U.S. patent application number 11/136997 was filed with the patent office on 2005-09-22 for hormone composition.
This patent application is currently assigned to Novo Nordisk A/S. Invention is credited to Koch, Karen, Kvorning, Ingelise.
Application Number | 20050209209 11/136997 |
Document ID | / |
Family ID | 27561836 |
Filed Date | 2005-09-22 |
United States Patent
Application |
20050209209 |
Kind Code |
A1 |
Koch, Karen ; et
al. |
September 22, 2005 |
Hormone composition
Abstract
Twice weekly administration of an analog to a Vagifem tablet
which only contains 10 .mu.g of active material has a sufficient
effect.
Inventors: |
Koch, Karen;
(Charlottenlund, DK) ; Kvorning, Ingelise;
(Bronshoj, DK) |
Correspondence
Address: |
NOVO NORDISK, INC.
PATENT DEPARTMENT
100 COLLEGE ROAD WEST
PRINCETON
NJ
08540
US
|
Assignee: |
Novo Nordisk A/S
Bagsvaerd
DK
DK-2880
|
Family ID: |
27561836 |
Appl. No.: |
11/136997 |
Filed: |
May 25, 2005 |
Related U.S. Patent Documents
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Application
Number |
Filing Date |
Patent Number |
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11136997 |
May 25, 2005 |
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10016858 |
Dec 14, 2001 |
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60260182 |
Jan 5, 2001 |
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60260183 |
Jan 5, 2001 |
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60260184 |
Jan 5, 2001 |
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Current U.S.
Class: |
514/182 |
Current CPC
Class: |
A61K 31/56 20130101 |
Class at
Publication: |
514/182 |
International
Class: |
A61K 031/56 |
Foreign Application Data
Date |
Code |
Application Number |
Dec 15, 2000 |
DK |
PA 2000 01890 |
Dec 15, 2000 |
DK |
PA 2000 01891 |
Dec 15, 2000 |
DK |
PA 2000 01892 |
Claims
1. A method for treating atrophic vaginitis in a patient in need of
such treatment, said method comprising administering vaginally to
said patient an amount of about 10 .mu.g estradiol, wherein
administration of said amount occurs once or twice per week.
2. A method according to claim 1, wherein the patient is a
menopausal or post-menopausal woman.
3. A method according to claim 1, wherein no progestogen is
administered.
4. A method according to claim 1, wherein said at least once-weekly
administration occurs over a time period of more than two
weeks.
5. A method according to claim 4, wherein said period of time is
more than 3 months.
6. A method according to claim 1, wherein said estradiol is
administered in tablet form and wherein each tablet comprises, in
addition to estradiol or a therapeutically equivalent amount of a
salt thereof, hypromellose, lactose monohydrate, maize starch, and
magnesium stearate.
7. A method according to claim 6, wherein said tablet comprises
about 60-80% w/w hypromellose; 20-25% w/w lactose; about 5-15%
maize starch; and about 0.2-1.5% magnesium stearate.
8. A method for treating atrophic vaginitis in a patient in need of
such treatment, said method comprising administering vaginally to
said patient a tablet comprising hypromellose, lactose monohydrate,
maize starch, and magnesium stearate.
9. A method according to claim 8, wherein said tablet comprises
about 60-80% w/w hypromellose; 20-25% w/w lactose; about 5-15%
maize starch; and about 0.2-1.5% magnesium stearate.
Description
CROSS-REFERENCE TO RELATED PATENT APPLICATIONS
[0001] This patent application is a continuation of copending U.S.
patent application Ser. No. 10/016,858, filed Dec. 14, 2001. This
patent application claims the benefit of U.S. Provisional Patent
Application No. 60/260,182 filed Jan. 5, 2001, U.S. Provisional
Patent Application 60/260,183 filed Jan. 5, 2001, and U.S.
Provisional Patent Application 60/260,184 filed Jan. 5, 2001 and
Danish Patent Application Nos. PA 2000 01890, filed Dec. 15, 2000,
PA 2000 01891, filed Dec. 15, 2000, and PA 2000 01892, filed Dec.
15, 2000.
[0002] The present invention relates to a composition containing
oestrogen, which is to be administered vaginally.
BACKGROUND OF THIS INVENTION
[0003] Vaginal atrophy can occur in postmenopausal woman and
estrogen deprived women who actually do not need any systemic
hormone replacement therapy but just local therapy. Consequently,
local, topical treatment is preferred in order to avoid the
systemic side effects due to long-lasting oestrogen therapy. Local
therapy for this purpose has been studied for a long period of time
and the hormone has been administered as creams, gels, and silastic
rings.
[0004] About every second postmenopausal women will experience
urogenital discomfort associated with estrogen deficiency. Previous
studies have shown that although many of these women use an oral
hormone replacement therapy, urogenital symptoms persist.
[0005] A composition commonly used is Vagifem.RTM. marketed by Novo
Nordisk A/S. Vagifem is developed to treat estrogen
deficiency-deprived atrophic vaginitis. Vagifem is a small tablet
containing 25 .mu.g 17.beta.-estradiol. For example, reference can
be made to Maturitas 14 (1991), 23-31, where the women initially
received 25 .mu.g estradiol for 2 weeks and, thereafter, 25 .mu.g
estradiol once weekly or twice weekly. A usual treatment is one
tablet of Vagifem containing 25 .mu.g estradiol daily for the first
2 weeks of treatment and, thereafter, one tablet twice a week.
[0006] Conveniently, Vagifem is administered by placing a tablet at
the top of a slim-line pencil-like disposable applicator. By
introducing the applicator to the vagina, the Vagifem tablet will,
due to the adhesive characteristics of Vagifem, stay in the
vagina.
[0007] A pharmaceutical medicament for local, essentially
non-systemic, treatment of vaginal dryness, in particular in the
menopausal woman, characterized by a unit galenical formulation
comprising a natural estrogen selected from the group consisting of
17.beta.-estradiol and its salts and its derivatives in solution or
in suspension in a lipophilic agent, with an estrogen content which
corresponds to an equivalent unit dose of at most 15 .mu.g,
preferably less than 10 .mu.g, of 17.beta.-estradiol, a hydrophilic
gel-forming bioadhesive agent, a gelling agent for the lipophilic
agent, and a hydrodispersible agent, is described in U.S. Pat. No.
6,060,077. Hence, according to the 6,060,077 specification,
17.beta.-estradiol and its salts and its derivatives are in
solution or in suspension. Consequently, it cannot be a tablet.
SUMMARY OF THIS INVENTION
[0008] One object of this invention is to furnish a hormone
composition which gives a clinical effect on vaginal symptoms which
is as good as that obtained by administration of Vagifem twice
weekly.
[0009] A further object of this invention is to furnish a hormone
composition furnishing no or only inferior systemic absorption.
[0010] A still further object of this invention is to furnish a
hormone composition furnishing significant improvement in the
vaginal mucosa.
[0011] A still further object of this invention is to furnish a
hormone composition furnishing no or only inferior systemic
effect.
[0012] A still further object of this invention is to furnish a
hormone composition furnishing low absorption of estrogen.
[0013] A still further object of this invention is to furnish a
hormone composition furnishing low serum concentration of
estradiol.
[0014] A still further object of this invention is to furnish a
hormone composition furnishing no or only inferior accumulation of
circulating estradiol.
[0015] A still further object of this invention is to furnish a
hormone composition furnishing positive effects on an atrophic
vaginal epithelum.
[0016] A still further object of this invention is to furnish a
hormone composition furnishing complete or substantial vaginal
maturation.
[0017] A still further object of this invention is to furnish a
hormone composition furnishing a reduced risk of osteporosis.
[0018] A still further object of this invention is to furnish a
hormone composition furnishing increases in percentage of
superficial vaginal cells.
[0019] A still further object of this invention is to furnish a
hormone composition which can be used for the treatment of atrophic
vaginitis.
[0020] A still further object of this invention is to furnish a
hormone composition furnishing a vaginal pH value below bout
5.5.
[0021] A very specific object of this invention is to furnish a
hormone composition furnishing all or most of the following
characteristics: Relief of vaginal symptoms, improved urogenital
atrophy, decreased vaginal pH, and improved cytologic maturation of
both the vaginal and urethral mucosa.
DETAILED DESCRIPTION OF THIS INVENTION
[0022] The vaginal symptoms treated by the use according to the
present invention are dryness, soreness, irritation, and
dyspareunia. The urogenital health is characterized by secretions,
epithelial integrity, surface thickness, and the pH value of the
vagina.
[0023] Surprisingly, it has been found that the use according to
the claims below have pharmaceutical and clinical advantages
compared with the known uses of similar compositions.
[0024] It is often recommended to precede the use according to the
claims below with a treatment with a somewhat higher dosage of an
estrogen, for example, estradiol. Such a treatment is herein
designated a pre-treatment. In a preferred embodiment, this
pre-treatment is the daily treatment with the same dose as that
used for a bi-weekly use according to the claims below.
[0025] The present invention relates to use of an oestrogen in the
manufacture of a composition containing oestrogen for the treatment
of atrophic vaginitis in woman, by administering weekly an amount
of about 10 to about 30 .mu.g estradiol to a woman. According to a
preferred embodiment, this invention relates to the use wherein the
women treated is menopausal or post-menopausal women. According to
a further preferred embodiment, this invention relates to the use
wherein weekly an amount of about 15 to about 25 .mu.g estradiol is
administered. According to a further preferred embodiment, this
invention relates to the use wherein daily about 1.5 to about 4
.mu.g estradiol is administered. According to a further preferred
embodiment, this invention relates to the use wherein daily about 2
to about 3 .mu.g estradiol is administered. According to a further
preferred embodiment, this invention relates to the use wherein
twice weekly about 5 to about 15 .mu.g estradiol is administered.
According to a further preferred embodiment, this invention relates
to the use wherein twice weekly about 7 to about 13 .mu.g estradiol
is administered. According to a further preferred embodiment, this
invention relates to the use wherein twice weekly about 9 to about
11 .mu.g estradiol is administered. According to a further
preferred embodiment, this invention relates to the use wherein no
progestogen is administered. According to a further preferred
embodiment, this invention relates to the use wherein the
composition is to be administered vaginally. According to a further
preferred embodiment, this invention relates to the use wherein it
is used for a period of time of more than 2 weeks, preferably more
than 1 month, more preferred more than 2 months, and even more
preferred more than 3 months. According to a further preferred
embodiment, this invention relates to the use wherein
administration is performed using a tablet. Furthermore, the
present invention relates to a method of treating atrophic
vaginitis, comprising administering a composition as described in
any of the previous use claims.
[0026] The compositions used according to this invention may be
prepared analogously to the preparation of similar compositions,
for example, Vagifem. The compositions used according to this
invention may contain any constituent used or suggest to be used in
similar compositions. The compositions used according to this
invention may be administered analogously with the administration
of similar compositions. All these aspects are known to the skilled
art worker.
[0027] According to a preferred embodiment of this invention, the
composition dealt with herein is a tablet. According to a preferred
embodiment, the composition dealt with herein consists of about 60%
through about 80% hypromellose (or another convenient matrix
former), about 20% through about 25% lactose (or another convenient
filler), about 5% through about 15% maize starch (or another
convenient filler), about 0.2% through about 1.5% magnesium
stearate (or another convenient lubricant) and about 0.2% through
about 5% film-coating, as well as E2. In a more preferred
embodiment, the composition consists of about 65% through about 70%
hypromellose (or another convenient matrix former), about 20%
through about 24% lactose (or another convenient filler), about 8%
through about 12% maize starch (or another convenient filler),
about 0.3% through about 1.3% magnesium stearate (or another
convenient lubricant) and about 0.3% through about 3% film-coating,
as well as E2. In an even more preferred embodiment, the
composition consists of about 67% hypromellose, about 22% lactose,
about 10% maize starch, about 0.5% magnesium stearate and about 1%
film-coating. According to a preferred embodiment of this
invention, each tablet contains, in addition to the active
material, about 53.7 mg hypromellose, about 17.9 mg lactose
monohydrate, about 8 mg maize starch, about 0.4 mg magnesium
stearate and the film-coating consisting of about 0.5 mg
hypromellose and about 0.06 mg macrogel 6000 (polyethylene glycol
6000 NF).
[0028] On a dry basis. In the final tablets, the content of water
is preferably below 10%, more preferred below 7%. All percentages
ratios given here are per weight basis.
[0029] One way of preparing the tablets is via the following steps:
Suspension of estradiol, granulation, blending, compression,
preparation of film-coating solution, and film-coating.
[0030] The present invention is further illustrated by the
following examples which, however, are not to be construed as
limiting the scope of protection. The features disclosed in the
foregoing description and in the following examples may, in any
combination thereof, be material for realizing the invention in
diverse forms thereof. Especially, interesting and surprising
effects are dealt with and described in examples 2 & 3.
EXAMPLE 1
[0031] 58 postmenopausal women were treated with tablets containing
either 10 or 25 .mu.g 17.beta.-estradiol. The women inserted 1
tablet intravaginally, once daily for the initial 2 weeks of the
study and then twice per week (Sunday & Thursday) for the
following 10 weeks. Hence, some of the women only received tablets
containing 10 .mu.g 17.beta.-estradiol and the remaining women only
received tablets containing 25 .mu.g 17.beta.-estradiol. The
estradiol profile when administering 25 or 10 .mu.g
17.beta.-estradiol was similar after the first dose (zero weeks of
treatment) and after the above continuous treatment with 25 or 10
.mu.g 17.beta.-estradiol twice weekly for 10 weeks.
EXAMPLE 2
[0032] Treatment of atrophic vaginitis according to the present
invention with low-dose 17.beta.-estradiol tablets results in
consistent, low absorption of estradiol without accumulation.
[0033] Objectives:
[0034] The vaginal absorption of 17.beta.-estradiol (hereinafter
designated E2) was evaluated and two low doses E2 (25 .mu.g and 10
.mu.g) were compared in postmenopausal women with atrophic
vaginitis.
[0035] Design:
[0036] In a double-blind, randomized, parallel-group study, 58
postmenopausal women were treated with either 25 or 10 .mu.g E2 for
12 weeks. Serum E2 and follicle stimulating hormone (hereinafter
designated FSH) concentrations were measured throughout the study
at specified intervals. The area under the curve, maximal
concentration, and time to maximal concentration were determined
for serum E2 concentrations. Maturation values of vaginal mucosal
cells were assessed as an indicator of changes in the condition of
the vaginal mucosa in response to treatment.
[0037] Results:
[0038] For both treatment groups, the E2 profiles were similar at
weeks 0 and 12. The mean E2 concentrations, areas under the curve,
and maximal concentrations were higher in the 25-.mu.g E2 group
than in the 10-.mu.g E2 group. For the majority of patients in each
treatment group, the areas under the curve remained below 600
.mu.g.multidot.hr/mL at each time point, and the mean FSH
concentrations were in the normal postmenopausal range. Patients in
each treatment group showed significant improvement (P.ltoreq.0.01)
in the condition of the vaginal mucosa.
[0039] Conclusion:
[0040] Treatment with either 25- or 10-.mu.g E2 vaginal tablets
resulted in improvements in the vaginal mucosa and low absorption
of estrogen without the systemic effects often associated with ERT.
After 12 weeks of therapy for atrophic vaginitis, absorption
patterns remained consistent, and patients did not experience an
accumulation of circulating E2.
[0041] Studies have shown that vaginal ERT preparations can result
in rapid and efficient absorption of E2 into systemic circulation.
However, low-dose preparations that contain 10 and 25 .mu.g E2
effectively relieve the symptoms of atrophic vaginitis without
unwanted systemic side effects. A low-dose (25 .mu.g) E2 vaginal
tablet (Vagifem.RTM.; Novo Nordisk, Denmark) has been developed to
treat estrogen deficiency-derived atrophic vaginitis. These vaginal
tablets contain a film-coated hydrophilic cellulose matrix that
adheres well to the vaginal mucosa and hydrates slowly to provide a
controlled release of E2. They are designed to provide
estrogenization of the vaginal mucosa while preventing significant
increases in serum estrogen concentrations. In this study, the
vaginal absorption of E2 was evaluated and two low doses of E2 (25
.mu.g and 10 .mu.g) were compared in postmenopausal women with
atrophic vaginitis.
MATERIALS AND METHODS
[0042] This single-center, randomized, double-blind, parallel-group
study was conducted in Atlanta, Ga. The study was approved by the
appropriate institutional review board, and written informed
consent was obtained from each patient. The study was conducted in
compliance with the Declaration of Helsinki of 1975, revised in
1983.
[0043] In this study, generally healthy, postmenopausal women
(hysterectomized or nonhysterectomized), aged 45 years or older,
were enrolled. Patients had no more than 5% superficial cells, as
assessed by vaginal cytology evaluation, and serum E2
concentrations no greater than 20 pg/mL. Nonhysterectomized
patients had endometrial thicknesses no greater than 4 mm, as
determined by pelvic ultrasound. Patients with known or suspected
history of breast cancer or other hormone-dependent tumors, acute
thrombophlebitis or thromboembolic disorders associated with
previous estrogen use, or vaginal infection requiring further
treatment (at baseline) were excluded from the study, as were
patients with genital bleeding of unknown etiology (within 12
months prior to screening). Patients were not to have used any type
of vaginal, oral, or vulvar preparations within 7 days prior to
screening; any exogenous corticosteroid or sex hormones within 8
weeks prior to baseline; any investigational new drug within the
past 30 days; or diethylstilbestrol.
[0044] After the screening visit, patients received no study
treatment during the 4-week run-in period prior to the baseline
visit. At the baseline visit, patients were randomized to receive
vaginal tablets containing either 25 or 10 .mu.g E2 on a 1:1 basis
using a computer-generated scheme. The vaginal tablets were
identical in appearance. Patients inserted 1 tablet intravaginally,
once daily for the initial 2 weeks of the study and then twice per
week (Sunday and Thursday) for the remaining 10 weeks. Patients
were instructed to use their medication at a consistent time each
day, preferably in the morning. After the baseline visit, patients
returned to the clinic at weeks 1, 2, 4, 8, and 12 for measurements
of serum E2 and FSH, as well as assessments of vaginal
cytology.
[0045] Upon presentation to the clinic for each visit, a vaginal
cytology specimen was obtained. Patients then inserted the tablets.
Blood samples were drawn 30 minutes before tablet insertion, and at
1, 2, 4, 5, 6, 7, 8, 10, 12, and 24 hours after insertion to
determine the serum E2 concentration via radioimmunoassay. The
blood samples obtained at 30 minutes before insertion, and at 6,
12, and 24 hours after insertion were also used to determine the
FSH concentration via immunoradiometric assay.
[0046] The maturation value of vaginal mucosal cells was calculated
from the percentages of parabasal, intermediate, and superficial
cells according to the following equation:
maturation value=0.times.[parabasal cells,
%]+0.5.times.[intermediate cells, %]+1.0.times.[superficial cells,
%]
[0047] The pharmacokinetic parameters of area under the
concentration-time curve from 30 minutes before tablet insertion to
24 hours after tablet insertion, maximal concentration, and time to
maximal concentration were determined for serum concentrations of
E2. Data for area under the curve and maximal concentration were
converted to a logarithmic scale, and changes from first dose (at
the baseline visit) in the logarithmic values were estimated using
95% confidence intervals derived from paired t-tests. Differences
between treatment groups in the degree of absorption of E2 were
determined using 95% confidence intervals derived from two sample
t-tests based on the observed mean values of the logarithms of area
under the curve and maximal concentration. Differences within
treatment groups in FSH concentration were determined using the
Wilcoxon signed rank test based on changes from baseline in mean
concentrations at weeks 2 and 12. Mean concentrations were defined
as the average concentrations obtained at 30 minutes before tablet
insertion and 6, 12, and 24 hours after insertion. Baseline
concentrations for E2 and FSH were defined as the values observed
at 30 minutes before tablet insertion at the baseline visit.
[0048] This manuscript presents data for the evaluable patient
population, which was defined as those patients who had serum E2
concentrations below 20 .mu.g/mL at baseline and who had complete
data available at the baseline visit and weeks 2 and 12.
RESULTS
[0049] A total of 58 women were treated with vaginal tablets
containing either 25 .mu.g E2 (28 women) or 10 .mu.g E2 (30 women).
Ten women discontinued prematurely from the study. The evaluable
patient population consisted of 42 women; 19 women received 25
.mu.g E2, and 23 women received 10 .mu.g E2. Demographic and
baseline characteristics for the evaluable patient population are
presented in Table 1. Patient characteristics were similar between
treatment groups, with the exception of percentage of parabasal
cells at baseline, which was significantly lower for patients in
the 25-.mu.g E2 group compared to those in the 10-.mu.g E2 group
(P=0.027, t-test).
[0050] The 24-hour concentration profiles for serum E2 at weeks 0
and 12 are presented in FIGS. 1 and 2, respectively, and the
associated pharmacokinetic characteristics are presented in Table
2. At weeks 0 and 12, the serum E2 profiles were similar within
each treatment group. The serum E2 concentrations, as well as the
corresponding mean area under the curve and maximal concentration,
were higher for patients who received 25 .mu.g E2 than for patients
who received 10 .mu.g E2. The average serum E2 concentrations over
24 hours were also higher in the 25-.mu.g E2 group than in the
10-.mu.g E2 group.
[0051] A comparison between the areas under the curve for serum E2
at weeks 0 and 12 is presented in FIG. 3. The majority of patients
in each treatment group had areas under the curve below 600
pg.multidot.hr/mL at both time points (14 patients [74%] and 22
patients [96%] in the 25- and 10-.mu.g E2 groups, respectively). A
comparison between area under the curve for serum E2 and mean FSH
concentration at week 12 is presented in FIG. 4. At week 12, the
majority of patients in each treatment group had mean FSH
concentrations in the normal postmenopausal range (at least 35
pg/mL); 3 patients in the 25-.mu.g E2 group had mean FSH
concentrations below 35 pg/mL.
[0052] The mean maturation value and mean change from baseline in
maturation value are presented in Table 3. In each treatment group,
patients experienced a significant increase in maturation value
over baseline values (P.ltoreq.0.001 at weeks 1 and 2, and
P.ltoreq.0.01 at week 12; 2-tailed, paired t-test). At all time
points, mean maturation values and mean changes from baseline in
maturation value were comparable between treatment groups. A
comparison between the area under the curve for serum E2 and the
maturation value at week 12 is presented in FIG. 5. The majority of
patients in each treatment group (13 patients [68%] and 14 patients
[64%] in the 25- and 10-.mu.g E2 groups, respectively) showed
increases in maturation values from the corresponding baseline
values (53.4 and 51.0 in the 25- and 10-.mu.g E2 groups,
respectively).
CONCLUSIONS
[0053] The optimum intravaginal therapy will provide consistent
estrogen absorption with adequate relief of vaginal symptoms
without systemic absorption and the associated side effects. The
low-dose vaginal tablets used in this study meet these
criteria.
[0054] This study examined the systemic absorption of E2 in
patients who received treatment with either 25- or 10-.mu.g E2
vaginal tablets for 12 weeks. The majority of patients in each
treatment group (74% in the 25-.mu.g E2 group and 96% in the
10-.mu.g E2 group) experienced low systemic absorption of E2 at
both the beginning and end of the 12-week treatment period, as
indicated by areas under the serum E2 concentration curve below 600
pg.multidot.hr/mL at each time point. Of the 6 remaining patients,
4 who did experience higher E2 absorption at week 12 also had areas
under the curve greater than 600 pg.multidot.hr/mL at both week 0
and 12, suggesting that these patients were characteristically high
E2 absorbers. It is likely that these patients would experience
greater absorption of E2 as a result of any ERT.
[0055] The 24-hour serum E2 profiles at weeks 0 and 12 were similar
for each treatment group, again indicating that overall, women had
consistent E2 absorption patterns at the beginning and end of the
treatment period. The average E2 concentrations at each time point
were within the normal postmenopausal range (normal postmenopausal
range for E2 concentration: .ltoreq.40 pg/mL). The promising
results from this study demonstrated consistent E2 absorption over
12 weeks of treatment.
[0056] In this study, after 12 weeks of treatment with either 25 or
10 .mu.g E2, FSH concentrations were rarely suppressed to
premenopausal levels, suggesting that the observed increase in
serum E2 concentration is not associated with clinically
significant systemic E2 potency. Both the 25- and 10-.mu.g E2 dose
levels demonstrated positive effects on an atrophic vaginal
epithelium while maintaining low serum concentrations of E2. The
improvement in vaginal health may be due to direct perfusion and/or
lymphatic absorption of the local E2 through the vaginal
epithelium. In this study, vaginal maturity was measured
exclusively with the maturation value. Since the vaginal response
is likely due to enhanced glycogenization and acidification of the
vagina, monitoring the vaginal pH would provide another useful
measure of vaginal health. Vaginal maturation with low
concentrations of circulating E2 is a primary treatment goal of
local vaginal ERT. Reduced risks of osteoporosis in postmenopausal
women have also been observed. These benefits likely rely on the
concentration of circulating E2 added to the endogenous production
of E2 in bone, which is especially true in older, natural
postmenopausal women. Since the average serum E2 concentrations
were higher for patients who recieved 25 .mu.g E2 than for those
who received 10 .mu.g E2, it is possible that patients who receive
the lower dose may derive additional benefits because of very low
likelihood of any systemic effect.
1TABLE 1 Demographic and Baseline Characteristics (Evaluable
Patients) Treatment group 25 .mu.g E2 10 .mu.g E2 Characteristic (N
= 19) (N = 23) Age (yr).sup.a 52.1 .+-. 5.6 (45-63) 54.8 .+-. 5.1
(48-69) Race Caucasian 16 (84.2%) 18 (78.3%) Other 3 (15.8%) 5
(21.7%) Time since last 10.7 .+-. 7.6 (1-25) 14.3 .+-. 8.7 (1-32)
menses (yr).sup.a Hysterectomized Yes 12 (63.2%) 17 (73.9%) No 7
(36.8%) 6 (26.1%) E2 concentration at 7.0 .+-. 2.8 (3-13) 7.6 .+-.
3.7 (2-18) screening (pg/mL).sup.a Vaginal cytology at screening
Parabasal cells (%).sup.a 1.9 .+-. 2.5.sup.b (0-7) 8.4 .+-.
12.9.sup.b (0-48) Intermediate cells (%).sup.a 95.2 .+-. 7.8
(65-100) 90.1 .+-. 12.4 (51-100) Superficial cells (%).sup.a 2.9
.+-. 8.0 (0-35) 1.5 .+-. 1.7 (0-6) SD = standard deviation; E2 =
estradiol .sup.aData presented as mean .+-. SD (range).
.sup.bStatistically significant; P = .027 (t-test)
[0057]
2TABLE 2 Pharmacokinetic Parameters for 24-Hour Serum Estradiol
Profiles (Evaluable Patients) Treatment group Pharmacokinetic 25
.mu.g E2 10 .mu.g E2 Time point characteristic (N = 19) (N = 23)
Week 0 Area under the curve 538 .+-. 265 349 .+-. 107 (pg
.multidot. hr/mL).sup.a Maximal concentration 51 .+-. 34 35 .+-. 17
(pg/mL).sup.a Time to maximal 15 .+-. 9 9 .+-. 5 concentration
(hr).sup.a Serum concentration 22 15 over 24 hours (pg/mL) Week 12
Area under the curve 563 .+-. 341 264 .+-. 120 (pg .multidot.
hr/mL).sup.a Maximal concentration 49 .+-. 27 22 .+-. 17
(pg/mL).sup.a Time to maximal 13 .+-. 6 10 .+-. 8 concentration
(hr).sup.a Serum concentration 23 11 over 24 hours (pg/mL) E2 =
estradiol; SD = standard deviation .sup.aData presented as mean
.+-. SD.
[0058]
3TABLE 3 Mean Maturation Values and Changes From Baseline (All
Patients) Time Treatment group point N 25 .mu.g E2 N 10 .mu.g E2
Week 0 Mean .+-. SD 25 52.4 .+-. 7.1 28 51.0 .+-. 6.2 Week 12 Mean
.+-. SD 20 58.4 .+-. 7.5 23 62.2 .+-. 15.7 Mean change .+-. SD 20
.sup. 7.0 .+-. 8.7.sup.b 23 .sup. 11.2 .+-. 17.8.sup.b SD =
standard deviation .sup.aStatistically significant; P .ltoreq. .001
(2-tailed, paired t-test) .sup.bStatistically significant; P
.ltoreq. .01 (2-tailed, paired t-test)
EXAMPLE 3
[0059] Treatment according to the present invention with low-dose
17.beta.-estradiol tablets relieves vaginal symptoms, improves
urogenital atrophy (vaginal health), and increases maturation of
the vaginal and urethral epithelia (mucosa) without abnormal
endometrial growth.
[0060] Objectives:
[0061] Vaginal tablets containing 25 or 10 .mu.g 17.beta.-estradiol
(herein designated E2) or placebo were evaluated and compared in
postmenopausal women with atrophic vaginitis.
[0062] Methods:
[0063] In a multicenter, randomized, double-blind,
placebo-controlled, parallel-group study, 230 post-menopausal women
received treatment with 25 or 10 .mu.g E2 or placebo for 12 weeks.
Efficacy was measured with composite scores of vaginal symptoms
(dryness, soreness, and irritation) and vaginal health (secretions,
epithelial integrity, surface thickness, and pH). Vaginal and
urethral cytology analyses were also performed, and the vaginal
maturation value was determined. Safety assessments included
endometrial biopsies.
[0064] Results:
[0065] Greater improvements in composite scores for vaginal
symptoms and vaginal health characteristics were reported for
patients in the active treatment groups than in the placebo group.
Significantly greater improvements were reported at Weeks 7 and 12
(P.ltoreq.0.05). At Week 12, over 75% of patients in the active
treatment groups had vaginal pH values below 5.5 compared to
approximately 40% of patients in the placebo group. Both vaginal
and urethral cytology analyses indicated larger increases in
percentages of superficial cells in the active treatment groups
than in the placebo group. Correspondingly, increases in vaginal
maturation value were higher in the active treatment groups than in
the placebo group. One patient who received 25 .mu.g E2 had an
abnormal biopsy result.
[0066] Conclusions:
[0067] Both the 25- and 10-.mu.g E2 vaginal tablets provided relief
of vaginal symptoms, improved vaginal health, and increased
maturation of both the vaginal and urethral mucosa without abnormal
endometrial growth.
INTRODUCTION
[0068] As endogenous estrogen production declines during menopause,
the vagina and other estrogen-dependent tissues gradually undergo
atrophic changes. The loss of estrogen-influenced cellular
maturation results in a condition identified as atrophic vaginitis.
The symptoms of atrophic vaginitis include dryness, soreness,
irritation, and dyspareunia. Additionally, the vaginal epithelium
becomes more susceptible to infection and secondary inflammation.
Oral estrogen therapy has been associated with metabolic side
effects as well as breast and endometrial hyperplasia.
[0069] Novo Nordisk has developed Vagifem.TM., a low-dose estrogen
vaginal tablet that contains 25 .mu.g E2 in a hydrophilic
cellulose-based matrix. Pharmacokinetic studies of Vagifem.TM. have
shown that in an atrophic vaginal epithelium, vaginally
administered E2 is readily absorbed, but after normalization and
maturation of the epithelium, E2 absorption is significantly
reduced.
[0070] This study evaluated and compared the efficacy and safety of
vaginal tablets containing 25 or 10 .mu.g E2 or placebo during 12
weeks of therapy for vaginal atrophy.
METHODS AND MATERIALS
[0071] This phase III, multicenter, randomized, double-blind,
placebo-controlled, parallel-group study was conducted at 9 centers
in the United States. The study was approved by the appropriate
institutional review boards, and informed consent was obtained from
each patient prior to beginning study procedures. The study was
conducted in compliance with the Declaration of Helsinki of 1975,
revised in 1983.
[0072] Women at least 45 years of age or older with
moderate-to-severe vaginal dryness and soreness were enrolled. All
patients were required to have serum E2 concentrations of 20 pg/mL
or less and to have no more than 5% superficial vaginal cells.
Patients with intact uteri were also required to be at least 12
months past natural menopause with an endometrial thickness of 5 mm
or less.
[0073] Patients with creatinine levels greater than 1.4 mg/dL,
bilirubin levels greater than 1.2 mg/dL, aspartate transaminase
levels greater than 50 U/L, or hemoglobin levels less than 11.5
g/dL were excluded from the study. Patients with a known or
suspected history of breast carcinoma, hormone-dependent tumor,
genital bleeding of unknown etiology, acute thrombophlebitis or
thromboembolic disorder associated with estrogen use, vaginal
infection requiring treatment, allergy to the test drug or its
constituents, or any serious disease or chronic condition that
could interfere with study compliance were also excluded from the
study. The use of an investigational drug within the 30 days
preceding screening, any homeopathic preparation within the 7 days
preceding study drug initiation, any exogenous corticosteroid or
sex hormones within the 8 weeks preceding study drug initiation, or
diethylstilbestrol was prohibited.
[0074] The purpose of this study was to compare 25 and 10 .mu.g E2
and placebo. Using a computer-generated randomization scheme,
subjects (patients) were randomized using a 2:2:1 ratio to receive
vaginal tablets that contained 25 .mu.g E2, 10 .mu.g E2, or
placebo. All vaginal tablets were identical in appearance. Patients
inserted 1 tablet daily for 14 days. Thereafter, patients inserted
1 tablet twice per week (Sunday and Thursday) for the remainder of
the trial. Patients were to insert the tablets at the same time
each day (preferably at bedtime). Patients were evaluated for
efficacy and safety at Week--4 (screening), Week 0 (baseline), and
Weeks 2, 7, and 12.
[0075] Efficacy assessments included patient ratings of atrophic
vaginitis symptoms, investigator ratings of vaginal health, and
vaginal and urethral cytology. Patients used intensity ratings of
none, mild, moderate, or severe to evaluate atrophic vaginitis
symptoms (dryness, soreness, irritation, dyspareunia, and vaginal
discharge). Intensity ratings were assigned ascending scores from 0
(none) to 3 (severe) for analysis. A composite score for atrophic
vaginitis symptoms was defined as the average of the individual
symptom scores for dryness, soreness, and irritation. This
composite score did not include scores for dyspareunia (which was
not evaluated by all patients) or vaginal discharge (which was
rated as none or mild by the majority of patients). The composite
score and the change from baseline for the composite score were
examined at each time point. Differences within and between
treatment groups were analyzed using an analysis of variance
(ANOVA).
[0076] Investigators used a severity scale of none, mild, moderate,
or severe to assess vaginal health characteristics (secretions,
epithelial integrity, surface thickness, color, and pH). Severity
categories were assigned ascending scores from 0 (none) to 3
(severe) for analysis. To avoid multiple endpoint issues, composite
scores were defined. A composite score for vaginal health was
defined as the average of the individual vaginal health
characteristic scores. The composite score and the change from
baseline for the composite score were examined at each time point.
Differences within and between treatment groups were analyzed using
an analysis of variance (ANOVA).
[0077] Vaginal and urethral cell samples were harvested and
analyzed by independent cytologists to determine the percentages of
parabasal, intermediate, and superficial cells. Maturation values
were calculated according to the following equation:
maturation value=1.0.times.[superficial cells,
%]+0.5.times.[intermediate cells, %]
[0078] Endometrial biopsies were performed at the end of the study
in patients with intact uteri. The number of patients with abnormal
biopsies was compared between treatment groups.
RESULTS
[0079] A total of 91 women received 25 .mu.g E2, 92 women received
10 .mu.g E2, and 47 women received placebo. Demographic and
baseline characteristics did not differ significantly between
treatment groups, with the exception of race (Table 4). The
percentage of nonwhite patients was significantly lower in the
25-.mu.g E2 group than in the placebo group (P=0.026,
Cochran-Mantel-Haenszel test). Nine patients (9.9%) in the 25-.mu.g
E2 group, 18 patients (19.6%) in the 10-.mu.g E2 group, and 8
patients (17.0%) in the placebo group discontinued prematurely from
the study.
[0080] The vaginal symptom composite score profiles between Weeks 0
and 12 are presented in FIG. 6. At Week 0, the vaginal symptom
composite scores measured approximately 1.9 in each treatment
group. At Weeks 2, 7, and 12, vaginal symptom composite scores were
significantly lower than the corresponding baseline values for each
treatment group (P.ltoreq.0.001; two-tailed paired t-test). In the
active treatment groups (the 25- and 10-.mu.g E2 groups), vaginal
symptom composite scores continued to decrease after Week 0 and
measured approximately 0.5 and 0.6 at Week 12, respectively. In
contrast, in the placebo group, vaginal symptom scores remained
nearly constant after Week 0 and measured approximately 1.1. At
Weeks 7 and 12, the differences from baseline observed in the
active treatment groups were significantly larger than those
observed in the placebo group (P.ltoreq.0.01 and P.ltoreq.0.05 in
the 25- and 10-.mu.g E2 groups, respectively; two-tailed linear
model analysis).
[0081] The urogenital (vaginal) health composite score profiles
between Weeks 0 and 12 are presented in FIG. 7. At Week 0, the
vaginal health composite scores measured approximately 1.7 in each
treatment group. At Weeks 2, 7, and 12, vaginal health composite
scores were significantly lower than the corresponding baseline
values for each treatment group (P.ltoreq.0.01; two-tailed paired
t-test). At Weeks 2, 7, and 12, the decreases in vaginal health
composite scores observed in the active treatment groups were
significantly larger than those observed in the placebo group
(P.ltoreq.0.001; two-tailed linear model analysis). At Week 7, the
decrease in vaginal health composite score was significantly larger
in the 25-.mu.g E2 group than in the 10-.mu.g E2 (P=0.004,
two-tailed linear model analysis).
[0082] The number and percentage of patients with vaginal pH values
below 5.5 at Weeks 0, 2, 7, and 12 are presented in Table 5. At
Week 0, approximately 35% of patients in each treatment group had
vaginal pH values below 5.5. At Weeks 2, 7, and 12, the percentage
of patients with vaginal pH values below 5.5 increased from the
baseline percentages for each treatment group. These increases were
significantly greater for patients in the active treatment groups
than in the placebo group (P.ltoreq.0.05; two-tailed linear model
analysis). At Week 12, over 75% of patients in the active treatment
groups and approximately 40% of patients in the placebo group had
vaginal pH values below 5.5.
[0083] The percentage of superficial cells from vaginal cytology
analysis at Weeks 0, 2, 7, and 12 are presented in FIG. 8. At all
time points after Week 0, subjects in the active treatment groups
showed either significant increases (P.ltoreq.0.05) or trends
toward increases in the percentage of superficial cells compared
with subjects in the placebo group. These increases are presented
in Table 7.
[0084] The maturation values at Weeks 0 through 12 are presented in
FIG. 9. At Week 0, the maturation values measured approximately 45%
in each treatment group. At each time point, the maturation values
were significantly higher than the corresponding baseline values
for each treatment group (P.ltoreq.0.01; two-tailed paired t-test).
The increases from baseline values were larger in the active
treatment groups than in the placebo group. At Week 12, the
maturation values measured approximately 60% in the active
treatment groups and approximately 55% in the placebo group. At
Weeks 2 and 7, the increases in maturation values observed in the
25-.mu.g E2 group were significantly larger than those observed in
the placebo group (P.ltoreq.0.05; two-tailed linear model
analysis). At Week 2, the increase in maturation value observed in
the 10-.mu.g E2 group was significantly larger than that observed
in the placebo group (P=0.001; two-tailed linear model
analysis).
[0085] The percentage superficial cells from urethral cytology
analysis at Weeks 0, 2, 7, and 12 are presented in FIG. 10. At all
time points after Week 0, subjects in the active treatment groups
showed either significant increases (P.ltoreq.0.05) or trends
toward increases in the percentage of superficial cells compared
with subjects in the placebo group. These increases are presented
in Table 8.
[0086] The percentage of superficial vaginal and urethral cells at
Weeks 0 and 12 are presented in FIGS. 11(a), (b), and (c) for the
25- and 10-.mu.g E2 groups and the placebo group, respectively. At
Week 0, the majority of the subjects in each treatment group had
percentages of both superficial vaginal and urethral cells less
that or equal to 5% (57 subjects [81%], 53 subjects [85%], and 34
subjects [97%] in the 25- and 10-.mu.g E2 groups and the placebo
group, respectively). At Week 12, more subjects in the active
treatment groups that in the placebo group had increases in
percentages of both superficial vaginal and urethral cells (52
subjects [74%], 44 subjects [71%], and 21 subjects [60%] in the 25-
and 10-.mu.g E2 groups and the placebo group, respectively).
[0087] The endometrial biopsy results at Week 12 are presented in
Table 6. Of subjects with biopsies that yielded sufficient tissue,
1 subject in the 25-.mu.g E2 group showed simple hyperplacia
without atypia. However, there was no pretreatment biopsy for
comparison.
[0088] The percentages of parabasal, intermediate, and superficial
cells from vaginal cytology analysis at Weeks 0, 2, 7, and 12 are
presented in FIG. 12. In most cases, the percentages of cells in
each category changed significantly from the corresponding baseline
values (P.ltoreq.0.01; two-tailed paired t-test). At each time
point, the percentage of superficial cells increased. At Weeks 2
and 7, the increases in percentage of superficial cells observed in
the 25-.mu.g E2 group were significantly larger than those observed
in the placebo group (P.ltoreq.0.003; two-tailed linear model
analysis). At Weeks 2 and 12, the differences in percentage of
superficial cells observed in the 10-.mu.g E2 group were
significantly larger than those observed in the placebo group
(P.ltoreq.0.035; two-tailed linear model analysis).
[0089] The percentages of parabasal, intermediate, and superficial
cells from urethral cytology analysis at Weeks 0, 2, 7, and 12 are
presented in FIG. 13. In most cases, the percentages of superficial
and parabasal cells changed significantly from the corresponding
baseline values (P.ltoreq.0.05; two-tailed linear model analysis).
Generally, the percentage of superficial cells increased, and the
percentages of intermediate and parabasal cells decreased. At Weeks
2 and 7, the increases in percentage of superficial cells observed
in the 25-.mu.g E2 group were significantly larger than those
observed in the placebo group (P.ltoreq.0.044; two-tailed linear
model analysis). At Week 2, the increases in percentage of
superficial cells observed in the 10-.mu.g E2 group were
significantly larger than those observed in the placebo group
(P.ltoreq.0.018; two-tailed linear model analysis).
CONCLUSIONS
[0090] In this 12-week study, treatment with either 25- or 10-.mu.g
E2 tablets resulted in greater improvement in vaginal symptoms (as
assessed by the patients) and vaginal health (as assessed by the
investigators) than treatment with placebo. At each time point
after baseline, improvements in the urogenital (vaginal) health
composite scores were significantly greater in the active (25-.mu.g
and 10-.mu.g E2) group than in the placebo group (P.ltoreq.0.01).
At each time point after 2 weeks of treatment, improvements in the
vaginal symptom composite scores were also significantly greater
(P.ltoreq.0.05). Additionally subjects in the active treatment
groups had statistically significant increases (P.ltoreq.0.05) or
trends toward increases in the percentage of superficial vaginal
cells compared with subjects in the placebo group. In this study,
treatment with 25- or 10-.mu.g E2 resulted in comparable
improvements as assessed by both patients and investigators.
[0091] Improvements in the symptoms of atrophic vaginitis become
physically evident and manifest as changes in the vaginal mucosa.
The condition of the vaginal mucosa can be determined through
vaginal cytology measurements and maturation value. In this study,
the percentages of immature parabasal and intermediate cells
decreased, consequently increasing the percentages of more mature
superficial cells in each treatment group. These changes are
reflected in significant increases over baseline values in
maturation value in each treatment group (P.ltoreq.5.01). After 12
weeks of treatment, the maturation values for patients in the 25-
or 10-.mu.g E2 groups were approximately 60%, while the maturation
values for patients in the placebo group were approximately
55%.
[0092] A second clinical measure of vaginal activity is the vaginal
pH, a component of the urogenital (vaginal) health composite score.
As estrogen production declines after menopause, lactobacilli,
which produce lactic acid from vaginal glycogen, disappear from the
vaginal flora and vaginal pH increases. Consequently, higher
vaginal pH values are associated with a lack of estrogen in the
vaginal mucosa. In this study approximately twice as many patients
who received 25 or 10 .mu.g E2 than those who received placebo had
vaginal pH values below 5.5 after 12 weeks of treatment (75% versus
40%, respectively). The results from analysis of vaginal cytology
and pH indicate a positive effect of the 25- and 10-.mu.g E2
vaginal tablets on estrogenation of the vaginal epithelum
(mucosa).
[0093] The lower portions of the vaginal and urinary tracts have
the same embryological origin, and genital tract disorders such as
atrophic vaginitis are often accompanied by atrophic changes in the
urinary tract that may include dysuria, stress incontinence, and
urinary tract infections. Consequently, estrogen therapy may also
have an effect on the urethral epithelium. In this study, the
condition of the urethral epithelium was determined through
urethral cytology. Similar to the vaginal cytology analysis, the
percentages of parabasal cells in the urethral epithelium decreased
and the percentage of superficial cells increased for each
treatment group. Although this study was not designed to further
determine benefits to the urinary tract, this urethral maturation
could be attributed to estrogenation of the urethral mucosa.
[0094] Thus, although the 25-.mu.g E2 vaginal tablets used in this
study appear to positively affect the vaginal and urethral
epithelia, they were not associated with endometrial
abnormalities.
4TABLE 4 Demographic and Baseline Characteristics Treatment group
25 .mu.g E2 10 .mu.g E2 Placebo Characteristic (N = 91) (N = 92) (N
= 47) Age (yr).sup.a 58.3 .+-. 7.4 (46-78) 57.7 .+-. 6.5 (46-79)
57.6 .+-. 4.8 (50-70) Race White 88 (96.7%) 83 (90.2%) 41 (87.2%)
Nonwhite 3 (3.3%).sup.b 9 (9.8%) 6 (12.8%).sup.b Time since last
14.8 .+-. 9.6 (1-40) 13.5 .+-. 7.8 (1-34) 13.6 .+-. 8.1 (1-33)
menses (yr).sup.a Hysterectomized Yes 42 (46.2%) 44 (47.8%) 23
(48.9%) No 49 (53.8%) 48 (52.2%) 24 (51.1%) SD = standard deviation
.sup.aMean .+-. SD (range) .sup.bStatistically significant; P =
.026 (Cochran-Mantel-Haenszel test)
[0095]
5TABLE 5 Number and Percentage of Patients With Vaginal pH Values
Below 5.5 Treatment group 25 .mu.g E2 10 .mu.g E2 Placebo Time
point n/N (%) n/N (%) n/N (%) Week 0 31/90 (34.4) 27/89 (30.3)
17/46 (37.0) Week 2 64/87 (73.6).sup.a 67/84 (79.8).sup.b 21/43
(48.8) Week 7 71/83 (85.5).sup.b,d 57/80 (71.3).sup.c 23/44 (52.3)
Week 12 63/79 (79.7).sup.b 54/71 (76.1).sup.b 15/38 (39.5) A
two-tailed linear model analysis was used to compare treatment
groups at each time point. .sup.aComparison with placebo,
statistically significant; P .ltoreq. .01 .sup.bComparison with
placebo, statistically significant; P .ltoreq. .001
.sup.cComparison with placebo, statistically significant; P
.ltoreq. .05 .sup.dComparison with 10 .mu.g 17 .beta.-E2,
statistically significant; P .ltoreq. .05
[0096]
6TABLE 6 Endometrial Biopsy Results at Week 12 Treatment group 25
.mu.g E2 10 .mu.g E2 Placebo Result (N = 32) (N = 32) (N = 21)
Normal.sup.a 28 (87.5%) 25 (78.1%) 18 (85.7%) Abnormal.sup.b 1
(3.1%) 0 (0.0%) 0 (0.0%) Other.sup.c 3 (9.4%) 7 (21.9%) 3 (14.3%)
.sup.aResults indicative of an atrophic endometrium, weakly
proliferative endometrium, proliferative endometrium, or secretory
endometrium were classified as normal. .sup.bResults indicative of
endometrial hyperplasia (simplex, complex, or atypical) or
carcinoma were classified as abnormal. .sup.cResults indicative of
a menstrual endometrium, mucosal polyps, insufficient tissue, or
other finding were classified as other.
[0097]
7TABLE 7 Mean and mean change from baseline in percentage of
superficial vaginal cells Treatment Group Time 25 .mu.g E2 10 .mu.g
E2 Placebo Point N Mean Change N Mean Change N Mean Change Week 86
4.0 79 3.1 45 4.3 0 Week 85 34.2 30.7.sup.a 76 28.3 25.0.sup.a 42
13.1 8.6 2 Week 80 28.2 23.9.sup.b,c 72 20.4 17.1 41 15.1 10.4 7
Week 75 19.9 15.4 68 20.1 16.9.sup.d 36 13.8 9.0 12 A two-tailed
linear model analysis was used to compare treatment groups at each
time point. .sup.aComparison with placebo, statistically
significant; P .ltoreq. .001 .sup.bComparison with placebo,
statistically significant; P .ltoreq. .01 .sup.cComparison with 10
.mu.g E2, statistically significant; P .ltoreq. .05
.sup.dComparison with placebo, statistically significant; P
.ltoreq. .05
[0098]
8TABLE 8 Mean and mean change from baseline in percentage of
superficial urethral cells Treatment Group Time 25 .mu.g E2 10
.mu.g E2 Placebo Point N Mean Change N Mean Change N Mean Change
Week 86 3.2 83 2.5 42 3.0 0 Week 83 21.9 19.2.sup.a,b 79 16.7
14.1.sup.c 34 6.5 3.3 2 Week 77 17.6 14.2.sup.d 70 13.5 10.7 38 8.6
5.5 7 Week 70 11.2 7.5 64 9.5 6.8 34 7.0 3.6 12 A two-tailed linear
model analysis was used to compare treatment groups at each time
point. .sup.aComparison with placebo, statistically significant; P
.ltoreq. .001 .sup.bComparison with 10 .mu.g E2, statistically
significant; P .ltoreq. .05 .sup.cComparison with placebo,
statistically significant; P .ltoreq. .01 .sup.dComparison with
placebo, statistically significant; P .ltoreq. .05
EXAMPLE 4
[0099] Manufacture of 10 .mu.g Tablets
[0100] Suspension of Estradiol
[0101] 10.3 g estradiol hemihydrate (equivalent to 10.0 g
estradiol, anhydrous) is suspended in a solution of hypromellose
(14.8 g) in purified water 15.6 L) while stirring.
[0102] Granulation
[0103] Blending, granulation, and drying are performed in a fluid
bed.
[0104] Hypromellose (53.69 kg), lactose monohydrate (17.90 kg), and
maize starch (8.00 kg) are sucked into the fluid bed through a
sieve and then blended.
[0105] The granulation takes place by spraying the suspension of
estradiol on the mixture of excipients. After spraying the
granulate is dried.
[0106] Blending
[0107] Sieving is performed and magnesium stearate (400 g) is
blended into the granulate
[0108] Compression
[0109] The tablets are compressed using a rotary tablet press.
[0110] Preparation of Film-Coating Solution
[0111] Hypromellose (400 g) and macrogol 6000 (50 g) are dissolved
in purified water (9.55 kg)
[0112] Film-Coating
[0113] In a coating pan, the tablets are coated with the coating
solution (0.576 mg dried substance/tablet), using an air atomizing
spray system. After coating sampling of tablets to release testing
takes place.
EXPLANATION TO THE FIGURES
[0114]
9 FIG. 1. Serum concentrations of estradiol at week 0. 25 .mu.g E2
10 .mu.g E2 FIG. 2. Serum concentrations of estradiol at week 12.
25 .mu.g E2 10 .mu.g E2 FIG. 3. Area under the serum estradiol
curve at weeks 0 and 12. 25 .mu.g E2 10 .mu.g E2 FIG. 4. Area under
the serum estradiol curve and serum FSH concentration at week 12.
25 .mu.g E2 10 .mu.g E2 FIG. 5. Area under the serum estradiol
curve and maturation value at week 12. Maturation values at
baseline were 52.4 in the 25-.mu.g E2 group and 51.0 in the
10-.mu.g E2 group. 25 .mu.g E2 10 .mu.g E2 FIG. 6. Vaginal symptom
composite score profiles - subjects who received at least 1 dose of
study medication, had baseline assessment, and had at least 1
post-baseline assessment Placebo E2 to 10 .mu.g E2 to 25 .mu.g FIG.
7. Vaginal health composite score profiles - subjects who received
at least 1 dose of study medication, had baseline assessment, and
had at least 1 post-baseline assessment Placebo E2 to 10 .mu.g E2
to 25 .mu.g FIG. 8. Vaginal cytology results (percentage of
superficial cells) - subjects who received at least 1 dose of study
medication, had baseline assessment, and had at least 1
post-baseline assessment. 10 .mu.g E2 Superficial 25 .mu.g E2 FIG.
9. Maturation values - subjects who received at least 1 dose of
study medication, had baseline assessment, and had at least 1
post-baseline assessment Placebo E2 to 10 .mu.g E2 to 25 .mu.g FIG.
10. Urethral cytology results - subjects who received at least 1
dose of study medication, had baseline assessment, and had at least
1 post-baseline assessment 10 .mu.g E2 Placebo 25 .mu.g E2 FIG. 11.
Percentages of superficial vaginal and urethral cells - subjects
who had superficial vaginal and urethral cell assessments at Weeks
0 and 12 (a) 25 .mu.g E2 (b) 10 .mu.g E2 (c) Placebo FIG. 12.
Vaginal cytology results .nu. Parabasal Intermediate Superficial
(a) Placebo (b) 10 .mu.g E2 (c) 25 .mu.g E2 FIG. 13. Urethral
cytology results .nu. Parabasal Intermediate Superficial (d)
Placebo (e) 10 .mu.g E2 (0 25 .mu.g E2
* * * * *