Abstract
Background
Dehydroepiandosterone (DHEA) is helpful for treating vaginal symptoms. This secondary analysis evaluated the impact of vaginal DHEA on hormone concentrations, bone turnover and vaginal cytology in women with a cancer history.
Methods
Postmenopausal women, diagnosed with breast or gynecologic cancer, were eligible if they reported at least moderate vaginal symptoms. Participants could be on tamoxifen or aromatase inhibitors (AI’s). Women were randomized to 3.25 versus 6.5 mg/d of DHEA versus a plain moisturizer (PM) control. Sex steroid hormone levels, biomarkers of bone formation, vaginal pH and maturation index were collected at baseline and 12 weeks. Analysis included independent t-tests and Wilcoxon rank tests, comparing each DHEA arm with the control.
Results
345 women contributed evaluable blood and 46 contributed evaluable cytology and pH values. Circulating DHEA-S and testosterone levels were significantly increased in those on vaginal DHEA in a dose dependent manner compared to PM. Estradiol was significantly increased in those on 6.5 mg/d DHEA but not 3.25 mg/d (p<.05; p=.05, respectively), and not in those on AI’s. Biomarkers of bone formation were unchanged in all arms. Maturation of vaginal cells was 100% (3.25 mg/d), 86% (6.5 mg/d) and 64% (PM); pH decreased more in DHEA arms.
Conclusion
DHEA resulted in increased hormone concentrations, though still in the lowest half or quartile of the postmenopausal range, and provided more favorable effects on vaginal cytology, compared to PM. Estrogen concentrations in women on AI’s were not changed. Further research on the benefit of vaginal DHEA is warranted in hormone dependent cancers.
Background
Menopause results in reduced concentrations of circulating estradiol in the female body and can be accompanied by many symptoms, such as vaginal dryness and dyspareunia1,2. Treatment for hormone sensitive breast cancer often seeks to largely deplete estradiol concentrations, sometimes by blocking aromatase, an enzyme necessary for estrogen conversion. This treatment can add to the extent and severity of menopausal symptoms, particularly vaginal symptoms such as dryness and dyspareunia3,4. Vaginal symptoms due to estrogen deprivation do not spontaneously resolve, in contrast to hot flashes, as there is a cumulative detrimental effect on the vaginal tissues over time5,2.
The relationship between estrogen deprivation and worsening vaginal symptoms over time is due to the major role that estrogen and estrogen receptors play in vaginal architecture6,7. The vaginal wall contains squamous epithelium, a lamina propria, a smooth muscle layer and a covering membrane, all of which are influenced by estrogen. The role of estradiol is multi-faceted and includes maintaining the fluid film that lines the vaginal walls, keeping the epithelium dense with more mature cells, keeping vaginal smooth muscle functional, and contributing to tissue elasticity6. Additionally, estrogen is responsible for vasodilatation in the lamina propria and promotes the expression of various neurotransmitters that ultimately result in increased blood flow6,7.
Without estrogen, the vagina undergoes changes that can negatively impact sexual function and satisfaction. The more mature epithelial cells decrease while less mature parabasal cells become the major cytology. Collagen, blood flow, and lubrication decrease, resulting in an inflexible network of dry cells with a higher pH; this leads to an increased susceptibility to infection and itching, and an uncomfortable sensation of dryness8. The smooth muscle becomes less functional, challenging orgasm. Intercourse can become painful, with friable tissues subject to bleeding and trauma. Upon visual inspection, an atrophic vagina appears thin and pale, with a parched epithelium. The vagina appears shorter, with a loss of rugae, elasticity and decreased secretions8,9.
Based on the important role of estrogen in the vagina, the gold standard treatment for vaginal symptoms has been localized estrogen10. However, vaginal estrogen may not a desirable option for some women, including women who are concerned about cancer risk and those with estrogen-sensitive tumors. Even low doses of vaginal estrogen have resulted in significant increases in systemic concentrations11–13 or effects outside of the vagina; after 6–12 months of 7.5 micrograms of vaginal estrogen there are improvements in lipid profiles14 and/or reductions in biomarkers of bone turnover15. These “off target”, outside of the vagina effects (such as effects on lipids, bones), may occur in the absence of detectable or clinically important increases in serum concentrations and are a theoretical risk for women with hormone sensitive cancer as estrogen can bind to receptors in any tissue, including the breast14,15. Consequently, effective treatments for vaginal symptoms that do not result in estrogenic systemic activity would be a welcome option for many women, particularly those on aromatase inhibitors, as safe levels of estradiol concentration increases have not been established16.
Dehydroepiandosterone (DHEA) is a vaginal treatment that has been studied in over 500 postmenopausal women17–19; it is believed to act locally to improve symptoms, without influencing systemic physiology20. DHEA is made by the adrenal gland and decreases with aging, not specifically with menopause. After menopause, DHEA is a major source of sex steroid hormones21. The Food and Drug Administration recently approved a DHEA ovule for the treatment of dyspareunia in postmenopausal women with the genitourinary syndrome of menopause. The ovule, or any other type of vaginal DHEA, had not previously been studied in women with a history of breast or gynecologic cancer.
The purpose of this paper is to report secondary physiologic outcomes from a phase III randomized, controlled clinical trial designed to evaluate two doses of a compounded vaginal DHEA gel for the improvement of vaginal symptoms, dryness or dyspareunia, in women with a history of breast or gynecologic cancer. The paper reporting the primary clinical endpoint related to symptom improvement, overall sexual function, and side effects is being published separately. Currently in this paper, we evaluate the impact of vaginal DHEA on 1) circulating sex steroid concentrations (estradiol, estrone, free and total testosterone, and DHEA-S), 2) markers of bone formation (osteocalcin and bone alkaline phosphatase), and 3) vaginal cytology, specifically maturation index and pH.
Methods
Population and design
These data were collected as part of a phase III randomized controlled trial evaluating two doses (3.25 mg/d and 6.5 mg/d) of vaginal DHEA compared to a plain moisturizer (PM). Eligibility criteria included women who reported problems with either vaginal dryness or dyspareunia, were postmenopausal, had a history of breast or gynecologic cancer, completed curative intent treatment and had no evidence of disease. Participants could be on endocrine therapy (tamoxifen or aromatase inhibitors) but had to be on it for the past two months without planned changes. Women could not be using vaginal products other than water-based lubricants during intercourse, nor could they be using any oral or transdermal hormonal products (i.e., estrogen), including soy or compounded hormones. They could not have had prior or current radiation therapy to the pelvis nor have had any active vaginal infections. All women were asked to provide a blood sample at baseline and at 12 weeks. Additionally, a small subset of accruing sites volunteered to participate in vaginal cytology collection and vaginal pH measurement.
Intervention and control
The vaginal DHEA was developed by a compounding pharmacist under the IND number 111454. The contents of the compounded base contained carbomer, squalane, vitamin E, and glycerin and was intended to act as a bioadhesive. DHEA was added to this base to provide 3.25 mg/d and 6.5 mg/d gels, while the PM arm consisted of the compounded bioadhesive base alone. Participants were instructed to use one prefilled syringe every night, after any sexual activity, if applicable, for the entire 12 weeks.
Physiologic endpoints
The evaluated physiologic endpoints included local effects on the vagina, specifically vaginal maturation index (VMI) and vaginal pH, systemic effects on serum sex steroid hormone concentrations: estradiol, estrone, free and total testosterone, dehydroepiandrosterone-sulfate (DHEA-S), and “off target” effects, specifically biomarkers of bone formation: osteocalcin and bone alkaline phosphatase. These data were collected at baseline (before the start of the study treatment), and at the end of 12 weeks of treatment. Thirty mL (no additive) and 10 mL (EDTA) of whole blood weredrawn and shipped on the same day with a cold pack to Mayo Clinic, Rochester, MN where blood was processed into serum and plasma, respectively, and frozen at −80°C until the assays were performed. All labs were performed by CLIA-approved Mayo Research Laboratories, using well validated assays. Sex steroid hormone concentrations were measured to evaluate systemic absorption through vaginal tissue and explore mechanisms of action. Bone formation biomarkers were included as a surrogate measure to evaluate activity outside of the vagina, as increases in circulating estrogens improve biomarkers of bone turnover, both formation and resorption22,23.
Vaginal cytology collection kits, consisting of pH papers (Baker pHIX) and a bottle of PreservCyt (Thin Prep), were provided to the subset of institutions participating in this collection. The vaginal cytology collection process included a vaginal exam, recording of the vaginal pH, and collection of vaginal cells. To collect pH, a pH indicator strip was held to the lateral wall of the mid portion of the vagina until fully moistened and color changed (15–30 seconds). The corresponding pH value was recorded on a data sheet included in the kit. While the speculum was still open, the rounded end of a spatula was used to gently scrape cells from the lateral wall of the middle portion of the vagina, opposite from the side used for pH sampling. The spatula was inserted into the Thin Prep container and gently stirred back and forth to dislodge the cells24,25. The specimen was mailed to the Mayo Clinic for central pathology review. The cytological specimens were all read by the same pathologist who was blinded to the treatment assignment.
Statistical analysis
To evaluate the impact of vaginal DHEA on estradiol, estrone, free and total testosterone, DHEA-S, and markers of bone formation (osteocalcin and bone alkaline phosphatase), changes were calculated in each of the above biomarkers from baseline to 12 weeks. Two independent sample t-tests were performed, comparing each DHEA treatment arm in turn, to the PM arm. Subset analyses were also performed, comparing biomarker concentrations between those on AI’s and those not on AI’s. Differences at baseline in sex steroid hormone concentrations between those on and not on AI’s were also analyzed with a Wilcoxon or an equal variance t-test, as appropriate.
To evaluate the impact of vaginal DHEA on the vaginal maturation index, due to the small numbers of women who participated in the vaginal cytology collection, we did not perform statistical analyses for VMI. Rather, we calculated the number and percent of women who had increases in the percentage of intermediate and superficial cells as opposed to parabasal cells. With regard to the pH, mean values were calculated from the recorded pH values and the change from baseline in these mean values was calculated. Descriptive data for pH are reported without performing statistical tests, due to the low number of participants in this portion of the study.
Results
Eighty institutions contributed blood specimens, representing 345 participants across the three arms who had evaluable specimens at baseline and after 12 weeks; eight institutions participated in collecting vaginal tissue/pH, representing 46 women who had evaluable data. The CONSORT diagram is shown in Figure 1. The demographic characteristics of those who contributed blood specimens for the systemic effects are identical to those reported in the manuscript about the primary outcome. A majority of women (97%) had a history of breast cancer, with 2% having a history of ovarian cancer and 1% with a history of endometrial cancer. The mean age was 57 years and 95% were white. A majority of the women were on an AIs (56%) and had been on that therapy for a mean of almost 2 years. Demographic characteristics of those who contributed vaginal cytology at both data points, baseline and 12 weeks, are listed in Table 1.
Figure 1.
CONSORT diagram
Table 1.
Demographics of those providing evaluable vaginal cytology
| 3.25 DHEA (mcg/dL) (N=14) |
6.5 DHEA (mcg/dL) (N=17) |
Plain Moisturizer (N=15) |
P-value | |
|---|---|---|---|---|
| Type of Cancer | ||||
| Breast | 14 (100%) | 16 (94.17%) | 13 (86.7 | 0.20082 |
| Ovarian | 0 (0.0%) | 1 (5.9%) | 0 (0.0%) | |
| Endometrial | 0 (0.0%) | 0 (0.0%) | 2 (13.3%) | |
| Age (years) | 57.7 ± 6.4 | 59.2 ± 4.6 | 61.0 ± 4.2 | 0.28201 |
| Race | ||||
| White | 13 (92.9%) | 13 (76.5%) | 13 (86.7%) | 0.40442 |
| Black or African American | 0 (0.0%) | 3 (17.6%) | 1 (6.7%) | |
| Not reported: patient refused, unsure | 1 (7.1%) | 1 (5.9%) | 1 (6.7%) | |
| Oophorectomy | ||||
| Single | 2 (14.3%) | 0 (0.0%) | 0 (0.0%) | 0.37392 |
| Bilateral | 5 (35.7%) | 6 (35.3%) | 5 (33.3%) | |
| Chemical ovarian ablation | 1 (7.1%) | 0 (0.0%) | 1 (6.7%) | |
| Naturally menopausal | 6 (42.9%) | 11 (64.7%) | 9 (60.0%) | |
| Current Tamoxifen Therapy (yes) | 2 (14.3%) | 3 (17.6%) | 1 (6.7%) | 0.64582 |
| Concurrent Aromatase Inhibitor Use | ||||
| Anastrozole/letrozole | 7 (50.0%) | 6 (35.3%) | 7 (46.7%) | 0.67302 |
| Exemestane | 1 (7.1%) | 2 (11.8%) | 0 (0.0%) | |
| None | 6 (42.9%) | 9 (52.9%) | 8 (53.3%) | |
| Current Endocrine Therapy (months) | 19.4 ± 16.4 | 23.9 ± 14.4 | 21.0 ± 21.7 | 0.69501 |
| Duration of Vaginal Dryness (months) | 41.0 ± 40.9 | 57.4 ± 56.3 | 69.9 ± 75.3 | 0.50211 |
| Previous (not current) Hormonal Therapy | ||||
| Tamoxifen | 3 (21.4%) | 5 (29.4%) | 2 (13.3%) | 0.64432 |
| Anastrozole/letrozole | 3 (21.4%) | 3 (17.6%) | 3 (20.0%) | |
| Exemestane | 2 (14.3%) | 2 (11.8%) | 0 (0.0%) | |
| None | 6 (42.9%) | 7 (41.2%) | 10 (66.7%) | |
| Prior Endocrine Therapy (months) | 41.3 ± 40.6 | 26.4 ± 24.0 | 43.3 ± 37.6 | 0.66131 |
| Previous Adjuvant Chemotherapy (yes) | 8 (57.1%) | 9 (52.9%) | 7 (46.7%) | 0.85012 |
| Cigarette Smoking | ||||
| Current | 0 (0.0%) | 2 (11.8%) | 1 (6.7%) | 0.22162 |
| Past | 8 (57.1%) | 7 (41.2%) | 3 (20.0%) | |
| Never | 6 (42.9%) | 8 (47.1%) | 11 (73.3%) |
Kruskal Wallis
Chi Square
Data are given as mean ± SD or n (%).
Hormone and bone formation biomarker concentrations before the intervention, at 12 weeks and changes from baseline are shown in Table 2. For the group as a whole, DHEA-S levels increased in a dose-dependent manner for those receiving DHEA and were significantly different from the PM group. The change from baseline to 12 weeks in estrone and testosterone (total and free) concentrations also significantly differed from PM for both doses of DHEA. For estradiol, only the 6.5 mg/d DHEA dose demonstrated a statistically significant increase compared with PM (p<.05). Bone formation biomarkers were not significantly changed, irrespective of arm (Table 2).
Table 2.
Concentrations of sex steroid hormones and biomarkers of bone turnover at baseline and 12 weeks; change from baseline to week 12 (numbers are rounded)
| Variable | Plain Moisturizer N=118 |
3.25 DHEA (mcg/dL) N=117 |
6.5 DHEA (mcg/dL) N=110 |
|
|---|---|---|---|---|
| DHEA-S (mcg/dL) | ||||
| Baseline | 70.3 ± 41.9 | 80.5 ± 47.7 | 74.7 ± 50.8 | |
| At 12 weeks | 70.3 ± 46.6 | 96.2 ± 52.2*** | 103.4 ± 56.3*** | |
| Change from baseline | 0 | 15.7 ± 27.2* | 28.8 ± 31*** | |
| Estradiol (pg/mL) | ||||
| Baseline | 3.5 ± 2.3 | 3.6 ± 2.5 | 3.6 ± 2.3 | |
| At 12 weeks | 3.7 ± 3.3 | 4.7 ± 6.4 | 4.0± 2.8 | |
| Change from baseline | 0.2 ± 2.5 | 0.9 ± 5.0 | 0.6 ± 1.9§ | |
| Estrone (pg/mL) | ||||
| Baseline | 11 ± 10.5 | 10.7 ± 11.7 | 10.9 ± 10.4 | |
| At 12 weeks | 11.2 ± 11.3 | 13.4 ± 16.7 | 13.8 ± 14.5 | |
| Change from baseline | 0.2 ± 4.4 | 2.0 ± 6.6§ | 3.4 ± 8.3** | |
| Total Testosterone (ng/dL) | ||||
| Baseline | 17.8 ± 9.6 | 16.8 ± 8.7 | 16.4 ± 10.7 | |
| At 12 weeks | 17.6 ± 9.1 | 21.1 ± 10.9** | 24.7 ± 13.1*** | |
| Change from baseline | −0.1 ± 5.6 | 4.4 ± 6.3*** | 8.3 ± 10.5*** | |
| Free Testosterone (ng/dL) | ||||
| Baseline | 0.3 ± 0.2 | 0.3 ± 0.2 | 0.3 ± 0.2 | |
| At 12 weeks | 0.3 ± 0.2 | 0.5 ± 0.3** | 0.5 ± 0.3*** | |
| Change from baseline | 0 ± 0.2 | 0.1 ± 0.2*** | 0.2 ± 0.2*** | |
| Bone Alkaline Phosphatase (mcg/L) | ||||
| Baseline | 33 ± 11.5 | 32.2 ± 13.5 | 31.6 ± 11.9 | |
| At 12 weeks | 34.6 ± 12.9 | 35.5 ± 14.5 | 32.9 ± 12 | |
| Change from baseline | 1.6 ± 7.4 | 3.3 ± 9.3 | 1.3 ± 8.4 | |
| Osteocalcin (ng/mL) | ||||
| Baseline | 20.1 ± 8.9 | 20.6 ± 8.7 | 19.9 ± 8.6 | |
| At 12 weeks | 20.5 ± 9.5 | 20.4 ± 8.8 | 19.6 ± 8.8 | |
| Change from baseline | 0.4 ± 5.1 | −0.2 ± 5.7 | −0.1 ± 4.9 | |
p<0.0001,
p<0.001,
p<0.01,
p<0.05
Asterisks and symbols indicating significant p-values in the 3.25 mg DHEA (mcg/dL) column refer to 3.25 DHEA (mcg/dL) vs. Plain Moisturizer.
Asterisks and symbols indicating significant p-values in the 6.5 mg DHEA (mcg/dL) column refer to 6.5 DHEA (mcg/dL) vs. Plain Moisturizer.
Data are given as mean ± SD
When hormone concentrations were evaluated by whether women were on aromatase inhibitors, there were significant differences at baseline for estradiol and estrone, both being higher in those not on aromatase inhibitors (Table 3). At baseline, there were significantly higher concentrations of DHEA-S, free testosterone, bone alkaline phosphatase and osteocalcin in women who were on AIs; total testosterone concentrations were not significantly different. After 12 weeks on their assigned treatment, there were no significant increases in either estradiol or estrone concentrations among women taking AIs compared to PM, as opposed to significant increases in these concentrations in the women who were not taking an AI compared to PM (Table 4).
Table 3.
Differences in hormone and biomarker concentrations at baseline between those on aromatase inhibitors and those not on aromatase inhibitors
| Hormone-biomarker | NO AI (n=159) Median concentrations |
AI (N=186) Median concentrations |
P-value |
|---|---|---|---|
| DHEA-S (mcg/dL) | 59 | 69.5 | 0.02 |
| Estradiol (pg/mL) | 3.8 | 2.4 | <0.0001 |
| Estrone (pg/mL) | 18 | 2.4 | <0.0001 |
| Free testosterone (ng/dL) | 0.2 | 0.3 | 0.0038 |
| Total testosterone (ng/dL) | 14.5 | 15 | 0.5535 |
| Bone alkaline phosphatase (mcg/L) | 28.3 | 32.7 | 0.0004 |
| Osteocalcin (ng/mL) | 17.4 | 19.4 | 0.0005 |
Table 4.
Concentrations of sex steroid hormones and biomarkers of bone turnover at baseline and 12 weeks, and change from baseline to week 12 by AI use
| Variable | Plain Moisturizer | 3.25 DHEA (mcg/dL) | 6.5 DHEA (mcg/dL) | ||||
|---|---|---|---|---|---|---|---|
| AI N=61 |
No AI N=57 |
AI N=67 |
No AI N=50 |
AI N=58 |
No AI N=52 |
||
| DHEA-S (mcg/dL) | |||||||
| Baseline | 75 ± 40.2 | 65.3 ± 43.4 | 84.8 ± 46.8 | 74.7 ± 48.7 | 77.8± 50.4 | 71.1 ± 51.5 | |
| At 12 weeks | 73.4 ± 39 | 66.9 ± 53.7 | 96.1 ± 49.8 | 96.2 ± 55.8 | 101.9 ± 58.4 | 105.1 ± 54.5 | |
| Change from baseline | −1.6 ± 17.2 | 1.6 ± 37.5 | 11.4 ± 19.7** | 21.6 ± 34.2** | 24.1 ± 34.1** | 34 ± 26.4** | |
| Estradiol (pg/mL) | |||||||
| Baseline | 2.6 ± 0.6 | 4.5 ± 2.9 | 2.4 ± 0.1 | 5.2 ± 3.2 | 2.8 ± 1.7 | 4.4 ± 2.6 | |
| At 12 weeks | 2.9 ± 3.2 | 4.6 ± 3.2 | 2.4 ± 0.2 | 7.7 ± 8.9 | 2.6 ± 1.3 | 5.8 ± 3.2 | |
| Change from baseline | 0.3 ± 3.3 | 0.1 ± 1.4 | 0 ± 0.3 | 2.1 ± 7.6* | −0.2 ± 0.7 | 1.4 ± 2.4* | |
| Estrone (pg/mL) | |||||||
| Baseline | 3.6 ± 3.8 | 18.8 ± 9.6 | 2.8 ± 1.6 | 21.5 ± 10.8 | 3.9 ± 6.6 | 18.4 ± 8.3 | |
| At 12 weeks | 3.6 ± 4.0 | 19.6 ± 10.7 | 2.7 ± 1.9 | 27.8 ± 16.9 | 3.9 ± 6.6 | 25.6 ± 12.3 | |
| Change from baseline | 0 ± 1.2 | 0.5 ± 6.3 | 0 ± 2.5 | 4.8 ± 9.0* | 0 ± 1.4 | 7.2 ± 10.9** | |
| Total Testosterone (ng/dL) | |||||||
| Baseline | 17.7 ± 9.7 | 18 ± 9.6 | 17 ± 8.9 | 16.4 ± 8.6 | 17.4 ± 12 | 15.2 ± 9.1 | |
| At 12 weeks | 17.3 ± 9 | 18 ± 9.2 | 21 ± 11.1 | 21.1 ± 10.8 | 24.8 ± 13.3 | 24.6 ± 13.1 | |
| Change from baseline | −0.2 ± 6.4 | 0 ± 4.8 | 4.1 ± 5.5* | 4.7 ± 7.3** | 7.4 ± 9.0** | 9.4 ± 11.9** | |
| Free Testosterone (ng/dL) | |||||||
| Baseline | 0.4 ± 0.2 | 0.3 ± 0.2 | 0.4 ± 0.2 | 0.3 ± 0.2 | 0.3 ± 0.2 | 0.3 ± 0.2 | |
| At 12 weeks | 0.4 ± 0.2 | 0.3 ± 0.2 | 0.5 ± 0.3 | 0.4 ± 0.2 | 0.5 ± 0.3 | 0.4 ± 0.2 | |
| Change from baseline | 0 ± 0.2 | 0 ± 0.1 | 0.1 ± 0.2 | 0.1 ± 0.1 | 0.2 ± 0.2 | 0.2 ± 0.2 | |
| Bone Alkaline Phosphatase (mcg/L) | |||||||
| Baseline | 35.2 ± 12.6 | 30.7 ± 9.8 | 34.1 ± 12.9 | 29.7 ± 14.1 | 34.2 ± 12.4 | 28.8 ± 10.7 | |
| At 12 weeks | 36.8 ± 15.4 | 32.4 ± 9.4 | 38 ± 15.4 | 32.1 ± 12.6 | 33.8 ± 12.5 | 32 ± 11.5 | |
| Change from baseline | 1.5 ± 7.8 | 1.7 ± 6.9 | 4.0 ± 10.2 | 2.3 ± 7.9 | −0.4 ± 8.5 | 3.2 ± 7.8 | |
| Osteocalcin (ng/mL) | |||||||
| Baseline | 21.4 ± 9.6 | 18.8 ± 7.9 | 22.1 ± 8.8 | 18.5 ± 8.3 | 21.8 ± 8.9 | 17.9 ± 7.9 | |
| At 12 weeks | 21.9 ± 10.8 | 19 ± 7.8 | 21.7 ± 9.1 | 18.7 ± 8.3 | 21.2 ± 8.9 | 18 ± 8.4 | |
| Change from baseline | 0.5 ± 5.8 | 0.2 ± 4.3 | −0.5 ± 6.0 | 0.2 ± 5.3 | −0.3 ± 6.0 | 0.1 ± 3.3 | |
p<0.001,
p<0.01
Asterisks indicating significant p-values in the 3.25 mg DHEA (mcg/dL) AI column refer to 3.25 DHEA (mcg/dL) AI vs. Plain Moisturizer AI.
Asterisks indicating significant p-values in the 3.25 mg DHEA (mcg/dL) No AI column refer to 3.25 DHEA (mcg/dL) No AI vs. Plain Moisturizer No AI.
Asterisks indicating significant p-values in the 6.5 mg DHEA (mcg/dL) AI column refer to 6.5 DHEA (mcg/dL) AI vs. Plain Moisturizer No AI.
Asterisks indicating significant p-values in the 6.5 mg DHEA (mcg/dL) No AI column refer to 6.5 DHEA (mcg/dL) No AI vs. Plain Moisturizer No AI.
Data are given as mean ± SD.
Cytological effects are shown in Table 5. No woman who received the PM experienced a decrease in pH to a level less than 5, while a small percent of women receiving either dose of vaginal DHEA experienced this level of decrease. In addition, more women on DHEA experienced cell maturation.
Table 5.
Vaginal Cytology Results
| Variable | Plain Moisturizer N=15 |
3.25 DHEA (mcg/dL) N=14 |
6.5 DHEA (mcg/dL) N=17 |
|---|---|---|---|
| pH at baseline | 6.4 | 6.0 | 6.1 |
| pH at week 12 | 5.6 | 5.1 | 5.4 |
| change from baseline to week 12 | −0.65 | −0.69 | −0.72 |
| Baseline pH >5 reduced to pH ≤5 at 12 weeks | 0 (0%) | 4 (9%) | 3 (7%) |
| No intermediate/superficial cells at baseline changed to some intermediate/superficial cells at 12 weeks | 9 (64%) | 14 (100%) | 12 (86%) |
Data are given as mean or n (%).
Discussion
Laboratory data from this clinical trial are consistent with previous studies that demonstrate vaginal tissue is a permeable membrane allowing for both systemic and local dose-dependent effects. Systemic sex steroid hormone concentrations were small and similar to those described by Labrie26. Systemic absorption is best illustrated by the significant increases in systemic DHEA-S concentrations that were dose dependent.
The upper limit of normal for DHEA-S values per Mayo laboratories for a woman aged 50 and 60 are 200 mcg/dL and 157 mcg/dL, respectively. Post-treatment values in both DHEA arms were significantly increased from baseline but still well within the normal range for post-menopausal women.
Post-menopausal estradiol values <10 pg/mL by high sensitivity assay are considered to be low and the post-treatment mean estradiol concentrations in this study remained <5 pg/mL in both DHEA arms. Unexpectedly, however, the estradiol concentration changes from baseline were higher for the 3.25 mg/d DHEA group, with a larger standard deviation, than for the 6.5 mg/d DHEA group, even though the 3.25 mg/d DHEA group was not statistically significantly different from PM. This finding is not consistent with a dose dependent conversion of DHEA to systemic estradiol, and the reason for this is unknown. One possible explanation is that this data may reflect normal variations in estradiol levels within and between individuals.
Estrone is a less potent estrogen than estradiol. The Mayo laboratory postmenopausal reference range for the estrone assay used is 7–40 pg/mL. Mean estrone concentrations after using DHEA increased from baseline but remained in the lower half of the normal postmenopausal range (less than 15 pg/mL).
Neither estradiol nor estrone concentrations changed in women taking AIs and were not significantly different than those on PM. However, women taking AIs who received DHEA experienced the same level of improvement in their vaginal symptoms as those not on AIs27. This finding would support the hypothesis that vaginal DHEA is not working through estrogenic means.
Results of this laboratory analysis support the lack of “off target” effects of vaginal DHEA. Bone turnover biomarkers increase as women age, with post-menopausal values for bone alkaline phosphatase (BAP) being <22 mcg/L, and for osteocalcin being between 9–42 ng/mL. Estrogen based hormone replacement therapy at 12 weeks results in significant improvements in markers of bone formation, BAP and osteocalcin23. BAP values for the women in this study were higher (worse) than usually seen after menopause, both at baseline and at 12 weeks and were even higher at baseline for women who were on AIs28. If vaginal DHEA was having systemic effects on bone, one would expect to see significant decreases for BAP and osteocalcin. This did not occur, with BAP increasing and osteocalcin decreasing minimally. This is consistent with a lack of “off target” bone effects. One limitation of this analysis is that data were not collected about whether women were on bisphosphonates or any other medications that could impact bone health.
Vaginal DHEA did impact androgen concentrations and the increases in androgen levels were consistent with the mild androgen side effects reported in the clinical outcomes27. Total testosterone ranges normally from 8–60 ng/dL in adult women. Total testosterone levels increased statistically significantly with both doses of DHEA, compared to the PM, with larger increases seen in the higher dose arm. However, 12-week total testosterone values remained ≤25 ng/dL in all three arms. Total testosterone is a measure that includes bound testosterone which would generally not have physiologic activity. Free testosterone, that which is not protein bound and is available for physiologic activity, ranges normally from 3–19 ng/dL in women. In this study, mean free testosterone values were very low, <1 ng/dL with a high sensitivity assay, both before and after the study intervention, irrespective of treatment arm.
Given the small but clear increase in systemic androgen concentrations, the safety of increased androgens is at issue with regard to hormone dependent cancers such as breast cancer. Breast tissue does have enzymes required to convert DHEA into both androgens and estrogens, with a bias towards androgen formation in normal breast tissue. Data to date would suggest that the proliferation of both normal and cancerous tissue of the breast results from the balance between the stimulatory effects of estrogen and the inhibitory effects of androgens29,30. There are two opposing perspectives about the safety of androgens, both informed by preclinical data which is not easy to extrapolate to the clinical setting due to complexities of cellular and tissue intracrinology31. In short, the current preclinical data favors a positive impact of androgens on both normal and malignant breast tissue30,32.
In summary, these data support the lack of extra-vaginal physiologic effects, the absence of estradiol conversion in women on aromatase inhibitors, and improved vaginal cytological effects from DHEA. For women with severe vulvovaginal symptoms, DHEA may be helpful in providing cytological improvement which may result in more comprehensive symptom relief. Larger studies to evaluate risks versus benefits in cancer survivors, particularly those on AI’s, are desired.
Acknowledgments
Funding: This work was supported by the National Cancer Institute of the National Institutes of Health [grant UG1CA189823, to the Alliance for Clinical Trials in Oncology NCORP Grant], and also in part by the Public Health Service [grants U10CA025224, U10CA035090, U10CA035101, U10CA035103, U10CA035113, U10CA035119, U10CA035267, U10CA035269, U10CA035415, U10CA035431, U10CA035448, U10CA037404, U10CA037417, U10CA052352, U10CA063848, U10CA063849, U10CA180790, UG1CA189863, and UG1CA189971]. This work was also supported in part by funds from a grant from the Breast Cancer Research Foundation. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Cancer Institute or the National Institutes of Health.
This study was supported by the National Cancer Institute and the Breast Cancer Research Foundation. The work is solely that of that the authors and does not reflect the views of the funding agencies. One of the co-authors, Mike Riepl, has a patent pending on the vaginal dehydroepiandosterone compounded product used in this study. The data is under the control of the Statistics and Data Management group of the Alliance and if required, the data can be produced in support of the analysis described in this paper.
Footnotes
Conflict of Interest:
None of the authors have any conflicts of interest with either of these two funding agencies.
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