The Vaginal Health Trial

The Menopause Strategies: Finding Lasting Answers for Symptoms and Health (MsFLASH) Clinical
Trials network was established in 2009. By the end of 2014, the network completed 4 clinical
trials testing 7 interventions in approximately 1000 women ages 40-62 with vasomotor (VMS)
and other menopause symptoms.

The current trial will evaluate a relatively understudied area of menopause - vaginal health
and sexual function. This is a 3-arm, randomized, controlled, double-blind, clinical trial
among postmenopausal women ages 45-70.

Our primary aim is to evaluate the effectiveness of ultra-low dose vaginal estradiol (Vagifem
10 mcg), non-hormonal hydrophilic non-prescriptive vaginal gel (Replens) and placebo in
reducing the Most Bothersome Symptom (MBS) severity. Choices for MBS include vulvovaginal
itching, pain, dryness, irritation, or pain with penetration.

Secondary aims include an evaluation of a composite score of vaginal symptoms, sexual
function, treatment satisfaction, menopause quality of life, and objective measures of
genitourinary atrophy. We will also create a biorepository of vaginal and blood specimens. In
a subset of women, we will examine whether treatment response is related to: a) the
post-menopausal vaginal microbiome; b) vaginal mucosal inflammation; and c) reproductive
hormone profiles. The in-depth focus on the mechanisms associated with postmenopausal vaginal
symptoms will use state of the art microbiologic techniques on longitudinally collected
biologic specimens and will guide future translational studies.

Inclusion Criteria

- Females aged 45-70 years

- 2 or more years since last natural menstrual period, or surgical menopause (bilateral
oophorectomy)

- At least 1 vaginal symptom (inside or outside the vagina) reported from the following
list, experienced in the past 30 days which is moderate or severe:

- Dryness at least once a week

- Itching at least once a week

- Irritation at least once a week

- Soreness/Pain at least once a week

- Pain associated with sexual activity at least once

- Signed informed consent

Exclusion Criteria

- Current unexplained abnormal genital bleeding (or any unevaluated bleeding since
menopause)

- Currently pregnant, attempting pregnancy or breast feeding

- Current acute vaginal infection (as indicated by wet mount at V1)

- Pelvic or vaginal surgery in prior 60 days

- Antibiotic use in the past 30 days

- Women under age 55 with endometrial ablation

- Women under age 55 with hysterectomy and at least one ovary

- Current cancer treatment (exception basal or squamous skin cell cancers)

- Current or past thromboembolic disease (pulmonary embolus or deep vein thrombosis, not
including thrombophlebitis), myocardial infarction or stroke

- Current severe liver disease

- Current or past breast or endometrial cancer or pre-cancer

- Blood clotting disorder (e.g., Factor V Leiden, prothrombin mutation, protein C,
protein or antithrombin deficiency)

- Porphyria

- Current or past lichen sclerosus or lichen planus

- History of adverse reaction to vaginal estrogen or Replens

- Use of any systemic reproductive hormones (hormonal contraception, postmenopausal
hormone therapies, SERMS) in the past 2 months

- Use of hormonal contraception in the past year

- Use of any type of vaginal estrogen product (however interested women will be allowed
to join the study if they abstain from use during the month preceding enrollment)

- Use of any type of vaginal moisturizer, douche, vaginal prebiotic or probiotic, or
soap in the vagina in the past month (however interested women will be allowed to join
the study if they abstain from use during the month preceding enrollment)

- Unwilling to abstain from use of any non-study vaginal moisturizer, vaginal estrogen,
douche, or soap in the vagina throughout the trial

- Unable to follow instructions, complete questionnaires, or physically unable to place
product in the vagina

- Current participation in another drug trial or intervention study

- Chronic vulvo-vaginal symptoms in the 5 years before menopause (defined as a vaginal
or vulvar condition requiring more than 4 visits to a health care provider in a given
year)