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Lensen S, Paramanandam VS, Gabes M, Kann G, Donhauser T, Waters NF, Li AD, Peate M, Susanto NS, Caughey LE, Rangoonwal F, Liu J, Condron P, Anagnostis P, Archer DF, Avis NE, Bell RJ, Carpenter JS, Chedraui P, Christmas M, Davies M, Hillard T, Hunter MS, Iliodromiti S, Jaff NG, Jaisamrarn U, Joffe H, Khandelwal S, Kiesel L, Maki PM, Mishra GD, Nappi RE, Panay N, Pines A, Roberts H, Rozenberg S, Rueda C, Shifren J, Simon JA, Simpson P, Siregar MFG, Stute P, Garcia JT, Vincent AJ, Wolfman W, Hickey M. Recommended measurement instruments for menopausal vasomotor symptoms: the COMMA (Core Outcomes in Menopause) consortium. Menopause 2024:00042192-990000000-00324. [PMID: 38688464 DOI: 10.1097/gme.0000000000002370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2024]
Abstract
OBJECTIVE The aim of the study is to identify suitable definitions and patient-reported outcome measures (PROMs) to assess each of the six core outcomes previously identified through the COMMA (Core Outcomes in Menopause) global consensus process relating to vasomotor symptoms: frequency, severity, distress/bother/interference, impact on sleep, satisfaction with treatment, and side effects. METHODS A systematic review was conducted to identify relevant definitions for the outcome of side-effects and PROMs with acceptable measurement properties for the remaining five core outcomes. The consensus process, involving 36 participants from 16 countries, was conducted to review definitions and PROMs and make final recommendations for the measurement of each core outcome. RESULTS A total of 21,207 publications were screened from which 119 reporting on 40 PROMs were identified. Of these 40 PROMs, 36 either did not adequately map onto the core outcomes or lacked sufficient measurement properties. Therefore, only four PROMs corresponding to two of the six core outcomes were considered for recommendation. We recommend the Hot Flash Related Daily Interference Scale to measure the domain of distress, bother, or interference of vasomotor symptoms and to capture impact on sleep (one item in the Hot Flash Related Daily Interference Scale captures interference with sleep). Six definitions of "side effects" were identified and considered. We recommend that all trials report adverse events, which is a requirement of Good Clinical Practice. CONCLUSIONS We identified suitable definitions and PROMs for only three of the six core outcomes. No suitable PROMs were found for the remaining three outcomes (frequency and severity of vasomotor symptoms and satisfaction with treatment). Future studies should develop and validate PROMs for these outcomes.
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Affiliation(s)
- Sarah Lensen
- From the Department of Obstetrics and Gynaecology, Royal Women's Hospital, University of Melbourne, Melbourne, Australia
| | | | | | | | - Theresa Donhauser
- Institute of Social Medicine and Health Systems Research, Otto-von-Guericke-University Magdeburg, Magdeburg, Germany
| | - Niamh F Waters
- From the Department of Obstetrics and Gynaecology, Royal Women's Hospital, University of Melbourne, Melbourne, Australia
| | - Anna D Li
- From the Department of Obstetrics and Gynaecology, Royal Women's Hospital, University of Melbourne, Melbourne, Australia
| | - Michelle Peate
- From the Department of Obstetrics and Gynaecology, Royal Women's Hospital, University of Melbourne, Melbourne, Australia
| | - Nipuni S Susanto
- From the Department of Obstetrics and Gynaecology, Royal Women's Hospital, University of Melbourne, Melbourne, Australia
| | - Lucy E Caughey
- From the Department of Obstetrics and Gynaecology, Royal Women's Hospital, University of Melbourne, Melbourne, Australia
| | - Fatema Rangoonwal
- From the Department of Obstetrics and Gynaecology, Royal Women's Hospital, University of Melbourne, Melbourne, Australia
| | - Jingbo Liu
- From the Department of Obstetrics and Gynaecology, Royal Women's Hospital, University of Melbourne, Melbourne, Australia
| | - Patrick Condron
- University Library, The University of Melbourne, Parkville, Australia
| | - Panagiotis Anagnostis
- Unit of Reproductive Endocrinology, 1 Department of Obstetrics and Gynecology, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - David F Archer
- Department of Obstetrics and Gynaecology, Eastern Virginia Medical School, Norfolk, VA
| | - Nancy E Avis
- Wake Forest University School of Medicine, Winston-Salem, NC
| | - Robin J Bell
- Women's Health Research Program, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | | | - Peter Chedraui
- Escuela de Posgrado en Salud, Universidad Espíritu Santo, Samborondón, Ecuador
| | - Monica Christmas
- Department of Obstetrics and Gynaecology, University of Chicago, Chicago, IL
| | - Melanie Davies
- Institute for Women's Health, University College London, UK
| | - Tim Hillard
- Department of Obstetrics and Gynaecology, University Hospitals Dorset NHS Trust, Poole, Dorset, UK
| | - Myra S Hunter
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Stamatina Iliodromiti
- Women's Health Research Unit, Wolfson Institute of Population Health, QMUL, London, United Kingdom
| | - Nicole G Jaff
- Department of Chemical Pathology, National Health Laboratory Service and University of the Witwatersrand Faculty of Health Sciences, Johannesburg, South Africa
| | - Unnop Jaisamrarn
- Center of Excellence in Menopause and Aging Women Health, Department of Obstetrics and Gynecology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Hadine Joffe
- Connors Center for Women's Health and Gender Biology and the Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Sunila Khandelwal
- Department of Obstetrics and Gynaecology, Fortis Escort Hospital, Jaipur, India
| | - Ludwig Kiesel
- Department of Gynaecology and Obstetrics, University of Muenster, Germany
| | - Pauline M Maki
- University of Illinois at Chicago, Departments of Psychiatry, Psychology and Obstetrics and Gynecology, Chicago, IL
| | - Gita D Mishra
- Australian Women and Girls' Health Research Centre, School of Public Health, University of Queensland, St Lucia, Australia
| | - Rossella E Nappi
- Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Research Center for Reproductive Medicine, Gynecological Endocrinology and Menopause, IRCCS San Matteo Foundation, Pavia, Italy
| | - Nick Panay
- Queen Charlotte's & Chelsea Hospital, Imperial College London, London, UK
| | - Amos Pines
- Tel-Aviv University School of Medicine, Tel-Aviv, Israel
| | - Helen Roberts
- Menopause clinic, Te Toka Tumai, Auckland Hospital, Auckland, New Zealand
| | - Serge Rozenberg
- Department of Ob-Gyn CHU St Pierre, Université Libre de Bruxelles, Brussels, Belgium
| | - Camilo Rueda
- University La Sábana, Country Clinic, Bogotá, Colombia
| | - Jan Shifren
- Midlife Women's Health Center, Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - James A Simon
- Department of Obstetrics and Gynecology, George Washington University, Washington, DC
| | - Paul Simpson
- Department of Obstetrics & Gynaecology, Norfolk & Norwich University Hospital NHS Foundation Trust, Norwich, UK
| | - Muhammad Fidel Ganis Siregar
- Department of Obstetrics and Gynecology, Faculty of Medicine Universitas Sumatera Utara, Sumatera Utara, Indonesia
| | - Petra Stute
- Department of Obstetrics and Gynecology, University Clinic Inselspital, Bern, Switzerland
| | - Joan Tan Garcia
- Menopause Clinic, Department of Obstetrics & Gynecology, St Lukes Medical Center, Quezon City, Philippines
| | - Amanda J Vincent
- Monash Centre for Health Research and Implementation, Monash University, Clayton, Australia
| | - Wendy Wolfman
- Department of Obstetrics and Gynaecology and Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | - Martha Hickey
- From the Department of Obstetrics and Gynaecology, Royal Women's Hospital, University of Melbourne, Melbourne, Australia
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Jensen JT, Edelman A, Westhoff CL, Schreiber CA, Archer DF, Teal S, Thomas M, Brown J, Blithe DL. Use of serum evaluation of contraceptive and ovarian hormones to assess reduced risk of pregnancy among women presenting for emergency contraception in a multicenter clinical trial. Contraception 2024:110475. [PMID: 38670302 DOI: 10.1016/j.contraception.2024.110475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 04/06/2024] [Accepted: 04/16/2024] [Indexed: 04/28/2024]
Abstract
OBJECTIVE To evaluate ovulation risk among women enrolling in an emergency contraception (EC) study by measuring contraceptive steroids and ovarian hormones. STUDY DESIGN We used standard chemoluminescent assays to evaluate endogenous hormones [estradiol (E2), progesterone (P4), FSH, LH] and liquid chromatography-tandem triple quadrupole mass spectrometry (LC-MS/MS) to simultaneously analyze concentrations of ethinylestradiol (EE), dienogest (DNG), norelgestromin (NGMN), norethindrone (NET), gestodene (GSD), levonorgestrel (LNG), etonogestrel (ENG), segesterone acetate (NES), medroxyprogesterone acetate (MPA), and drospirenone (DRSP), in serum samples obtained at the time of enrollment in a recent study comparing oral ulipristal acetate and LNG EC in women with weight ≥ 80kg reporting no recent use of hormonal contraception. RESULTS We enrolled 532 and obtained a valid baseline blood sample from 520 women. Of these, 117 (22.5%) had detectable concentrations of a progestin [MPA (n=58, 11.2%), LNG (50, 9.6%), ENG (11, 2.1%), NET (5, 0.96%), NGMN (3, 0.06%), or DRSP (1, 0.02%)]. LNG was co-detected in all three participants with samples containing NGMN. Multiple progestins were detected in 8 other women: ENG/MPA (1); ENG/LNG (2); MPA/LNG (5). Samples from 55 (10.6%) had concentrations of one or more progestin considered above the minimum level for contraceptive [MPA ≥ 0.1ng/mL, n = 19; NGMN/LNG ≥ 0.2ng/mL, n = 31; ENG ≥ 0.09 ng/mL, n = 8; NET ≥ 0.35 ng/mL, n = 4]. We detected concentrations of serum P4 ≥ 3ng/mL, indicative of luteal phase (post-ovulation) status, in an additional 194 (37.3%) samples. CONCLUSIONS More than one third of enrolled in our clinical trial of oral emergency contraception had evidence of prior ovulation at the time of enrollment. Additionally, about 23% had evidence of recent use of hormonal contraception recent use of hormonal contraception. This results would have decreased the expected risk of pregnancy in the study. IMPLICATIONS Many participants in a recent clinical trial of oral emergency contraception did not appear to be at risk for pregnancy or would not have benefited from intervention due to cycle timing. Investigators should consider the effects of these findings on expected pregnancy rates when determining sample size in future EC clinical trials, particularly when using non-inferiority designs or historical controls.
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Affiliation(s)
| | | | | | | | - David F Archer
- Clinical Research Center, Department of Obstetrics and Gynecology, Eastern Virginia Medical School
| | | | | | - Jill Brown
- Eunice Kennedy Shriver National Institute of Child Health and Human Development
| | - Diana L Blithe
- Eunice Kennedy Shriver National Institute of Child Health and Human Development
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Stanczyk FZ, Winer SA, Foidart JM, Archer DF. Comparison of estrogenic components used for hormonal contraception. Contraception 2024; 130:110310. [PMID: 37863464 DOI: 10.1016/j.contraception.2023.110310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 10/12/2023] [Accepted: 10/13/2023] [Indexed: 10/22/2023]
Abstract
Attempts have been made over the years to replace ethinyl estradiol (EE) in combined oral contraceptives (COCs) with the less potent natural estrogen estradiol (E2), or its prodrug, E2 valerate (E2V), to improve their safety and tolerability. Recently, a COC incorporating a novel weak natural estrogen, estetrol (E4), combined with drospirenone, has become available. We present a comparative analysis of the three prevailing estrogens used in COCs, focusing on their structure-function relationships, receptor-binding affinity, potency, metabolism, pharmacokinetic parameters, and pharmacodynamics. The binding affinity of EE to estrogen receptor (ER)α is twice that of E2, whereas its affinity for ERβ is about one-half that of E2. E4 has a lower binding affinity for the ERs than E2. The high potency of EE is notable in its dramatic increase in estrogen-sensitive hepatic globulins and coagulation factors. EE and E2 undergo extensive and comparable metabolism, while E4 produces only a very limited number of metabolites. E4 has the highest bioavailability among the three estrogens, with E2 having <5%. Studies demonstrate consistent ovulation inhibition, although a higher dose of E4 (15 mg) in COCs is required to achieve follicular suppression compared to E2 (1-3 mg) and EE (0.01-0.035 mg). E2 and E4 in COCs may be less stimulatory of coagulant proteins than EE. Studies with E2/dienogest suggest a comparable risk of venous thromboembolism to EE/levonorgestrel, while data assessing risk with an E4-based COC are insufficient. Nevertheless, the E4-based formulation shows promise as a potential alternative to EE and E2 due to its lower potency and possibly fewer side effects.
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Affiliation(s)
- Frank Z Stanczyk
- Department of Obstetrics and Gynecology, University of Southern California, Keck School of Medicine, Los Angeles, CA, United States.
| | - Sharon A Winer
- Department of Obstetrics and Gynecology, University of Southern California, Keck School of Medicine, Los Angeles, CA, United States
| | - Jean-Michel Foidart
- Department of Obstetrics and Gynecology, University of Liege, Liege, Belgium
| | - David F Archer
- Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA, United States
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4
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Creinin MD, Angulo A, Colli E, Archer DF. The efficacy, safety, and tolerability of an estrogen-free oral contraceptive drospirenone 4 mg (24/4-day regimen) in obese users. Contraception 2023; 128:110136. [PMID: 37544572 DOI: 10.1016/j.contraception.2023.110136] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 07/25/2023] [Accepted: 08/02/2023] [Indexed: 08/08/2023]
Abstract
OBJECTIVES This study aimed to compare contraceptive efficacy and safety of drospirenone 4 mg in a 24/4-day regimen in nonobese and obese users and describe pharmacokinetics according to bodyweight. STUDY DESIGN We analyzed data from three drospirenone 4 mg trials (2 European and 1 United States) to report outcomes in nonobese (body mass index <30 kg/m2) and obese (body mass index ≥30 kg/m2) users. We used data from the US trial to calculate the Pearl Index (pregnancies per 100 woman-years) in nonbreastfeeding participants aged ≤35 years at enrollment for confirmed pregnancies. We assessed safety outcomes from all trials based on reported treatment-emergent adverse events. We evaluated pharmacokinetics by bodyweight in the US trial. RESULTS The three trials combined comprised 2152 nonobese and 425 obese participants, including 590 nonobese and 325 obese participants in the US trial. Eight nonobese and four obese participants had confirmed pregnancies in the US trial, resulting in Pearl Indices of 3.0 (95% CI: 1.3-5.8) and 2.9 (95% CI: 0.8-7.3), respectively. Two-hundred forty-four (11.3%) nonobese and 39 (9.2%) obese participants discontinued due to a treatment-emergent adverse event. The pharmacokinetic analysis included 814 participants with a median weight of 73 (interquartile range 61-89) kg and median plasma drospirenone exposure (AUC0-24ss) of 661.3 (interquartile range 522-828) ng∙h/mL. Changing bodyweight from the median to the fifth percentile (51 kg) or 95th percentile (118 kg) changed drospirenone exposure (AUC0-24,ss) by 22.2% and -23.6%, respectively. CONCLUSIONS Drospirenone 4 mg demonstrated similar contraceptive efficacy for both nonobese and obese users despite a difference in exposure based on bodyweight. IMPLICATIONS Our limited comparison between obese and nonobese users of drospirenone-only oral contraception demonstrated no evidence that efficacy or discontinuation for adverse events differs between groups. Serum drospirenone levels vary by bodyweight and may correlate with bleeding outcomes.
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Affiliation(s)
- Mitchell D Creinin
- Department of Obstetrics and Gynecology, University of California, Davis, Sacramento, CA, United States
| | | | | | - David F Archer
- Clinical Research Center, Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA, United States
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5
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Stanczyk FZ, Archer DF. Biosynthesis of estetrol in human pregnancy: Potential pathways. J Steroid Biochem Mol Biol 2023; 232:106359. [PMID: 37390976 DOI: 10.1016/j.jsbmb.2023.106359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 06/26/2023] [Accepted: 06/26/2023] [Indexed: 07/02/2023]
Abstract
Estetrol (E4) has emerged as a novel and highly promising estrogen for therapeutic use. E4 is a weak natural estrogen produced only in pregnancy. Because of its novelty, there is considerable interest by clinicians in how it is produced in pregnancy. Although the fetal liver plays a key role in its production, the placenta is also involved. A current view is that estradiol (E2) formed in the placenta enters the fetal compartment and is then rapidly sulfated. E2 sulfate then undergoes 15α-/16α-hydroxylation in the fetal liver thereby forming E4 sulfate (phenolic pathway). However, another pathway involving 15α,16α-dihydroxy-DHEAS formed in the fetal liver and converted to E4 in the placenta also plays a significant role (neutral pathway). It is not known which pathway predominates, but both pathways appear to be important in E4 biosynthesis. In this commentary, we summarize the well-established pathways in the formation of estrogens in the nonpregnant and pregnant female. We then review what is known about the biosynthesis of E4 and describe the 2 proposed pathways involving the fetus and placenta.
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Affiliation(s)
- Frank Z Stanczyk
- Department of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States.
| | - David F Archer
- Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA, United States
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Jensen JT, Archer DF, Westhoff CL, Nelson AL, Graham S, Bernick B. Satisfaction with a Segesterone Acetate and Ethinyl Estradiol Contraceptive Vaginal System Among Recent Oral Contraceptive or Hormonal Contraceptive Vaginal Ring Users. J Womens Health (Larchmt) 2023; 32:808-815. [PMID: 37253139 DOI: 10.1089/jwh.2022.0264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023] Open
Abstract
Background: We evaluated satisfaction with use of a segesterone acetate and ethinyl estradiol (0.15/0.013 mg) contraceptive vaginal system (CVS) among women who had recently used a monthly contraceptive vaginal ring or contraceptive pills. The CVS is a ring-shaped device used in a 21-days-in/7-days-out regimen for 13 cycles. Materials and Methods: We analyzed post hoc satisfaction responses at cycle 3 and end of study (EOS) from a subset of participants with documented recent use of the monthly ring or daily pills before enrollment in a multinational, phase 3, 13-cycle trial evaluating the CVS. EOS included results from participants who had completed ≥10 cycles. Results were summarized descriptively. Results: We identified 128 recent ring and 219 recent pill users at cycle 3 (of 1033 survey participants), and 92 and 148, respectively, at EOS (of 622 survey participants); overall satisfaction with CVS use was high (≥90%). At EOS, most ring (89%) and pill (97%) users liked the CVS as much/better than any previous method. The two most-liked CVS features included ease of use and 1-year duration; the two most disliked features included ring insertion and feeling it coming out. At EOS, ≥88% of both groups reported no concern about using the same CVS for a year, and most (>80%) had recommended it to friends or family members. Conclusion: The CVS clinical trial participants who were recent ring/pill users reported high satisfaction and liked it as much/better than any previously used contraceptive; the CVS may be a good contraceptive option for switchers. Clinical trial registration NCT00263341.
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Affiliation(s)
- Jeffrey T Jensen
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, Oregon, USA
| | - David F Archer
- Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, Virginia, USA
| | - Carolyn L Westhoff
- Department of Obstetrics and Gynecology, Columbia University, New York, New York, USA
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Panay N, Nappi RE, Stute P, Palacios S, Paszkowski T, Kagan R, Archer DF, Héroux J, Boolell M. Oral estradiol/micronized progesterone may be associated with lower risk of venous thromboembolism compared with conjugated equine estrogens/medroxyprogesterone acetate in real-world practice. Maturitas 2023; 172:23-31. [PMID: 37084589 DOI: 10.1016/j.maturitas.2023.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 04/03/2023] [Accepted: 04/07/2023] [Indexed: 04/23/2023]
Abstract
OBJECTIVES The Women's Health Initiative study reported an increased risk of venous thromboembolism among menopausal women treated with conjugated equine estrogens/medroxyprogesterone acetate (CEE/MPA) versus placebo. Newer hormone therapies may have a lower venous thromboembolism risk. The study compared the risk of venous thromboembolism between women treated with the combined oral product 17β-estradiol/micronized progesterone (E2/P4) and those treated with oral CEE/MPA regimens. STUDY DESIGN In a retrospective longitudinal study using real-world claims data from April 2019 to June 2021, women aged 40 years or more treated with oral E2/P4 or oral CEE/MPA who did not have a venous thromboembolism diagnosis before first dispensing claim of CEE/MPA or E2/P4 identified on or after May 1st 2019 (index date) were observed for 6 months or more after the index date. Oral E2/P4 and oral CEE/MPA had been prescribed by the treating physician in real-world practice and were observed through pharmacy dispensing records. MAIN OUTCOME MEASURES Venous thromboembolism risk was compared between women receiving oral E2/P4 versus oral CEE/MPA. RESULTS The study included 36,061 women treated with oral E2/P4 or oral CEE/MPA. In the analyses weighted by the inverse probability of treatment for control of potential confounding factors, the incidence of venous thromboembolism was significantly lower for oral E2/P4 compared with oral CEE/MPA (37/10,000 women-years for oral E2/P4 vs 53/10,000 women-years for oral CEE/MPA; incidence rate ratio 0.70, 95 % confidence interval: 0.53-0.92). CONCLUSIONS Real-world evidence suggests that the risk of venous thromboembolism is significantly lower among women treated with oral E2/P4 compared with oral CEE/MPA.
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Affiliation(s)
- Nick Panay
- Imperial College Healthcare NHS Trust, The Bays, S Wharf Rd, London W2 1NY, United Kingdom; Chelsea and Westminster NHS Foundation Trust, 369 Fulham Road, 116, London SW10 9NH, United Kingdom; Queen Charlotte's & Chelsea Hospital, Du Cane Rd, London W12 0HS, United Kingdom
| | - Rossella E Nappi
- Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Research Center for Reproductive Medicine, Gynecological Endocrinology and Menopause, IRCCS San Matteo Foundation, Piazzale Golgi 2, 27100 Pavia, Italy
| | - Petra Stute
- Department of Obstetrics and Gynecology, Inselspital, University Clinic Bern, Friedbühlstr. 19, 3010 Bern, Switzerland
| | - Santiago Palacios
- Palacios Institute of Women's Health and Medicine, Calle Antonio Acuña, 9, Madrid 28009, Spain
| | - Tomasz Paszkowski
- III Chair and Department of Gynecology, Medical University of Lublin, 8 Jaczewskiego St., 20-954 Lublin, Poland
| | - Risa Kagan
- Sutter East Bay Medical Group, Affiliated with Sutter East Bay Medical Foundation, Department of Obstetrics, Gynecology and Reproductive Sciences, UCSF, 2500 Milvia Street, Berkeley, CA, USA
| | - David F Archer
- Clinical Research Center, Department of Obstetrics and Gynecology, Eastern Virginia Medical School, 601 Colley Avenue, Suite 241, Norfolk, VA 23507, USA
| | - Julie Héroux
- Heroux Consulting, Vrouwe Meilendislaan 14, Den Haag 2553EX, Netherlands
| | - Mitra Boolell
- Theramex HQ UK Ltd., Sloane Square House, 1 Holbein Place, London SW1W 8NS, United Kingdom.
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8
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Stanczyk FZ, Archer DF, Lohmer LRL, Pirone J, Previtera M, Korner P. Extended regimen of a levonorgestrel/ethinyl estradiol transdermal delivery system: Predicted serum hormone levels using a population pharmacokinetic model. PLoS One 2022; 17:e0279640. [PMID: 36574387 PMCID: PMC9794042 DOI: 10.1371/journal.pone.0279640] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 12/06/2022] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE This study employed population pharmacokinetic (popPK) models to predict levonorgestrel (LNG) and ethinyl estradiol (EE) exposure after dosing with the transdermal contraceptive TWIRLA® (LNG/EE TDS) as a 12-week extended regimen in a healthy female population. METHODS PopPK models were developed using data from a previously published phase 1, open-label, randomized clinical trial, ATI-CL14 (NCT01243580), in 36 healthy individuals. Models used cycle 2 data from 18 individuals who received the LNG/EE TDS, delivering LNG 120 μg/day and EE 30 μg/day, followed by a 1-week TDS-free period. Noncompartmental PK analyses were performed on simulated concentration-time profiles of 12 consecutive weeks of LNG/EE TDS use. RESULTS The simulated concentration-time profiles and PK parameters for the simulated extended regimen indicated that predicted LNG and EE exposures at week 12 were similar to week 3 (predicted geometric mean EE area under the concentration-time curve from time 0 to 168 h [AUC0-168] on week 3 was 0.2% lower than week 12 and LNG AUC0-168 on week 3 was 0.9% lower than week 12), suggesting both were at steady state by week 3. Therefore, no notable accumulation beyond that at week 3 is predicted for LNG and EE following a 12-week extended regimen. The results are supported by the accumulation ratios based on maximum concentration and the area under the curve being similar at weeks 3 and 12 for LNG and EE. CONCLUSION These results indicate that a 12-week extended LNG/EE regimen would provide similar systemic hormonal exposure as that seen by week 3 in a standard 28-day regimen, without further hormonal accumulation. The data support the safe use of a non-daily, low-dose hormonal contraceptive in an extended regimen but should be confirmed in a clinical PK study.
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Affiliation(s)
- Frank Z. Stanczyk
- Keck School of Medicine, University of Southern California, Los Angeles, Los Angeles, California, United States of America
- * E-mail:
| | - David F. Archer
- Eastern Virginia Medical School, Norfolk, Virginia, United States of America
| | | | - Jason Pirone
- Nuventra, LLC, Durham, North Carolina, United States of America
| | - Michelle Previtera
- Agile Therapeutics, Inc., Princeton, New Jersey, United States of America
| | - Paul Korner
- Agile Therapeutics, Inc., Princeton, New Jersey, United States of America
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9
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Chen MJ, Jensen JT, Kaunitz AM, Achilles SL, Zatik J, Weyers S, Piltonen T, Suturina L, Apolikhina I, Bouchard C, Archer DF, Jost M, Foidart JM, Creinin M. Tolerability and safety of the estetrol/drospirenone combined oral contraceptive: Pooled analysis of two multicenter, open-label phase 3 trials. Contraception 2022; 116:44-50. [PMID: 36257374 DOI: 10.1016/j.contraception.2022.10.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 10/04/2022] [Accepted: 10/09/2022] [Indexed: 01/31/2023]
Abstract
OBJECTIVES To evaluate tolerability and safety of estetrol (E4) 15 mg/drospirenone (DRSP) 3 mg oral contraceptive using pooled data from two, multicenter, phase 3 trials. STUDY DESIGN The two trials enrolled participants aged 16-50 years with a body mass index ≤35.0 kg/m2 to use E4/DRSP in a 24/4-day regimen for up to 13 cycles. We pooled data from participants who used at least one E4/DRSP dose and had a follow-up assessment to analyze adverse events (AEs), vital signs, and laboratory parameters, including serum lipids, glucose, glycated hemoglobin, and potassium. We consolidated similar Medical Dictionary for Regulatory Activities preferred terms into groupings. RESULTS Of 3725 participants enrolled, we included 3417 in the analyses of whom 1786 (52.3%) reported ≥1 AE. Most participants with reported AEs had AEs that investigators rated as mild or moderate (n = 1665, 93.2%); of participants reporting AEs, 1105 (61.9%) did so during cycles 1 to 3. In total, 981 (28.7%) participants experienced ≥1 treatment-related AE, most frequently related to bleeding complaints (n = 323, 9.5%), breast pain or tenderness (n = 136, 4.0%), acne (n = 113, 3.3%), and mood disturbance (n = 111, 3.2%). Discontinuation due to treatment-related AEs occurred in 272 participants (8.0%), with only bleeding complaints (n = 97, 2.8%) and mood disturbance (n = 38, 1.1%) at rates exceeding 1%. Three participants experienced serious AEs, which the site investigators considered treatment-related: one venous thromboembolism, one worsening of depression, and one ectopic pregnancy. We found no clinically relevant changes in weight, blood pressure, heart rate, or laboratory parameters during treatment. CONCLUSIONS E4/DRSP is associated with a favorable tolerability and safety profile. IMPLICATIONS STATEMENT Pooling data allowed for a robust assessment of tolerability and safety, including relatively infrequent events. Other than bleeding complaints and mood disturbance, no adverse event resulted in E4/DRSP discontinuation at rates >1%. Post-marketing surveillance studies are needed to evaluate long-term safety of the E4/DRSP COC and population-based venous thromboembolism risks.
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Affiliation(s)
- Melissa J Chen
- Department of Obstetrics and Gynecology, University of California, Davis, Sacramento, California, USA
| | - Jeffrey T Jensen
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, Oregon, USA
| | - Andrew M Kaunitz
- Department of Obstetrics and Gynecology, University of Florida College of Medicine, Jacksonville, Jacksonville, Florida, USA
| | - Sharon L Achilles
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh and Magee-Womens Research Institute, Pittsburgh, Pennsylvania, USA
| | - János Zatik
- Gynecological Praxis St. Anna, Debrecen, Hungary
| | - Steven Weyers
- Department of Obstetrics and Gynecology, University Hospital, Gent, Belgium
| | - Terhi Piltonen
- Department of Obstetrics and Gynecology, PEDEGO Research Unit, Medical Research Center, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Larisa Suturina
- Scientific Centre for Family Health and Human Reproduction Problems, Irkutsk, Russia
| | - Inna Apolikhina
- National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov, Ministry of Healthcare of the Russia, Moscow, Russia
| | - Celine Bouchard
- Clinique de Recherche en Santé de la Femme (RSF), Québec, Canada
| | - David F Archer
- Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, Virginia, USA
| | - Maud Jost
- Estetra SRL, an affiliate company of Mithra Pharmaceuticals, Liège, Belgium.
| | - Jean-Michel Foidart
- Estetra SRL, an affiliate company of Mithra Pharmaceuticals, Liège, Belgium; Department of Obstetrics and Gynecology, University of Liège, Liège, Belgium
| | - Mitchell Creinin
- Department of Obstetrics and Gynecology, University of California, Davis, Sacramento, California, USA
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10
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Abstract
Objective: The objective of the present document was to review/summarize reported outcomes compared between menopausal hormone therapy (MHT) containing estradiol (E2) versus other estrogens and MHT with progesterone (P4) versus progestins (defined as synthetic progestogens).Methods: PubMed and EMBASE were systematically searched through February 2021 for studies comparing oral E2 versus oral conjugated equine estrogens (CEE) or P4 versus progestins for endometrial outcomes, venous thromboembolism (VTE), cardiovascular outcomes, breast outcomes, cognition, and bone outcomes in postmenopausal women.Results: A total of 74 comparative publications were identified/summarized. Randomized studies suggested that P4 and progestins are likely equally effective in preventing endometrial hyperplasia/cancer when used at adequate doses. E2- versus CEE-based MHT had a similar or possibly better risk profile for VTE and cardiovascular outcomes, and P4- versus progestin-based MHT had a similar or possibly better profile for breast cancer and cardiovascular outcomes. E2 may potentially protect better against age-related cognitive decline and bone fractures versus CEE; P4 was similar or possibly better versus progestins for these outcomes. Limitations are that many studies were observational and some were not adequately powered for the reported outcomes.Conclusions: Evidence suggests a differential effect of MHT containing E2 or P4 and those containing CEE or progestins, with some evidence trending to a potentially better safety profile with E2 and/or P4.
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Affiliation(s)
| | - David F Archer
- Department of Obstetrics and Gynecology, Clinical Research Center, Eastern Virginia Medical School, Norfolk, VA
| | - James A Simon
- School of Medicine, George Washington University, Washington, DC
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Sadek S, Jacot TA, Thomas MC, Archer DF, Duffy DM. PGE2 REGULATES THE PLASMINOGEN ACTIVATOR PATHWAY IN HUMAN ENDOMETRIAL ENDOTHELIAL CELLS THROUGH PROSTAGLANDIN-E2 RECEPTORS (PTGER) 1 AND 2. Fertil Steril 2022. [DOI: 10.1016/j.fertnstert.2022.09.342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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12
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Archer DF, Angulo A, Murphy P, Gilbert ML, Krychman M. CLUSTER ANALYSIS: RATES OF FAVORABLE AND UNFAVORABLE VAGINAL BLEEDING PATTERNS WITH ONGOING DROSPIRENONE 4mg EXPOSURE BASED ON EARLY BLEEDING PATTERN. Fertil Steril 2022. [DOI: 10.1016/j.fertnstert.2022.08.490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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13
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Hubacher D, Schreiber CA, Turok DK, Jensen JT, Creinin MD, Nanda K, White KO, Dayananda I, Teal SB, Chen PL, Chen BA, Goldberg AB, Kerns JL, Dart C, Nelson AL, Thomas MA, Archer DF, Brown JE, Castaño PM, Burke AE, Kaneshiro B, Blithe DL. Continuation rates of two different-sized copper intrauterine devices among nulliparous women: Interim 12-month results of a single-blind, randomised, multicentre trial. EClinicalMedicine 2022; 51:101554. [PMID: 35865736 PMCID: PMC9294241 DOI: 10.1016/j.eclinm.2022.101554] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 05/19/2022] [Accepted: 06/22/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The most widely used copper intrauterine device (IUD) in the world (the TCu380A), and the only product available in many countries, causes side effects and early removals for many users. These problems are exacerbated in nulliparous women, who have smaller uterine cavities compared to parous women. We compared first-year continuation rates and reasons/probabilities for early removal of the TCu380A versus a smaller Belgian copper IUD among nulliparous users. METHODS This 12-month interim report is derived from a pre-planned interim analysis of a sub population and focused on key secondary comparative endpoints. In this participant-blinded trial at 16 centres in the USA, we randomised participants aged 17-40 in a 4:1 ratio to the NT380-Mini or the TCu380A. In the first year, participants had follow-up visits at 6-weeks and 3, 6, and 12-months, and a phone contact at 9 months; we documented continued use, expulsions, and reasons for removal. Among participants with successful IUD placement, we compared probabilities of IUD continuation and specific reasons for discontinuation using log-rank tests. This trial is registered with ClinicalTrials.gov number NCT03124160 and is closed to recruitment. FINDINGS Between June 1, 2017, and February 25, 2019, we assigned 927 nulliparous women to either the NT380-Mini (n = 744) or the TCu380A (n = 183); the analysis population was 732 (NT380-Mini) and 176 (TCu380A). Participants using the NT380-Mini, compared to the TCu380A, had higher 12-month continuation rates (78·7% [95% CI: 72·9-84·5%] vs. 70·2% [95% CI: 59·7-80·7], p = 0·014), lower rates of removal for bleeding and/or pain (8·1% vs. 16·2%, p = 0·003) and lower IUD expulsion rates (4·8% vs. 8·9%, p = 0·023), respectively. INTERPRETATION The NT380-Mini offers important benefits for a nulliparous population compared to the TCu380A in the first twelve months, when pivotal experiences typically occur. Higher continuation rates with the NT380-Mini may avert disruptions in contraceptive use and help users avoid unintended pregnancy. FUNDING Bill & Melinda Gates Foundation, Eunice Kennedy Shriver National Institute of Child Health and Human Development, and Mona Lisa, N.V. (Belgium).
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Affiliation(s)
- David Hubacher
- FHI 360, Durham, NC, USA
- Corresponding author at: FHI 360, 359 Blackwell Street, Suite 200, Durham, NC, 27701 USA.
| | - Courtney A. Schreiber
- Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, PA, USA
| | - David K. Turok
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT, USA
| | - Jeffrey T. Jensen
- Department of Obstetrics & Gynecology, Oregon Health & Science University, Portland, OR, USA
| | - Mitchell D. Creinin
- Department of Obstetrics and Gynecology, University of California, Davis, Sacramento, CA, USA
| | | | | | - Ila Dayananda
- Planned Parenthood Greater New York, New York, NY, USA
| | - Stephanie B. Teal
- Department of Obstetrics and Gynecology, University Hospitals Medical Center and Case Western Reserve University, Cleveland, OH, USA
| | | | - Beatrice A. Chen
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh and Magee-Womens Research Institute, Pittsburgh, PA, USA
| | | | - Jennifer L. Kerns
- Department of Obstetrics, Gynecology and Reproductive Sciences, Center for Global Reproductive Health, University of California, San Francisco, San Francisco, CA, USA
| | | | | | - Michael A. Thomas
- Department of Obstetrics and Gynecology, University of Cincinnati, Cincinnati, OH, USA
| | - David F. Archer
- Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA, USA
| | - Jill E. Brown
- Contraceptive Development Program, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - Paula M. Castaño
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, NY, USA
| | - Anne E. Burke
- Department of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, MD, USA
| | - Bliss Kaneshiro
- Department of Obstetrics, Gynecology, and Women's Health, University of Hawaii, Honolulu, HI, USA
| | - Diana L. Blithe
- Contraceptive Development Program, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
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Stewart EA, Archer DF, Owens CD, Barnhart KT, Bradley LD, Feinberg EC, Gillispie-Bell V, Imudia AN, Liu R, Kim JH, Al-Hendy A. Reduction of Heavy Menstrual Bleeding in Women Not Designated as Responders to Elagolix Plus Add Back Therapy for Uterine Fibroids. J Womens Health (Larchmt) 2022; 31:698-705. [PMID: 34582715 PMCID: PMC9133968 DOI: 10.1089/jwh.2021.0152] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Objective: To assess outcomes of women with uterine fibroids (UFs) and heavy menstrual bleeding (HMB) treated with 300 mg elagolix twice daily plus add-back therapy (E2 1 mg/NETA 0.5 mg once daily) or placebo who were not considered responders in pooled analysis of two phase 3, 6-month randomized clinical trials (Elaris UF-1 and UF-2). Methods: Responders were defined as women who met both primary end point bleeding criteria (<80 mL menstrual blood loss [MBL] during the final month and ≥50% reduction in MBL from baseline to the final month) and either completed the study or discontinued due to predefined reasons. Thus, women termed nonresponders who were analyzed in this study who met neither or one bleeding end point or met both criteria but prematurely discontinued treatment because of adverse events, perceived lack of efficacy, or required surgical or interventional treatment for UFs were analyzed in this study. This post hoc analysis assessed mean changes from baseline in MBL, as well as adverse events. Results: Among 367 women receiving elagolix with add-back with observed data, 89 (24%) were not considered responders. Within this subset, 17 (19%) women met both bleeding criteria but prematurely discontinued treatment for the reasons mentioned above, while 23 (26%) met one bleeding criterion and 49 (55%) met neither bleeding criteria, regardless of discontinuation status. Among all nonresponders, a numerical trend toward greater mean reductions in MBL was observed in those receiving elagolix with add-back, compared with placebo group nonresponders. No differences in adverse events were observed between responders and nonresponders. Conclusion: Forty of 89 (45%) women with HMB and UFs who were classified as nonresponders in the UF-1 or UF-2 trials may have had a clinically meaningful response to elagolix with add-back therapy because they met at least one of the objective bleeding criteria. Clinical Trial Registration: Clinicaltrials.gov, NCT02654054 and NCT02691494. (NEJM 2020; 382:328-340) DOI: 10.1056/NEJMoa1904351.
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Affiliation(s)
- Elizabeth A. Stewart
- Division of Reproductive Endocrinology, Department of Obstetrics & Gynecology and Surgery, Mayo Clinic and Mayo Clinic Alix School of Medicine, Rochester, Minnesota, USA
| | - David F. Archer
- Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, Virginia, USA
| | | | - Kurt T. Barnhart
- Division of Reproductive Endocrinology and Infertility, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Linda D. Bradley
- Department of Obstetrics and Gynecology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Eve C. Feinberg
- Department of Obstetrics and Gynecology, Northwestern University School of Medicine, Chicago, Illinois, USA
| | | | - Anthony N. Imudia
- Department of Obstetrics and Gynecology, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
| | - Ran Liu
- AbbVie, Inc., North Chicago, Illinois, USA
| | - Jin Hee Kim
- Department of Obstetrics and Gynecology, Columbia University, New York, New York, USA
| | - Ayman Al-Hendy
- Department of Obstetrics and Gynecology, University of Chicago, Chicago, Illinois, USA
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15
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Westhoff CL, Archer DF, Barnhart K, Darney P, Gilliam M, Jensen J, Nelson A, Teal S, Thomas M, Hu J, Brown J, Blithe DL. Evaluation of ovulation and safety outcomes in a multi-center randomized trial of three 84-day ulipristal acetate regimens. Contraception 2022; 112:54-60. [DOI: 10.1016/j.contraception.2022.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 03/31/2022] [Accepted: 04/06/2022] [Indexed: 11/03/2022]
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16
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Gérard C, Arnal JF, Jost M, Douxfils J, Lenfant F, Fontaine C, Houtman R, Archer DF, Reid RL, Lobo RA, Gaspard U, Coelingh Bennink HJT, Creinin MD, Foidart JM. Profile of estetrol, a promising native estrogen for oral contraception and the relief of climacteric symptoms of menopause. Expert Rev Clin Pharmacol 2022; 15:121-137. [PMID: 35306927 DOI: 10.1080/17512433.2022.2054413] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Estrogens used in women's healthcare have been associated with increased risks of venous thromboembolism (VTE) and breast cancer. Estetrol (E4), an estrogen produced by the human fetal liver, has recently been approved for the first time as a new estrogenic component of a novel combined oral contraceptive (E4/drospirenone [DRSP]) for over a decade. In phase 3 studies, E4/DRSP showed good contraceptive efficacy, a predictable bleeding pattern, and a favorable safety and tolerability profile. AREAS COVERED This narrative review discusses E4's pharmacological characteristics, mode of action, and the results of preclinical and clinical studies for contraception, as well as for menopause and oncology. EXPERT OPINION Extensive studies have elucidated the properties of E4 that underlie its favorable safety profile. While classical estrogens (such as estradiol) exert their actions via both activation of nuclear and membrane estrogen receptor α (ERα), E4 presents a specific profile of ERα activation: E4 binds and activates nuclear ERα but does not induce the activation of membrane ERα signaling pathways in specific tissues. E4 has a small effect on normal breast tissue proliferation and minimally affects hepatic parameters. This distinct profile of ERα activation, uncoupling nuclear and membrane activation, is unique.
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Affiliation(s)
- Céline Gérard
- Department Research and Development, Estetra Srl, an Affiliate Company of Mithra Pharmaceuticals, Liège, Belgium
| | - Jean-François Arnal
- CHU de Toulouse, Université Toulouse III, Toulouse, France.,INSERM-UPS UMR U1297, Institut des Maladies Métaboliques et Cardiovasculaires, Université de Toulouse, Toulouse, France
| | - Maud Jost
- Department Research and Development, Estetra Srl, an Affiliate Company of Mithra Pharmaceuticals, Liège, Belgium
| | - Jonathan Douxfils
- Qualiblood S.a, Namur, Belgium.,Department of Pharmacy, Namur Thrombosis and Hemostasis Center, NAmur Research Institute for Life Sciences, University of Namur, Namur, Belgium
| | - Françoise Lenfant
- CHU de Toulouse, Université Toulouse III, Toulouse, France.,INSERM-UPS UMR U1297, Institut des Maladies Métaboliques et Cardiovasculaires, Université de Toulouse, Toulouse, France
| | - Coralie Fontaine
- CHU de Toulouse, Université Toulouse III, Toulouse, France.,INSERM-UPS UMR U1297, Institut des Maladies Métaboliques et Cardiovasculaires, Université de Toulouse, Toulouse, France
| | | | | | - Robert L Reid
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynaecology, Queen's University, Kingston, Canada
| | - Rogerio A Lobo
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, USA
| | - Ulysse Gaspard
- Department of Obstetrics and Gynecology, University of Liège, Liège, Belgium
| | | | - Mitchell D Creinin
- Department of Obstetrics and Gynecology, University of California, Sacramento, USA
| | - Jean-Michel Foidart
- Department Research and Development, Estetra Srl, an Affiliate Company of Mithra Pharmaceuticals, Liège, Belgium.,Department of Obstetrics and Gynecology, University of Liège, Liège, Belgium
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Demirel E, Sabouni R, Chandra N, Slayden OD, Archer DF. The Plasminogen Activator System, Glucocorticoid, and Mineralocorticoid Receptors in the Primate Endometrium During Artificial Menstrual Cycles. Reprod Sci 2022; 29:1001-1019. [PMID: 34796470 PMCID: PMC8863636 DOI: 10.1007/s43032-021-00797-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 11/03/2021] [Indexed: 11/26/2022]
Abstract
As a key mechanism in fibrinolysis and tissue remodeling, the plasminogen activator system has been suggested in the process of endometrial shedding and tissue remodeling. Previous studies have explored the role of estrogen, progesterone, and androgen receptors as well as elements of the renin-angiotensin-aldosterone system in shaping the morphology of the endometrium. This study investigates the distribution and concentrations of the mineralocorticoid receptor, glucocorticoid receptor, tissue plasminogen activator, urokinase plasminogen activator, and plasminogen activator inhibitor-1 within the endometrial stroma, glandular, and endothelial cells of the primate endometrium during artificial menstrual cycles. Our immunohistochemistry quantification shows mineralocorticoid and glucocorticoid receptors are ubiquitously distributed within the macaque endometrium with their patterns of expression following similar fluctuations to urokinase and tissue plasminogen activators particularly within the endometrial vasculature. These proteins are present in endometrial vasculature in high levels during the proliferative phase, decreasing levels during the secretory phase followed by rising levels in the menstrual phase. These similarities could suggest overlapping pathways and interactions between the plasminogen activator system and the steroid receptors within the endometrium. Given the anti-inflammatory properties of glucocorticoids and the role of plasminogen activators in endometrial breakdown, the glucocorticoid receptor may be contributing to stabilizing the endometrium by regulating plasminogen activators during the proliferative phase and menstruation. Furthermore, given the anti-mineralocorticoid properties of certain anti-androgenic progestins and their reduced unscheduled uterine bleeding patterns, the mineralocorticoid receptor may be involved in unscheduled endometrial bleeding.
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Affiliation(s)
- Esra Demirel
- Department of Obstetrics and Gynecology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, 300 Community Dr, Manhasset, NY, 11030, USA.
| | - Reem Sabouni
- The Clinical Research Center, Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA, USA
| | - Neelima Chandra
- The Clinical Research Center, Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA, USA
| | - Ov D Slayden
- Oregon National Primate Research Center, Beaverton, OR, USA
| | - David F Archer
- The Clinical Research Center, Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA, USA
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Pickar JH, Archer DF, Graham S, Zablotna R, Boolell M, Mirkin S. Amenorrhea rates in women treated with novel oral, continuous hormonal therapy of body identical 17β-estradiol and micronized progesterone. Maturitas 2021. [DOI: 10.1016/j.maturitas.2021.08.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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19
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Muneyyirci-Delale O, Archer DF, Owens CD, Barnhart KT, Bradley LD, Feinberg E, Gillispie V, Hurtado S, Kim JH, Wang A, Wang H, Stewart EA. Efficacy and safety of elagolix with add-back therapy in women with uterine fibroids and coexisting adenomyosis. F S Rep 2021; 2:338-346. [PMID: 34553161 PMCID: PMC8441572 DOI: 10.1016/j.xfre.2021.05.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 04/28/2021] [Accepted: 05/20/2021] [Indexed: 10/28/2022] Open
Abstract
Objective To determine if coexisting adenomyosis limits the efficacy of elagolix, an oral gonadotropin-releasing hormone antagonist, with hormonal add-back therapy in reducing heavy menstrual bleeding in women with uterine fibroids. Design Pooled analysis of two identical, double-blind, randomized, placebo-controlled, 6-month phase 3 trials (Elaris Uterine Fibroids [UF]-1 and UF-2). Setting A total of 153 gynecological clinical care settings in the United States and Canada. Patients Premenopausal women (18-51 years) with >80 mL of menstrual blood loss (MBL)/cycle and uterine fibroids with and without coexisting adenomyosis diagnosed by ultrasound and/or magnetic resonance imaging at baseline. Interventions Participants were randomized 1:1:2 to placebo, elagolix 300 mg twice daily alone, or elagolix 300 mg twice daily with estradiol 1 mg/norethindrone acetate 0.5 mg once daily. Main Outcome Measures The primary endpoint was the proportion of women who had <80 mL of MBL during the final month and ≥50% reduction in MBL from baseline to the final month. Adverse events were monitored. Results Of 786 women treated across the two trials, 16% (126 women) had coexisting adenomyosis. Among this subset, a significantly greater proportion of women who received elagolix with add-back therapy (77.1% [95% confidence interval, 66.2, 88.0]) met both primary endpoint criteria compared with women who received placebo (12.2% [95% confidence interval, 1.0, 23.4]). Adverse events most frequently reported in the elagolix with add-back adenomyosis subset were hot flushes (18.3%), nausea (11.7%), and night sweats (8.3%). Conclusions Elagolix with add-back therapy significantly reduced heavy menstrual bleeding in women with uterine fibroids and coexisting adenomyosis, suggesting that elagolix efficacy was not adversely affected by the presence of adenomyosis (Elaris UF-1 and UF-2 Clinical-Trials.gov numbers, NCT02654054 and NCT02691494).
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Affiliation(s)
- Ozgul Muneyyirci-Delale
- Department of Obstetrics & Gynecology, State University of New York (SUNY) Downstate Health Sciences University, Brooklyn, New York
| | - David F Archer
- Department of Obstetrics & Gynecology, Eastern Virginia Medical School, Norfolk, Virginia
| | | | - Kurt T Barnhart
- Division of Reproductive Endocrinology and Infertility, Perleman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Linda D Bradley
- Department of Obstetrics & Gynecology, Cleveland Clinic, Cleveland, Ohio
| | - Eve Feinberg
- Department of Obstetrics & Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Sandra Hurtado
- Department of Obstetrics & Gyneocology, University of Texas Health Science Center at Houston, Houston, Texas
| | - Jin Hee Kim
- Department of Obstetrics & Gyneocolgy, Columbia University, New York, New York
| | | | - Hui Wang
- AbbVie Inc., North Chicago, Illinois
| | - Elizabeth A Stewart
- Departments of Obstetrics & Gynecology & Surgery, Mayo Clinic and Mayo Medical School, Rochester, Minnesota
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Sadek S, Jacot TA, Thomas MC, Liu X, Duffy DM, Archer DF. PGE2 REGULATES THE PLASMINOGEN ACTIVATOR PATHWAY IN HUMAN ENDOMETRIAL ENDOTHELIAL CELLS: DIFFERENCES BETWEEN NORMAL AND HEAVY MENSTRUAL BLEEDERS. Fertil Steril 2021. [DOI: 10.1016/j.fertnstert.2021.07.824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Jensen JT, Archer DF, Merkatz RB, Nelson AL, Creinin MD, Kushner H, Graham S, Bernick B, Mirkin S. SATISFACTION WITH THE SEGESTERONE ACETATE AND ETHINYL ESTRADIOL CONTRACEPTIVE VAGINAL SYSTEM AMONG PREVIOUS ORAL CONTRACEPTIVE OR CONTRACEPTIVE VAGINAL RING USERS. Fertil Steril 2021. [DOI: 10.1016/j.fertnstert.2021.07.780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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22
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Kaunitz AM, Nelson AL, Barnhart KT, Thomas MA, Archer DF, Chiodo JA, Previtera M, Korner P. IMPACT OF APPLICATION SITE AND BODY MASS INDEX ON ADHESION AND TOLERABILITY OF A LEVONORGESTREL/ETHINYL ESTRADIOL TRANSDERMAL CONTRACEPTIVE DELIVERY SYSTEM. Fertil Steril 2021. [DOI: 10.1016/j.fertnstert.2021.07.782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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23
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Mirkin S, Simon JA, Liu JH, Archer DF, Castro PD, Graham S, Bernick B, Komm B. Evaluation of endometrial progesterone receptor expression after 12 weeks of exposure to a low-dose vaginal estradiol insert. Menopause 2021; 28:998-1003. [PMID: 34054104 PMCID: PMC8386586 DOI: 10.1097/gme.0000000000001801] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 03/29/2021] [Accepted: 03/29/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate endometrial progesterone receptor (PGR) expression in menopausal women who used vaginal 4-μg and 10-μg estradiol (E2) inserts or placebo. METHODS REJOICE was a randomized, placebo-controlled trial investigating vaginal E2 inserts in women with moderate to severe dyspareunia due to menopause. In this post hoc analysis, 25 eligible women with endometrial biopsies were randomly selected from each treatment group (4-μg and 10-μg E2 vaginal inserts and placebo). Endometrial biopsy sections were immunostained using an anti-PR (A and B) monoclonal antibody. Cell staining was quantified using an artificial intelligence feature-recognition algorithm. Mean PGR expression levels were analyzed between baseline and week 12. RESULTS PGR expression results were available for 22 women in the 4-μg E2 group, and 25 women each for the 10-μg E2 and placebo groups. Similar PGR expression levels were observed at baseline (0.301-0.470 pmol/mg) and after 12 weeks of treatment (0.312-0.432 pmol/mg) for all treatment groups, with no significant differences between baseline and week 12. CONCLUSIONS No meaningful differences in endometrial PGR expression were observed with the vaginal E2 (4- and 10-μg) inserts at week 12 from baseline, supporting the hypothesis that local exposure to E2 from a low-dose, vaginal insert placed near the vaginal introitus will not be sufficient to upregulate endometrial PGR expression. Coupled with the lack of histologic changes and systemic absorption, our data suggest that these softgel vaginal E2 inserts would not be expected to stimulate endometrial hyperplasia leading to a potential endometrial safety issue in postmenopausal women with moderate to severe dyspareunia, a symptom of vulvar and vaginal atrophy. Further study on the endometrial safety of softgel vaginal E2 inserts is under way.
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Affiliation(s)
| | - James A. Simon
- IntimMedicine Specialists, School of Medicine, George Washington University, Washington, DC
| | - James H. Liu
- University Hospitals Cleveland Medical Center, Cleveland, OH
| | - David F. Archer
- Clinical Research Center, Eastern Virginia Medical School, Norfolk, VA
| | - Patricia D. Castro
- Department of Pathology and Immunology, Baylor College of Medicine, Houston, TX
| | | | | | - Barry Komm
- Komm-Sandin Pharma Consulting, Newtown Square, PA
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Creinin MD, Westhoff CL, Bouchard C, Chen MJ, Jensen JT, Kaunitz AM, Achilles SL, Foidart JM, Archer DF. Estetrol-drospirenone combination oral contraceptive: North American phase 3 efficacy and safety results. Contraception 2021; 104:222-228. [PMID: 34000251 DOI: 10.1016/j.contraception.2021.05.002] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 04/19/2021] [Accepted: 05/04/2021] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To assess efficacy, cycle control, and safety of an oral contraceptive containing estetrol (E4) 15 mg and drospirenone (DRSP) 3 mg. STUDY DESIGN Women aged 16 to 50 years with a body mass index ≤35 kg/m2 enrolled in this multicenter, open-label, 13-cycle, phase 3 trial evaluating E4/DRSP in a 24-active/4-placebo regimen. Follow-up was scheduled at Cycles 2, 4, 7, and 10 and within 3 weeks of completing Cycle 13. Participants used daily diaries to record pill use and vaginal bleeding. We evaluated efficacy outcomes in women 16 to 35 years and bleeding patterns and safety (adverse events [AEs]) in all participants. We assessed overall and method-failure pregnancy rates using the Pearl index (PI) and life-table analysis. Scheduled bleeding included spotting or bleeding starting during the 4-day placebo period or first 3 days of the next cycle. RESULTS We enrolled 1864 women of whom 1674 were 16 to 35 years. Women 16 to 35 years had a PI of 2.65 (95% CI 1.73-3.88), method-failure PI of 1.43 (95% CI 0.7-2.39) and 13-cycle life-table pregnancy rate of 2.1%. Scheduled bleeding occurred in 82.9% to 87.0% of women per cycle; median duration was 4.5 days. Unscheduled bleeding decreased from 30.3% in Cycle 1 to 21.3% to 22.1% during Cycles 2 to 4 and remained stable (15.5% to 19.2%) thereafter. The most frequently reported AEs were headache (5.0%) and metrorrhagia (4.6%). One-hundred thirty-two (7.1%) women discontinued the study early for an AE, most commonly for metrorrhagia (0.9%) and menorrhagia (0.8%). No thromboembolic events occurred. CONCLUSION E4/DRSP is an effective oral contraceptive with a predictable bleeding pattern for most women and low AE rates. IMPLICATIONS STATEMENT A new oral contraceptive with a novel estrogen, estetrol, combined with drospirenone has efficacy and safety within the range of other available oral contraceptives. Large phase 4 studies will be needed to confirm if this combination is associated with an improved adverse event profile or lower thrombosis risk.
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Affiliation(s)
- Mitchell D Creinin
- Department of Obstetrics and Gynecology, University of California, Davis, Sacramento, CA, United States.
| | - Carolyn L Westhoff
- Department of Obstetrics and Gynecology, Columbia University Medical Center, New York, NY, United States
| | - Céline Bouchard
- Clinique de Recherche en Santé des Femmes, Quebec City, QC, Canada
| | - Melissa J Chen
- Department of Obstetrics and Gynecology, University of California, Davis, Sacramento, CA, United States
| | - Jeffrey T Jensen
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, OR, United States
| | - Andrew M Kaunitz
- Department of Obstetrics and Gynecology, University of Florida Jacksonville, Jacksonville, FL, United States
| | - Sharon L Achilles
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh/Magee-Womens Hospital, Pittsburgh, PA, United States
| | - Jean-Michel Foidart
- Mithra Pharmaceuticals, Liège, Belgium; Department of Obstetrics and Gynecology, University of Liège, Liège, Belgium
| | - David F Archer
- Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA, United States
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Sabouni R, Archer DF, Jacot T. Drospirenone Effects on the Plasminogen Activator System in Immortalized Human Endometrial Endothelial Cells. Reprod Sci 2021; 28:1974-1980. [PMID: 33559058 DOI: 10.1007/s43032-020-00433-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 12/13/2020] [Indexed: 12/09/2022]
Abstract
Drospirenone (DRSP) is a fourth-generation progestin that interacts with the progesterone receptor (PR) and androgen receptor (AR) in addition to uniquely interacting to the mineralocorticoid receptor (MR). The known effects of DRSP via the mineralocorticoid receptor (MR) are limited. This study seeks to determine if DRSP alters plasminogen activator inhibitor-1 (PAI-1) and tissue plasminogen activator (tPA) in human immortalized endometrial endothelial cells (HEEC) and if such changes in the plasminogen activator system (PAS) are mediated through the MR or AR. The in vitro cell culture experiments utilizing an immortalized human endometrial endothelial cell line evaluated two concentrations of DRSP on PAI-1 and tPA levels in the culture media using specific enzyme-linked immunoassays (ELISA). Experiments adding DRSP with an androgen receptor blocker, flutamide, or a mineralocorticoid receptor agonist, aldosterone, were performed to elucidate which receptor(s) mediated the PAS effects. DRSP 10 μM significantly decreased both HEEC levels of PAI-1 and tPA to 0.75 ± 0.04 and 0.82 ± 0.05 of control, respectively. These direct effects were blunted by flutamide, an AR antagonist. PAI-1 and tPA were not changed by the MR agonist, aldosterone. DRSP significantly decreased both PAI-1 and tPA in the HEECs via the androgen receptor.
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Affiliation(s)
- Reem Sabouni
- Department of Obstetrics and Gynecology, Jones Institute for Reproductive Medicine/Eastern Virginia Medical School, Norfolk, VA, USA.
| | - David F Archer
- Department of Obstetrics and Gynecology, Jones Institute for Reproductive Medicine/Eastern Virginia Medical School, Norfolk, VA, USA
| | - Terry Jacot
- Department of Obstetrics and Gynecology, Jones Institute for Reproductive Medicine/Eastern Virginia Medical School, Norfolk, VA, USA
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Agarwal SK, Singh SS, Archer DF, Mai Y, Chwalisz K, Gordon K, Surrey E. Endometriosis-Related Pain Reduction During Bleeding and Nonbleeding Days in Women Treated with Elagolix. J Pain Res 2021; 14:263-271. [PMID: 33564263 PMCID: PMC7866925 DOI: 10.2147/jpr.s284703] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 01/12/2021] [Indexed: 01/12/2023] Open
Abstract
Objective In this post hoc analysis, we evaluated the impact of elagolix on dysmenorrhea and nonmenstrual pelvic pain across menstrual period (bleeding days) and nonmenstrual (nonbleeding) days. Methods Data from two randomized, 6-month, placebo-controlled trials (Elaris Endometriosis (EM)-I and EM-II) of elagolix (150 mg once daily (QD) and 200 mg twice daily (BID)) in premenopausal women with moderate to severe endometriosis-associated pain (N = 1686) were pooled. Women recorded the presence of menstrual period and severity of dysmenorrhea or nonmenstrual pelvic pain in a daily electronic diary. Results At baseline, women in the placebo group and both elagolix treatment groups reported moderate or severe dysmenorrhea, on average, 81% of their menstrual period days and moderate/severe nonmenstrual pelvic pain, on average, 56% of their nonmenstrual (nonbleeding) days. Compared with placebo at month 6, elagolix-treated women had a significantly lower mean (standard deviation (SD)) percentage of menstrual period days with moderate or severe dysmenorrhea (elagolix 150 mg QD = 52.4 (38.9), p = 0.002; elagolix 200 mg BID = 38.5 (43.6), p < 0.001, placebo = 61.3 (33.7)) and a significantly lower mean (SD) percentage of nonmenstrual (nonbleeding) days with moderate or severe nonmenstrual pelvic pain (elagolix 150 mg QD = 31.1 (35.8), p < 0.001; elagolix 200 mg BID = 19.7 (29.9), p < 0.001; placebo = 35.6 (33.9)). Conclusion Following 6 months of elagolix treatment, women who still menstruated had a lower proportion of menstrual period days with moderate or severe dysmenorrhea compared with placebo, demonstrating pain reduction despite continued menses. Additionally, pain did not shift from dysmenorrhea to nonmenstrual pelvic pain, as the percentage of days with moderate or severe nonmenstrual pelvic pain was also reduced for elagolix-treated women compared with placebo. Trial Registration The Elaris EM-I study is registered with the US National Library of Medicine, www.ClinicalTrials.gov, NCT01620528. The Elaris EM-II study is registered with the US National Library of Medicine, www.ClinicalTrials.gov, NCT01931670. Both studies are registered with the EU Clinical Trial Register, www.clinicaltrialsregister.ed, 2011-004295-11.
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Affiliation(s)
- Sanjay K Agarwal
- Department of Obstetrics and Gynecology and Reproductive Sciences, Center for Endometriosis Research and Treatment, UC San Diego, La Jolla, CA, USA
| | - Sukhbir S Singh
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - David F Archer
- Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA, USA
| | - Yabing Mai
- Statistics, AbbVie Inc, North Chicago, IL, USA
| | | | - Keith Gordon
- Medical Affairs, AbbVie Inc, North Chicago, IL, USA
| | - Eric Surrey
- Colorado Center for Reproductive Medicine, Lone Tree, CO, USA
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27
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Al-Hendy A, Bradley L, Owens CD, Wang H, Barnhart KT, Feinberg E, Schlaff WD, Puscheck EE, Wang A, Gillispie V, Hurtado S, Muneyyirci-Delale O, Archer DF, Carr BR, Simon JA, Stewart EA. Predictors of response for elagolix with add-back therapy in women with heavy menstrual bleeding associated with uterine fibroids. Am J Obstet Gynecol 2021; 224:72.e1-72.e50. [PMID: 32702363 PMCID: PMC8800453 DOI: 10.1016/j.ajog.2020.07.032] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 06/17/2020] [Accepted: 07/16/2020] [Indexed: 11/08/2022]
Abstract
BACKGROUND: Uterine fibroids are one of the most common neoplasms found among women globally, with a prevalence of approximately 11 million women in the United States alone. The morbidity of this common disease is significant because it is the leading cause of hysterectomy and causes significant functional impairment for women of reproductive age. Factors including age, body mass index, race, ethnicity, menstrual blood loss, fibroid location, and uterine and fibroid volume influence the incidence of fibroids and severity of symptoms. Elagolix is an oral gonadotropin-releasing hormone receptor antagonist that competitively inhibits pituitary gonadotropin-releasing hormone receptor activity and suppresses the release of gonadotropins from the pituitary gland, resulting in dose-dependent suppression of ovarian sex hormones, follicular growth, and ovulation. In Elaris Uterine Fibroids 1 and Uterine Fibroids 2, 2 replicate multicenter, double-blind, randomized, placebo-controlled, phase 3 studies, treatment of premenopausal women with elagolix with hormonal add-back therapy demonstrated reduction in heavy menstrual bleeding associated with uterine fibroids. OBJECTIVE: This analysis aimed to evaluate the safety and efficacy of elagolix (300 mg twice a day) with add-back therapy (1 mg estradiol/0.5 mg norethindrone acetate once a day) in reducing heavy menstrual bleeding associated with uterine fibroids in various subgroups of women over 6 months of treatment. STUDY DESIGN: Data were pooled from Elaris Uterine Fibroid-1 and Uterine Fibroid-2 studies, which evaluated premenopausal women (18–51 years) with heavy menstrual bleeding (>80 mL menstrual blood loss per cycle, alkaline hematin methodology) and ultrasound-confirmed uterine fibroid diagnosis. Subgroups analyzed included age, body mass index, race, ethnicity, baseline menstrual blood loss, fibroid location, and uterine and primary fibroid volume (largest fibroid identified by ultrasound). The primary endpoint was the proportion of women with <80 mL menstrual blood loss during the final month and ≥50% menstrual blood loss reduction from baseline to final month. Secondary and other efficacy endpoints included mean change in menstrual blood loss from baseline to final month, amenorrhea, symptom severity, and health-related quality of life. Adverse events and other safety endpoints were monitored. RESULTS: The overall pooled Elaris Uterine Fibroid-1 and Uterine Fibroid-2 population was typical of women with fibroids, with a mean age of 42.4 (standard deviation, 5.4) years and a mean body mass index of 33.6 (standard deviation, 7.3) kg/m2 and 67.6% of participants being black or African American women. A wide range of baseline uterine and fibroid volumes and menstrual blood loss were also represented in the overall pooled study population. In all subgroups, the proportion of responders to the primary endpoint, mean change in menstrual blood loss, amenorrhea, reduction in symptom severity, and improvement in health-related quality of life were clinically meaningfully greater for women who received elagolix with add-back therapy than those who received placebo and consistent with the overall pooled study population for the primary endpoint (72.2% vs 9.3%), mean change in menstrual blood loss (−172.5 mL vs −0.8 mL), amenorrhea (50.4% vs 4.5%), symptom severity (−37.1 vs −9.2), and health-related quality of life score (39.9 vs 8.9). Adverse events by subgroup were consistent with the overall pooled study population. CONCLUSION: Elagolix with hormonal add-back therapy was effective in reducing heavy menstrual bleeding associated with uterine fibroids independent of age, body mass index, race, ethnicity, baseline menstrual blood loss, fibroid location, and uterine and primary fibroid volume.
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Abstract
Uterine bleeding is a common reason why women discontinue menopausal hormone therapy (HT). This systematic review compared bleeding profiles reported in studies for continuous-combined HT approved in North America and Europe for moderate to severe vasomotor symptoms in postmenopausal women with a uterus. Non-head-to-head studies showed that uterine bleeding varies by formulation and administration route, with oral having a better bleeding profile than transdermal formulations. Cumulative amenorrhea over a year ranged from 18 to 61% with oral HT and from 9 to 27% with transdermal HT, as reported for continuous-combined HT containing 17β-estradiol (E2)/progesterone (P4) (56%), E2/norethisterone acetate (NETA) (49%), E2/drospirenone (45%), conjugated equine estrogens/medroxyprogesterone acetate (18-54%), ethinyl estradiol/NETA (31-61%), E2/levonorgestrel patch (16%), and E2/NETA patch (9-27%). Amenorrhea rates and the mean number of bleeding/spotting days improved over time. The oral E2/P4 combination was amongst those with lower bleeding rates and may be an appropriate alternative for millions of women seeking bioidentical HT and/or those who have bleeding concerns with other HT.
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Affiliation(s)
- J H Pickar
- Department of Obstetrics and Gynecology, Columbia University Medical Center, New York, NY, USA.,KMITL Faculty of Medicine, Bangkok, Thailand
| | - D F Archer
- Clinical Research Center, Eastern Virginia Medical School, Norfolk, VA, USA
| | - S R Goldstein
- Department of Obstetrics and Gynecology, New York University School of Medicine, New York, NY, USA
| | - R Kagan
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco and Sutter East Bay Medical Foundation, Berkeley, CA, USA
| | | | - S Mirkin
- TherapeuticsMD, Boca Raton, FL, USA
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Chen MJ, Creinin MD, Turok DK, Archer DF, Barnhart KT, Westhoff CL, Thomas MA, Jensen JT, Variano B, Sitruk-Ware R, Shanker A, Long J, Blithe DL. Dose-finding study of a 90-day contraceptive vaginal ring releasing estradiol and segesterone acetate. Contraception 2020; 102:168-173. [PMID: 32416145 DOI: 10.1016/j.contraception.2020.05.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 04/22/2020] [Accepted: 05/06/2020] [Indexed: 01/12/2023]
Abstract
OBJECTIVE To evaluate serum estradiol (E2) concentrations during use of 90-day contraceptive vaginal rings releasing E2 75, 100, or 200 mcg/day and segesterone acetate (SA) 200 mcg/day to identify a dose that avoids hypoestrogenism. STUDY DESIGN We conducted a multicenter dose-finding study in healthy, reproductive-aged women with regular cycles with sequential enrollment to increasing E2 dose groups. We evaluated serum E2 concentrations twice weekly for the primary outcome of median E2 concentrations throughout initial 30-day use (target ≥40 pg/mL). In an optional 2-cycle extension substudy, we randomized participants to 2- or 4-day ring-free intervals per 30-day cycle to evaluate bleeding and spotting based on daily diary information. RESULTS Sixty-five participants enrolled in E2 75 (n = 22), 100 (n = 21), and 200 (n = 22) mcg/day groups; 35 participated in the substudy. Median serum E2 concentrations in 75 and 100 mcg/day groups were <40 pg/mL. In the 200 mcg/day group, median E2 concentrations peaked on days 4-5 of CVR use at 194 pg/mL (range 114-312 pg/mL) and remained >40 pg/mL throughout 30 days; E2 concentrations were 37 pg/mL (range 28-62 pg/mL) on days 88-90 (n = 11). Among the E2 200 mcg/day substudy participants, all had withdrawal bleeding following ring removal. The 2-day ring-free interval group reported zero median unscheduled bleeding and two (range 0-16) and three (range 0-19) unscheduled spotting days in extension cycles 1 and 2, respectively. The 4-day ring-free interval group reported zero median unscheduled bleeding or spotting days. CONCLUSIONS Estradiol concentrations with rings releasing E2 200 mcg/day and SA 200 mcg/day avoid hypoestrogenism over 30-day use. IMPLICATIONS A 90-day contraceptive vaginal ring releasing estradiol 200 mcg/day and segesterone acetate 200 mcg/day achieves estradiol concentrations that should avoid hypoestrogenism and effectively suppresses ovulation.
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Affiliation(s)
- Melissa J Chen
- Department of Obstetrics and Gynecology, University of California, Davis, Sacramento, CA, United States.
| | - Mitchell D Creinin
- Department of Obstetrics and Gynecology, University of California, Davis, Sacramento, CA, United States
| | - David K Turok
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT, United States
| | - David F Archer
- Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA, United States
| | - Kurt T Barnhart
- Department of Obstetrics and Gynecology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
| | - Carolyn L Westhoff
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, NY, United States
| | - Michael A Thomas
- Reproductive Medicine Research, Department of Obstetrics and Gynecology, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Jeffrey T Jensen
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, OR, United States
| | - Bruce Variano
- Center for Biomedical Research, Population Council, New York, NY, United States
| | - Regine Sitruk-Ware
- Center for Biomedical Research, Population Council, New York, NY, United States
| | | | - Jill Long
- Contraceptive Development Program, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, United States
| | - Diana L Blithe
- Contraceptive Development Program, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, United States
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Simon JA, Liu JH, Archer DF, Komm BS, Bernick B, Mirkin S. MON-006 Progesterone Receptor Expression in Endometrial Biopsies After 12 Weeks of Exposure to A 4-µg E2 Softgel Vaginal Insert or Placebo. J Endocr Soc 2020. [PMCID: PMC7208576 DOI: 10.1210/jendso/bvaa046.632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
The softgel, vaginal 17β-estradiol (E2) insert (TX-004HR) significantly improved the maturation index of the vaginal epithelium, dyspareunia and vaginal dryness in menopausal women with vulvar and vaginal atrophy (VVA) and moderate to severe dyspareunia, without histological changes to the endometrium (Constantine G et al, Menopause 2017;24:409-416). The 4-μg and 10-μg E2 doses were FDA approved as Imvexxy® (TherapeuticsMD, Boca Raton, FL), for the treatment of moderate to severe dyspareunia, a symptom of VVA, due to menopause. The progesterone receptor (PR) is an estrogen-regulated gene with expression that is very sensitive to E2 exposure (Xiao CW and Goff AK, J Reprod Fertil.1999;115:101-109). Endometrial PR expression in the biopsies of women using the softgel vaginal 4-µg E2 insert was used as a marker of E2 exposure to determine whether sufficient E2 applied with the vaginal insert reaches the endometrium to upregulate PR expression. Our hypothesis posits that there would be insufficient E2 from the 4-µg E2 insert to stimulate an increase in endometrial PR expression. In this post hoc analysis of the REJOICE trial, endometrial biopsies from 25 women who had a normal baseline biopsy, an on-therapy biopsy after study day 70, and tissue readings from all pathologists were randomly selected from the 4-µg E2 vaginal insert and placebo groups. Endometrial tissue sections were stained to visualize PR expression using PgR1294 (Agilent; Santa Clara, CA). Cell staining was quantified using a trainable feature-recognition algorithm and mean expression levels between baseline and week 12 were analyzed by 2-sided t-tests. Acceptable PR expression results were available for 22 women in the 4-µg E2 group (three had insufficient tissue for analysis) and 25 women in the placebo group. For the 4-µg E2 group, mean ± SD (pmol/mg) PR expression was 0.455 ± 0.203 at baseline and 0.506 ± 0.226 at week 12. For the placebo group, mean PR expression was 0.579 ± 0.196 at baseline and 0.563 ± 0.213 at week 12. Mean PR expression levels at baseline and week 12 were not significantly different from each other within the 4-µg E2 (P=0.438) or placebo (P=0.783) group. No meaningful difference in endometrial PR expression was observed with the vaginal 4-µg E2 insert at week 12. These data support our hypothesis and the assertion that low-dose, local vaginal E2 exposure with the insert placed in the lower part of the vagina, does not pose an endometrial safety issue in postmenopausal women.
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Affiliation(s)
- James A Simon
- George Washington University, School of Medicine, IntimMedicine Specialists, Washington, DC, USA
| | - James H Liu
- University Hospitals Cleveland Medical Center, Cleveland, OH, USA
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Liu JH, Archer DF, Simon JA, Kaunitz AM, Plagianos M, Bernick B, Mirkin S. SAT-013 Segesterone Acetate (SA) Serum Levels with a Statistical Model of Continued Use of the SA/Ethinyl Estradiol (EE) Contraceptive Vaginal System. J Endocr Soc 2020. [PMCID: PMC7209220 DOI: 10.1210/jendso/bvaa046.665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
The novel, ring-shaped, contraceptive vaginal system (CVS; Annovera™), contains 103 mg of SA and 17.4 mg of EE, and delivers a mean dose of SA 0.15/EE 0.013 mg/day. The CVS was designed to last thirteen cycles in a 21 day-in/7 day-out regimen. Objectives of these analyses were to determine the amount of SA/EE remaining in the CVS after 13 cycles of use and to estimate the SA level in serum after 1 year of continuous use. Residual SA/EE levels from CVS used by women (n=18) for 13 cycles of 21/7 regimen in a phase 3 clinical trial were further analyzed in vitro. Hypothetical SA level in serum after 1 year of continuous use was estimated using data from 39 women who participated in a 13-cycle pharmacokinetic study of the 21/7 CVS regimen. The serum data were used to construct a statistical model for the change in serum SA concentrations from cycle 1 to cycle 13. The data from each individual subject was modeled to estimate the serum SA level based on days of use. Each subject’s model was then used to estimate the serum SA level after 364 days of continuous CVS use. The average of all 364-day values from valid models was then calculated. After 13 cycles of a 21/7 regimen, the amount of SA/EE remaining in the CVS was 61.7 mg/14.0 mg (60%/80% of the original SA/EE load), which established the release of 0.15 mg SA and 0.013 mg EE per day for a total of 273 days. The model predicted that the mean serum SA level after 364 days of continuous use was 71 pmol/L with a lower limit of the 90% CI of 52 pmol/L. A high percentage of SA/EE remained in the CVS after 13 cycles of use. Serum SA levels predicted by the model following 1 year of continuous use were similar to those previously observed (mean 73 pmol/L) at 1 year in a SA silicone implant trial in which there were no reported pregnancies at 1 year (Sivin et al, Contraception. 2004;69:137-144). No pregnancy or PK data with continuous use of the CVS is available at this time. Further study on the continuous use of the CVS is warranted.
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Affiliation(s)
- James H Liu
- University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | | | - James A Simon
- George Washington University, School of Medicine, IntimMedicine Specialists, Washington, DC, USA
| | - Andrew M Kaunitz
- University of Florida College of Medicine-Jacksonville, Jacksonville, FL, USA
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Archer DF, Ng J, Chwalisz K, Chiu YL, Feinberg EC, Miller CE, Feldman RA, Klein CE. Elagolix Suppresses Ovulation in a Dose-Dependent Manner: Results From a 3-Month, Randomized Study in Ovulatory Women. J Clin Endocrinol Metab 2020; 105:5606934. [PMID: 31650182 DOI: 10.1210/clinem/dgz086] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 10/03/2019] [Indexed: 11/19/2022]
Abstract
CONTEXT Elagolix is an oral gonadotropin-releasing hormone (GnRH) antagonist recently approved for the treatment of endometriosis-associated pain and being developed for heavy menstrual bleeding associated with uterine fibroids. OBJECTIVE The objective was to evaluate the effects of elagolix on ovulation and ovarian sex hormones. DESIGN AND SETTING This was a randomized, open-label, multicenter study. PARTICIPANTS Participants were healthy ovulatory women aged 18 to 40 years. INTERVENTIONS Elagolix was administered orally for 3 continuous 28-day dosing intervals at 100 to 200 mg once daily (QD), 100 to 300 mg twice daily (BID), and 300 mg BID plus estradiol/norethindrone acetate (E2/NETA) 1/0.5 mg QD. MAIN OUTCOME MEASURES The main outcomes measures were ovulation rates measured by transvaginal ultrasound, progesterone concentrations, and hormone suppression. RESULTS Elagolix suppressed ovulation in a dose-dependent manner. The percentage of women who ovulated was highest at 100 mg QD (78%), intermediate at 150 and 200 mg QD and 100 mg BID (47%-57%), and lowest at 200 and 300 mg BID (32% and 27%, respectively). Addition of E2/NETA to elagolix 300 mg BID further suppressed the ovulation rate to 10%. Elagolix also suppressed luteinizing hormone and follicle stimulating hormone in a dose-dependent manner, leading to dose-dependent suppression of estradiol and progesterone. Elagolix had no effect on serum biomarker of ovarian reserve, and reduced endometrial thickness compared to the screening cycle. CONCLUSION Women being treated with elagolix may ovulate and should use effective methods of contraception. The rate of ovulation was lowest with elagolix 300 mg BID plus E2/NETA 1/0.5 mg QD.
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Affiliation(s)
- David F Archer
- Department of Obstetrics & Gynecology, Eastern Virginia Medical School, Norfolk, Virginia
| | - Juki Ng
- Clinical Pharmacology and Pharmacometrics, AbbVie Inc., North Chicago, Illinois
| | | | - Yi-Lin Chiu
- Data and Statistical Sciences, AbbVie Inc., North Chicago, Illinois
| | - Eve C Feinberg
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | | | - Cheri E Klein
- Clinical Pharmacology and Pharmacometrics, AbbVie Inc., North Chicago, Illinois
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Kimble T, Burke AE, Barnhart KT, Archer DF, Colli E, Westhoff CL. A 1-year prospective, open-label, single-arm, multicenter, phase 3 trial of the contraceptive efficacy and safety of the oral progestin-only pill drospirenone 4 mg using a 24/4-day regimen. Contracept X 2020; 2:100020. [PMID: 32550535 PMCID: PMC7286157 DOI: 10.1016/j.conx.2020.100020] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 01/16/2020] [Accepted: 01/21/2020] [Indexed: 11/17/2022] Open
Abstract
Objectives To evaluate contraceptive effectiveness and safety of oral drospirenone 4 mg 24/4-day regimen in the United States. Study design We performed a prospective, single-arm, multicenter phase 3 trial in sexually active women for up to thirteen 28-day treatment cycles. Primary outcome was the Pearl index, calculated using confirmed on-drug pregnancies and evaluable cycles in nonbreastfeeding women aged ≤ 35 years. We assessed adverse events (AEs), including hyperkalemia and venous thromboembolism. Results Of 1006 women who received at least one dose of drospirenone, 352 women (35.0%) completed the trial and 654 (65.0%) women discontinued before trial end. Most participants (92.2%) were ≤ 35 years; one third had a body mass index (BMI) ≥ 30 kg/m2. Among nonbreastfeeding women aged ≤ 35 years, there were 17 pregnancies (Pearl index: 4.0; 95% confidence interval [CI], 2.3-6.4; n = 953), of which three were unconfirmed and two were from sites excluded from the main analysis for major breaches of Food and Drug Administration regulations. The Pearl index was 2.9 (95% CI: 1.5-5.1) for confirmed pregnancies among 915 nonbreastfeeding women aged ≤ 35 years from sites with no protocol violations. Nearly all (95.4%) treatment-emergent AEs were mild or moderate in intensity. No cases of venous thromboembolism were reported. The frequency of hyperkalemia was 0.5%. Women with baseline systolic/diastolic blood pressure ≥ 130/85 mmHg had a mean reduction from baseline in blood pressure at exit visit (- 8.5/- 4.9 mmHg; n = 119). No other clinically relevant changes were observed. Participant satisfaction was high. Conclusion Drospirenone 4 mg 24/4 regimen provides effective contraception with a good safety/tolerability profile in a broad group of women, including overweight or obese women. Implications This new progestin-only contraceptive, drospirenone 4 mg in a 24/4 regimen, provides a contraceptive option for the majority of women regardless of blood pressure or BMI.
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Affiliation(s)
- Thomas Kimble
- Eastern Virginia Medical School, Norfolk, VA, USA
- Corresponding author at: Eastern Virginia Medical School; 601 Colley Avenue, Norfolk, VA 23507. Tel.: + 1 757 446 7900.
| | - Anne E. Burke
- Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Kurt T. Barnhart
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | | | - Carolyn L. Westhoff
- Department of Obstetrics and Gynecology, and Mailman School of Public Health, Columbia University, New York, NY, USA
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Schlaff WD, Ackerman RT, Al-Hendy A, Archer DF, Barnhart KT, Bradley LD, Carr BR, Feinberg EC, Hurtado SM, Kim J, Liu R, Mabey RG, Owens CD, Poindexter A, Puscheck EE, Rodriguez-Ginorio H, Simon JA, Soliman AM, Stewart EA, Watts NB, Muneyyirci-Delale O. Elagolix for Heavy Menstrual Bleeding in Women with Uterine Fibroids. N Engl J Med 2020; 382:328-340. [PMID: 31971678 DOI: 10.1056/nejmoa1904351] [Citation(s) in RCA: 82] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Uterine fibroids are hormone-responsive neoplasms that are associated with heavy menstrual bleeding. Elagolix, an oral gonadotropin-releasing hormone antagonist resulting in rapid, reversible suppression of ovarian sex hormones, may reduce fibroid-associated bleeding. METHODS We conducted two identical, double-blind, randomized, placebo-controlled, 6-month phase 3 trials (Elaris Uterine Fibroids 1 and 2 [UF-1 and UF-2]) to evaluate the efficacy and safety of elagolix at a dose of 300 mg twice daily with hormonal "add-back" therapy (to replace reduced levels of endogenous hormones; in this case, estradiol, 1 mg, and norethindrone acetate, 0.5 mg, once daily) in women with fibroid-associated bleeding. An elagolix-alone group was included to assess the impact of add-back therapy on the hypoestrogenic effects of elagolix. The primary end point was menstrual blood loss of less than 80 ml during the final month of treatment and at least a 50% reduction in menstrual blood loss from baseline to the final month; missing data were imputed with the use of multiple imputation. RESULTS A total of 412 women in UF-1 and 378 women in UF-2 underwent randomization, received elagolix or placebo, and were included in the analyses. Criteria for the primary end point were met in 68.5% of 206 women in UF-1 and in 76.5% of 189 women in UF-2 who received elagolix plus add-back therapy, as compared with 8.7% of 102 women and 10% of 94 women, respectively, who received placebo (P<0.001 for both trials). Among the women who received elagolix alone, the primary end point was met in 84.1% of 104 women in UF-1 and in 77% of 95 women in UF-2. Hot flushes (in both trials) and metrorrhagia (in UF-1) occurred significantly more commonly with elagolix plus add-back therapy than with placebo. Hypoestrogenic effects of elagolix, especially decreases in bone mineral density, were attenuated with add-back therapy. CONCLUSIONS Elagolix with add-back therapy was effective in reducing heavy menstrual bleeding in women with uterine fibroids. (Funded by AbbVie; Elaris UF-1 and Elaris UF-2 ClinicalTrials.gov numbers, NCT02654054 and NCT02691494.).
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Affiliation(s)
- William D Schlaff
- From Thomas Jefferson University (W.D.S.) and the University of Pennsylvania (K.T.B.), Philadelphia; Comprehensive Clinical Trials, West Palm Beach, FL (R.T.A.); University of Illinois at Chicago (A.A.-H.) and Northwestern University (E.C.F.), Chicago, AbbVie, North Chicago (R.L., C.D.O., A.M.S.), and InVia Fertility, Hoffman Estates (E.E.P.) - all in Illinois; Eastern Virginia Medical School, Norfolk (D.F.A.); Cleveland Clinic, Cleveland (L.D.B.); University of Texas Southwestern Medical Center, Dallas (B.R.C.); University of Texas Health Science Center at Houston (S.M.H.) and Advances in Health (A.P.), Houston; Columbia University (J.K.) and SUNY Downstate Health Sciences University (O.M.-D.), New York; private practice, Las Vegas (R.G.M.); Wayne State University, Detroit (E.E.P.); Torre de Auxilio Mutuo, San Juan, Puerto Rico (H.R.-G.); George Washington University, Washington, DC (J.A.S.); Mayo Clinic and Mayo Clinic Alix School of Medicine, Rochester, MN (E.A.S.); and Mercy Health, Cincinnati (N.B.W.)
| | - Ronald T Ackerman
- From Thomas Jefferson University (W.D.S.) and the University of Pennsylvania (K.T.B.), Philadelphia; Comprehensive Clinical Trials, West Palm Beach, FL (R.T.A.); University of Illinois at Chicago (A.A.-H.) and Northwestern University (E.C.F.), Chicago, AbbVie, North Chicago (R.L., C.D.O., A.M.S.), and InVia Fertility, Hoffman Estates (E.E.P.) - all in Illinois; Eastern Virginia Medical School, Norfolk (D.F.A.); Cleveland Clinic, Cleveland (L.D.B.); University of Texas Southwestern Medical Center, Dallas (B.R.C.); University of Texas Health Science Center at Houston (S.M.H.) and Advances in Health (A.P.), Houston; Columbia University (J.K.) and SUNY Downstate Health Sciences University (O.M.-D.), New York; private practice, Las Vegas (R.G.M.); Wayne State University, Detroit (E.E.P.); Torre de Auxilio Mutuo, San Juan, Puerto Rico (H.R.-G.); George Washington University, Washington, DC (J.A.S.); Mayo Clinic and Mayo Clinic Alix School of Medicine, Rochester, MN (E.A.S.); and Mercy Health, Cincinnati (N.B.W.)
| | - Ayman Al-Hendy
- From Thomas Jefferson University (W.D.S.) and the University of Pennsylvania (K.T.B.), Philadelphia; Comprehensive Clinical Trials, West Palm Beach, FL (R.T.A.); University of Illinois at Chicago (A.A.-H.) and Northwestern University (E.C.F.), Chicago, AbbVie, North Chicago (R.L., C.D.O., A.M.S.), and InVia Fertility, Hoffman Estates (E.E.P.) - all in Illinois; Eastern Virginia Medical School, Norfolk (D.F.A.); Cleveland Clinic, Cleveland (L.D.B.); University of Texas Southwestern Medical Center, Dallas (B.R.C.); University of Texas Health Science Center at Houston (S.M.H.) and Advances in Health (A.P.), Houston; Columbia University (J.K.) and SUNY Downstate Health Sciences University (O.M.-D.), New York; private practice, Las Vegas (R.G.M.); Wayne State University, Detroit (E.E.P.); Torre de Auxilio Mutuo, San Juan, Puerto Rico (H.R.-G.); George Washington University, Washington, DC (J.A.S.); Mayo Clinic and Mayo Clinic Alix School of Medicine, Rochester, MN (E.A.S.); and Mercy Health, Cincinnati (N.B.W.)
| | - David F Archer
- From Thomas Jefferson University (W.D.S.) and the University of Pennsylvania (K.T.B.), Philadelphia; Comprehensive Clinical Trials, West Palm Beach, FL (R.T.A.); University of Illinois at Chicago (A.A.-H.) and Northwestern University (E.C.F.), Chicago, AbbVie, North Chicago (R.L., C.D.O., A.M.S.), and InVia Fertility, Hoffman Estates (E.E.P.) - all in Illinois; Eastern Virginia Medical School, Norfolk (D.F.A.); Cleveland Clinic, Cleveland (L.D.B.); University of Texas Southwestern Medical Center, Dallas (B.R.C.); University of Texas Health Science Center at Houston (S.M.H.) and Advances in Health (A.P.), Houston; Columbia University (J.K.) and SUNY Downstate Health Sciences University (O.M.-D.), New York; private practice, Las Vegas (R.G.M.); Wayne State University, Detroit (E.E.P.); Torre de Auxilio Mutuo, San Juan, Puerto Rico (H.R.-G.); George Washington University, Washington, DC (J.A.S.); Mayo Clinic and Mayo Clinic Alix School of Medicine, Rochester, MN (E.A.S.); and Mercy Health, Cincinnati (N.B.W.)
| | - Kurt T Barnhart
- From Thomas Jefferson University (W.D.S.) and the University of Pennsylvania (K.T.B.), Philadelphia; Comprehensive Clinical Trials, West Palm Beach, FL (R.T.A.); University of Illinois at Chicago (A.A.-H.) and Northwestern University (E.C.F.), Chicago, AbbVie, North Chicago (R.L., C.D.O., A.M.S.), and InVia Fertility, Hoffman Estates (E.E.P.) - all in Illinois; Eastern Virginia Medical School, Norfolk (D.F.A.); Cleveland Clinic, Cleveland (L.D.B.); University of Texas Southwestern Medical Center, Dallas (B.R.C.); University of Texas Health Science Center at Houston (S.M.H.) and Advances in Health (A.P.), Houston; Columbia University (J.K.) and SUNY Downstate Health Sciences University (O.M.-D.), New York; private practice, Las Vegas (R.G.M.); Wayne State University, Detroit (E.E.P.); Torre de Auxilio Mutuo, San Juan, Puerto Rico (H.R.-G.); George Washington University, Washington, DC (J.A.S.); Mayo Clinic and Mayo Clinic Alix School of Medicine, Rochester, MN (E.A.S.); and Mercy Health, Cincinnati (N.B.W.)
| | - Linda D Bradley
- From Thomas Jefferson University (W.D.S.) and the University of Pennsylvania (K.T.B.), Philadelphia; Comprehensive Clinical Trials, West Palm Beach, FL (R.T.A.); University of Illinois at Chicago (A.A.-H.) and Northwestern University (E.C.F.), Chicago, AbbVie, North Chicago (R.L., C.D.O., A.M.S.), and InVia Fertility, Hoffman Estates (E.E.P.) - all in Illinois; Eastern Virginia Medical School, Norfolk (D.F.A.); Cleveland Clinic, Cleveland (L.D.B.); University of Texas Southwestern Medical Center, Dallas (B.R.C.); University of Texas Health Science Center at Houston (S.M.H.) and Advances in Health (A.P.), Houston; Columbia University (J.K.) and SUNY Downstate Health Sciences University (O.M.-D.), New York; private practice, Las Vegas (R.G.M.); Wayne State University, Detroit (E.E.P.); Torre de Auxilio Mutuo, San Juan, Puerto Rico (H.R.-G.); George Washington University, Washington, DC (J.A.S.); Mayo Clinic and Mayo Clinic Alix School of Medicine, Rochester, MN (E.A.S.); and Mercy Health, Cincinnati (N.B.W.)
| | - Bruce R Carr
- From Thomas Jefferson University (W.D.S.) and the University of Pennsylvania (K.T.B.), Philadelphia; Comprehensive Clinical Trials, West Palm Beach, FL (R.T.A.); University of Illinois at Chicago (A.A.-H.) and Northwestern University (E.C.F.), Chicago, AbbVie, North Chicago (R.L., C.D.O., A.M.S.), and InVia Fertility, Hoffman Estates (E.E.P.) - all in Illinois; Eastern Virginia Medical School, Norfolk (D.F.A.); Cleveland Clinic, Cleveland (L.D.B.); University of Texas Southwestern Medical Center, Dallas (B.R.C.); University of Texas Health Science Center at Houston (S.M.H.) and Advances in Health (A.P.), Houston; Columbia University (J.K.) and SUNY Downstate Health Sciences University (O.M.-D.), New York; private practice, Las Vegas (R.G.M.); Wayne State University, Detroit (E.E.P.); Torre de Auxilio Mutuo, San Juan, Puerto Rico (H.R.-G.); George Washington University, Washington, DC (J.A.S.); Mayo Clinic and Mayo Clinic Alix School of Medicine, Rochester, MN (E.A.S.); and Mercy Health, Cincinnati (N.B.W.)
| | - Eve C Feinberg
- From Thomas Jefferson University (W.D.S.) and the University of Pennsylvania (K.T.B.), Philadelphia; Comprehensive Clinical Trials, West Palm Beach, FL (R.T.A.); University of Illinois at Chicago (A.A.-H.) and Northwestern University (E.C.F.), Chicago, AbbVie, North Chicago (R.L., C.D.O., A.M.S.), and InVia Fertility, Hoffman Estates (E.E.P.) - all in Illinois; Eastern Virginia Medical School, Norfolk (D.F.A.); Cleveland Clinic, Cleveland (L.D.B.); University of Texas Southwestern Medical Center, Dallas (B.R.C.); University of Texas Health Science Center at Houston (S.M.H.) and Advances in Health (A.P.), Houston; Columbia University (J.K.) and SUNY Downstate Health Sciences University (O.M.-D.), New York; private practice, Las Vegas (R.G.M.); Wayne State University, Detroit (E.E.P.); Torre de Auxilio Mutuo, San Juan, Puerto Rico (H.R.-G.); George Washington University, Washington, DC (J.A.S.); Mayo Clinic and Mayo Clinic Alix School of Medicine, Rochester, MN (E.A.S.); and Mercy Health, Cincinnati (N.B.W.)
| | - Sandra M Hurtado
- From Thomas Jefferson University (W.D.S.) and the University of Pennsylvania (K.T.B.), Philadelphia; Comprehensive Clinical Trials, West Palm Beach, FL (R.T.A.); University of Illinois at Chicago (A.A.-H.) and Northwestern University (E.C.F.), Chicago, AbbVie, North Chicago (R.L., C.D.O., A.M.S.), and InVia Fertility, Hoffman Estates (E.E.P.) - all in Illinois; Eastern Virginia Medical School, Norfolk (D.F.A.); Cleveland Clinic, Cleveland (L.D.B.); University of Texas Southwestern Medical Center, Dallas (B.R.C.); University of Texas Health Science Center at Houston (S.M.H.) and Advances in Health (A.P.), Houston; Columbia University (J.K.) and SUNY Downstate Health Sciences University (O.M.-D.), New York; private practice, Las Vegas (R.G.M.); Wayne State University, Detroit (E.E.P.); Torre de Auxilio Mutuo, San Juan, Puerto Rico (H.R.-G.); George Washington University, Washington, DC (J.A.S.); Mayo Clinic and Mayo Clinic Alix School of Medicine, Rochester, MN (E.A.S.); and Mercy Health, Cincinnati (N.B.W.)
| | - JinHee Kim
- From Thomas Jefferson University (W.D.S.) and the University of Pennsylvania (K.T.B.), Philadelphia; Comprehensive Clinical Trials, West Palm Beach, FL (R.T.A.); University of Illinois at Chicago (A.A.-H.) and Northwestern University (E.C.F.), Chicago, AbbVie, North Chicago (R.L., C.D.O., A.M.S.), and InVia Fertility, Hoffman Estates (E.E.P.) - all in Illinois; Eastern Virginia Medical School, Norfolk (D.F.A.); Cleveland Clinic, Cleveland (L.D.B.); University of Texas Southwestern Medical Center, Dallas (B.R.C.); University of Texas Health Science Center at Houston (S.M.H.) and Advances in Health (A.P.), Houston; Columbia University (J.K.) and SUNY Downstate Health Sciences University (O.M.-D.), New York; private practice, Las Vegas (R.G.M.); Wayne State University, Detroit (E.E.P.); Torre de Auxilio Mutuo, San Juan, Puerto Rico (H.R.-G.); George Washington University, Washington, DC (J.A.S.); Mayo Clinic and Mayo Clinic Alix School of Medicine, Rochester, MN (E.A.S.); and Mercy Health, Cincinnati (N.B.W.)
| | - Ran Liu
- From Thomas Jefferson University (W.D.S.) and the University of Pennsylvania (K.T.B.), Philadelphia; Comprehensive Clinical Trials, West Palm Beach, FL (R.T.A.); University of Illinois at Chicago (A.A.-H.) and Northwestern University (E.C.F.), Chicago, AbbVie, North Chicago (R.L., C.D.O., A.M.S.), and InVia Fertility, Hoffman Estates (E.E.P.) - all in Illinois; Eastern Virginia Medical School, Norfolk (D.F.A.); Cleveland Clinic, Cleveland (L.D.B.); University of Texas Southwestern Medical Center, Dallas (B.R.C.); University of Texas Health Science Center at Houston (S.M.H.) and Advances in Health (A.P.), Houston; Columbia University (J.K.) and SUNY Downstate Health Sciences University (O.M.-D.), New York; private practice, Las Vegas (R.G.M.); Wayne State University, Detroit (E.E.P.); Torre de Auxilio Mutuo, San Juan, Puerto Rico (H.R.-G.); George Washington University, Washington, DC (J.A.S.); Mayo Clinic and Mayo Clinic Alix School of Medicine, Rochester, MN (E.A.S.); and Mercy Health, Cincinnati (N.B.W.)
| | - R Garn Mabey
- From Thomas Jefferson University (W.D.S.) and the University of Pennsylvania (K.T.B.), Philadelphia; Comprehensive Clinical Trials, West Palm Beach, FL (R.T.A.); University of Illinois at Chicago (A.A.-H.) and Northwestern University (E.C.F.), Chicago, AbbVie, North Chicago (R.L., C.D.O., A.M.S.), and InVia Fertility, Hoffman Estates (E.E.P.) - all in Illinois; Eastern Virginia Medical School, Norfolk (D.F.A.); Cleveland Clinic, Cleveland (L.D.B.); University of Texas Southwestern Medical Center, Dallas (B.R.C.); University of Texas Health Science Center at Houston (S.M.H.) and Advances in Health (A.P.), Houston; Columbia University (J.K.) and SUNY Downstate Health Sciences University (O.M.-D.), New York; private practice, Las Vegas (R.G.M.); Wayne State University, Detroit (E.E.P.); Torre de Auxilio Mutuo, San Juan, Puerto Rico (H.R.-G.); George Washington University, Washington, DC (J.A.S.); Mayo Clinic and Mayo Clinic Alix School of Medicine, Rochester, MN (E.A.S.); and Mercy Health, Cincinnati (N.B.W.)
| | - Charlotte D Owens
- From Thomas Jefferson University (W.D.S.) and the University of Pennsylvania (K.T.B.), Philadelphia; Comprehensive Clinical Trials, West Palm Beach, FL (R.T.A.); University of Illinois at Chicago (A.A.-H.) and Northwestern University (E.C.F.), Chicago, AbbVie, North Chicago (R.L., C.D.O., A.M.S.), and InVia Fertility, Hoffman Estates (E.E.P.) - all in Illinois; Eastern Virginia Medical School, Norfolk (D.F.A.); Cleveland Clinic, Cleveland (L.D.B.); University of Texas Southwestern Medical Center, Dallas (B.R.C.); University of Texas Health Science Center at Houston (S.M.H.) and Advances in Health (A.P.), Houston; Columbia University (J.K.) and SUNY Downstate Health Sciences University (O.M.-D.), New York; private practice, Las Vegas (R.G.M.); Wayne State University, Detroit (E.E.P.); Torre de Auxilio Mutuo, San Juan, Puerto Rico (H.R.-G.); George Washington University, Washington, DC (J.A.S.); Mayo Clinic and Mayo Clinic Alix School of Medicine, Rochester, MN (E.A.S.); and Mercy Health, Cincinnati (N.B.W.)
| | - Alfred Poindexter
- From Thomas Jefferson University (W.D.S.) and the University of Pennsylvania (K.T.B.), Philadelphia; Comprehensive Clinical Trials, West Palm Beach, FL (R.T.A.); University of Illinois at Chicago (A.A.-H.) and Northwestern University (E.C.F.), Chicago, AbbVie, North Chicago (R.L., C.D.O., A.M.S.), and InVia Fertility, Hoffman Estates (E.E.P.) - all in Illinois; Eastern Virginia Medical School, Norfolk (D.F.A.); Cleveland Clinic, Cleveland (L.D.B.); University of Texas Southwestern Medical Center, Dallas (B.R.C.); University of Texas Health Science Center at Houston (S.M.H.) and Advances in Health (A.P.), Houston; Columbia University (J.K.) and SUNY Downstate Health Sciences University (O.M.-D.), New York; private practice, Las Vegas (R.G.M.); Wayne State University, Detroit (E.E.P.); Torre de Auxilio Mutuo, San Juan, Puerto Rico (H.R.-G.); George Washington University, Washington, DC (J.A.S.); Mayo Clinic and Mayo Clinic Alix School of Medicine, Rochester, MN (E.A.S.); and Mercy Health, Cincinnati (N.B.W.)
| | - Elizabeth E Puscheck
- From Thomas Jefferson University (W.D.S.) and the University of Pennsylvania (K.T.B.), Philadelphia; Comprehensive Clinical Trials, West Palm Beach, FL (R.T.A.); University of Illinois at Chicago (A.A.-H.) and Northwestern University (E.C.F.), Chicago, AbbVie, North Chicago (R.L., C.D.O., A.M.S.), and InVia Fertility, Hoffman Estates (E.E.P.) - all in Illinois; Eastern Virginia Medical School, Norfolk (D.F.A.); Cleveland Clinic, Cleveland (L.D.B.); University of Texas Southwestern Medical Center, Dallas (B.R.C.); University of Texas Health Science Center at Houston (S.M.H.) and Advances in Health (A.P.), Houston; Columbia University (J.K.) and SUNY Downstate Health Sciences University (O.M.-D.), New York; private practice, Las Vegas (R.G.M.); Wayne State University, Detroit (E.E.P.); Torre de Auxilio Mutuo, San Juan, Puerto Rico (H.R.-G.); George Washington University, Washington, DC (J.A.S.); Mayo Clinic and Mayo Clinic Alix School of Medicine, Rochester, MN (E.A.S.); and Mercy Health, Cincinnati (N.B.W.)
| | - Henry Rodriguez-Ginorio
- From Thomas Jefferson University (W.D.S.) and the University of Pennsylvania (K.T.B.), Philadelphia; Comprehensive Clinical Trials, West Palm Beach, FL (R.T.A.); University of Illinois at Chicago (A.A.-H.) and Northwestern University (E.C.F.), Chicago, AbbVie, North Chicago (R.L., C.D.O., A.M.S.), and InVia Fertility, Hoffman Estates (E.E.P.) - all in Illinois; Eastern Virginia Medical School, Norfolk (D.F.A.); Cleveland Clinic, Cleveland (L.D.B.); University of Texas Southwestern Medical Center, Dallas (B.R.C.); University of Texas Health Science Center at Houston (S.M.H.) and Advances in Health (A.P.), Houston; Columbia University (J.K.) and SUNY Downstate Health Sciences University (O.M.-D.), New York; private practice, Las Vegas (R.G.M.); Wayne State University, Detroit (E.E.P.); Torre de Auxilio Mutuo, San Juan, Puerto Rico (H.R.-G.); George Washington University, Washington, DC (J.A.S.); Mayo Clinic and Mayo Clinic Alix School of Medicine, Rochester, MN (E.A.S.); and Mercy Health, Cincinnati (N.B.W.)
| | - James A Simon
- From Thomas Jefferson University (W.D.S.) and the University of Pennsylvania (K.T.B.), Philadelphia; Comprehensive Clinical Trials, West Palm Beach, FL (R.T.A.); University of Illinois at Chicago (A.A.-H.) and Northwestern University (E.C.F.), Chicago, AbbVie, North Chicago (R.L., C.D.O., A.M.S.), and InVia Fertility, Hoffman Estates (E.E.P.) - all in Illinois; Eastern Virginia Medical School, Norfolk (D.F.A.); Cleveland Clinic, Cleveland (L.D.B.); University of Texas Southwestern Medical Center, Dallas (B.R.C.); University of Texas Health Science Center at Houston (S.M.H.) and Advances in Health (A.P.), Houston; Columbia University (J.K.) and SUNY Downstate Health Sciences University (O.M.-D.), New York; private practice, Las Vegas (R.G.M.); Wayne State University, Detroit (E.E.P.); Torre de Auxilio Mutuo, San Juan, Puerto Rico (H.R.-G.); George Washington University, Washington, DC (J.A.S.); Mayo Clinic and Mayo Clinic Alix School of Medicine, Rochester, MN (E.A.S.); and Mercy Health, Cincinnati (N.B.W.)
| | - Ahmed M Soliman
- From Thomas Jefferson University (W.D.S.) and the University of Pennsylvania (K.T.B.), Philadelphia; Comprehensive Clinical Trials, West Palm Beach, FL (R.T.A.); University of Illinois at Chicago (A.A.-H.) and Northwestern University (E.C.F.), Chicago, AbbVie, North Chicago (R.L., C.D.O., A.M.S.), and InVia Fertility, Hoffman Estates (E.E.P.) - all in Illinois; Eastern Virginia Medical School, Norfolk (D.F.A.); Cleveland Clinic, Cleveland (L.D.B.); University of Texas Southwestern Medical Center, Dallas (B.R.C.); University of Texas Health Science Center at Houston (S.M.H.) and Advances in Health (A.P.), Houston; Columbia University (J.K.) and SUNY Downstate Health Sciences University (O.M.-D.), New York; private practice, Las Vegas (R.G.M.); Wayne State University, Detroit (E.E.P.); Torre de Auxilio Mutuo, San Juan, Puerto Rico (H.R.-G.); George Washington University, Washington, DC (J.A.S.); Mayo Clinic and Mayo Clinic Alix School of Medicine, Rochester, MN (E.A.S.); and Mercy Health, Cincinnati (N.B.W.)
| | - Elizabeth A Stewart
- From Thomas Jefferson University (W.D.S.) and the University of Pennsylvania (K.T.B.), Philadelphia; Comprehensive Clinical Trials, West Palm Beach, FL (R.T.A.); University of Illinois at Chicago (A.A.-H.) and Northwestern University (E.C.F.), Chicago, AbbVie, North Chicago (R.L., C.D.O., A.M.S.), and InVia Fertility, Hoffman Estates (E.E.P.) - all in Illinois; Eastern Virginia Medical School, Norfolk (D.F.A.); Cleveland Clinic, Cleveland (L.D.B.); University of Texas Southwestern Medical Center, Dallas (B.R.C.); University of Texas Health Science Center at Houston (S.M.H.) and Advances in Health (A.P.), Houston; Columbia University (J.K.) and SUNY Downstate Health Sciences University (O.M.-D.), New York; private practice, Las Vegas (R.G.M.); Wayne State University, Detroit (E.E.P.); Torre de Auxilio Mutuo, San Juan, Puerto Rico (H.R.-G.); George Washington University, Washington, DC (J.A.S.); Mayo Clinic and Mayo Clinic Alix School of Medicine, Rochester, MN (E.A.S.); and Mercy Health, Cincinnati (N.B.W.)
| | - Nelson B Watts
- From Thomas Jefferson University (W.D.S.) and the University of Pennsylvania (K.T.B.), Philadelphia; Comprehensive Clinical Trials, West Palm Beach, FL (R.T.A.); University of Illinois at Chicago (A.A.-H.) and Northwestern University (E.C.F.), Chicago, AbbVie, North Chicago (R.L., C.D.O., A.M.S.), and InVia Fertility, Hoffman Estates (E.E.P.) - all in Illinois; Eastern Virginia Medical School, Norfolk (D.F.A.); Cleveland Clinic, Cleveland (L.D.B.); University of Texas Southwestern Medical Center, Dallas (B.R.C.); University of Texas Health Science Center at Houston (S.M.H.) and Advances in Health (A.P.), Houston; Columbia University (J.K.) and SUNY Downstate Health Sciences University (O.M.-D.), New York; private practice, Las Vegas (R.G.M.); Wayne State University, Detroit (E.E.P.); Torre de Auxilio Mutuo, San Juan, Puerto Rico (H.R.-G.); George Washington University, Washington, DC (J.A.S.); Mayo Clinic and Mayo Clinic Alix School of Medicine, Rochester, MN (E.A.S.); and Mercy Health, Cincinnati (N.B.W.)
| | - Ozgul Muneyyirci-Delale
- From Thomas Jefferson University (W.D.S.) and the University of Pennsylvania (K.T.B.), Philadelphia; Comprehensive Clinical Trials, West Palm Beach, FL (R.T.A.); University of Illinois at Chicago (A.A.-H.) and Northwestern University (E.C.F.), Chicago, AbbVie, North Chicago (R.L., C.D.O., A.M.S.), and InVia Fertility, Hoffman Estates (E.E.P.) - all in Illinois; Eastern Virginia Medical School, Norfolk (D.F.A.); Cleveland Clinic, Cleveland (L.D.B.); University of Texas Southwestern Medical Center, Dallas (B.R.C.); University of Texas Health Science Center at Houston (S.M.H.) and Advances in Health (A.P.), Houston; Columbia University (J.K.) and SUNY Downstate Health Sciences University (O.M.-D.), New York; private practice, Las Vegas (R.G.M.); Wayne State University, Detroit (E.E.P.); Torre de Auxilio Mutuo, San Juan, Puerto Rico (H.R.-G.); George Washington University, Washington, DC (J.A.S.); Mayo Clinic and Mayo Clinic Alix School of Medicine, Rochester, MN (E.A.S.); and Mercy Health, Cincinnati (N.B.W.)
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Archer DF, Soliman AM, Agarwal SK, Taylor HS. Elagolix in the treatment of endometriosis: impact beyond pain symptoms. Ther Adv Reprod Health 2020; 14:2633494120964517. [PMID: 33294846 PMCID: PMC7708701 DOI: 10.1177/2633494120964517] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 09/15/2020] [Indexed: 11/15/2022] Open
Abstract
While the most common symptom associated with endometriosis is pelvic pain, the systemic manifestations of the disease and the accompanying adverse psychological, emotional, social, familial, sexual, educational and workplace effects are increasingly recognized. Elagolix is an oral gonadotropin-releasing hormone receptor antagonist that is approved for the management of moderate to severe pain associated with endometriosis. However, the benefits of elagolix extend beyond reducing pain symptoms. This article reviews the non-pain systemic manifestations associated with endometriosis and summarizes the beneficial effects of elagolix on non-pain outcomes. This includes improvements in quality of life, reductions in fatigue and improvements in workplace and household productivity. These results indicate that elagolix provides non-pain benefits in women with endometriosis and improves outcomes that are clinically meaningful to patients.
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Affiliation(s)
- David F. Archer
- CONRAD Clinical Research Center, Department of
Obstetrics and Gynecology, Eastern Virginia Medical School, 601 Colley
Avenue, Suite 241, Norfolk, VA 23507, USA
| | - Ahmed M. Soliman
- Health Economics and Outcomes Research, AbbVie,
Inc., North Chicago, IL, USA
| | - Sanjay K. Agarwal
- Center for Endometriosis Research and Treatment,
University of California, San Diego, CA, USA
| | - Hugh S. Taylor
- Department of Obstetrics and Gynecology and
Reproductive Sciences, Yale School of Medicine, New Haven, CT, USA
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Muneyyirci-Delale O, Archer DF, Kim JHJ, Liu R, Owens C, Puscheck E. Phase 3 Trial Results: Efficacy and Safety of Elagolix in a Subset of Women with Uterine Fibroids and Adenomyosis. J Minim Invasive Gynecol 2019. [DOI: 10.1016/j.jmig.2019.09.580] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Leyland N, Taylor HS, Archer DF, Peloso PM, Soliman AM, Palac HL, Martinez M, Abrao MS. Elagolix reduced dyspareunia and improved health-related quality of life in premenopausal women with endometriosis-associated pain. Journal of Endometriosis and Pelvic Pain Disorders 2019. [DOI: 10.1177/2284026519872401] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objectives: The objective was to evaluate the effects of elagolix on dyspareunia in women with endometriosis-associated pain. Methods: Data were pooled from two similar, randomized, double-blind, placebo-controlled, 6-month phase 3 studies (Elaris Endometriosis-I and Elaris Endometriosis-II) of elagolix at two doses (150 mg QD and 200 mg BID) in women with endometriosis-associated pain. In this post hoc analysis, dyspareunia responders were defined as having a clinically meaningful decrease from baseline in the dyspareunia score and decreased or stable use of rescue analgesic agents, as recorded in a daily electronic diary. Sexual relationship was assessed using the 30-item Endometriosis Health Profile questionnaire sexual relationship module. Results: A total of 1384 women reported ⩾1 day of sexual activity at baseline (35 days prior to and including day 1 of treatment). Of these 1384 women, 1297 (94%) reported ⩾1 day of any dyspareunia (mild, moderate, or severe), of which 51% reported ⩾1 day of severe dyspareunia. Among sexually active women who reported any dyspareunia at baseline, both elagolix doses led to improvements in dyspareunia. Women in the 200-mg BID group showed more months at which the dyspareunia response rates were statistically significantly greater than placebo, particularly in a subgroup of women with severe dyspareunia at baseline. Compared to placebo, both elagolix doses led to statistically significantly greater improvements in the mean 30-item Endometriosis Health Profile sexual relationship module score. Conclusion: Up to 6 months of elagolix treatment improved dyspareunia in women with endometriosis-associated pain in a dose-dependent manner, with 200-mg BID dose showing the most significant improvements in dyspareunia and quality of sexual relationships compared with placebo.
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Affiliation(s)
- Nicholas Leyland
- Department of Obstetrics and Gynaecology, Hamilton Health Sciences, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | | | | | | | | | | | | | - Mauricio S Abrao
- Hospital das Clinicas Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
- BP-A Beneficencia Portuguesa de Sao Paulo, Sao Paulo, Brazil
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Archer DF, Barnhart KT, Nelson AL, Creinin MD, Jensen JT, Mirkin S, Merkatz RB. Bleeding patterns and endometrial safety with a 1-year, segesterone acetate/ethinyl estradiol contraceptive vaginal system. Fertil Steril 2019. [DOI: 10.1016/j.fertnstert.2019.07.163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Archer DF, Simon JA, Portman DJ, Goldstein SR, Goldstein I. Ospemifene for the treatment of menopausal vaginal dryness, a symptom of the genitourinary syndrome of menopause. Expert Rev Endocrinol Metab 2019; 14:301-314. [PMID: 31526199 DOI: 10.1080/17446651.2019.1657008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 08/14/2019] [Indexed: 01/31/2023]
Abstract
Introduction: Vulvovaginal atrophy (VVA), a component of the genitourinary syndrome of menopause, is a progressive condition due to decline in estrogen leading to vaginal and vulvar epithelial changes. Accompanying symptoms of dryness, irritation, burning, dysuria, and/or dyspareunia have a negative impact on quality of life. Ospemifene is a selective estrogen receptor modulator (SERM) approved by the FDA for moderate to severe dyspareunia and vaginal dryness due to postmenopausal VVA. Areas covered: PubMed was searched from inception to March 2019 with keywords ospemifene and vulvar vaginal atrophy to review preclinical and clinical data describing the safety and efficacy of ospemifene for vaginal dryness and dyspareunia due to VVA. Covered topics include efficacy of ospemifene on vaginal cell populations, vaginal pH, and most bothersome VVA symptoms; imaging studies of vulvar and vaginal tissues; effects on sexual function; and safety of ospemifene on endometrium, cardiovascular system, and breast. Expert opinion: Ospemifene is significantly more effective than placebo in all efficacy analyses studied, working through estrogen receptors and possibly androgen receptors. Safety as assessed by adverse events was generally comparable to that with placebo and to other SERMs, and/or adverse events were not clinically meaningful. No cases of endometrial or breast cancer were reported.
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Affiliation(s)
- David F Archer
- Clinical Research Center, Eastern Virginia Medical School , Norfolk , VA , USA
| | - James A Simon
- School of Medicine, and IntimMedicine Specialists, George Washington University , Washington , DC , USA
| | | | - Steven R Goldstein
- Department of Obstetrics and Gynecology, New York University School of Medicine , New York , NY , USA
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Walsh TL, Snead MC, St Claire BJ, Schwartz JL, Mauck CK, Frezieres RG, Blithe DL, Archer DF, Barnhart KT, Jensen JT, Nelson AL, Thomas MA, Wan LS, Weaver MA. Comparison of self-reported female condom failure and biomarker-confirmed semen exposure. Contraception 2019; 100:406-412. [PMID: 31381878 DOI: 10.1016/j.contraception.2019.07.143] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 07/20/2019] [Accepted: 07/24/2019] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To investigate whether rates of self-reported Woman's Condom (WC) clinical failure and semen exposure from a functionality study are comparable to results from a contraceptive efficacy substudy. STUDY DESIGN We structured our comparative analysis to assess whether functionality studies might credibly supplant contraceptive efficacy studies when evaluating new female condom products. Couples not at risk of pregnancy in the functionality (breakage/slippage/invagination/penile misdirection) study and women in the contraceptive efficacy study completed condom self-reports and collected precoital and postcoital vaginal samples for up to four uses of the WC. Both studies used nearly identical self-report questions and the same self-sampling procedures and laboratory for prostatic specific antigen (PSA), a well-studied semen biomarker. We compared condom failure and semen exposure proportions using generalized estimating equations methods accounting for within-couple correlation. RESULTS Ninety-five (95) efficacy substudy participants used 334 WC and 408 functionality participants used 1572 WC. Based on self-report, 19.2% WC (64 condoms) clinically failed in the efficacy substudy compared to 12.3% WC (194 condoms) in the functionality study (p=.03). Of the 207 WC efficacy uses with evaluable postcoital PSA levels, 14.5% (30 uses) resulted in semen exposure compared to 14.2% (184 uses) of the 1293 evaluable WC functionality study uses. CONCLUSIONS When evaluating the ability of an experimental condom to prevent semen exposure, the rate of clinical condom failure reported by participants risking pregnancy in an efficacy substudy was significantly higher than the rate reported by participants not risking pregnancy in a functionality study. The rate of semen exposure, assessed by an objective biomarker was nearly identical for the two studies. IMPLICATIONS Our results suggest that an objective marker of semen exposure in functionality studies could provide a reasonable alternative to contraceptive efficacy studies in evaluating risk of unintended pregnancy and inferring protection from sexually transmitted infection than condom failure rates based on self-report.
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Affiliation(s)
- Terri L Walsh
- Essential Access Health (formerly California Family Health Council), 3600 Wilshire Blvd., Ste. 600, Los Angeles, CA 90010.
| | - Margaret C Snead
- Division of Reproductive Health, Centers for Disease Control and Prevention, 1600 Clifton Rd., Atlanta, GA 30333
| | - Breione J St Claire
- Essential Access Health (formerly California Family Health Council), 3600 Wilshire Blvd., Ste. 600, Los Angeles, CA 90010
| | - Jill L Schwartz
- CONRAD/EVMS, 1911 N. Fort Myer Drive, Ste. 900, Arlington, VA 22209
| | | | - Ron G Frezieres
- Essential Access Health (formerly California Family Health Council), 3600 Wilshire Blvd., Ste. 600, Los Angeles, CA 90010
| | - Diana L Blithe
- Contraceptive Development Program, Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, 6710B Rockledge Dr, Bethesda, MD 20817
| | - David F Archer
- Obstetrics & Gynecology, Eastern Virginia Medical School, PO Box 1980, Norfolk, VA 23501
| | - Kurt T Barnhart
- University of Pennsylvania Medical Center, 3701 Market St., Ste. 800, Philadelphia, PA 19104
| | - Jeffrey T Jensen
- Department of Obstetrics & Gynecology, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd., Portland, OR 97239
| | - Anita L Nelson
- Essential Access Health (formerly California Family Health Council), 3600 Wilshire Blvd., Ste. 600, Los Angeles, CA 90010
| | - Michael A Thomas
- Department of Obstetrics & Gynecology, University of Cincinnati Medical Center, 234 Goodman St., Cincinnati, OH 45219
| | - Livia S Wan
- Department of Obstetrics & Gynecology, New York University,462 First Ave., New York, NY 10016
| | - Mark A Weaver
- Department of Mathematics and Statistics, Elon University, Elon, NC 27244
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Archer DF, Bernick BA, Mirkin S. A combined, bioidentical, oral, 17β-estradiol and progesterone capsule for the treatment of moderate to severe vasomotor symptoms due to menopause. Expert Rev Clin Pharmacol 2019; 12:729-739. [DOI: 10.1080/17512433.2019.1637731] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- David F. Archer
- Clinical Research Center, Eastern Virginia Medical School, Norfolk, VA, USA
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Pickar JH, Graham S, Archer DF, Bernick B, Mirkin S. Uterine bleeding rates with hormone therapies in menopausal women with vasomotor symptoms. Maturitas 2019. [DOI: 10.1016/j.maturitas.2019.04.082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Constantine GD, Simon JA, Pickar JH, Archer DF, Bernick B, Graham S, Mirkin S. Estradiol vaginal inserts (4 µg and 10 µg) for treating moderate to severe vulvar and vaginal atrophy: a review of phase 3 safety, efficacy and pharmacokinetic data. Curr Med Res Opin 2018; 34:2131-2136. [PMID: 30238814 DOI: 10.1080/03007995.2018.1527578] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
OBJECTIVE To review safety, efficacy and pharmacokinetic (PK) data from the phase 3 REJOICE trial, which evaluated a 17β-estradiol (E2) softgel vaginal insert approved in 2018 for moderate to severe dyspareunia associated with menopausal vulvar and vaginal atrophy (VVA). METHODS REJOICE (Clinicaltrials.gov: NCT02253173) was a randomized, double-blind, placebo-controlled trial in which women with moderate to severe dyspareunia due to menopausal VVA received 4 µg, 10 µg or 25 µg of an E2 vaginal insert or placebo for 12 weeks. The published data for the recently approved 4 µg and 10 µg doses of the E2 vaginal insert, including four co-primary efficacy endpoints (change from baseline to week 12 in percentages of superficial and parabasal cells, vaginal pH and severity of dyspareunia), safety and PK (which included serum E2 levels measured by gas chromatography and tandem mass spectrometry), are summarized here. RESULTS Women were randomized to receive the E2 vaginal insert (4 µg [n = 186] or 10 µg [n = 188]; Imvexxy a ) or placebo (n = 187) in the modified intention-to-treat population. The E2 vaginal insert (4 µg and 10 µg) significantly improved the percentages of superficial and parabasal cells (p < .0001), vaginal pH (p < .0001), and the severity score for dyspareunia (p < .05) from baseline to week 12 compared with placebo. The recently approved E2 vaginal insert was well tolerated, with no clinically significant differences in treatment-emergent or serious adverse events versus placebo. Systemic absorption of E2 with both doses was minimal. CONCLUSIONS The recently FDA-approved E2 softgel vaginal insert (4 µg and 10 µg) was safe and effective over 12 weeks for treating moderate to severe dyspareunia due to menopausal VVA with minimal systemic E2 levels.
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Affiliation(s)
| | - James A Simon
- b George Washington University, School of Medicine, IntimMedicine Specialists , Washington , DC , USA
| | - James H Pickar
- c Columbia University Medical Center , New York , NY , USA
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Abstract
A woman's vaginal pH has many implications on her health and it can be a useful tool in disease diagnosis and prevention. For that reason, the further examination of the relationship between the human vaginal pH and microbiota is imperative. In the past several decades, much has been learned about the physiological mechanisms modulating the vaginal pH, and exogenous/genetic factors that may influence it. A unified, coherent understanding of these concepts is presented to comprehend their interrelationships and their cumulative effect on a woman's health. In this review, we explore research on vaginal pH and microbiota throughout a woman's life, vaginal intermediate cell anaerobic metabolism and net proton secretion by the vaginal epithelial, and the way these factors interact to acidify the vaginal pH. This review provides foundational information about what a microbiota is and its relationship with human physiology and vaginal pH. We then evaluate the influence of physiological mechanisms, demographic factors, and propose ideas for the mechanisms behind their action on the vaginal pH.
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Affiliation(s)
| | - Kelly M Tucker
- b Department of Obstetrics and Gynecology , CONRAD Clinical Research Center, Eastern Virginia Medical School , Norfolk , VI , USA
| | | | - David F Archer
- b Department of Obstetrics and Gynecology , CONRAD Clinical Research Center, Eastern Virginia Medical School , Norfolk , VI , USA
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Stanczyk FZ, Burke AE, Hong KM, Archer DF. Morbid obesity: potential effects of hormonal contraception. Contraception 2018; 98:174-180. [PMID: 29777662 DOI: 10.1016/j.contraception.2018.05.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Revised: 05/06/2018] [Accepted: 05/07/2018] [Indexed: 12/22/2022]
Affiliation(s)
- Frank Z Stanczyk
- Departments of Obstetrics and Gynecology, and Preventive Medicine, Keck School of Medicine of USC, Los Angeles, CA 90033, USA.
| | - Anne E Burke
- Department of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, MD 21224, USA
| | - Kurt M Hong
- Center of Clinical Nutrition and Applied Health Research, Keck School of Medicine of USC, Los Angeles, CA 90033, USA
| | - David F Archer
- Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA 23507, USA
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Li R, Luo X, Archer DF, Chegini N. Retraction notice to Doxycycline Alters the Expression of Matrix Metalloproteases in the Endometrial Cells Exposed to Ovarian Steroids and Pro-inflammatory Cytokine JRI 73/2 (April 2017);118-129. J Reprod Immunol 2018; 125:106. [PMID: 29406209 DOI: 10.1016/j.jri.2017.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Rongxiu Li
- Department of OB/GYN, University of Florida, Gainesville, FL, USA
| | - Xiaoping Luo
- Department of OB/GYN, University of Florida, Gainesville, FL, USA
| | | | - Nasser Chegini
- Department of OB/GYN, University of Florida, Gainesville, FL, USA
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Jensen JT, Edelman AB, Chen BA, Archer DF, Barnhart KT, Thomas MA, Burke AE, Westhoff CL, Wan LS, Sitruk-Ware R, Kumar N, Variano B, Blithe DL. Continuous dosing of a novel contraceptive vaginal ring releasing Nestorone® and estradiol: pharmacokinetics from a dose-finding study. Contraception 2018; 97:422-427. [PMID: 29409834 DOI: 10.1016/j.contraception.2018.01.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Revised: 01/08/2018] [Accepted: 01/23/2018] [Indexed: 11/25/2022]
Abstract
BACKGROUND As part of a program to develop a novel estradiol-releasing contraceptive vaginal ring (CVR), we evaluated the pharmacokinetic (PK) profile of CVRs releasing segesterone acetate (Nestorone® (NES)) combined with one of three different estradiol (E2) doses. STUDY DESIGN A prospective, double-blind, randomized, multi-centered study to evaluate a 90-day CVR releasing NES [200mcg/day] plus E2, either 10mcg/day, 20mcg/day, or 40mcg/day in healthy reproductive-age women with regular cycles. Participants provided blood samples twice weekly for NES and E2 levels during the first 60 days (ring 1) and the last 30 days (ring 2) of use. A subset underwent formal PK assessments at ring initiation, ring exchange (limited PK), and study completion. RESULTS The main study enrolled 197 women; 22 participated in the PK substudy. Baseline characteristics between the main and PK participants were comparable, with an average BMI of 25.8 kg/m2 (SD 4.3). In the PK substudy, all three rings showed similar NES PK: mean area under the curve (AUC(0-72)) 34,181 pg*day/mL; concentration maximum (Cmax) 918 pg/mL; time to maximum concentration (Tmax) 3.5 h. For E2, the Cmax occurred at 2 h, and was significantly higher with the 20 mcg/day ring (mean 390 pg/mL); 10 mcg/day, 189 pg/mL, p=.003; 40 mcg/day, 189 pg/mL, p<.001), and declined rapidly to≤50 pg/mL for all doses by 24 h. For all subjects, the median E2 levels remained under 35 pg/mL during treatment. CONCLUSION PK parameters of NES were not affected when paired with different doses of E2, but E2 levels from all three doses were lower than anticipated and no dose response was observed. IMPLICATIONS While these novel estradiol-releasing combination contraceptive vaginal rings provided sustained release of contraceptive levels of Nestorone over 90 days, the E2 levels achieved were not consistent with bone protection, and a dose-response was not observed.
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Affiliation(s)
- J T Jensen
- Department of Obstetrics & Gynecology, Oregon Health & Science University, Portland, OR.
| | - A B Edelman
- Department of Obstetrics & Gynecology, Oregon Health & Science University, Portland, OR
| | - B A Chen
- Department of Obstetrics, Gynecology & Reproductive Sciences, Magee-Womens Research Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - D F Archer
- Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA
| | - K T Barnhart
- Pennsylvania Clinical Research Center, Department of Obstetrics & Gynecology, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - M A Thomas
- Reproductive Medicine Research, Department of Obstetrics & Gynecology, University of Cincinnati College of Medicine, Cincinnati, OH
| | - A E Burke
- Department of Gynecology and Obstetrics, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - C L Westhoff
- Department of Obstetrics & Gynecology, Columbia University College of Physicians and Surgeons, New York, NY
| | - L S Wan
- Department of Obstetrics & Gynecology, New York University School of Medicine, New York, NY
| | - R Sitruk-Ware
- Center for Biomedical Research, Population Council, New York, NY
| | - N Kumar
- Center for Biomedical Research, Population Council, New York, NY
| | - B Variano
- Center for Biomedical Research, Population Council, New York, NY
| | - D L Blithe
- Contraceptive Development Program, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD
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Archer DF, Kimble TD, Lin FDY, Battucci S, Sniukiene V, Liu JH. A Randomized, Multicenter, Double-Blind, Study to Evaluate the Safety and Efficacy of Estradiol Vaginal Cream 0.003% in Postmenopausal Women with Vaginal Dryness as the Most Bothersome Symptom. J Womens Health (Larchmt) 2017; 27:231-237. [PMID: 29193980 PMCID: PMC5865261 DOI: 10.1089/jwh.2017.6515] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Vulvovaginal atrophy (VVA) is characterized by vaginal/vulvar dryness, irritation, dyspareunia, or dysuria. The objective of this study was to examine the efficacy and safety of a very low-dose estradiol vaginal cream (0.003%) applied twice per week in postmenopausal women with VVA-related vaginal dryness. Materials and Methods: In this phase 3, randomized, double-blind, placebo-controlled, multicenter study, postmenopausal women with moderate–severe vaginal dryness as the most bothersome VVA symptom were randomized (1:1) to estradiol cream 0.003% (15 μg estradiol; 0.5 g cream) or placebo (0.5 g cream). Treatments were applied vaginally once daily for 2 weeks followed by two applications/week for 10 weeks. Coprimary outcomes were changes in severity of vaginal dryness, percentage of vaginal superficial and parabasal cells, and vaginal pH at final assessment. Additional outcomes comprised changes in severity of other VVA signs and symptoms. Adverse events (AEs) were assessed. Results: Of the 576 randomized participants, most were white and had an average age of 59 years. At final assessment, estradiol reduced vaginal dryness severity, decreased vaginal pH, increased superficial cell percentage, and decreased parabasal cell percentage versus placebo (p ≤ 0.05, all). Estradiol also reduced vaginal dryness severity at Weeks 4–12 and dyspareunia at Week 8 versus placebo (p ≤ 0.05, all). Improvements in vaginal/vulvar irritation/itching severity and dysuria were similar between estradiol and placebo. Estradiol had comparable rates of treatment-emergent AEs to placebo. No deaths occurred. Conclusions: Very low-dose estradiol vaginal cream (0.003%) dosed twice weekly is an effective and well-tolerated treatment for VVA symptoms and dryness associated with menopause.
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Affiliation(s)
| | | | | | | | | | - James H Liu
- 4 Department of Obstetrics and Gynecology, University Hospitals Cleveland Medical Center , Cleveland, Ohio
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Archer DF, Labrie F, Montesino M, Martel C. Comparison of intravaginal 6.5mg (0.50%) prasterone, 0.3mg conjugated estrogens and 10μg estradiol on symptoms of vulvovaginal atrophy. J Steroid Biochem Mol Biol 2017; 174:1-8. [PMID: 28323042 DOI: 10.1016/j.jsbmb.2017.03.014] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Revised: 03/14/2017] [Accepted: 03/17/2017] [Indexed: 11/26/2022]
Abstract
The objective is to compare the effect of intravaginal dehydroepiandrosterone (DHEA, prasterone), conjugated equine estrogens (CEE) and estradiol (E2) on moderate to severe dyspareunia and/or vaginal dryness. In a review of available data, independent prospective, randomized, double-blind and placebo-controlled Phase III 12-week clinical trials involved daily administration of 6.5mg (0.50%) prasterone, daily (21days on/7days off) 0.3mg CEE, twice weekly 0.3mg CEE or 10μg E2 daily for 2 weeks followed by twice weekly for 10 weeks. Vulvovaginal atrophy (VVA) symptoms were evaluated by questionnaires. The total severity score of dyspareunia decreased from baseline by 1.27 to 1.63 units with prasterone treatment, 1.4 with CEE and 1.23 in one statistically significant study with E2 (combined symptoms). Decreases over placebo ranged from 0.35 to 1.21 with prasterone, 0.7 to 1.0 with CEE and 0.33 for the E2 study. The total decreases in vaginal dryness severity ranged from 1.44 to 1.58 units for prasterone, 1.1 unit for CEE and 1.23 unit for E2. The decreases over placebo of vaginal dryness intensity ranged from 0.30 to 0.43 unit for prasterone, 0.40 unit for CEE and 0.33 for the E2 study with combined symptoms. Daily 6.5mg (0.50%) prasterone appears to be at least as efficacious as 0.3mg CEE or 10μg E2 for treatment of the VVA symptoms. In summary, the beneficial effects on the VVA symptomatology can be obtained by the addition of a small amount of intravaginal prasterone to compensate for the low serum concentration of prasterone observed in the majority of women after menopause without concerns about systemic effects.
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Affiliation(s)
- David F Archer
- CONRAD Clinical Research Center, Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA, USA
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Sriprasert I, Pakrashi T, Kimble T, Archer DF. Heavy menstrual bleeding diagnosis and medical management. Contracept Reprod Med 2017; 2:20. [PMID: 29201425 PMCID: PMC5683444 DOI: 10.1186/s40834-017-0047-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 07/07/2017] [Indexed: 11/10/2022] Open
Abstract
Heavy menstrual bleeding (HMB) is a common gynecological problem that has a significant impact on a woman’s quality of life and the activities of daily living. Due to the difficulty in accurately describing menstrual bleeding abnormalities using older terminology, the PALM-COEIN classification system of the Federation Internationale de Gynecologie et d’Obstetrique was proposed to describe and identify the etiology of abnormal endometrial bleeding. As there is no single pathway that is associated with HMB, there are several therapeutic interventions involving different molecular pathways to reduce HMB. This article will highlight the current evidence as it relates to the etiology of HMB as well as medical modalities of treatment.
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Affiliation(s)
- Intira Sriprasert
- Department of Obstetrics and Gynecology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Tarita Pakrashi
- Department of Obstetrics and Gynecology, Jones Institute for Reproductive Medicine/Eastern Virginia Medical School, Norfolk, VA USA
| | - Thomas Kimble
- CONRAD Clinical Research Center, Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA USA
| | - David F Archer
- CONRAD Clinical Research Center, Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA USA
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