Disclosures Intira Sriprasert, Howard Hodis and Wendy Mack - PDF document

Effect of Estradiol Dose and Serum Estradiol Levels on Metabolic Measures in Early and Late Postmenopausal Women in the REPLENISH trial Effect of Estradiol Dose and Serum Estradiol Levels on Metabolic Measures in Early and Late Postmenopausal Women in the REPLENISH trial Intira Sriprasert 1,2 , Howard N. Hodis 1,3,4 , Brian Bernick 5 , Sebastian Mirkin 5 , Wendy J. Mack 1,4 1 Department of Preventive Medicine, Keck School of Medicine, University of Southern California 2 Department of Obstetrics and Gynecology , Faculty of Medicine, Chiang Mai University , Thailan d, 3 Department of Medicine, Keck School of Medicine, University of Southern California 4 Atherosclerosis Research Unit, Keck School of Medicine, University of Southern California, 5 TherapeuticsMD, Boca Raton, FL. Disclosures Intira Sriprasert, Howard Hodis and Wendy Mack • • Received an unrestricted research grant from TherapeuticsMD Brian Bernick and Sebastian Mirkin • • Employees of TherapeuticsMD • Own company stock/stock options 2 Sriprasert I. NAMS 2019 presentation on Sept 27, 2019 1

Effect of Estradiol Dose and Serum Estradiol Levels on Metabolic Measures in Early and Late Postmenopausal Women in the REPLENISH trial Hormone Therapy & Cardiovascular Disease • Hormone therapy (HT) timing hypothesis • Women who initiate HT at younger age or sooner after menopause have reduced risk of cardiovascular disease (CVD) and all-cause mortality compared with placebo. Effect of HT compared with placebo Meta-analysis: < 60 yrs ≥ 60 yrs < 10 yrs-since-menopaus e ≥ 10 yrs-since-menopause Coronary heart disease RR=0.52 RR=1.07 (0.29, 0.96) (0.96, 1.20) ELITE trial: < 6 yrs-since-menopause ≥ 10 yrs-since-menopause -3.45 um/yr 1.17 um/yr Atherosclerosis progression rate (-5.99, -0.91) (-0.98, 3.31) Boardman HMP , et al. Cochrane Database of Systematic Reviews 2015. Hodis HN, et al. NEJM 2016;374(13):1221-31. 3 Hormone Therapy & Metabolic Measures • High-density lipoprotein cholesterol (HDL) HT • Triglycerides (TRIG) Estrogen in the Prevention of Atherosclerosis (EPAT) trial: Higher HDL and lower LDL explained 30% of E2 therapy benefit on atherosclerosis progression • T otal cholesterol (CHOL) HT • Low density lipoprotein cholesterol (LDL) • Fasting blood glucose (GLUC) Salpeter SR, Diabetes Obes Metab, 2006;8:538-554. Hodis et al. NEJM 2003;349(6):535-45. Karim R, et al. JCEM 2008;93(1):131-8 4 Sriprasert I. NAMS 2019 presentation on Sept 27, 2019 2

Effect of Estradiol Dose and Serum Estradiol Levels on Metabolic Measures in Early and Late Postmenopausal Women in the REPLENISH trial Objectives 1. To identify the association of E2 dose and serum E2 level with change of metabolic measures E2 dose Change of metabolic measures Serum E2 levels Total cholesterol (CHOL) Low-density lipoprotein cholesterol (LDL) High-density lipoprotein cholesterol (HDL) Triglyceride (TRIG) Fasting blood glucose (GLUC) 2. To compare these associations in early and late postmenopausal women EARL Y postmenopause LATE postmenopause (< 6 years-since-menopause) vs. (≥ 10 years-since-menopause) 5 REPLENISH Trial Randomized, double-blinded, placebo-controlled trial • Tested HT efficacy and safety • 1 year intervention and follow-up • Healthy postmenopausal women 40-65 years with a uterus • Combined oral estradiol (E2) and progesterone (P4) or placebo 0.25 mg + 50 mg 0.5 mg + 50 mg 0.5 mg + 100 mg 1 mg + 100 mg Mirkin S, et al. Maturitas 2015 May;81(1):28-35. Lobo RA, et al. Obstet and gynecol 2018 Jul;132(1):161-70. 6 Sriprasert I. NAMS 2019 presentation on Sept 27, 2019 3

Effect of Estradiol Dose and Serum Estradiol Levels on Metabolic Measures in Early and Late Postmenopausal Women in the REPLENISH trial Analysis Population • REPLENISH participants • Available data at baseline and at least one follow-up visit • Randomized E2 dose • Serum E2 level • Metabolic measures • Early postmenopause ( < 6 years-since-menopause ) • Late postmenopause ( ≥ 10 years-since-menopause ) • The cut points were derived from differential effect of HT on CVD demonstrated in primate and human studies. Mikkola TS, et al. Ann Med 2004;36(6):402-13. Hodis HN, et al. NEJM 2016;374(13):1221-31. 7 Measurements At baseline, 3, 6, 9 and 12 months Randomized E2 dose • 0 mg, 0.25 mg, 0.5 mg and 1 mg Serum E2 levels • A single GC-MS/MS method Serum P4 levels • A single LC-MS/MS method Metabolic measures • At least 8-hour fasting blood sample • CHOL, LDL, HDL, TRIG and GLUC Mirkin S, et al. Maturitas 2015 May;81(1):28-35. 8 Sriprasert I. NAMS 2019 presentation on Sept 27, 2019 4

Effect of Estradiol Dose and Serum Estradiol Levels on Metabolic Measures in Early and Late Postmenopausal Women in the REPLENISH trial Statistical Analysis Baseline characteristics • Two-sample t-test or chi-square test Associations of E2 dose and serum E2 level with change of metabolic measures • Mixed-effects linear models Associations were expressed per • 0.25 mg increase of E2 dose • 1 pg/ml increase in serum E2 level 9 Table Baseline characteristics of women by postmenopausal strata Early Late postmenopause postmenopause p N=1216 N=297 > Age (years) 53.2 (3.7) 58.4 (4.1) <0.0001 Years-since-menopause 2.4 (1.7) 14.1 (3.9) <0.0001 Body mass index(kg/m 2 ) 26.8 (4.0) 26.7 (4.2) 0.90 Race White 806 (66.45) 185 (62.71) African American 377 (31.08) 107 (36.27) 0.19 Other 30 (2.47) 3 (2.02) < Serum E2 level (pg/ml) 6.64 (7.24) 5.28 (3.34) 0.002 Serum P4 level (pg/ml) 59.94 (94.45) 54.13 (15.45) 0.29 Continuous variables reported as mean(standard deviation), t-test Categorical variables reported as frequency (percent), χ 2 test 10 Sriprasert I. NAMS 2019 presentation on Sept 27, 2019 5

Effect of Estradiol Dose and Serum Estradiol Levels on Metabolic Measures in Early and Late Postmenopausal Women in the REPLENISH trial Figure 1 Estimated change from baseline of metabolic measures per 0.25 mg increase in E2 dose by postmenopausal strata ** ** ** ** ** ** significant CHOL HDL LDL TRIG GLUC different association 3.67 between early and Change from baseline late postmenopause * (mg/dl) 0.78 0.39 0.04 * significant -0.26 -0.37 -0.48 -0.84 association with -1.34 E2 dose -1.49 * * Early postmenopause Late postmenopause Estimates are from mixed effects models adjusted for baseline metabolic measure, serum P4 level and use of lipid-lowering medication 11 Figure 2 Estimated change from baseline of metabolic measures per 1 pg/ml increase in serum E2 level by postmenopausal strata CHOL HDL LDL TRIG GLUC 0.09 0.08 Change from baseline 0.02 (mg/dl) 0.001 * significant -0.02 -0.02 association with * -0.05 -0.05 -0.05 serum E2 level * * -0.09 Early postmenopause Late postmenopause Estimates are from mixed effects models adjusted for baseline metabolic measure, serum P4 level and use of lipid-lowering medication 12 Sriprasert I. NAMS 2019 presentation on Sept 27, 2019 6

Effect of Estradiol Dose and Serum Estradiol Levels on Metabolic Measures in Early and Late Postmenopausal Women in the REPLENISH trial Discussion E2 dose • • With higher E2 dose, CHOL and LDL was decreased and HDL was increased in EARLY postmenopausal women. • Meta-analysis: Dose-dependent E2 effects on lipids levels • Significant lower CHOL and LDL with conventional-dose estrogen compared to low-dose estrogen. CHOL (mg/dl) LDL (mg/dl) -5.50 (-0.88, -9.21) -4.49 (-0.59, -8.39) Mean difference (conventional-dose estrogen minus low-dose estrogen) Casanova G, et al. JCEM 2015 Mar;100(3):1028-37. 13 Discussion E2 dose • • More favorable effect of E2 dose on CHOL, LDL and HDL among early compared with late postmenopausal women. • Estrogen in the Prevention of Atherosclerosis (EPAT) Trial: Higher HDL and lower LDL explained 30% of E2 therapy benefit on atherosclerosis progression. • Early versus Late Intervention Trial with Estradiol (ELITE): Beneficial E2 effect on atherosclerosis progressionin early but not late postmenopausal women. Hodis et al. NEJM 2003;349(6):535-45. Karim R, et al. JCEM 2008;93(1):131-8. Hodis HN, et al. NEJM 2016;374(13):1221-31. 14 Sriprasert I. NAMS 2019 presentation on Sept 27, 2019 7

Effect of Estradiol Dose and Serum Estradiol Levels on Metabolic Measures in Early and Late Postmenopausal Women in the REPLENISH trial Discussion Why did we observe differential effects on metabolic • measures between early and late postmenopausal women with E2 dose but not serum E2 level ? E2 dose Serum E2 level • Further exploration of determinants of attained serum E2 level in response to E2 dose is needed. 15 Discussion Strengths • • Randomized clinical trial data • Different E2 doses (0 mg, 0.25 mg, 0.5 mg, 1 mg) • Longitudinal follow-up Limitations • • Smaller sample size of late postmenopausal women 16 Sriprasert I. NAMS 2019 presentation on Sept 27, 2019 8