Clinical equivalence of intranasal and oral 17β-estradiol for postmenopausal symptoms

The aim of this study was to demonstrate clinical equivalence between a novel intranasal estradiol formulation and a reference oral drug. In this multinational, double-blind, parallel-group study 659 postmenopausal women with moderate to severe postmenopausal symptoms were randomly assigned to receive either 300 γ/d intranasal 17β-estradiol (S21400) or 2 mg/d oral micronized estradiol, plus the appropriate placebo, for 24 weeks. All patients also received 10 mg/d dydrogesterone for 14 days per 28-day cycle. Adjustment of intranasal dosage was permitted from week 14 on. The primary efficacy criterion was the Kupperman index at week 14, with a predefined limit of equivalence of 4. Kupperman index scores improved similarly in the 2 groups, from 28.4 ± 6.2 to 10.0 ± 8.6 (mean ± SD) for S21400 and from 28.1 ± 6.0 to 8.9 ± 8.0 for oral therapy, with a difference between groups at week 14 of 1.1 ± 0.6 (90°/a confidence interval, 0.0 to 2.2). This was below the predefined equivalence limit of +4 for statistical noninferiority (P < .001). The daily number and intensity of hot flushes decreased similarly in the two treatment groups. Withdrawal bleeding was 20% less frequent with intranasal therapy (90% confidence interval, 12.5 to 27.6). Severe mastalgia was less frequent in the S21400 group (1.0%) than in the group with oral therapy (5.2%; P < .01). Triglyceride and angiotensinogen levels increased significantly with oral therapy but not with S21400. The same number of patients required dose adaptation in the 2 groups (approximately 20%). Intranasal administration of 300 gg/d estradiol was at least as effective as oral administration of 2 mg/d estradiol in alleviating postmenopausal symptoms, with less frequent mastalgia and uterine bleeding and without the metabolic consequences of the first-pass effect.