WO2008089405A1 - Composition of multiple hormones delivered vaginally in a single cream - Google Patents

Abstract

Pharmaceutical vaginal cream compositions comprising combinations of the hormones; estriol, estradiol, progesterone, testosterone, and optionally DHEA delivered in a single cream to treat both local and systemic symptoms. The present invention is also directed to a method of treating a menopausal condition in a female in need thereof, the method comprising vaginally administering a pharmaceutical vaginal cream.

Description

COMPOSITION OF MULTIPLE HORMONES DELIVERED VAGINALLY IN A

SINGLE CREAM

CROSS-REFERENCES TO RELATED APPLICATIONS

This application claims priority to U.S. Provisional Application No. 60/881,528 filed on January 19, 2007.

FIELD OF THE INVENTION

This invention relates to vaginal cream compositions containing hormones. More particularly, this invention relates to hormonal vaginal cream compositions having combinations and ratios of hormones that are beneficial to menopausal women.

BACKGROUND OF INVENTION

The vaginal delivery of hormones, including various estrogens, progesterone and testosterone, has been well established in the literature. It has been shown in multiple studies that hormones administered vaginally are absorbed systemically, bypass hepatic metabolism and are biologically active. Vaginally administered hormones are absorbed rapidly, with serum levels peaking between about 1 and 6 hours and gradually returning to baseline levels within 24 hours. It has also been shown that hormones applied to the mucous membranes are more readily absorbed than hormones applied to the skin. Hormones applied vaginally achieve higher plasma levels than if taken orally and the vaginal route appears to be more adequate than the oral one for hormone replacement therapy. Unfortunately, commercially available vaginal creams tend to be comprised of synthetic hormones.

Symptomatic relief of genital urinary symptoms as well as climacteric symptoms with vaginally administered hormones has also been described and is dose dependent.

Natural Hormone Replacement Therapy has been around for more than twenty years. The term "natural" comes from the fact that the hormones (estrogens such as estradiol, estrone, and estriol, testosterone, DHEA, pregnenolone and progesterone) come from natural sources. The reference to natural means that the hormones have substantially similar molecular structure as those produced by the body itself, thus the body recognizes the hormones as being "natural", because they are substantially and therapy utilizing these compounds is commonly referred to as Bio-identical Hormone Replacement Therapy (BHRT). It is thought that some of the benefits of BHRT include: fewer side effects compared with traditional Hormone Replacement Therapy (HRT) such as protection against heart disease, reduced risk of breast cancer, and improved lipid profile.

A problem with available forms and sources of BHRT pharmaceutical compositions is the variability of compositions and the ratios of the components of those compositions has led to formulations have little or no therapeutic effect. The ratio of the component hormones, both natural and synthetic has not necessarily been well understood and therefore the variability of the concentrations of such compositions has been such that the efficacy of the topical hormone compositions has been varied.

BRIEF SUMMARY OF THE INVENTION

The present invention is directed to pharmaceutical vaginal cream compositions comprising combinations of various members of the Androgen, Estrogen, and Progestagen groups of sex hormones including, but not limited to, estriol, estradiol, progesterone, testosterone, and optionally Dehydroepiandrosterone (DHEA) delivered in a single cream to treat both local and systemic symptoms. The present invention is also directed to a method of treating a menopausal condition in a female in need thereof, the method comprising vaginally administering a pharmaceutical vaginal cream.

It is a further aspect of the present disclosure that hormones, delivered through the mucous membranes of the labia and vagina are absorbed and have been shown to relieve climacteric symptoms.

It is yet a further aspect of the present disclosure that vaginal application of hormones is a convenient method to deliver a combination of hormones which has a high rate of patient compliance and adherence.

In another aspect of the invention vaginal cream compositions containing the following hormones in the formulation including, but not limited to, estriol (E3), estradiol (E2), progesterone (P) and testosterone (T).

In a further aspect of the invention, the vaginal cream compositions contain about the following levels of hormones (per cc of vaginal cream base): estriol (1-2 mg), estradiol (0-1 mg), progesterone (100-400 mg), and testosterone (0.5-2 mg).

In one illustrative embodiment according to the invention the hormones are found in about the following concentrations (per cc of vaginal cream base): estriol 2 mg, estradiol 0.5 mg, progesterone 100 mg and testosterone 2 mg. In yet another aspect of the invention, about 0.25 cc (1/4 ml) of hormone cream according to the invention is dispensed from a pre-filled 3 cc syringe delivering a measured dose of hormones providing about: estriol 0.5 mg, estradiol 0.125 mg, progesterone 25 mg and testosterone 0.5 mg per application.

In one aspect of the invention the hormone composition relieves the following conditions in menopausal women: vaginal dryness, urinary complaints, repeated urinary tract infection, urgency, hesitancy, frequency, stress incontinence, relief of dyspareunia and sexual function.

In a further aspect of the invention, the hormone composition according to the invention allows for the relief of systemic menopausal symptoms such as hot flashes, night sweats, foggy thinking, insomnia and fatigue.

In yet a further aspect of the invention the vaginally applied hormone composition allows for the delivery of HRT with consistent absorption that is unaffected by food intake and does not result in accumulation of hormones.

In a further aspect of the invention, the vaginally applied hormone composition is thought to mitigate the systemic toxicity associated with oral hormones because it bypasses first pass hepatic metabolism, resulting in the beneficial delivery of hormones with no evidence of liver toxicity, no affect on clotting factors, no evidence of increased blood clots, and decreased formation of metabolites, which are responsible for many of the side effects of hormone therapy, including a possible increased risk of breast cancer.

In another aspect of the invention, vaginal delivery of estriol and estradiol has been shown not to increase the risk of breast cancer, thereby permitting the use of these two hormones in patients with breast cancer.

In a further aspect of the invention, the vaginal delivery of estriol has been shown to be bone protective.

In another aspect of the invention, the vaginal delivery of bio-identical estriol has been shown to be more effective than oral delivery, which results in rapid metabolism of the hormone. Without being bound to any particular theory, it is thought that methyl-testosterone is toxic to the liver and increases the risk of breast cancer if given orally. Methyl testosterone is toxic to the liver and methyl testosterone has been shown to increase the risk of breast cancer. Bio-identical testosterone has been shown to be breast protective.

In yet another aspect of the invention, it is thought that vaginal testosterone is effective locally and provides therapeutic levels in serum and vaginal hormone therapy is superior to oral and topical hormone therapy for relief of vaginal and urinary symptoms. A further aspect of the invention is that vaginal progesterone therapy provides higher and more consistent levels of progesterone to the uterus than oral progesterone therapy and that vaginal progesterone has been shown to be heart protective with fewer side effects than oral progesterone therapy.

In yet a further aspect of the invention it is thought that estrogen given in combination with progesterone will avoid stimulation of the uterine lining.

In one illustrative embodiment according to the invention a ratio of progesterone: estradiol of about 100-200: 1 is uterine protective and prevents hyperplasia of the endometrium and subsequent bleeding problems. The addition of testosterone also balances the estrogen at the level of the uterus.

In a further aspect of the invention, it is thought that testosterone has not only been used to treat breast cancer, but also endometriosis and fibroids and that the addition of testosterone to the formulation allows the treatment of both local and systemic symptoms with safer, lower doses of estradiol.

In another aspect of the invention it is thought that by combining hormones, local and systemic symptoms are better controlled.

In a further aspect of the invention, the hormone combination cream is convenient for patients as it is a single cream applied once daily. It is easy to measure and is supplied in pre- fϊlled syringes, or in a metered pump that can dispense a pre-determined amount, with instructions on how to measure and apply.

In yet a further aspect of the invention, the use of a combination of hormones allows for multiple therapeutic uses as there is no need for separate preparations for vaginal and urinary symptoms.

In a further aspect of the invention, the hormones are delivered in a concentrated cream using a fraction of the volume of the other preparations, making this preparation much less messy and inconvenient. A vaginal applicator is not needed, as the small amount of cream is applied with the finger tip. There is no mess and no clean up resulting in high patient satisfaction and compliance.

In one illustrative embodiment according to the invention the ratio of progesterone: estradiol is between about 100: 1 and 400:0.5 with a minimum of about 100: 1 being used to prevent vaginal bleeding. In a preferred ratio of about 100-200: 1 with a daily dose of progesterone of 25 mg and estradiol 0.125 mg providing a safe 200: 1 ratio.

In yet a further aspect of the invention the multi-hormone cream according to this disclosure is applied topically to the skin of the face and found to be beneficial to the health of the skin. The ratio of the hormones is changed slightly for the skin preparation with lower levels of hormones and less testosterone (female formulation) compared to the estrogens.

DETAILED DESCRIPTION OF THE INVENTION

The present invention is directed to pharmaceutical vaginal cream composition comprising combinations of the hormones estriol, estradiol, progesterone, testosterone, and DHEA delivered in a single cream to treat both local and systemic symptoms. The present invention is also directed to a method of treating a menopausal condition in a female in need thereof, the method comprising vaginally administering a pharmaceutical vaginal cream composition.

Some illustrative embodiments, according to the present invention are directed to a kit or an applicator comprising a vaginal cream hormone composition comprising combinations of the hormones estriol, estradiol, progesterone, testosterone, and DHEA delivered in a single cream to treat both local and systemic symptoms. In some embodiments, the present invention is also directed to a method of treating a menopausal condition in a female in need thereof, the method comprising administering a vaginal cream composition comprising combinations of the hormones estriol, estradiol, progesterone, testosterone, and DHEA delivered in a single cream to treat both local and systemic symptoms.

In some further illustrative embodiments, the present invention is directed to a method of treating a menopausal condition in a female in need thereof, the method comprising vaginally administering a pharmaceutical vaginal cream composition combinations of the hormones estriol, estradiol, progesterone, testosterone, and DHEA delivered in a single cream to treat both local and systemic symptoms.

Various stabilizers can be used in the present invention. The term "stabilizer" refers to any substance that keeps the hormones chemically stable. Alternatively, the term "stabilizer" refers to any substance that slows or retards the degradation or alteration of a hormone within the vaginal composition. For example, a stabilizer can protect the hormones from instability caused by light, moisture, heat, or oxidation. In some embodiments, the stabilizer is lipophilic. In some embodiments, the stabilizer is hydrophilic. In some embodiments, the stabilizer can prevent or retard the oxidation of the oil. In some embodiments, the stabilizer can be, but is not limited to, butylated hydroxyanisole (BHA), butylated hydroxytoluene (BHT), ascorbic acid and its esters, vitamin E and its esters, e.g., vitamin E acetate, sodium bisulfite, sodium metabisulfϊte, 3-dehydroshikimic acid (DHS), tocopherols and their esters, alkyl gallates, chelating agents, EDTA (ethylenediaminetetraacetic acid; edetate disodium), citric acid, benzyl alcohol, or combinations thereof. In some embodiments, the stabilizer can be edetate disodium, butylated hydroxyanisole, butylated hydroxytoluene, or combinations thereof.

In some illustrative embodiments, the composition of the present invention further comprises a pharmaceutically acceptable excipient. As used herein, "excipient" refers to a substance, or mixture of substances, that is used in the formulation of vaginal cream compositions to give desirable physical characteristics to the formulation. As used herein, the term "pharmaceutically acceptable" refers to those compounds, materials, compositions, and/or dosage forms which are, within the scope of sound medical judgment, suitable for contact with the tissues of human beings and animals without excessive toxicity, irritation, allergic response, or other problem complications commensurate with a reasonable benefit/risk ratio. In some embodiments, the term "pharmaceutically acceptable" means approved by a regulatory agency of the Federal or a state government or listed in the U.S. Pharmacopeia or other generally recognized international pharmacopeia for use in animals, and more particularly in humans. Various pharmaceutically acceptable excipients can be used. In some embodiments, the pharmaceutically acceptable excipient can be, but is not limited to, a stiffening agent, an oil, a solvent, an emulsifier, a humectant, a buffering agent, a filler, an emollient, a stabilizer, or combinations thereof.

The term "stiffening agent" refers to a substance, or mixture of substances, added to make a vaginal cream composition more viscous at room temperature. In some embodiments, a stiffening agent is any substance that promotes formation of a formulation having a semi-solid consistency. The stiffening agent can be hydrophilic (e.g., carbopol, carboxymethylcellulose, hydroxypropylmethylcellulose, alginate, polyethylene glycol). In some embodiments, the stiffening agent has low hydrophilic-lipophilic balance (HLB). In some embodiments, the HLB value is less than 7. In some embodiments, the HLB value is less than 5. In some embodiments, the HLB value is about 4. Examples of suitable stiffening agents include, but are not limited to, hydrogenated vegetable oil, cetyl alcohol, cetyl esters wax, microcrystalline wax, paraffin, stearyl alcohol, lauryl alcohol, myristal alcohol, cetostearyl alcohol, white wax, yellow wax, beeswax, candelilla wax, cotton wax, carnauba wax, bayberry wax, rice-bran wax, and combinations thereof. In some embodiments, the stiffening agent is a mixture of cetyl esters wax, cetyl alcohol, and beeswax.

The term "solvent" refers to any substance capable of dissolving or dispersing one or more of the hormones or the excipients of the present invention. The solvent can be aqueous or non-aqueous. In some embodiments, the solvent is hydrophilic, and is 10% to 75% by weight, or 20% to 60% by weight, of the total composition. In some embodiments, the solvent is lipophilic, and is 20% to 60% by weight, or 25% to 50% by weight, of the total composition. In some embodiments, the solvent is water, a polyol (e.g., glycerol) or combinations thereof. In some embodiments, the solvent is an oil as described above.

The term "emulsifϊer" refers to any substance that promotes formation and stabilization of an emulsion or suspension. In some embodiments, the emulsifier includes, but is not limited to, sodium lauryl sulfate, propylene glycol monostearate, methyl stearate, glyceryl monostearate, and combinations thereof.

The term "humectant" refers to any substance that promotes retention of moisture in the composition of the present invention. In some embodiments, the humectant includes, but is not limited to, polyethylene glycol, propylene glycol, glycerin, polyol, polyol derivatives, and combinations thereof.

The term "buffering agent" refers to any substance capable of neutralizing both acids and bases and thereby maintaining the desired pH of the composition of the present invention. In some embodiments, the buffering agent affects the emulsifying properties. For example, different buffering agents can be provided to increase or decrease the emulsifϊcation of the conjugated estrogens or the excipients of the present invention. In some embodiments, the buffer can be, but is not limited to, Tris buffers (Tris EDTA (TE), Tris acetate (TAE), Tris phosphate (TPE), Tris glycine), phosphate buffers (e.g., sodium phosphate, potassium phosphate), bicarbonate buffers, acetate buffers (e.g., sodium acetate), ammonium buffers, citrate buffers, and derivatives and combinations thereof. In some embodiments, an organic acid buffer is used. In some embodiments, an acetate buffer, a phosphate buffer, or a citrate buffer can be used. In some embodiments, a zwitterionic buffer can be used. In some embodiments, the buffering agent is a phosphate buffer (e.g., sodium phosphate dibasic).

The pH of the composition of the invention can be physiologically compatible and/or sufficient to maintain stability of the composition. In some embodiments, the composition of the present invention can have a pH of 5.0 to 9.0, or a pH of 6.5 to 8.0.

As defined herein, an "emollient" is a substance that moisturizes and increases the pliability of the vaginal epithelium. In some embodiments, the emollient can be, but is not limited to, lanolin, isopropyl myristate, palmitate, oleyl alcohol, beeswax, mineral oil, silicone oil, or combinations thereof.

As defined herein, a "filler" is a substance used to give bulk to the composition without chemically reacting with the conjugated estrogens of the present invention. Fillers are known to those in the art, see e.g., Remington: The Science and Practice of Pharmacy, 20^th ed. (2000).

As defined herein, a "vaginal cream" is a semi-solid preparation suitable for application to the vaginal tract. In some embodiments, a vaginal cream can be a vaginal ointment, vaginal gel or vaginal emulsion. Various classes of vehicle bases can be used in the vaginal cream and are known to those in the art. For example, suitable vehicle bases include, but are not limited to, hydrocarbon bases or oleaginous bases, absorption bases, water-removable bases and water-soluble bases (Remington: The Science and Practice of Pharmacy, 20^th ed. (2000)). In some embodiments, the vehicle base is non-irritating, non- staining, stable, non-pH dependent and/or compatible with the conjugated estrogens of the present invention.

The amount of active agent or agents in a dosage form can vary. The exact dosage amount can be selected depending upon the needs of the female to which the active agent is being administered, as determined by a relevant person. In some embodiments, one of skill in the art can perform pharmacokinetic studies and use the results of the study to adjust the dosage amount for a female, or a group of females, to a suitable level. In some embodiments, one of skill in the art can determine an appropriate dosage amount based on varying dosage amounts and comparing to symptomatic relief. In some embodiments, appropriate animal studies may be performed to determine an appropriate dosage amount. A "relevant person" as used herein, includes, for example, a physician, physician assistant, nurse practitioner, pharmacist and customer service representative.

According to the disclosure the vaginal composition includes one or more steroid hormones alone or in combination, more particularly a estrogen or a steroidal or non-steroidal estrogen receptor active agent. Most preferably the primary agent is estriol (estra-1, 3,5(10)- triene-3,16,17-triol, E3, such as estriol succinate, estriol dihexanate or estriol sulfmate. However, the primary agent may be precursors or analogs of estriol (such as nyestriol), estrone (El) or precursors or analogs of estrone, 17β-estradiol (E2) or precursors (including aromatizable testosterone) or analogs of 17β-estradiol. The primary agent may also be a metabolite or derivatives of El, E2 or E3 which are active at the estrogen receptor α or β. Metabolites and derivatives may have a similar core structure to El, E2 or E3 but may have one or more different groups (ex. hydroxyl, ketone, halide, etc.) at one or more ring positions. Synthetic steroids which are effective at estrogen receptor are also useful in this invention, such as those described in WO 97/08188 or U.S. Pat. No. 6,043,236 to Brattsand. Example I

It has previously been demonstrated that the addition of progesterone to vaginal estradiol cream does not affect the absorption of the estradiol. See Carlstrδm K, Pschera H, Lunnell N. Serum levels of oestrogens, progesterone, follicle-stimulating hormone and sex- hormone-binding globulin during simultaneous vaginal administration of 17 beta-oestradiol and progesterone in the pre- and post-menopause. Maturitas 1988; 10, pp 307-16. In 1981, after documenting the superiority of intra-vaginal application of progesterone, it was hypothesized that 'full hormone replacement could be accomplished in the deficient states by cyclic vaginal application of both steroids', i.e. estrogen and progesterone, Villanueva B, Casper RF, Yen SC. Intravaginal Administration of Progesterone: Enhanced Absorption After Estrogen Treatment. Fertility and Sterility 1981; 35:4, 433-37..

In this pilot study, we were able to document the systemic absorption of multiple hormones by both saliva and blood testing as well as relief of climacteric symptoms by the standard 'Quality of Life Survey', Short Form 12 (SF- 12v2) and the symptom evaluation survey provided by ZRT Laboratory, Beaverton, Oregon.

Patients and Methods

12 post-menopausal females (bi-lateral oophorectomy or last menstrual period over 1 year) were recruited to participate in the study. Baseline salivary hormone levels (estrone, estradiol, estriol, progesterone, testosterone, DHEA-S, and Cortisol) were obtained. Baseline serum levels (estrone, estradiol, free estradiol, progesterone, testosterone, free testosterone and DHEA-S) were obtained. Patients were not taking additional prescription or nonprescription hormonal or natural products which might interfere with measurement of levels during the timeframe of the present study.

In the first arm of the study a compounded hormone cream was prepared by a compounding pharmacy using Versabase , micronized estriol USP , micronized estradiol USP^ , micronized progesterone USP^(a) , micronized dehydroepiandrosterone (DHEA) ^ , micronized testosterone propionate USP^ in a concentration of about Estriol 2mg, Estradiol 0.5 mg, Progesterone 100 mg, DHEA 5 mg, Testosterone 1 mg per cc of cream.

This was dispensed in pre-fϊlled, 1 cc syringes. Patients were instructed to apply 0.25 cc ' s of cream to the mucous membranes of the labia and vagina each morning using their index finger, supplying a daily dose of about Estriol 0.5 mg, Estradiol 0.125 mg, Progesterone 25 mg, DHEA 1.25 mg, and Testosterone 0.25 mg.

On day 28, serum was collected at 6 hours and saliva was collected at 24 hours following the application of hormone. Saliva was collected at 24 hours which is typically the collection time recommended for topical application (24-48 hours following last dose).

It was felt that the collection of saliva at 24 hours following the application of hormones to the labia and vagina may have underestimated the absorption of hormones. It was also felt that the dose of some of the hormones may have been inadequate. In the second arm of the study, seven of the 12 post menopausal patients, with low baseline levels of DHEA-S and testosterone were selected and agreed to use a second compounded cream with higher concentrations of hormones. A combined cream was prepared similarly in Versabase in the following approximate concentration: Estriol lmg, Estradiol 1 mg, Progesterone 100 mg, DHEA 100 mg, Testosterone 1 mg per cc of cream.

Patients were instructed to apply 0. 5 cc's of cream to the mucous membranes of the labia and vagina each morning using their index finger, supplying a daily dose of about Estriol 0.5 mg, estradiol 0.5 mg, progesterone 50 mg, DHEA 50 mg, and Testosterone 0.5 mg.

After 2 weeks of therapy, saliva was collected at 6 hours (vs. 24 hours) following the last dose and hormone levels were measured. Without being bound to any particular theory it is thought that steady state is achieved within about one week.

Methodologies and Materials

Saliva Collection

Saliva (minimal 5 ml) was collected in polypropylene tubes in the morning before breakfast (7-9 am) at baseline and in the first arm of the study and at 6 hours after application of hormone cream in the second arm of the study. Food and beverages (exception water) were avoided 2 hr prior to saliva collection. Saliva samples were shipped within 24 hours to a laboratory for analysis.

Saliva Processing

Saliva was processed by adding about 50 ul of about 0.14 mg/ml dithiothreitol (DTT) per ml of saliva to break up mucins that interfere with saliva extraction. Steroids were then extracted from 1.5 ml of saliva by C- 18 column chromatograpy. Samples were gently pulled through the columns by vacuum. Control and calibrator samples were prepared from Biorad Lyphocheck diluted 1/100 in phosphate buffered saline (PBS) buffer containing DTT. Following absorption to C- 18 columns, the samples, controls, and calibrators are washed with PBS buffer and the steroids eluted with alcohol solvent. The eluted solvent containing the steroids was dried under nitrogen and then reconstituted in PBS buffer containing 0.1% T904 detergent and 0.05% Proclin antimicrobial (assay buffer).

Steroid Testing

Steroids in the extracted/reconstituted saliva were quantified by enzyme immunoassay (EIA) with commercial kits from DRG, Germany. Standards were prepared in assay buffer from a concentrated stock of each hormone with serial dilution. Interassay and intraassay coefficient of variations for low and high controls for all steroids tested were 10% or less. ZRT Laboratory has performed weekly approximately 1500 samples of each of the steroids (estradiol, progesterone, testosterone, DHEA, and Cortisol). Ranges are based on gender, age, menstrual status (e.g., follicular vs. luteal phase of the menstrual cycle), and hormone therapy.

Data Collection-Retrieval: ZRT Symptom Profile

The ZRT symptom profile is intended as a disease-specific quality of life instrument. Symptoms of hormonal imbalance (e.g., hot flashes, sleep disturbances, etc. -50 total symptoms self graded as none-0, mild-l, moderate-2, or severe-3). These symptoms correlate with specific hormone deficiencies and are measurable. This information is stored in the ZRT database and can be retrieved (de-identified) with software programs developed at ZRT. ZRT symptom profile is based on specific symptoms of estrogen and androgen deficiencies scored by multiplying relative frequency of the symptom (a constant value rated from 0-100%) times self rated intensity of the symptom ( 0=none, l=mild, 2=moderate, 3=severe). For example, hot flashes and night sweats are rated as 100% with regard to frequency because they are the most common complaints in women in, or close to, menopause. The frequency, which is a constant, is multiplied times the self-rated severity of the symptom to derive a score for each symptom from 0 to 300. Each of the individual symptom scores for estrogen deficiency or androgen deficiency is added to derive a total score. This score is then divided by the highest score possible for the symptom category (e.g. estrogen deficiency) to derive a percent (0-100%) with 100% representing all symptoms within a symptom category scoring severe (3). The advantage of this method is that it allows some appreciation for relative individual changes in individual symptoms as well as symptom categories of hormone deficiency or excess. Any relative changes or improvement due to hormone therapy would be reflected in the individual symptoms and a reduction in the percentage of the overall symptom profile.

General health-related quality of life was measured using the short- form 12 version 2 (SF-12v2, Quality Metric, Inc., Lincoln, RI). Patients self-administered the written surveys on days 0 and 28. Scoring was completed using SF Outcomes Scoring Software™ (Quality Metric, Inc., Lincoln, RI).

Serum testing

Serum testing was completed for the following hormones via the associated testing methodologies:

Estriol: ICMA (Immunochemiluminometric assay)

Estradiol: ADVIA Centaur (Competitive immunoassay direct chemiluminescent)

Estradiol free: ADVIA

Estrone: RIA

Testosterone total: ICMA

Testosterone free: RIA

DHEAS: ICMA

Progesterone: ICMA

Results

In the first arm of the study, using a daily dose of Estriol 0.5 mg, Estradiol 0.125 mg, Progesterone 25 mg, DHEA 1.25 mg and Testosterone 0.25 mg in 0.25 cc's of cream applied to the mucous membranes of the labia and vagina, the following results were obtained in the 12 post menopausal females; serum levels are shown in table 1 and saliva levels are shown in table 2.

Table 1

Table 1 Average serum levels in post-menopausal females at day 28 collected 6 hours following mm/vaginal administration of Estπol 0.5mg, estradiol 0.125 mg, progesterone 25 mg, testosterone 0.25 mg and DHEA 1.25 mg.

Table 2

Table 2 Average salivary levels in post-menopausal females at day 28 collected 24hours following mm/vaginal administration of Estπol 0.5 mg, estradiol 0.125 mg, progesterone 25 mg, testosterone 0.25 mg and DHEA 1.25 mg. n=9; one saliva test was lost and 2 were contaminated specimens.

Estriol in serum was not sensitive as it was measured in nanograms per ml. versus picograms per ml. Other studies have show elevation of serum levels with 0.5 mg of estriol delivered vaginally when measured in pg/ml or nmol/1 and by suppression of LH and FSH [2- 5, 10, 18, and 19]. Estradiol and free estradiol were elevated in serum and saliva. Estrone levels did not significantly change with vaginal estradiol as has been previously demonstrated in the literature See. Punnonen R, Vilska S, Grδnroos M, Rauramo L. The vaginal absorption of oestrogens in post-menopausal women. Maturitas 1980; 2:4, pp 321-26.

Progesterone was also elevated in serum and saliva. Systemic absorption of progesterone has also been previously demonstrated in the literature with vaginal administration of a progesterone gel. Ross D, Cooper A, Pryse-Davies J, Bergeron C, Collins W, Whitehead M. Randomized, double-blind, dose-ranging study of the endometrial effects of a vaginal progesterone gel in estrogen-treated postmenopausal women. Am J Obstet. Gynecol. 1997; 177:4, pp 937-41. Baseline levels of testosterone and DHEA did not differ between pre and postmenopausal patients. Total serum testosterone declined. Serum and salivary DHEA were not altered. Serum free testosterone was elevated at 6 hours and correlated with relief of symptoms related to low testosterone levels (see discussion).

The dose of DHEA was felt to be inadequate and was increased in the second arm of the study. It was felt that the later collection of saliva (24 hours) could have missed the rise in testosterone.

The second arm of the study looked at higher doses of hormones; estradiol, progesterone, testosterone and DHEA, and earlier collection of saliva; 6 hours vs. 24 hours as shown in table 3.

Table 3

Table 3 Average saliva levels in 7 post-menopausal females at day 0 and day 42 (14 days using the higher strength cream) collected 6 hours after using Estriol 0.5 mg, Estradiol 0.5 mg, Progesterone 50 mg, Testosterone 0.5 mg and DHEA 50 mg.

Absorption of all hormones was documented at 6 hours following use of the higher strength cream ( Estriol 0.5 mg, estradiol 0.5 mg, progesterone 50 mg, testosterone 0.5 mg, and DHEA 50 mg) applied to the mucous membranes of the labia and the vagina. Estrone was not felt to be significantly elevated.

Systemic climacteric symptoms were relieved with mucous membrane/vaginal hormone therapy as documented on the SF 12 v2 quality of life survey done on day 0 and 28 as shown in table 4. Table 4

Health Construct Day 28 Change

Mean (Std Dev) Mean (Std Dev)

Table 4 Health Construct table.

The eight health constructs and two summary component scores (PCS and MCS) have been widely used and validated in the medical literature [23-27]. Norm-based scoring of the SF- 12 tool assigns a score of 50 as the norm for any given construct, with a scaled standard deviation of 10 [23]. So, (a) the scores for most of the measured constructs were within one standard deviation (below) the US population norm other than emotional health (slightly greater than 1 SD below US population norm at time point 0); and (b) while some of the individual patients within the study had a worsening of a single construct, when examined as a group, all of the measured health constructs (and summary scores) improved over the 28 day timeframe. These effects were between a mean change of 2.15 for physical functioning (least effect) to a mean change of 6.98 and 7.00 for role emotional and bodily pain, respectively (greatest effect).

These effects were consistent with relief of symptoms of estrogen and testosterone deficiency as documented on the 50-item ZRT symptom profile survey provided by ZRT laboratory (see Materials and Methodologies, Data Collection and Retrieval: ZRT symptom profile). There was improvement at day 28 and further improvement of symptoms with increasing doses of hormones as shown in table 5.

Table 5

Day O Day 28 Day 42

Symptoms of 31.98 24.76 16.38 Testosterone

Deficiency

Symptoms of 31.78 18.88 10.22

Estrogen

Deficiency

Table 5 Average scores of ZRT symptom profile based on 5 of 7 patients who participated in the second (higher dose) arm of the study, who completed the symptom survey on day 0, 28, and 42.

In the second arm of the study, one patient had complaints consistent with androgen excess. The 50 mg dose of DHEA was felt to be excessive. The vaginal dose for DHEA has not been established. 1.25 mg was felt to be inadequate and the 50 mg. dose excessive.

Patient satisfaction with this method of delivery was high with all 12 patients choosing to continue with hormone therapy. Two of 12 patients had minor irritation with the cream base. Patients found the once daily, single cream, mucous membrane/vaginal method convenient and easy to use. It is also a cost effective method of delivery of hormones which avoids first pass hepatic metabolism and provides relief of systemic symptoms along with relief of vaginal and urinary symptoms. 87% of patients in this study had genital urinary symptoms before therapy. All patients had relief of genital urinary symptoms with therapy at day 28.

The vaginal formula is balanced (with a progesterone to estradiol ratio of at least 100: 1) and in practice, patients may increase or decrease the amount of cream used depending on symptoms. In practice the cream may be applied intra-vaginally, to the external mucous membranes or both. Absorption is adequate with either application site.

All references cited herein are incorporated herein by reference. Where the meaning of any term as used within the application itself differs from the meaning of that same term in any of the references, the meaning of the term as used within the application itself controls.

It is to be understood that he embodiments described above are intended to be illustrative and not limiting. Many other embodiments will be apparent to those skilled in the art once that have read the above description and examples. The Foregoing description and illustrative embodiments therefore are merely exemplary and are not intended to limit the scope of the invention, which encompasses all equivalents of what is described herein and set forth particularly by the appended claims. REFERENCES

1. Schiff I, Tulchinsky D, Ryan K. Vaginal absorption of estrone and 17β-estradiol. Fertility and Sterility 1977; 28;10, pp 1063-66

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3. Punnonen R, Vilska S, Grδnroos M, Rauramo L. The vaginal absorption of oestrogens in post-menopausal women. Maturitas 1980; 2:4, pp 321-26

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Claims

What is claimed is:

I) A vaginal pharmaceutical composition, comprising: a) two or more hormones; b) at least one pharmaceutically acceptable excipient;

2) The vaginal pharmaceutical composition of claim 1 wherein said hormones are selected from the group consisting of androgens, estrogens, and progestagens.

3) The vaginal pharmaceutical composition of claim 1 wherein said hormones are further selected from the group consisting of estriol, estradiol, progesterone, and testosterone.

4) The vaginal pharmaceutical composition of claim 3 wherein said composition comprises about 1-2 mg of Estriol, about 0-1 mg of Estradiol, about 100-400 mg of Progesterone, about 0.5-2 mg of Testosterone, or any combination thereof.

5) The vaginal pharmaceutical composition of claim 4 wherein said progesterone and said estradiol are in a ratio of about 100-200 to about 1.

6) The vaginal pharmaceutical composition of claim 4 wherein the ratio of said progesterone:estradiol is between about 100: 1 to about 400:0.5 with a minimum of about 100: 1.

7) The vaginal pharmaceutical composition of claim 3 further comprising Dehydroepiandrosterone.

8) The vaginal pharmaceutical composition of claim 1 wherein said pharmaceutically acceptable excipient is selected from the group consisting of stiffening agents, oils, solvents, emulsifϊers, humectants, buffering agents, fillers, emollients, stabilizers, or any combination thereof.

9) The vaginal pharmaceutical composition of claim 8 wherein said stabilizer is lipohilic.

10) The vaginal pharmaceutical composition of claim 8 wherein said stabilizer is hydrophilic.

11) The vaginal pharmaceutical composition of claim 8 wherein said stabilizer is selected from the group consisting of butylated hydroxyanisole (BHA), butylated hydroxytoluene (BHT), ascorbic acid and its esters, vitamin E and its esters, sodium bisulfite, sodium metabisulfϊte, 3-dehydroshikimic acid (DHS), tocopherols and their esters, alkyl gallates, chelating agents, EDTA (ethylenediaminetetraacetic acid; edetate disodium), citric acid, benzyl alcohol, or combinations thereof.

12) The vaginal pharmaceutical composition of claim 8 wherein said stabilizer are selected from the group consisting of edetate disodium, butylated hydroxyanisole, butylated hydroxytoluene, or combinations thereof. 13) The vaginal pharmaceutical composition of claim 8 wherein said composition has a pH of about 5.0 to about 9.0.

14) A method of alleviating menopause in a patient comprising, labial or intra-vaginal application of the vaginal pharmaceutical composition of claim 1.

15) A method of alleviating menopause in a patient comprising, labial or intra-vaginal application of the vaginal pharmaceutical composition of claim 2.

16) A method of alleviating menopause in a patient comprising, labial or intra-vaginal application of the vaginal pharmaceutical composition of claim 4.

17) A method of delivering a measured dose of the vaginal pharmaceutical composition comprising, a pump that can dispense a pre-determined amount of hormone vaginal cream composition of claim 1 for labial or intra-vaginal application.

18) A topical hormone cream composition, comprising: a) two or more hormones; b) at least one pharmaceutically acceptable excipient;

19) The topical hormone cream composition of Claim 18 wherein said hormones are selected from the group consisting of androgens, estrogens, and progestagens.

20) The topical hormone cream composition of Claim 19 wherein said hormones are further selected from the group consisting of estriol, estradiol, progesterone, and testosterone.

21) The topical hormone cream composition of claim 20 further composing DHEA.

22) The topical hormone cream composition of Claim 20 wherein said composition comprises about 1-2 mg of Estriol, about 0-1 mg of Estradiol, about 100-400 mg of Progesterone, about 0.5-2 mg of Testosterone, or any combination thereof.

23 A method of improving skin health of a patient comprising, topical application of the hormone cream composition of Claim 18.

24) A method of improving skin health of a patient comprising, topical application of the hormone cream composition of Claim 19.

25) A method of improving skin health of a patient comprising, topical application of the hormone cream composition of Claim 19.