlin, Germany
| | - Andrea Wagenfeld
- Research & Development, Pharmaceuticals, Bayer AG, Müllerstrasse 170, 13342 Berlin, Germany
| | - Wilhelm Bone
- Research & Development, Pharmaceuticals, Bayer AG, Müllerstrasse 170, 13342 Berlin, Germany
| | - Eckhard Bender
- Research & Development, Pharmaceuticals, Bayer AG, Aprather Weg 18a, 42113 Wuppertal, Germany
| | - Katrin Nowak-Reppel
- Research & Development, Pharmaceuticals, Bayer AG, Müllerstrasse 170, 13342 Berlin, Germany
| | | | - Reinhard Nubbemeyer
- Research & Development, Pharmaceuticals, Bayer AG, Müllerstrasse 170, 13342 Berlin, Germany
| | - Stefan Bäurle
- Research & Development, Pharmaceuticals, Bayer AG, Müllerstrasse 170, 13342 Berlin, Germany
| | - Sven Ring
- Research & Development, Pharmaceuticals, Bayer AG, Müllerstrasse 170, 13342 Berlin, Germany
| | - Norbert Schmees
- Research & Development, Pharmaceuticals, Bayer AG, Müllerstrasse 170, 13342 Berlin, Germany
| | - Olaf Prien
- Research & Development, Pharmaceuticals, Bayer AG, Müllerstrasse 170, 13342 Berlin, Germany
| | - Martina Schäfer
- Research & Development, Pharmaceuticals, Bayer AG, Müllerstrasse 170, 13342 Berlin, Germany
| | - Christian Friedrich
- Research & Development, Pharmaceuticals, Bayer AG, Müllerstrasse 170, 13342 Berlin, Germany
| | - Thomas M Zollner
- Research & Development, Pharmaceuticals, Bayer AG, Müllerstrasse 170, 13342 Berlin, Germany
| | - Andreas Steinmeyer
- Research & Development, Pharmaceuticals, Bayer AG, Müllerstrasse 170, 13342 Berlin, Germany
| | - Thomas Mueller
- Research & Development, Pharmaceuticals, Bayer AG, Aprather Weg 18a, 42113 Wuppertal, Germany
| | - Gernot Langer
- Research & Development, Pharmaceuticals, Bayer AG, Müllerstrasse 170, 13342 Berlin, Germany
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15
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Agarwal SK, Soliman AM, Pokrzywinski RM, Snabes MC, Coyne KS. Clinically Meaningful Reduction in Dyspareunia Is Associated With Significant Improvements in Health-Related Quality of Life Among Women With Moderate to Severe Pain Associated With Endometriosis: A Pooled Analysis of Two Phase III Trials of Elagolix. J Sex Med 2020; 17:2427-2433. [PMID: 32928659 DOI: 10.1016/j.jsxm.2020.08.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 06/23/2020] [Accepted: 08/03/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Dyspareunia experienced by women diagnosed with endometriosis is associated with a decreased health-related quality of life (HRQoL). AIM We evaluated the relationship of clinically meaningful improvements in dyspareunia with HRQoL changes among women with endometriosis. METHODS This was a post hoc analysis of pooled data from the phase III ELARIS-I and ELARIS-II clinical trials. Women aged 18-49 years with moderate to severe endometriosis-associated pain were randomized to placebo, elagolix 150 mg once daily, or elagolix 200 mg twice daily. HRQoL was measured using the validated Endometriosis Health Profile-30 questionnaire (EHP-30), consisting of 5 core domains and a sexual intercourse modular domain. Dyspareunia was ranked 0-3 (none, mild, moderate, or severe) or not applicable using a daily eDiary and averaged monthly. A woman with a clinically meaningful dyspareunia response (dyspareunia responder) was defined as a woman with a reduction from the baseline in dyspareunia score greater than or equal to a predetermined cutoff while maintaining stable/decreased analgesic use. OUTCOMES Dyspareunia response impact on EHP-30 scores was determined at 3 and 6 months using multivariate linear regression controlling for age, baseline EHP-30 scores, and dysmenorrhea and non-menstrual pelvic pain symptom severity. RESULTS Analysis included 1,368 women with a mean age of 32.2 years. Dyspareunia responders had significant improvements vs non-responders in all adjusted mean EHP-30 domain scores at months 3 and 6 (control and powerlessness: -17.8 and -18.5; emotional well-being: -10.0 and -10.4; pain: -15.3 and -15.7; self-image: -11.4 and -12.8; social support: -14.3 and -14.0; and sexual intercourse: -18.1 and -19.7; all P < .0001). CLINICAL IMPLICATIONS Dyspareunia improvements are associated with both personal and psychological benefits. STRENGTHS & LIMITATIONS This study involved a large sample of women from a well-defined patient population to provide statistical power in evaluating the results. As such, the findings may not be generalizable in a real-world setting. Although the perception of dyspareunia and its severity and the associated effect on HRQoL was subjective, the use of a large patient sample was used to minimize potential issues with this limitation. CONCLUSION Clinically meaningful responses in dyspareunia are associated with improvements across multiple HRQoL domains among women with endometriosis. Agarwal SK, Soliman AM, Pokrzywinski RM, et al. Clinically Meaningful Reduction in Dyspareunia Is Associated with Significant Improvements in Health-Related Quality of Life Among Women with Moderate to Severe Pain Associated with Endometriosis: A Pooled Analysis of Two Phase III Trials of Elagolix. J Sex Med 2020;17:2427-2433.
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Affiliation(s)
- Sanjay K Agarwal
- Center for Endometriosis Research and Treatment, University of California, San Diego, La Jolla, CA, USA.
| | - Ahmed M Soliman
- Health Economics and Outcomes Research, AbbVie Inc, North Chicago, IL, USA
| | | | - Michael C Snabes
- Global Pharmaceutical Research and Development, AbbVie Inc, North Chicago, IL, USA
| | - Karin S Coyne
- Patient-Centered Research, Evidera, Bethesda, MD, USA
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16
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Finnie R. Welcome to the 10th volume of Pain Management. Pain Manag 2020. [DOI: 10.2217/pmt-2019-0061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Rhiannon Finnie
- Future Science Group, Unitec House, 2 Albert Place, London, N3 1QB, UK
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