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Douxfils J, Gaspard U, Taziaux M, Jost M, Bouvy C, Lobo RA, Utian WH, Foidart JM. Impact of estetrol (E4) on hemostasis, metabolism and bone turnover in postmenopausal women. Climacteric 2023; 26:55-63. [PMID: 36399023 DOI: 10.1080/13697137.2022.2139599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
OBJECTIVE This study aimed to determine the effects of estetrol (E4) on hemostasis, lipids, carbohydrate metabolism and bone turnover in postmenopausal women. METHODS This study was a multicenter, randomized, double-blind placebo-controlled phase 2 trial. Participants (n = 180, age 43-64 years) received E4 2.5 mg, 5 mg, 10 mg and 15 mg or placebo once daily for 12 weeks. Changes from baseline at week 12 were evaluated versus placebo for hemostasis parameters, sex hormone binding globulin (SHBG), lipids, carbohydrate metabolism and bone markers. RESULTS Changes for hemostasis parameters were minimal with a small increase only in the normalized activated protein C sensitivity ratio in the E4 15 mg group versus placebo. SHBG increased in the E4 5 mg, 10 mg and 15 mg groups versus placebo. High-density lipoprotein cholesterol increased in all E4 groups; changes were not consistent for other lipids. Significant decreases versus placebo were seen for insulin resistance (E4 10 mg group), hemoglobin A1c (E4 15 mg group) and type 1 collagen C-terminal telopeptide (E4 10 mg and 15 mg groups). Small decreases in osteocalcin in the E4 5 mg, 10 mg and 15 mg groups were significant versus the increase observed in placebo. CONCLUSION E4 had limited impact on hemostasis and potentially beneficial effects on lipids, carbohydrate metabolism and bone turnover.
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Affiliation(s)
- J Douxfils
- Department of Pharmacy, Namur Thrombosis and Hemostasis Center, University of Namur, Namur, Belgium.,QUALIblood s.a, Namur, Belgium
| | - U Gaspard
- Department of Obstetrics and Gynecology, University of Liège, Liège, Belgium
| | - M Taziaux
- Estetra SRL, an affiliate company of Mithra Pharmaceuticals, Liège, Belgium
| | - M Jost
- Estetra SRL, an affiliate company of Mithra Pharmaceuticals, Liège, Belgium
| | - C Bouvy
- QUALIblood s.a, Namur, Belgium
| | - R A Lobo
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, NY, USA
| | - W H Utian
- Case Western Reserve Medical School, Cleveland, OH, USA
| | - J-M Foidart
- Department of Obstetrics and Gynecology, University of Liège, Liège, Belgium.,Estetra SRL, an affiliate company of Mithra Pharmaceuticals, Liège, Belgium
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Coelingh Bennink HJT, Krijgh J, Egberts JFM, Slootweg M, van Melick HHE, Roos EPM, Somford DM, Zimmerman Y, Schultz IJ, Clarke NW, van Moorselaar RJA, Debruyne FMJ. Maintaining bone health by estrogen therapy in patients with advanced prostate cancer: a narrative review. Endocr Connect 2022; 11:e220182. [PMID: 36283120 PMCID: PMC9716371 DOI: 10.1530/ec-22-0182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 10/25/2022] [Indexed: 11/08/2022]
Abstract
The purpose of androgen deprivation therapy (ADT) in prostate cancer (PCa), using luteinizing hormone-releasing hormone agonists (LHRHa) or gonadotrophin-releasing hormone antagonists, is to suppress the levels of testosterone. Since testosterone is the precursor of estradiol (E2), one of the major undesired effects of ADT is the concomitant loss of E2, causing among others an increased bone turnover and bone loss and an increased risk of osteoporosis and fractures. Therefore, the guidelines for ADT indicate to combine ADT routinely with bone-sparing agents such as bisphosphonates, denosumab or selective estrogen receptor modulators. However, these compounds may have side effects and some require inconvenient parenteral administration. Co-treatment with estrogens is an alternative approach to prevent bone loss and at the same time, to avoid other side effects caused by the loss of estrogens, which is the topic explored in the present narrative review. Estrogens investigated in PCa patients include parenteral or transdermal E2, diethylstilbestrol (DES), and ethinylestradiol (EE) as monotherapy, or high-dose estetrol (HDE4) combined with ADT. Cardiovascular adverse events have been reported with parenteral E2, DES and EE. Encouraging effects on bone parameters have been obtained with transdermal E2 (tE2) and HDE4, in the tE2 development program (PATCH study), and in the LHRHa/HDE4 co-treatment study (PCombi), respectively. Confirmation of the beneficial effects of estrogen therapy with tE2 or HDE4 on bone health in patients with advanced PCa is needed, with special emphasis on bone mass and fracture rate.
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Affiliation(s)
| | - Jan Krijgh
- Pantarhei Oncology, Zeist, The Netherlands
| | | | | | | | - Erik P M Roos
- Department of Urology, Antonius Hospital, Sneek, The Netherlands
| | - Diederik M Somford
- Department of Urology, Canisius-Wilhelmina Hospital, Nijmegen, The Netherlands
| | | | | | - Noel W Clarke
- The Christie and Salford Royal NHS Foundation Trusts, Manchester, UK
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Zimmerman Y, Frydenberg M, van Poppel H, van Moorselaar RJA, Roos EP, Somford DM, Roeleveld TA, de Haan TD, van Melick HH, Reisman Y, Krijgh J, Debruyne FM, Coelingh Bennink HJ. Estetrol Prevents Hot Flushes and Improves Quality of Life in Patients with Advanced Prostate Cancer Treated with Androgen Deprivation Therapy: The PCombi Study. EUR UROL SUPPL 2022; 45:59-67. [PMID: 36353657 PMCID: PMC9637725 DOI: 10.1016/j.euros.2022.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/15/2022] [Indexed: 11/06/2022] Open
Abstract
Background Androgen deprivation therapy (ADT) for prostate cancer (PCa) is accompanied by side effects affecting health-related quality of life (HRQL). Objective To assess the effects of the fetal estrogen estetrol (E4) on symptoms related to estrogen and androgen deficiency, and on HRQL measured using the validated Functional Assessment of Cancer Therapy-Prostate (FACT-P) questionnaire. Design, setting, and participants This was a phase 2, double-blind, randomized, placebo-controlled study in patients with advanced PCa. Intervention Patients receiving ADT were randomly assigned at a 2:1 ratio to daily treatment with a high dose of E4 (HDE4; n = 41) or placebo (n = 21) for 24 wk. Outcome measurements and statistical analysis The primary outcome was the effect of HDE4 cotreatment on hot flushes (HFs). Secondary outcomes were the Q-Man questionnaire for evaluation of the effect on estrogen and androgen deficiency symptoms, and the FACT-P questionnaire for evaluating HRQL. Results and limitations At 24 wk, the number of patients experiencing HFs was significantly lower in the HDE4 group than in the placebo group (14.3% vs 60.0%; p < 0.001). HDE4 treatment was associated with lower incidence of night sweats, arthralgia, and fatigue, but more nipple tenderness and gynecomastia. At 24 wk, the mean HRQL score favored HDE4 over placebo for the FACT-P total score (122.2 ± 12.3 vs 118.7 ± 19.7) and for several other FACT subscales. Conclusions Daily HDE4 coadministration almost completely prevented HFs in patients with advanced PCa treated with ADT. HDE4 also had positive effects on HRQL and counteracted other estrogen deficiency symptoms caused by ADT. These data support the dual efficacy concept of ADT and HDE4 to improve HRQL and increase the antitumor effect of ADT. Patient summary For patients on androgen deprivation therapy for advanced prostate cancer, cotreatment with a high dose of estetrol almost completely prevents the occurrence of hot flushes and improves quality of life and well-being, but nipple sensitivity and an increase in breast size may occur.
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Coelingh Bennink HJT, van Moorselaar JA, Crawford ED, Roos EPM, Somford DM, Roeleveld TA, de Haan TD, van Melick HHE, Reisman Y, Zimmerman Y, van Osta G, Krijgh J, Shore ND, Saad F, Schally AV, Debruyne FMJ. Estetrol Cotreatment of Androgen Deprivation Therapy in Infiltrating or Metastatic, Castration-sensitive Prostate Cancer: A Randomized, Double-blind, Phase II Trial (PCombi). EUR UROL SUPPL 2021; 28:52-61. [PMID: 34337526 DOI: 10.1016/j.euros.2021.04.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/16/2021] [Indexed: 12/22/2022] Open
Abstract
Background Androgen deprivation therapy (ADT) for prostate cancer with luteinizing hormone-releasing hormone (LHRH) agonists can be improved. Objective To assess safety, the frequency and severity of hot flushes (HFs), bone health, and antitumor effects of high-dose estetrol (HDE4) when combined with ADT. Design, setting and participants A phase II, double-blind, randomized, placebo-controlled study was conducted in advanced prostate cancer patients requiring ADT (the PCombi study). Intervention Patients receiving LHRH agonist treatment were randomized 2:1 to 40 mg HDE4 (n = 41) or placebo (n = 21) cotreatment for 24 wk. Outcome measurements and statistical analysis Coprimary endpoints were frequency/severity of HFs and levels of total and free testosterone (T). Secondary endpoints included assessments of bone metabolism (osteocalcin and type I collagen telopeptide [CTX1]), prostate-specific antigen (PSA), and follicle-stimulating hormone (FSH). Efficacy analysis was based on the selected per-protocol (PP) population. Results and limitations Of 62 patients included in the study, 57 were suitable for a PP analysis (37 HDE4; 20 placebo). No E4-related serious cardiovascular adverse events occurred at 24 wk. Weekly HFs were reported by 13.5% of patients with HDE4 and 60.0% with placebo (p < 0.001). Daily HFs occurred in 5.9% versus 55%. Bone turnover parameters decreased significantly with HDE4 (p < 0.0001). Total and free T decreased earlier (p < 0.05), and free T was suppressed further (p < 0.05). PSA suppression was more profound and earlier (p < 0.005). FSH levels were suppressed by 98% versus 57% (p < 0.0001). Estrogenic side effects were nipple sensitivity (34%) and gynecomastia (17%). Conclusions HDE4 cotreatment of ADT patients with advanced prostate cancer was well tolerated, and no treatment-related cardiovascular adverse events were observed at 24 wk. HFs and bone turnover were substantially reduced. Suppression of free T, PSA, and FSH was more rapid and profound, suggesting enhanced disease control by HDE4 cotreatment. Larger and longer-lasting studies are needed to confirm the results of the study reported here. Patient summary Cotreatment of androgen deprivation therapy with high-dose estetrol in advanced prostate cancer patients results in fewer occurrences of hot flushes, bone protection, and other antitumor benefits. Nipple sensitivity and gynecomastia may occur as side effects.
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Noirrit-Esclassan E, Valera MC, Tremollieres F, Arnal JF, Lenfant F, Fontaine C, Vinel A. Critical Role of Estrogens on Bone Homeostasis in Both Male and Female: From Physiology to Medical Implications. Int J Mol Sci 2021; 22:ijms22041568. [PMID: 33557249 PMCID: PMC7913980 DOI: 10.3390/ijms22041568] [Citation(s) in RCA: 57] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 01/29/2021] [Accepted: 02/01/2021] [Indexed: 02/07/2023] Open
Abstract
Bone is a multi-skilled tissue, protecting major organs, regulating calcium phosphate balance and producing hormones. Its development during childhood determines height and stature as well as resistance against fracture in advanced age. Estrogens are key regulators of bone turnover in both females and males. These hormones play a major role in longitudinal and width growth throughout puberty as well as in the regulation of bone turnover. In women, estrogen deficiency is one of the major causes of postmenopausal osteoporosis. In this review, we will summarize the main clinical and experimental studies reporting the effects of estrogens not only in females but also in males, during different life stages. Effects of estrogens on bone involve either Estrogen Receptor (ER)α or ERβ depending on the type of bone (femur, vertebrae, tibia, mandible), the compartment (trabecular or cortical), cell types involved (osteoclasts, osteoblasts and osteocytes) and sex. Finally, we will discuss new ongoing strategies to increase the benefit/risk ratio of the hormonal treatment of menopause.
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Affiliation(s)
- Emmanuelle Noirrit-Esclassan
- I2MC, INSERM UMR 1297, University of Toulouse III, F-31000 Toulouse, France; (E.N.-E.); (M.-C.V.); (F.T.); (J.-F.A.); (F.L.); (C.F.)
- Department of Pediatric Dentistry, Faculty of Dental Surgery, University of Toulouse III, F-31000 Toulouse, France
| | - Marie-Cécile Valera
- I2MC, INSERM UMR 1297, University of Toulouse III, F-31000 Toulouse, France; (E.N.-E.); (M.-C.V.); (F.T.); (J.-F.A.); (F.L.); (C.F.)
- Department of Pediatric Dentistry, Faculty of Dental Surgery, University of Toulouse III, F-31000 Toulouse, France
| | - Florence Tremollieres
- I2MC, INSERM UMR 1297, University of Toulouse III, F-31000 Toulouse, France; (E.N.-E.); (M.-C.V.); (F.T.); (J.-F.A.); (F.L.); (C.F.)
- Menopause and Metabolic Bone Disease Center, Hôpital Paule de Viguier, University Hospital of Toulouse, F-31000 Toulouse, France
| | - Jean-Francois Arnal
- I2MC, INSERM UMR 1297, University of Toulouse III, F-31000 Toulouse, France; (E.N.-E.); (M.-C.V.); (F.T.); (J.-F.A.); (F.L.); (C.F.)
| | - Françoise Lenfant
- I2MC, INSERM UMR 1297, University of Toulouse III, F-31000 Toulouse, France; (E.N.-E.); (M.-C.V.); (F.T.); (J.-F.A.); (F.L.); (C.F.)
| | - Coralie Fontaine
- I2MC, INSERM UMR 1297, University of Toulouse III, F-31000 Toulouse, France; (E.N.-E.); (M.-C.V.); (F.T.); (J.-F.A.); (F.L.); (C.F.)
| | - Alexia Vinel
- I2MC, INSERM UMR 1297, University of Toulouse III, F-31000 Toulouse, France; (E.N.-E.); (M.-C.V.); (F.T.); (J.-F.A.); (F.L.); (C.F.)
- Department of Periodontology, Faculty of Dental Surgery, University of Toulouse III, F-31000 Toulouse, France
- Correspondence: ; Tel.: +33-5-61-77-36-10
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