The Interaction Between Diabetes and Estradiol on Human Brain Metabolism in Postmenopausal Women
Phase: PHASE1
Conditions: Diabetes Type 2, Dementia
Sponsor: Wake Forest University Health Sciences

 
Protocol – V8.03/16/2021 
FEMALE ESTROGEN MENOPAUSE MIND and ENERGY 
(FEMME): The interaction between diabetes and 
estradiol on human brain metabolism in 
postmenopausal women 
National Clinical Trial (NCT) Identified Number:  NCT03681691 
Principal Investigator: Christina E. Hugenschmidt, PhD 
Sponsor: National Institutes of Health (NIH) 
Funded by: National Institute on Aging (NIA) 
Version Number:  V8.0 
16 MAR 2021 
 
Summary of Changes from Previous Version: 
Affected 
Section(s) 
Summary of Revisions Made 
Rationale 
2.3.1 
Added potential risk of menstrual bleeding. 
Some women have experienced blood flow 
greater than “spotting” and similar to that 
of a monthly period while wearing the 
estrogen patch. This is an expected and 
generally low-risk adverse event that was 
inadvertently omitted from the initial risks 
section. This possibility has been added to 
the “risks” section of the protocol. 

  
Protocol – V8.0 03/16/2021 
ii 
Table of Contents 
STATEMENT OF COMPLIANCE ............................................................................................................................. 1 
1 
PROTOCOL SUMMARY ............................................................................................................................... 1 
1.1 
Synopsis ................................................................................................................................................ 1 
1.2 
Schema ................................................................................................................................................. 2 
1.3 
Schedule of Activities (SoA) ............................................................................................................... 3 
2 
INTRODUCTION ............................................................................................................................................ 3 
2.1 
Study Rationale .................................................................................................................................... 3 
2.2 
Background ........................................................................................................................................... 4 
2.3 
Risk/Benefit Assessment .................................................................................................................... 5 
2.3.1 
Known Potential Risks ..................................................................................................... 5 
2.3.2 
Known Potential Benefits ................................................................................................ 9 
2.3.3 
Assessment of Potential Risks and Benefits ................................................................ 9 
3 
OBJECTIVES AND ENDPOINTS ................................................................................................................ 9 
4 
STUDY DESIGN ........................................................................................................................................... 10 
4.1 
Overall Design .................................................................................................................................... 10 
4.2 
Scientific Rationale for Study Design .............................................................................................. 10 
4.3 
Justification for Dose ......................................................................................................................... 10 
4.4 
End of Study Definition ..................................................................................................................... 11 
5 
STUDY POPULATION ................................................................................................................................ 11 
5.1 
Inclusion Criteria ................................................................................................................................ 11 
5.2 
Exclusion Criteria ............................................................................................................................... 11 
5.3 
Screen Failures .................................................................................................................................. 12 
5.4 
Strategies for Recruitment and Retention ...................................................................................... 12 
6 
STUDY INTERVENTION ............................................................................................................................ 12 
6.1 
Study Intervention Administration.................................................................................................... 12 
6.1.1 
Study Intervention Description ..................................................................................... 12 
6.1.2 
Dosing and Administration ............................................................................................ 13 
6.2 
Preparation/Handling/Storage/Accountability ................................................................................ 13 
6.2.1 
Acquisition and accountability ...................................................................................... 13 
6.2.2 
Formulation, Appearance, Packaging, and Labeling ................................................ 13 
6.2.3 
Product Storage and Stability ....................................................................................... 13 
6.2.4 
Preparation ...................................................................................................................... 13 
6.3 
Measures to Minimize Bias: Randomization and Blinding ........................................................... 14 
6.4 
Study Intervention Compliance ........................................................................................................ 14 
6.5 
Concomitant Therapy ........................................................................................................................ 14 
6.5.1 
Rescue Medicine ............................................................................................................ 14 
7 
STUDY INTERVENTION DISCONTINUATION AND PARTICIPANT 
DISCONTINUATION/WITHDRAWAL .................................................................................................................... 14 
7.1 
Discontinuation of Study Intervention ............................................................................................. 14 
7.2 
Participant Discontinuation/Withdrawal from the Study ............................................................... 14 
7.3 
Lost to Follow-Up ............................................................................................................................... 15 
8 
STUDY ASSESSMENTS AND PROCEDURES ...................................................................................... 15 
8.1 
Assessments ...................................................................................................................................... 15 
8.2 
Safety and Other Assessments ....................................................................................................... 19 
8.3 
Adverse Events and Serious Adverse Events ............................................................................... 20 
8.3.1 
Definition of Adverse Events (AE) ............................................................................... 20 

  
Protocol – V8.0 03/16/2021 
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8.3.2 
Definition of Serious Adverse Events (SAE) .............................................................. 20 
8.3.3 
Classification of an Adverse Event .............................................................................. 20 
8.3.4 
Time Period and Frequency for Event Assessment and Follow-Up ....................... 22 
8.3.5 
Adverse Event Reporting .............................................................................................. 22 
8.3.6 
Reporting Events to Participants ................................................................................. 23 
8.3.7 
Reporting of Pregnancy ................................................................................................ 23 
8.4 
Unanticipated Problems .................................................................................................................... 23 
8.4.1 
Definition of Unanticipated Problems (UP) ................................................................. 23 
8.4.2 
Unanticipated Problem Reporting ................................................................................ 24 
9 
STATISTICAL CONSIDERATIONS .......................................................................................................... 24 
9.1 
Statistical Hypotheses ....................................................................................................................... 24 
9.2 
Sample Size Determination .............................................................................................................. 25 
9.3 
Populations for Analyses .................................................................................................................. 26 
9.4 
Statistical Analyses ............................................................................................................................ 26 
9.4.1 
General Approach .......................................................................................................... 26 
10 
SUPPORTING DOCUMENTATION AND OPERATIONAL CONSIDERATIONS .............................. 26 
10.1 
Regulatory, Ethical, and Study Oversight Considerations ........................................................... 26 
10.1.1 
Informed Consent Process ........................................................................................... 26 
10.1.2 
Study Discontinuation and Closure ............................................................................. 26 
10.1.3 
Confidentiality and Privacy ........................................................................................... 27 
10.1.4 
Future Use of Stored Specimens and Data ............................................................... 28 
10.1.5 
Key Roles and Study Governance .............................................................................. 28 
10.1.6 
Safety Oversight ............................................................................................................. 28 
10.1.7 
Quality Assurance and Quality Control ....................................................................... 28 
10.1.8 
Data Handling and Record Keeping ............................................................................ 29 
10.1.9 
Protocol Deviations ........................................................................................................ 30 
10.1.10 
Publication and Data Sharing Policy ........................................................................... 30 
10.1.11 
Conflict of Interest Policy .............................................................................................. 30 
10.2 
Abbreviations ...................................................................................................................................... 31 
10.3 
Protocol Amendment History ........................................................................................................... 32 
11 
REFERENCES ............................................................................................................................................. 34 
 

FEMME 
Protocol – V8.0 03/16/2021 
 
1 
STATEMENT OF COMPLIANCE 
The protocol, informed consent form(s), recruitment materials, and all participant materials will be 
submitted to the Institutional Review Board (IRB) for review and approval.  Approval of both the 
protocol and the consent form must be obtained before any participant is enrolled.  Any amendment to 
the protocol will require review and approval by the IRB before the changes are implemented to the 
study.  In addition, all changes to the consent form will be IRB-approved; a determination will be made 
regarding whether a new consent needs to be obtained from participants who provided consent, using a 
previously approved consent form. 
1 
 
PROTOCOL SUMMARY 
1.1 
SYNOPSIS  
Title: 
The interaction between diabetes and estradiol on human brain 
metabolism in postmenopausal women 
Study Description: 
Epidemiological studies suggest there may be an interaction between type 
2 diabetes and estrogen in postmenopausal women, such that diabetes 
may interact with estrogen levels over time to increase risk for dementia. 
The mechanism for this effect is now known. However, animal research 
suggests that it may occur through estrogen’s effects on cellular 
metabolism of glucose and ketone bodies. The primary aim of this study is 
to test whether type 2 diabetes interacts with estradiol on brain 
metabolism in vivo in humans. This will be accomplished by imaging brain 
metabolism using positron emission tomography before and after short-
term administration of transdermal 17β-estradiol in 10 postmenopausal 
women with diabetes and 10 non-diabetic postmenopausal women.  
Objectives: 
 
Primary Objective: The primary objective is to determine whether the 
effects of glucose and ketone body uptake to the brain in response to 8-
week administration of transdermal 17β-estradiol differ in 
postmenopausal women with and without type 2 diabetes. 
 
Secondary Objectives:  Secondary objective: 1) Determine whether 8-week 
administration of transdermal 17β-estradiol alters cognitive performance 
in postmenopausal women with and without type 2 diabetes. 
Endpoints: 
Primary Endpoint: Glucose and ketone body uptake in brain measures with 
positron emission tomography. Regions of interest include the posterior 
cingulate, temporal cortex, and prefrontal cortex. 
Secondary Endpoints: Cognitive function assessed using composite scores 
of short-term memory and executive functioning. The short-term memory 
composite will be generated by summing z-scores from Story Recall, List 
Learning, and computerized tasks. The executive function composite will 
be generated by summing z-scores of Trails part B-A, computerized tasks, 
and semantic access (letter and category word fluency). 
Study Population: 
Postmenopausal women aged 60-80 years old will be recruited, 10 with 
type 2 diabetes and 10 without from the region of Forsyth County, North 
Carolina.  
Phase: 
N/A 

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Protocol – V8.0 03/16/2021 
 
2 
Description of 
Sites/Facilities Enrolling 
Participants: 
This is a single-site study that will take place at Wake Forest School of 
Medicine (WFSM). 
Description of Study 
Intervention: 
Participants receive 0.075 mg/day of transdermal 17β-estradiol delivered 
via a Climara patch for 8 weeks. Estrogen levels will be measured on 9-11 
days after estrogen administration begins to titrate levels as needed to 
attain a circulating level of 50-100pg/ml for each woman. Patches will be 
changed weekly. The study coordinator will contact participants weekly to 
monitor safety and ensure compliance. If women have a uterus, progestin 
will be prescribed at the end of the study to reverse potential endometrial 
stimulation. All hormone administration will be supervised by Jantira 
Thomas, DO, Assistant Professor of Internal Medicine, Medical Director 
Acute Care for the Elderly Unit, Gerontology and Geriatric Medicine. 
Study Duration: 
It is estimated that the study will last 24-36 months from enrollment to 
completion of primary data analyses. 
Participant Duration: 
Participants are expected to take 14-18 weeks (3-4 months) to complete 
all participant visits.  
1.2 
SCHEMA 
 
 
Day -90 to Day -1 
Screening 
Day 1 
Study Visit 1 
Baseline 
Day 1-14 
Study Visit 2 
Baseline PET 
 9-11 days after 
estrogen begins 
Study Visit 3 
Titration 
Week 8 of estrogen 
administration 
Study Visit 4 
Follow-up PET 
Week 8 of estrogen 
administration 
Study Visit 5 
Follow-up 
Week 13-15 
Follow-up as necessary (progesterone, 
weekly phone calls) 
Type 2 Diabetes/Prediabetics  N=10 
Non-diabetic  N=10 
Weekly 
telephone 
contacts 

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Protocol – V8.0 03/16/2021 
 
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1.3 
SCHEDULE OF ACTIVITIES (SOA) 
1. 
Only subjects without diagnosis of diabetes or prediabetes will receive OGTT 
2.  Non-fasting blood draw to assess serum estradiol levels 
 
2 
 
INTRODUCTION 
 
2.1 
STUDY RATIONALE  
Type 2 diabetes (T2D) affects an estimated 26% of people over the age of 651 and increases their risk for 
dementia by 50-60%.2 It also may increase the risk for dementia more in women than in men.2  One 
hypothesis suggests that metabolic dysregulation (T2D and insulin resistance) raises the risk of dementia 
by altering substrate use in bioenergetic pathways to rely less on glucose and more on ketone bodies.3 
Estrogen acts on these same bioenergetic pathways,4 and evidence is emerging that serum estrogen 
concentrations may interact with type 2 diabetes to substantially increase the risk of dementia in 
women. This hypothesis supports the healthy cell bias theory for estrogen action, which hypothesizes 
that estrogen has beneficial effects in healthy cells, but can have deleterious effects on cells that are 
affected by diseases such as T2D. The healthy cell bias theory of estrogen action has been demonstrated 
in animal models, but not yet in humans. Here, we propose to test it in humans by using dual-tracer 
positron emission tomography (PET) to assess whether estrogen affects the uptake of glucose and 
ketone bodies differently in women with and without T2D. 
 
 
Procedures 
Screening  Day -90 to -1 
Enrollment/Study Visit 1 
Study Visit 2/Day 1-30 
Estrogen Day 1* 
Estrogen Week 2 
SC Phone Call 
Study Visit 3/3 Days Post 
Estrogen Week 2 
Estrogen Week 3 
SC Phone Call 
Estrogen Week 4 
SC Phone Call 
Estrogen Week 5 
SC Phone Call 
Estrogen Week 6 
SC Phone Call 
Estrogen Week 7 
SC Phone Call 
Study Visit 4 
Day 49-56 after Day 1 
Study Visit 5 
Day  50-56 after Day 1 
14-day Progesterone 
administration (PRN) 
Day 57 +/-7 days 
Final Phone Call  
Day 71 +/-7 days 
Informed consent 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
Demographics 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
Medical history 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
Anthropometrics/Vital signs 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
Oral Glucose Tolerance Test1 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
Snack 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
Montreal Cognitive Assessment 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
Medical Record Review 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
Medication Review 
X 
 
 
 
 
 
 
 
 
 
 
 
 
 
Fasting blood draw 
X 
X 
X 
 
X2 
 
 
 
 
 
X 
X 
 
 
Snack 
 
X 
 
 
 
 
 
 
 
 
 
X 
 
 
Cognitive testing 
 
X 
 
 
 
 
 
 
 
 
 
X 
 
 
MRI Scan (30 minute) 
 
X 
 
 
 
 
 
 
 
 
 
X 
 
 
PET Scan 
 
 
X 
 
 
 
 
 
 
 
X 
 
 
 
Apply Estrogen Patch 
 
 
X* 
X 
 
X 
X 
X 
X 
X 
 
 
 
 
Weekly Phone Calls 
 
 
 
X 
 
X 
X 
X 
X 
X 
 
 
X 
X 
Dispense progestin for daily use 
 
 
 
 
 
 
 
 
 
 
 
 
X 
 

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4 
2.2 
BACKGROUND  
Dementia is a pressing public concern because of its high 
cost to society and to the individual. Alzheimer’s disease 
(AD) is the most commonly diagnosed form of dementia, 
estimated to affect 1 in 9 adults over the age of 65 and 1 
in 3 over 85. According to the Alzheimer’s Association, 
AD is the 6th leading cause of death in the United 
States,5 and a recent publication suggests this may be an 
under-estimation.6 Care for AD and other dementias was 
estimated to cost the US $203 billion in 2013, and is 
estimated to cost over a trillion dollars by 2050.5  
AD affects more women than men. For about 2 decades, 
evidence from large trials has suggested that women 
may be at greater risk for dementia than men,7-11 and approximately two-thirds of those diagnosed with 
AD in the United States are women.12 As age is a primary risk factor for AD, it has long been thought that 
the increased risk for dementia in women was due to their longer lifespan.13 In addition, certain risk 
factors are more common in women than men, such as lower levels of education and higher risk for 
depression.14 However, evidence is emerging that risk factors for AD may affect women differently than 
men. A population-based study aimed at investigating risk profiles for AD found that risk profiles were 
different in men and women.15 Accumulation of misfolded proteins confers greater risk for developing 
clinical dementia for women than for men; for each unit of AD pathology observed on autopsy, men’s 
risk of clinical dementia increased 3-fold, but women’s risk increased 11-fold.16 In addition, the effect of 
APOE4, a common risk gene for late-onset AD, was found to confer higher risk for hippocampal atrophy 
and memory loss in women than in men.17  
Type 2 diabetes is a potent risk factor for dementia that may differentially affect women. Type 2 
diabetes (T2D) affects an estimated 26% of people over the age of 651 and increases the risk for 
dementia by 50-60%.2 T2D may also increase the risk for dementia more in women than in men.2 In 
particular, T2D status may interact with serum levels of estrogen to increase risk for dementia. In a 
recent study, women with type 2 diabetes who were in the highest quartile of serum estrogen 
concentrations had 14 times the risk for dementia relative to diabetic women with lower estrogen 
concentrations.18 Two recent papers from our group support this finding. Women with type 2 diabetes 
randomized to receive conjugated equine estrogen therapy in the Women’s Health Initiative Memory 
Study (WHIMS) had an increased risk for dementia and lower brain volumes.19, 20  
Scientific Premise 
One mechanistic explanation for the population-level observation of an interaction between T2D status 
and estrogen is the healthy cell bias (HCB) theory of estrogen action.4 The HCB theory posits that the 
bioenergetic effects of estrogen depend on the metabolic health of the cell they are acting on. Work in 
animal models shows that estrogen enhances glucose transport and metabolism, mitochondrial 
respiration, and expression of genes involved in glucose metabolism, and inhibits expression of genes 
used in ketone body metabolism.4 Ketone bodies are produced from fat and can be used by cells as an 
energy substrate. While the brain cannot directly metabolize fat, it can use ketone bodies as a fuel 
source.21, 22 The HCB theory posits that in healthy brain cells using glucose as their main substrate, 
estrogen’s glucose-enhancing properties augment the bioenergetic capability of cells; estrogen’s action 
is protective in this situation. However, in cells challenged by stress, aging, or disease, the brain’s 
bioenergetic system may begin to rely on alternate fuel sources such as ketone bodies to meet its heavy 
Commonly Used Abbreviations 
AcAc 
  Acetoacetate 
AD 
  Alzheimer’s Disease 
E2            Estradiol 
FDG 
  Fluorodeoxyglucose  
HCB         Healthy Cell Bias 
MCI 
  Mild Cognitive Impairment 
MRI 
  Magnetic Resonance Imaging 
PET 
  Positron Emission Tomography 
T2D 
  Type 2 Diabetes 
WFSM   Wake Forest School of Medicine 

FEMME 
Protocol – V8.0 03/16/2021 
 
5 
metabolic demands.4 In this case, estrogen’s glucose-enhancing effects may be ineffective. At the same 
time, estrogen’s suppression of ketone use may deprive cells of an alternate energy substrate. Such a 
scenario could pose a risk to brain health, as cells might not be able to fully meet their energy needs.  
Three compounds are generally referred to by the term ‘ketone body’: acetone, acetoacetate (AcAc) and 
3-betahydroxybutyrate (BHB). Acetone is considered to have limited significance in metabolism.22 The 
rate of ketone metabolism in the brain is regulated primarily by blood concentration, and secondly by 
blood brain barrier transport.22 Ketone bodies enter the brain via diffusion and monocarboxylic acid 
transporters (MCT1 and MCT2).22 Elevating circulating ketones, either through infusion or during 
diabetic ketoacidosis, results in parallel increases in brain metabolism of AcAc and BHB.23-25 Persistently 
high levels of ketones, which can occur through prolonged fasting (3.5 days) or a ketogenic diet, increase 
permeability of the blood-brain barrier to ketones, suggesting an upregulation of transporters.22, 26 
Current evidence suggests that circulating ketones are upregulated in people with T2D.27-30 This 
observation supports the idea that ketone bodies may be a viable supplemental bioenergetic substrate 
in people with T2D, because increased levels of circulating ketones augment availability of ketones to 
the brain. The premise of this study is to test the HCB theory of estrogen action in humans by measuring 
brain metabolism of ketone bodies and glucose using a novel dual-tracer PET method before and after 
administration of estradiol in women with and without diabetes.  
Hypothesis 
Estrogen affects brain metabolism of ketone bodies and glucose differently in women with T2D and 
those without, in accordance with the healthy cell bias theory of estrogen action.  
Strengths and Weaknesses of Supporting Data 
1) Previous results showing interaction between T2D and estrogen or gender on brain and cognitive 
outcomes are all large trials or epidemiological studies;2, 18-20 characterization of T2D in these studies 
lacks relevant details. The WHIMS studies19, 20 have the advantage that WHIMS is a randomized trial, so 
the observed effects of estrogen on cognitive and brain imaging outcomes are less likely to be 
attributable to biases or a confounding factor, as potential confounding factors should be approximately 
equivalent between the groups. Our study will be an important contribution by examining this potential 
effect with rigor and detail. 
2) The dual-tracer PET has been successfully used to assess difference in ketone body and glucose 
uptake in healthy younger and older adults31, 32 and older adults with cognitive impairment.33 Our 
preliminary data from an ongoing study (Fig. 2, section 3.4) show the method is sensitive to increased 
ketone uptake in response to a dietary intervention. Elevated ketone body levels have been observed in 
people with T2D,21, 22, 27, 29 but the number of studies is currently small. There is not good representation 
of women and no research that we know of assessing circulating levels of ketone bodies in people of 
non-European descent with T2D. 
 
2.3 
RISK/BENEFIT ASSESSMENT   
 
2.3.1 KNOWN POTENTIAL 
RISKS                                                                                                                                                   
• 
Administration of estrogen. Estrogen administration has known risks in postmenopausal 
women. Side effects associated with short–term estrogen replacement therapy may include 
nausea, breast tenderness, spotting, or bleeding that is sometimes similar to menstrual bleeding 

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6 
(monthly period).  Side effects associated with long-term (several years) estrogen use include 
the potential for developing thrombosis (blood clot) in the leg, over-growth of the uterine lining 
that may lead to a type of uterine cancer, and a possible increased risk for breast cancer. 
 
Administration of estrogen in this study will be short term (8 weeks). This dose of estrogen, 
commonly used in clinical practice, is below that used in previous studies without any medical 
complications,34-36 and with a very low incidence of adverse effects (i.e., mild skin irritation at 
the patch site, slight breast tenderness). If women have a uterus, progestin will be prescribed at 
the end of the study to reverse potential endometrial stimulation. In addition, estrogen levels 
will be monitored during the second week of estrogen administration to ensure they are 
between 50-100pg/ml for each woman. The reference range for circulating levels of estrogen in 
ovulating premenopausal women used by LabCorp  is 85-498 pg/ml. The selected level for this 
study, 50-100pg/ml, is commonly used in clinical practice because it is within a physiologically 
active range, but has a low incidence of adverse events. All hormone administration will be 
supervised by Jantira Thomas, DO (Assistant Professor of Internal Medicine, Medical Director 
Acute Care for the Elderly Unit, Gerontology and Geriatric Medicine).37, 38  A study coordinator 
will contact participants weekly to monitor safety and ensure compliance.  
 
We considered options other than administering estrogen to postmenopausal women to test 
our hypothesis. Three constraints are important to understand the options we rejected. First, 
the age range selected for the study (60-80 years) is based on the few studies that have 
observed this effect in women. The 3 Cities Study reported on women in this age range,18 and 
this was also the approximate age range in the Women’s Health Initiative Memory Study 
(WHIMS).39, 40 We were concerned that changing the age range might alter the outcomes. For a 
first, proof-of-concept study with a small sample size, it seemed most conservative to specify a 
tight age range that matched the literature well. Second, the route of estrogen administration 
and kind of estrogen administered can influence outcomes in the brain. Although human studies 
are currently limited in number, research suggests transdermal administration of 17β estradiol 
unopposed by progesterone may be more effective in modifying brain outcomes than other 
forms of estrogens. 41-45_ENREF_41 Third, this is a very small, proof-of-concept study that uses a 
new method to move a theory posited in animal models to a human model. Because the sample 
size is small, it is important to minimize variability whenever possible.  
 
One option was to bring in postmenopausal women and screen them for naturally occurring 
estrogen levels in the blood, as was done in the epidemiological 3 Cities Study mentioned 
above.18 However, circulating estrogens in postmenopausal women are naturally very low, at 
the threshold of detection, which could present problems with the reliability of the assays. 
There was concern on the study team that the findings from the 3 Cities Study might not be 
replicable by us, as the number of women in the top quartile was quite small, the reported 
estrogen levels were low, and the findings have not been replicated yet by other groups. In 
addition, obesity is associated with higher estrogen levels. Indeed, body mass index was higher 
in the women in the high estrogen quartile in the 3 Cities Study. Stratifying participants based 
on naturally occurring estrogen levels would likely result in large differences in excess adiposity 
between high and low estrogen groups. Since obesity may be an independent risk factor for 
dementia,46-48 this would introduce a serious confound into the study.  
 
Another option considered was to recruit women who were currently taking hormone 
replacement therapy and have them cease taking hormones for a period of time. However, 

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7 
finding enough women in that age range who were taking the appropriate dosage and 
medication (transdermal 17β estradiol), were willing with the support of their prescribing 
physicians to stop their medication for the duration of the study, and finding half with type 2 
diabetes would likely require screening of a prohibitive number of women. In addition, women 
who are prescribed estrogen in this age range are not an unbiased sample and may have 
different characteristics than women who are not prescribed estrogen.  
 
With these considerations in mind, we decided that the best controlled, safest study we could 
design to test these hypotheses was to bring in a small number of postmenopausal women in 
the desired age range screened for contraindicated health conditions, and administer 
transdermal 17β estradiol at a safe, physiological dose for a short period of time with close 
monitoring and appropriate follow-up. 
 
• 
PET scan. Exposure to radiation from PET and paired low-dose CT scans. The amount of whole 
body radiation dose/participant/year of the Radiation Drug Research Committee (RDRC) is 30 
mSv (3 rem).  Each woman will be scanned twice and be exposed to a total of 2.62 rem, which is 
below RDRC limit. 
1. [F-18]FDG PET:  2 x 1.10 rem    = 2.2 rem 
2. [C-11]AcAc PET: 2 x 0.0374 rem = 0.0748 rem 
3. Low-dose CT:    4 x 0.084 rem  = 0.336 rem 
 
Participants will be screened for prior radiation exposure within the past year, and be instructed 
to increase their fluid intake and to void frequently following each PET scanning session to 
minimize bladder exposure. This radiation dose is not expected to produce any harmful effects, 
although there is no known minimum level of radiation exposure considered to be totally free of 
the risk of causing genetic defects or cancer. The risk associated with the amount of radiation 
exposure participants receive in this study is considered low and comparable to every day risks. 
Because the targeted population is postmenopausal women, no PET studies will be performed 
on pregnant or potentially pregnant women or children. 
 
[C-11] Acetoacetate administration has not demonstrated any toxic effects in patients, as 
reported by the Cunnane research group at Université de Sherbrooke (143 patients) (Tremblay 
et al. 2007, Applied Radiation and Isotopes, 65(8): 934-940; Nugent et al. 2014, Neurobiology of 
Aging, 35(6): 1386-1395). The radiopharmaceutical preparation has no pharmacological effects. 
Sodium Acetoacetate C-11 Injection is administered intravenously in 3-6 mL of citrate buffer 
solution for Injection, USP. The pH of the solution is 3.5-6.5. There is no evidence that 
administration of [C-11] Acetoacetate increases the risk of ketoacidosis. Based on the maximum 
amount of Methyllithium reagent used for the synthesis and a 21% reaction yield, the maximum 
amount of acetoacetic acid synthesized is 2-5 mg. This amount is not significant considering 
that the amount of acetic acid normally present in the plasma is ~25 mg/L. However, a rare 
reaction to any of the drugs or procedures to which the participant will be exposed is possible. 
Thus, a physician will be available at all times during scanning, and an emergency cart will be in 
close proximity. If adverse effects occur, medical intervention will be provided promptly.  
• 
MRI scan. The MRI machine does not use radiation (such as x-rays) and is considered safe. No 
serious biological effects have been reported from MRI scans. However, operation of the MRI 
machine produces loud noise. Participants are required to wear earplugs provided at the MRI 
center. All MRI scans are administered by a trained MRI technician on a research-dedicated 

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8 
scanner. The technician is trained to help participants insert earplugs and to check whether they 
have been inserted correctly.  With earplugs, the risk to hearing is insignificant.  
Some people may experience discomfort in the scanner if they are claustrophobic. All 
participants will be screened for claustrophobia over the phone and again face-to-face prior to 
the scan. Participants are given a hand-held device that can be squeezed to signal the MRI 
technician that they need to stop the scan. If a participant experiences fear of the confined 
space while in the scanner, they can stop the test at any time.  
 
Metal inclusions in the body are a contraindication for an MRI scan. Participants will be screened 
over the phone prior to enrollment about potential metal in their bodies. Participants will be 
screened again face-to-face by study staff the morning of the MRI scan, and then separately 
screened face-to-face by the trained MRI technician prior to the scan. The MRI suite has MRI-
safe gowns, socks, and pants and a private changing area with a locker that locks for participants 
to store their personal belongings during the scan.  
 
When MRI scans are viewed for research purposes, incidental findings may be observed. In 
some cases, incidental findings may reveal a previously unknown health concern that would 
benefit the participant to know about so that they can seek treatment. However, as the scans 
performed are for research and not diagnostic purposes, incidental findings may not reflect a 
real problem if a diagnostic scan is performed later. In this case, incidental findings can lead to 
unnecessary testing. The consent form explains incidental findings in lay language and allows 
participants to choose if they wish to have incidental findings reported them. Some people do 
not wish to be given this information. All of our MRI scans will be read by a board-certified 
neuroradiologist regardless to rule out major abnormalities or issues that might lead to scans 
being excluded from the study. If an incidental finding is noted and the participant has 
requested to be notified, we will contact them and provide the feedback from the 
neuroradiologist. At the participant’s request, we will share the research MRI scans with their 
physician.  
 
• 
Blood sampling. Participants may experience discomfort, bruising and/or bleeding where the 
needle is inserted.  Occasionally, some people become dizzy, lightheaded or feel faint. Infection 
may occur on rare occasions.  To minimize these risks, blood will be drawn only by trained and 
experienced phlebotomists who will minimize the discomfort as much as possible and will use 
good clinical practice procedures to reduce risk of infection. 
 
• 
Genetic testing. We will be assessing for presence of the APOE ε4 allele and potentially other 
cognitively or metabolically relevant genes in the future if new evidence comes to light that 
these might be important for understanding the results of the study. Genotype information will 
not be shared with study participants, as is currently recommended research practice for the 
gene and population we will be studying 49. Knowing genotype information will not provide any 
direct benefit to participants, but may cause anxiety. For example, the APOE ε4 allele is 
established as a risk factor for late onset Alzheimer’s disease. However, it is not causal (you may 
have the allele and never get the disease), there is no known treatment or prevention strategy 
that targets the presence of the allele, and its predictive ability is diminished after the age of 70 
49. Therefore, knowing about the risk genotype cannot benefit the participant in terms of 
treatment, but may needlessly raise anxiety about cognitive decline.  

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As with other data, genotype information will be identified by subject number only. The Center 
for Human Genomics will complete the genotyping as for-fee service and will not have access to 
any identifying information. As only a limited number of cognition-related genetic loci will be 
characterized, there is not potential for identifying a subject based on genetic information alone 
as might be a concern for genome-wide studies.  
• 
Cognitive testing. Participants will be asked to complete a short battery of cognitive tests. The 
tests may be given orally, on paper, or on a computer. Participants will be informed that the 
testing in these visits is not intended or adequate for diagnostic purposes. Careful instructions 
will be given before the testing. There is a risk that some people may feel frustrated or worried 
when taking the tests. Participants will be encouraged to communicate with study staff if they 
are experiencing distress. Study staff will be trained to anticipate this risk and be alert for non-
verbal signs of distress. Study staff and participants will both be instructed that testing may be 
discontinued at any time if the participant chooses. 
 
2.3.2 KNOWN POTENTIAL BENEFITS  
There are no anticipated short- or long-term benefits to an 8-week administration of transdermal 17β 
estradiol in postmenopausal women. 
 
2.3.3 ASSESSMENT OF POTENTIAL RISKS AND BENEFITS  
It is becoming clear that risks for cognitive decline may be different between the sexes. Even if overall 
risk is the same, it may be that, as in heart disease, different factors contribute risk to development of 
dementia. Evidence from animal work suggests that the effects of estrogen on bioenergetic pathways 
may be an important risk factor contributing to lo ng-term declines in glucose uptake in the brain in 
women, a known precursor to Alzheimer’s disease, and a shift in bioenergetic fuel source to more 
reliance on ketone bodies. This has implications both for administration of estrogen in healthy states, 
and in common metabolic diseases, such as T2D.  However, proof of this theory in humans is entirely 
absent. A potential mechanism for interaction between common diseases and estrogen  is important, 
because it might lead to changes in the prescribing of estrogens. 
 
The Women’s Health Initiative Memory Study (WHIMS) initially published that oral administration of 
conjugated equine estrogens increased risk for cognitive decline.50, 51 However, our recent reanalysis of 
the data taking diabetes status into account showed that the presence of T2D largely accounted for this 
effect.19, 20   
 
While there is no anticipated direct benefit of this study, risks are temporary and reversible. There is a 
body of literature that examined estrogen therapy as a means to prevent Alzheimer’s disease . Multiple 
studies were published in this age range with this or higher dosage, both transdermal and oral routes, 
but longer duration of estrogen administration.34-36, 52-54 Across these studies, side effects were minimal 
until after 12 weeks of administration, which is 4 weeks longer than the proposed administration here. 
The study team has planned frequent monitoring to minimize risks further.  
 
3 
OBJECTIVES AND ENDPOINTS 
 
OBJECTIVES 
ENDPOINTS 
JUSTIFICATION 
FOR ENDPOINTS 
Primary: 
 
 

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OBJECTIVES 
ENDPOINTS 
JUSTIFICATION 
FOR ENDPOINTS 
To assess whether 8-week 
administration of estrogen alters 
brain glucose and ketone body 
uptake in women with and without 
type 2 diabetes. 
Brain uptake of glucose and ketone 
bodies using [F-18]FDG PET and  [C-
11]AcAc PET. 
Using PET tracers 
allows direct 
measurement of 
ketone and glucose 
uptake to the brain. 
Secondary 
 
 
To assess whether 8-week 
administration of estrogen alters 
cognitive test scores in women 
with and without type 2 diabetes. 
 
Composite scores of memory and 
executive function. 
The cognitive tests 
selected are commonly 
used to assess for 
dementia and 
dementia risk. 
4 
STUDY DESIGN  
 
4.1 
OVERALL DESIGN 
This is an investigation of the effects of transdermal estrogen administration on brain uptake of glucose 
and ketone bodies in postmenopausal women with and without T2D. The main hypothesis is that 
estrogen affects brain metabolism of ketone bodies and glucose differently in women with T2D and 
those without, in accordance with the healthy cell bias theory of estrogen action. All women will be 
tested before and after 8-week estrogen administration. It is a single-site study with two comparison 
groups: one with T2D (n=10) and one without (n=10). Randomization is not possible, as the comparison 
is between women affected and unaffected by T2D (and women cannot be randomized to have T2D). 
The study will include women of European American and African American descent and with Hispanic 
ethnicity in proportion to the local population for this age group. No interim analysis is planned. 
 
4.2 
SCIENTIFIC RATIONALE FOR STUDY DESIGN 
This study will compare the effects of estrogen on brain uptake of glucose and ketone bodies in women 
with and without T2D. We are comparing women with and without T2D because T2D is a potent risk 
factor for dementia that may differentially affect women. Type 2 diabetes (T2D) affects an estimated 
26% of people over the age of 651 and increases the risk for dementia by 50-60%.2 T2D may also 
increase the risk for dementia more in women than in men.2 In particular, T2D status may interact with 
serum levels of estrogen to increase risk for dementia. In a recent study, women with type 2 diabetes 
who were in the highest quartile of serum estrogen concentrations had 14 times the risk for dementia 
relative to diabetic women with lower estrogen concentrations.18 Two recent papers from our group 
support this finding. Women with type 2 diabetes randomized to receive conjugated equine estrogen 
therapy in the Women’s Health Initiative Memory Study (WHIMS) had an increased risk for dementia 
and lower brain volumes.19, 20 
 
4.3 
JUSTIFICATION FOR DOSE 
Women will receive 0.075 mg/day of transdermal estrogen delivered via a Climara patch. Serum 
estrogen levels will be measured on day 3 of the second week of estrogen administration to titrate 
levels as needed to attain a circulating level of 50-100pg/ml for each woman. This dosage of estrogen 
was chosen because it is within physiological limits. Transdermal administration was selected over oral 
administration because this method of dosing better approximates physiological conditions than oral 
administration. 

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11 
 
4.4 
END OF STUDY DEFINITION 
A participant is considered to have completed the study if he or she has completed all phases of the 
study including the last visit or the last scheduled procedure shown in the Schedule of Activities (SoA), 
Section 1.3. 
 
5 
STUDY POPULATION 
 
5.1 
INCLUSION CRITERIA 
In order to be eligible to participate in this study, an individual must meet all of the following criteria: 
1. Willing to provide written informed consent 
2. Stated willingness to comply with all study procedures and availability for the duration of the 
study  
3. Female, postmenopausal, aged 60-80 
4. Normal results on recommended healthcare screenings (e.g., mammogram, pap smear, 
colonoscopy)  
5. BMI 20-35 kg/m2 
6. No evidence of dementia or mild cognitive impairment (MoCA score >25) 
7. Women with diabetes, physician diagnosis of type 2 diabetes, or, per American Diabetes 
Association criteria,55 showing two markers of dysregulated blood glucose levels at one time 
(e.g., fasting plasma glucose ≥ 126 mg/dL, 2-hr glucose ≥ 200mg/dL, or elevated HbA1c ≥6.5%) 
or showing elevated blood glucose using any of these measures at more than one time point.  
8. Women with prediabetes, no diagnosis of Type II diabetes and A1c in the pre-diabetic range of 
5.7-6.4 or higher. 
 
 
5.2 
EXCLUSION CRITERIA 
An individual who meets any of the following criteria will be excluded from participation in this study: 
1. Use of hormone replacement therapy within the past 3 months  
2. History of renal, heart, liver, or neurological disease; head injury with loss of consciousness in 
the past 5 years; chronic pain, anxiety or depression 
3. Presence of medical conditions that might contraindicate estrogen use (e.g., unexplained vaginal 
bleeding, history of reproductive tissue cancer, thrombosis) 
4. Currently taking insulin, metformin, or any other drug or medication judged by the study 
physician to affect safety or research outcomes of interest 
5. Involved in another research study 
6. Contraindications for MRI or PET scanning 
7. Current smoker 
8. Women without diabetes, no physician diagnosis of type 2 diabetes or prediabetes, and 
evidence of healthy glucose regulation, indicated by an HbA1c <5.7% and fasting plasma glucose 
<100mg/dL or 2-hr glucose <140mg/dL. 
9. Reporting a level of radiation exposure in the past year that would cause radiation levels to 
exceed recommended limits if the person participates in this study 
10. Participants will be excluded for taking metformin or insulin, other hormone replacement 
therapies, dantrolene (Dantrium, Ryanodex, Revonto), Viekira Pak (ombitasvir-paritaprevir-

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12 
Ritonavir-dasabuvir), carfilzomib (Kyprolis), tranexamic acid (Cyklokapron, Lysteda), hemin 
(Panhematin), lenalidomide (Revlimid), pomalidomide (Pomalyst), or thalidomide (Thalomid).  
 
As this study targets the effects of estrogen on brain post-menopause, men are excluded. 
 
5.3 
SCREEN FAILURES 
Screen failures are defined as participants who consent to participate in the clinical trial but are not 
subsequently entered in the study. A minimal set of screen failure information is required to ensure 
transparent reporting of screen failure participants, to meet the Consolidated Standards of Reporting 
Trials (CONSORT) publishing requirements and to respond to queries from regulatory authorities. 
Minimal information includes demography, screen failure details, eligibility criteria, and any serious 
adverse event (SAE). 
 
Individuals who do not meet the criteria for participation in this trial (screen failure) because of a 
current medication, participation in another trial, use of hormone replacement therapy within the past 3 
months, availability during study duration, or access to transportation may be rescreened. Rescreened 
participants should be assigned the same participant number as for the initial screening. 
 
5.4 
STRATEGIES FOR RECRUITMENT AND RETENTION 
This single-site study aims to recruit 10 postmenopausal women with type 2 diabetes and 10 
postmenopausal without type 2 diabetes. All women should be between the ages of 60-80 years and 
may be of any race or ethnicity. In the Winston-Salem, Forsyth County region, which is the catchment 
area for this study, approximately 25% of people in this age range identify as minority (primarily African 
America, less than 1% identify as Hispanic ethnicity). To reflect these demographics, we aim to include 
2-3 African American women in each arm of the study. 
 
We anticipate enrolling 1-2 women per month and screening up to 200 women to reach enrollment. 
Women will be recruited through fliers posted in the general public, hospital, and outpatient clinics; 
physician outreach in outpatient clinics; advertisement through the VITAL newsletter of the Section on 
Gerontology and Geriatric Medicine; community talks given by the PI or study staff; and word-of-mouth. 
Recruitment venues include Wake Forest Baptist Health and Wake Forest School of Medicine clinics, and 
public venues such as the YMCA, community centers, or churches. Recruitment of historically under-
represented populations, such as African American women, will be accomplished through outreach to 
the African American community through our Aging Center and engagement of historically African 
American churches in the area. The Aging Center has a strong history of enrolling 25% or more African 
American participants in research studies. 
 
Study retention will be facilitated by compensating participants for study visits and through weekly 
contact with the study coordinator to ensure safety and compliance.  
 
6 
STUDY INTERVENTION 
 
6.1 
STUDY INTERVENTION ADMINISTRATION 
 
6.1.1 STUDY INTERVENTION DESCRIPTION 
Participants will be administered 0.075 mg/day of transdermal estrogen via a Climara patch for 8 weeks.  

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13 
6.1.2 DOSING AND ADMINISTRATION 
The starting dose of estrogen will be 0.075 mg/day administered transdermally with a Climara patch. 
Serum estrogen levels will be measured 48-96 hours (2-4 days) after administration of the second patch 
to titrate levels as needed to attain a circulating level of 50-100pg/ml for each woman. Patches will be 
changed weekly.  A higher dose may be administered at the study physician’s discretion if the minimum 
circulating level is less than 50pg/ml. Conversely, the dose may be lowered at the study physician’s 
discretion if the circulating level is greater than 100pg/ml. If advised by the study physician, additional 
follow up measures of serum estrogen levels may be collected at appropriate time points.  
 
Participants will be instructed to change their patch weekly. A study coordinator will contact them 
weekly to remind them. If a patch change is missed, the participant will be instructed to change it as 
soon as possible. If a participant goes 7 days without changing a patch, they will be withdrawn from the 
study. 
 
Short-term (less than 12 weeks) administration of estrogen has low risk of side effects. Participants will 
be screened thoroughly to exclude participants with existing risk factors for estrogen treatment. 
Participants will be contacted weekly by the study coordinator to remind them to change their patch 
and will be asked a series of questions to screen for potential adverse side effects.  As the intervention is 
being administered as an experimental manipulation, not treatment, if participants experience 
concerning side effects, they will be encouraged to discontinue use of estrogen, contact their primary 
care physician as needed, and the study physician will be notified.  
 
6.2 
PREPARATION/HANDLING/STORAGE/ACCOUNTABILITY 
 
6.2.1 ACQUISITION AND ACCOUNTABILITY 
Climara patches are a standard treatment, and will be ordered through the pharmacy. The patches will 
be distributed to participants by study staff. If a participant does not use the patches they are given, 
they will be requested to return the patches to study staff. 
 
6.2.2 FORMULATION, APPEARANCE, PACKAGING, AND LABELING 
Climara patches are manufactured by Bayer Pharmaceuticals. Each patch comes in an individually sealed 
protective pouch within a box. Each patch has one adhesive side that is used to adhere to the skin. Per 
packaging instructions, the adhesive side should be placed on a clean, dry area of the lower abdomen or 
upper quadrant of the buttock, and should not be applied to or near the breasts. The site selected 
should not be oily, damaged or irritated, and the waistline should be avoided to prevent tight clothing 
from rubbing the patch off. Application sites must be rotated, with at least a 1-week interval between 
applications to the same site.  Patches will be labeled as sold.  
 
6.2.3 PRODUCT STORAGE AND STABILITY 
It is recommended by the manufacturer that Climara patches be stored between 66-77°F, with 
excursions in temperature allowed between 59°F and 86°F. The patch should be applied immediately 
after removal from the protective pouch. 
 
6.2.4 PREPARATION 
The Climara patch will require no additional preparation.  
 

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14 
6.3 
MEASURES TO MINIMIZE BIAS: RANDOMIZATION AND BLINDING 
As this is a study to experimentally manipulate estrogen levels in women with and without type 2 
diabetes, there is no randomization or blinding. 
 
6.4 
STUDY INTERVENTION COMPLIANCE 
Compliance will be monitored through serum tests of estradiol levels at baseline, week 2 of estrogen 
administration, and follow-up. Compliance will also be monitored through weekly phone calls with study 
staff. If participants miss 7 days of patch wearing, they may be asked to discontinue the study.  
 
6.5 
CONCOMITANT THERAPY 
For this protocol, a prescription medication is defined as a medication that can be prescribed only by a 
properly authorized/licensed clinician. Medications to be reported in the Case Report Form (CRF) are 
concomitant prescription medications, over-the-counter medications and supplements. Participants will 
be excluded for taking metformin or insulin, other hormone replacement therapies, dantrolene 
(Dantrium, Ryanodex, Revonto), Viekira Pak (ombitasvir-paritaprevir-Ritonavir-dasabuvir), carfilzomib 
(Kyprolis), tranexamic acid (Cyklokapron, Lysteda), hemin (Panhematin), lenalidomide (Revlimid), 
pomalidomide (Pomalyst), or thalidomide (Thalomid).  
 
6.5.1 RESCUE MEDICINE 
Participants should take any required rescue medications.  
 
7 
STUDY INTERVENTION DISCONTINUATION AND PARTICIPANT 
DISCONTINUATION/WITHDRAWAL 
  
7.1 
DISCONTINUATION OF STUDY INTERVENTION 
As this is not a treatment intervention, discontinuation from the Climara patch means discontinuation 
from the study after an appropriate follow-up for safety. For example, women with an intact uterus 
should take 14 days of 5 mg/day of progestin to minimize the risk of potential endometrial stimulation, 
and those who withdraw or are asked to discontinue will be followed appropriately. Remaining study 
procedures, such as the follow-up blood draws and PET scans should not be completed, as they will not 
be useful to answer the research question and will expose the participant to risk.   
 
If a participant withdraws from the study, study staff will contact the participant to schedule any 
necessary follow-up (i.e., administration of progestin) and to collect any unused Climara patches. The 
same procedure will be followed if the participant is requested to discontinue the study for 
noncompliance or any other reason.  
 
The data to be collected at the time of study intervention discontinuation will include the reason for 
withdrawal or discontinuation. 
 
7.2 
PARTICIPANT DISCONTINUATION/WITHDRAWAL FROM THE STUDY 
Participants are free to withdraw from participation in the study at any time upon request. 
An investigator may discontinue or withdraw a participant from the study for the following reasons: 
 

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15 
• 
Significant study intervention non-compliance. Examples of significant non-compliance include 
missing 7 days of estrogen administration, not communicating with study staff for 3 weeks, and 
canceling or not showing up for 2 scheduled study visits.  
• 
If any clinical adverse event (AE), laboratory abnormality, or other medical condition or situation 
occurs such that continued participation in the study would not be in the best interest of the 
participant. 
• 
If the participant meets an exclusion criterion (either newly developed or not previously 
recognized) that precludes further study participation. 
• 
Participant unable to receive the Climara patch for 7 days within the administration period. 
The reason for participant discontinuation or withdrawal from the study will be recorded on the Study 
Completion form. As this intervention is not a treatment trial, any participant who withdraws, drops out, 
or is discontinued may be replaced if funds and time permit.  
7.3 
LOST TO FOLLOW-UP 
A participant will be considered lost to follow-up if they do not return phone calls from study staff for 3 
weeks and/or cancel or do not attend 3 scheduled study visits. 
 
The following actions must be taken if a participant fails to return to the clinic for a required study visit: 
• 
Study staff will attempt at least twice per week to contact the participant and reschedule the 
missed visit. If the participant is reached, staff will counsel the participant on the importance of 
maintaining the assigned visit schedule and ascertain if the participant wishes to and/or should 
continue in the study. 
• 
If study staff phone calls are not returned for at least 1.5 weeks, a letter will be sent to the 
participant asking them to contact study staff and reminding them of the need for follow-up (if 
applicable). These contact attempts should be documented in the participant’s medical record 
or study file.  
• 
If study staff phone calls are not returned for 3 weeks, a second letter will be sent informing the 
participant that we consider them to have dropped out of the study and request that they 
communicate within the next week so that we can follow-up medically if appropriate.  
• 
Should the participant continue to be unreachable, he or she will be considered to have 
withdrawn from the study with a primary reason of lost to follow-up. 
 
Lost to follow-up will be minimized by thorough explanation of study requirements during consent, 
remuneration of the participant for completing study visits, and weekly contact with study staff.  
 
8 
STUDY ASSESSMENTS AND PROCEDURES 
 
8.1 
ASSESSMENTS  
The first visit will be a screening visit (SV) to determine if participants meet criteria for enrollment. 
Screening will be completed 0-3 months prior to beginning the experiment and will take approximately 3 
hours. The following will take place during screening:  
• 
An IRB-approved written informed consent will be completed prior to any data collection 
• 
Collection of anthropometric information (height, weight, blood pressure) 
• 
Fasting blood draw (complete blood count (CBC), HbA1c, metabolic panel, lipid panel) 
• 
For non-diabetic women, an Oral Glucose Tolerance Test (OGTT) to assess for diabetes status 

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• 
Eat a healthy snack 
• 
Demographic and contact information 
• 
Montreal Cognitive Assessment 
• 
Centers for Epidemiological Studies Depression Scale (CESD-10) 
• 
Detailed self-report health history and review of medications, specifically including smoking 
status, history of hormone replacement therapy, medical conditions that are contraindicated for 
estrogen use (listed below under chart review), and radiation exposure in the past year. 
• 
Review of medical record to confirm no evidence of potential contraindications to participate. 
Specifically, chart review will confirm that relevant screenings such as pap smear and 
mammogram have been completed in compliance with USPTF recommendations and were 
negative; assess for a history of the following: unexplained vaginal bleeding, breast cancer, 
ovarian cancer, blood clots, stroke, myocardial infarction, liver disease, kidney disease, 
hypothyroidism, endometriosis or fibroids, porphyria, lupus, migraines, or tobacco use. Chart 
review will also be used to confirm the participant is not taking contraindicated medications.  
 
Between 1-30 days after the screening visit, the results of the screening will be reviewed with the study 
physician to determine eligibility. If the study physician is traveling for an extended period, she may 
delegate screening review to another physician during that time. The participant will be notified 0-10 
days after eligibility is determined and remaining visits will be scheduled as needed. 
 
The second visit will be study visit 1 (V1). V1 will take place 0-3 months after screening. The following 
will take place during V1, which will last approximately 2 hours: 
• 
Fasting blood draw for future research, serum estrogen, cortisol, glucose, and insulin levels 
• 
Snack 
• 
Cognitive testing. Cognitive testing will include assessment of executive function, working 
memory, reaction time, episodic memory and verbal memory using a combination of 
handwritten and computerized tests that can be accomplished in less than 60 minutes.  
• 
60 minute MRI scan. Participants will have images taken of their brain and may be asked to view 
images and make a button press in response during the scan. 
 
The third visit will be study visit 2 (V2). V2 will take place preferably 1-14 days after V1 but, depending 
on participant, equipment and staff availability, may take place up to 30 days after V1 and will last 
approximately 3 hours. Participants will be required to fast for 6-7 hours prior to undergoing the PET 
scan.  The following will take place during V2: 
• 
Dual tracer PET scan during which time blood draws will take place to assess ketone bodies 
(betahydroxy butyrate (BHB)) 
 
At the conclusion of V2, participants will be given 8 Climara patches. Written instructions for using the 
patches will be provided and reviewed verbally by study staff. Participants may begin estrogen 
administration after the PET scan or within 48 hours after completing the PET scan, confirmed by a 
phone call with the study coordinator. Participants will wear a Climara patch for transdermal estrogen 
administration for 8 weeks, changing the patch weekly.  
 
Study visit 3 (V3), the fourth visit, will take place 48-96 hours (2-4 days) after administration of the 
second estrogen patch and will consist of a blood draw (not fasting) to assess serum estradiol levels and 
genetic assessment [CH1]Assay levels will be returned within 1 week. If levels are less than 50pg/ml or 
greater than 100pg/ml, they will be provided to the study physician for review. The study physician will 

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then determine whether the dosage of transdermal estrogen should be increased or decreased to attain 
the desired range of serum estrogen, and if further blood draws are necessary to assess serum estrogen 
levels.  
 
Study visits 4 (V4) and 5 (V5) will take place during week 8 of estrogen administration. Participants will 
be required to fast for 6-7 hours prior to undergoing the PET scan.  The following will take place during 
V4: 
• 
Dual tracer PET scan during which time blood draws will take place to assess ketone bodies 
(betahydroxy butyrate (BHB)) 
 
The following will take place during V5: 
• 
Fasting blood draw 
• 
Snack 
• 
Cognitive testing 
• 
30 minute MRI scan 
 
If the participant has a uterus, estrogen will be continued for 2 additional weeks along with progestin for 
10-14 days to reverse potential endometrial stimulation.  
 
Results of blood tests, such as fasting glucose, HbA1c, OGTT, and lipid panel will be provided to 
participants at their request. If a participant scores lower than a 24 (or 1.5 standard deviations below 
their age, race, and education adjusted normative score) on the MoCA, when they are contacted to 
inform them they are not eligible for the study, they will be informed that they may wish to follow-up 
with their physician for a more detailed cognitive screening. All MRI scans will be viewed by a 
neuroradiologist. During the consent process, participants will be given the option of having any 
incidental findings noted by the neuroradiologist reported to them or their physician if they wish, and 
copies of the scans may be provided by request as well.  
 
DETAILS OF PET SCAN METHODOLOGY AND PROCEDURES 
 
Method of assay and instrumentation. The radioactive drug will be assayed in a Capintec radioisotope 
calibrator. The capintec in use will be checked for linearity quarterly and constancy daily. 
 
Radioactive drug chosen. [18F]Fluorodeoxyglucose (or FDG) is often used in both research and clinical 
settings as a surrogate of glucose metabolism. In Alzheimer’s disease, use of [18F]FDG is a powerful 
technique providing a signature pattern of brain regions with impaired glucose metabolism. The 
metabolic changes seen in Alzheimer’s disease are evident even in preclinical stages of the disease 56. 
Thus, lending this technique to applications in understanding the impact of brain glucose metabolism 
and disease progression. [11C]Acetoacetate (or AcAc) is a novel radiotracer with primary applications in 
study of acetoacetate or ketone body metabolism.  
We will use an established method of production for [11C]AcAc that has been used in other institutions, 
including by our collaborators led by Dr. Stephen Cunnane, PhD, Université de Sherbrooke 32, 33, 57-60. The 
production of this radiotracer is published and an automated synthesis and injection unit has been 
established at WFU PET center. The utilization of both [11C]AcAc and [18F]FDG in an established dual-
tracer PET scan may provide valuable insight into impaired brain metabolism, how impaired brain 
metabolism is linked with cognitive decline, and how it may be modified by interventions. 

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18 
Pharmacological dose of [11C]AcAc. Consistent with 21 CFR 361.1, there has been no reported 
pharmacological effect caused by [11C]AcAc (143 patients performed).  Quality control specifications 
included:  
• 
Bubble Point Filter Membrane Integrity  
• 
Visual inspection (clear and colorless solution without presence of particulate matter) 
• 
Radiochemical purity >90%;  
• 
Demonstration of sterility and apyrogenecity. 
 
Quality of radioactive drug. We will synthesize [11C]AcAc as described in our local drug master file 
(LDMF) and batch record sheets located in the radiopharmaceutical laboratory and attached to this 
application. Final product [11C]AcAc will have: 
• 
A radiochemical purity of >90%  
• 
Sterility and apyrogenicity testing performed as described in LDMF and will be recorded in 
batch record files. 
[18F]FDG is an FDA approved drug and will be obtained from an FDA approved radiopharmacy. 
 
PET scan procedure.  
• 
Subjects will report to the ground floor of the MRI building to the Molecular Imaging 
Research PET/CT scanner at Wake Forest Baptist Medical Center. 
• 
Vital signs (blood pressure, heart rate, temperature) and body weight will be within 30 
minutes of radiotracer injection.  
• 
An indwelling catheter will be placed into a forearm vein in both arms. 
• 
30 minutes prior to the PET scan, a heating pad is wrapped around one arm (44 degrees 
Celcius). Up to 10mL of blood for Glucose, AcAc, and Beta-hydroxybutyrate (or BHB, the 
other major ketone body) quantification. This blood is stored on ice and immediately 
processed for analysis after the PET scan.  
 
Part 1 of Scan (0-30 minutes):  
• 
Prior to PET acquisition, a low dose CT scan of the head will be obtained for attenuation 
correction. 
• 
Patients will be injected with an intravenous bolus of up to 5-10mCi (370 MBq) (+/- 10%) of 
[11C]AcAc (over 2 minutes). This is the standard dose used in published clinical studies using 
[11C]AcAc (3-5).  
• 
The PET acquisition will begin immediately after the tracer injection and last for a total of 30 
minutes.   2 ml of blood will be sampled from the forearm vein at 3, 6, 8, 12, 20, and 28 
minutes post [11C]AcAc tracer injection. This will be used for quantification of radiation 
estimates throughout the scan-period.  
 
Washout Period (30-60 minutes): 
• 
A washout (“washing”) period will occur from 30-60 minutes after the injection of the first 
tracer. This will be used to ensure most of the first tracer has been excreted prior to 
injection of the [18F]FDG tracer and second part of the dual-tracer scan.   
 
Part 2 of Scan (60-120 minutes): 
• 
Prior to PET acquisition, a low dose CT scan of the head will be obtained for attenuation 
correction. 

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19 
• 
Patients will be injected with an intravenous bolus of 5mCi (370 MBq) (+/- 10%) of [18F]FDG 
(over 20 seconds). This is the standard dose used in published clinical studies using [18F]FDG 
(3-5).  
• 
The PET acquisition will begin immediately after the tracer injection and last for a total of 60 
minutes.  
• 
2ml of blood will be sampled from the forearm vein at 3, 8, 16, 24, 35, and 55 minutes post 
[18F]FDG tracer injection. This will be used for quantification of radiation estimates 
throughout the scan-period.  
 
General Procedures: 
• 
Patients will be positioned in the PET/CT scanner by trained staff. Subjects will be monitored 
via audio microphone and video. During PET imaging, subjects must remain as still as 
possible and thus every effort will be made to provide for their comfort including blankets, 
pillows and diligent assessment. The dual-tracer [11C]AcAC/[18F]FDG PET brain imaging 
procedure is similar to that used by previous clinical trials utilizing the technique (3-5). 
Scanning will begin with a standard low dose CT transmission scan of the head that will be 
used to correctly position the patient and for attenuation correction. For the [11C]AcAc scan 
brain emission images will be acquired continuously for a 30 minute period. For the 
[18F]FDG scan brain emission images will be acquired continuously for a 60 minute period. 
The images will be immediately assessed for technical validity by the PET technologist and if 
considered inadequate due to motion or other artifact, the subject will have an additional 
20 minutes of continuous imaging. 
• 
From the time of first tracer injection until after the whole imaging session is complete, 
patients will be observed continuously for signs of adverse events or serious adverse events. 
The injection site will be observed for excessive inflammation or damage to the surrounding 
tissue.  
• 
A physician or a person designated by the physician with appropriate training and 
experience will be present during the tracer injection and to approve discharge of the 
subject from the PET suite. 
• 
Study participants will be contacted 24-72 hours after they are injected with 
[11C]AcAC/[18F]FDG to inquire if any adverse events occurred within 24 hours of injection. 
 
8.2 
SAFETY AND OTHER ASSESSMENTS 
The primary safety assessments are assessing medical history through self-report and chart review, and 
weekly phone calls with participants to monitor potential side effects of estrogen administration. If a 
participant is found to have a contraindication in their medical history, they will be informed that they 
are not eligible to participate within 1 month of this determination. If a participant is taking a 
contraindicated medication, they will also be informed they are not eligible to participate. If the 
participant wishes to cease taking the medication in order to participate in the study, they will be asked 
to provide a letter from their physician that this is acceptable, and the risks and consequences of this 
will be reviewed with the study physician prior to enrolling them.  
 
If a participant reports a concerning side effect, the study physician or a proxy physician will be notified 
immediately to determine appropriate next steps. If the participant reports vaginal bleeding, this will be 
reported to the study physician and the participant will be advised to follow up with their primary care 
provider.  
   

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8.3 
ADVERSE EVENTS AND SERIOUS ADVERSE EVENTS 
 
8.3.1 DEFINITION OF ADVERSE EVENTS (AE) 
An adverse event (AE) is any untoward medical occurrence in a subject during participation in the clinical 
study or with use of the experimental agent being studied. 
 
8.3.2 DEFINITION OF SERIOUS ADVERSE EVENTS (SAE)  
A serious adverse event (SAE) is one that meets one or more of the following criteria: 
• 
Results in death 
• 
Is life-threatening (places the subject at immediate risk of death from the event as it occurred) 
• 
Results in inpatient hospitalization or prolongation of existing hospitalization 
• 
Results in a persistent or significant disability or incapacity or substantial disruption of the ability 
to conduct normal life functions 
• 
Results in a congenital anomaly or birth defect   
An important medical event that may not result in death, be life threatening, or require hospitalization 
may be considered an SAE when, based upon appropriate medical judgment, the event may jeopardize 
the subject and may require medical or surgical intervention to prevent one of the outcomes listed in 
this definition. 
 
8.3.3 CLASSIFICATION OF AN ADVERSE EVENT 
8.3.3.1 SEVERITY OF EVENT 
The following scale will be used to grade adverse events: 
1. Mild: no intervention required; no impact on activities of daily living (ADL) 
2. Moderate: minimal, local, or non-invasive intervention indicated; moderate impact on ADL 
3. Severe: significant symptoms requiring invasive intervention; subject seeks medical attention, 
needs major assistance with ADL 
 
8.3.3.2 RELATIONSHIP TO STUDY INTERVENTION 
All adverse events (AEs) must have their relationship to study intervention assessed by the clinician who 
examines and evaluates the participant based on temporal relationship and his/her clinical judgment. 
The degree of certainty about causality will be graded using the categories below.  
 
• 
Definitely Related – There is clear evidence to suggest a causal relationship, and other possible 
contributing factors can be ruled out. The clinical event, including an abnormal laboratory test 
result, occurs in a plausible time relationship to study intervention administration and cannot be 
explained by concurrent disease or other drugs or chemicals. The response to withdrawal of the 
study intervention (de-challenge) should be clinically plausible. The event must be 
pharmacologically or phenomenologically definitive, with use of a satisfactory rechallenge 
procedure if necessary. 
• 
Probably Related – There is evidence to suggest a causal relationship, and the influence of other 
factors is unlikely. The clinical event, including an abnormal laboratory test result, occurs within 
a reasonable time after administration of the study intervention, is unlikely to be attributed to 

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concurrent disease or other drugs or chemicals, and follows a clinically reasonable response on 
withdrawal (dechallenge). Rechallenge information is not required to fulfill this definition. 
• 
Potentially Related – There is some evidence to suggest a causal relationship (e.g., the event 
occurred within a reasonable time after administration of the trial medication). However, other 
factors may have contributed to the event (e.g., the participant’s clinical condition, other 
concomitant events). Although an AE may rate only as “possibly related” soon after discovery, it 
can be flagged as requiring more information and later be upgraded to “probably related” or 
“definitely related”, as appropriate. 
• 
Unlikely to be related – A clinical event, including an abnormal laboratory test result, whose 
temporal relationship to study intervention administration makes a causal relationship 
improbable (e.g., the event did not occur within a reasonable time after administration of the 
study intervention) and in which other drugs or chemicals or underlying disease provides 
plausible explanations (e.g., the participant’s clinical condition, other concomitant treatments). 
• 
Not Related – The AE is completely independent of study intervention administration, and/or 
evidence exists that the event is definitely related to another etiology. There must be an 
alternative, definitive etiology documented by the clinician.] 
 
8.3.3.3 EXPECTEDNESS  
The PI and/or study physician will be responsible for determining whether an adverse event (AE) is 
expected or unexpected.  An AE will be considered unexpected if the nature, severity, or frequency of 
the event is not consistent with the risk information previously described for the intervention.  This 
study includes administration of transdermal estrogen. According to the package insert, expected risks 
when administering estrogens include the list below.  
 
Less common but serious: 
• 
Breast cancer 
• 
Cancer of the uterus 
• 
Stroke 
• 
Heart attack 
• 
Blood clots 
• 
Dementia 
• 
Gallbladder disease 
• 
Ovarian cancer 
 
Warning signs of serious side effects: 
• 
Breast lumps 
• 
Unusual vaginal bleeding 
• 
Dizziness and faintness 
• 
Changes in speech 
• 
Severe headaches 
• 
Chest pain 
• 
Shortness of breath 
• 
Pains in your legs 
• 
Changes in vision 
• 
Vomiting 
 
Common side effects: 

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• 
Headache 
• 
Breast pain 
• 
Irregular vaginal bleeding or spotting 
• 
Stomach/abdominal cramps, bloating 
• 
Nausea and vomiting 
• 
Hair loss 
 
Other side effects: 
• 
High blood pressure 
• 
Liver problems 
• 
High blood sugar 
• 
Fluid retention 
• 
Enlargement of benign tumors of the uterus (“fibroids”) 
• 
Vaginal yeast infection 
 
It is worth noting that these are risks for administration of any estrogens and for long duration. Many of 
these risks were established from the Women’s Health Initiative Study, a landmark study that used long-
term oral administration of conjugated equine estrogens. Reported risks from research using short-term 
administration of transdermal estradiol have been minimal.34-36, 52, 54 
8.3.4 TIME PERIOD AND FREQUENCY FOR EVENT ASSESSMENT AND FOLLOW-UP 
The occurrence of an adverse event (AE) or serious adverse event (SAE) may come to the attention of 
study personnel during study visits and interviews of a study participant presenting for medical care, or 
upon review by a study monitor. 
 
All AEs including local and systemic reactions not meeting the criteria for SAEs will be captured on the 
appropriate case report form (CRF). Information to be collected includes event description, time of 
onset, clinician’s assessment of severity, relationship to study product (assessed only by those with the 
training and authority to make a diagnosis), and time of resolution/stabilization of the event. All AEs 
occurring while on study must be documented appropriately regardless of relationship. All AEs will be 
followed to adequate resolution. 
 
Any medical condition that is present at the time that the participant is screened will be considered as 
baseline and not reported as an AE. However, if the study participant’s condition deteriorates at any 
time during the study, it will be recorded as an AE.  
 
Changes in the severity of an AE will be documented to allow an assessment of the duration of the event 
at each level of severity to be performed. AEs characterized as intermittent require documentation of 
onset and duration of each episode. 
 
Study staff will record all reportable events with start dates occurring any time after informed consent is 
obtained until 7 (for non-serious AEs) or 30 days (for SAEs) after the last day of study participation.  At 
each study visit, study staff will inquire about the occurrence of AE/SAEs since the last visit.  Events will 
be followed for outcome information until resolution or stabilization. 
 
8.3.5 ADVERSE EVENT REPORTING  

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Any major AE, i.e., any serious injury including all SAEs that are unanticipated, serious, and possibly 
related to the study intervention will be recorded and reported to the PI immediately after completing 
any and all actions that are necessary to protect the subject’s health and safety. A description of the 
event and the date and location of the event will be recorded on the AE Reporting Form. Reported 
events will be compiled to submit to the IRB and NIA annually, unless it is a serious event that requires 
more immediate reporting.  
• 
Unexpected fatal or life-threatening AEs related to the intervention will be reported to the IRB 
and NIA within 3 days of the investigator becoming aware of the event.  Other serious and 
unexpected AEs related to the intervention will be reported within 7 days. 
• 
Anticipated or unrelated SAEs will be handled in a less urgent manner but will be reported to 
the IRB and NIA on an annual basis.    
• 
All other AEs documented during the course of the trial will be reported to the IRB and NIA on 
an annual basis by way of inclusion in the annual report. 
 
8.3.6 REPORTING EVENTS TO PARTICIPANTS  
During the consenting process, incidental findings will be explained to the participant. Participants will 
be informed that incidental findings may reveal a previously unknown health concern that it would 
benefit the participant to know about so that they can seek treatment. However, because the tests we 
are performing are for research and not diagnostic purposes, incidental findings may not reflect a real 
problem if a diagnostic scan is performed later. In this case, incidental findings can lead to unnecessary 
testing.  
 
Participants will be informed of study-related results under the following circumstances.  
• 
If a participant does not qualify for the study at screening, they will be informed why they did 
not qualify. If they did not qualify because a screening measure was out of range and may 
indicate an underlying health concern (incidental finding), that will be explained. The nature of 
incidental findings will also be reviewed with the participant.  
• 
When MRI scans are viewed for research purposes, incidental findings may be observed. In 
some cases, incidental findings may reveal a previously unknown health concern that it would 
benefit the participant to know about so that they can seek treatment. However, in our 
experience, some people do not wish to be informed of MRI-related incidental findings. 
Therefore, during consent, participants will be asked if they wish to be informed of MRI-related 
incidental findings.  All of our MRI scans will be read by a board-certified neuroradiologist 
regardless to rule out major abnormalities or issues that might lead to scans being excluded 
from the study. If an incidental finding is noted and the participant has requested to be notified, 
we will contact them and provide the feedback from the neuroradiologist. At the participant’s 
request, we will share the research MRI scans with their physician.  
 
8.3.7 REPORTING OF PREGNANCY  
All women in the study will be postmenopausal.  
 
8.4 
UNANTICIPATED PROBLEMS 
 
8.4.1 DEFINITION OF UNANTICIPATED PROBLEMS (UP) 
 

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The Office for Human Research Protections (OHRP) considers unanticipated problems involving risks to 
participants or others to include, in general, any incident, experience, or outcome that meets all of the 
following criteria: 
 
• 
Unexpected in terms of nature, severity, or frequency given (a) the research procedures that are 
described in the protocol-related documents, such as the Institutional Review Board (IRB)-
approved research protocol and informed consent document; and (b) the characteristics of the 
participant population being studied; 
• 
Related or possibly related to participation in the research (“possibly related” means there is a 
reasonable possibility that the incident, experience, or outcome may have been caused by the 
procedures involved in the research); and 
• 
Suggests that the research places participants or others at a greater risk of harm (including 
physical, psychological, economic, or social harm) than was previously known or recognized. 
 
8.4.2  UNANTICIPATED PROBLEM REPORTING  
The PI and study staff will report unanticipated problems (UPs) to the reviewing Institutional Review 
Board (IRB). 
 
• 
Protocol identifying information: protocol title and number, PI’s name, and the IRB project 
number; 
• 
A detailed description of the event, incident, experience, or outcome;  
• 
An explanation of the basis for determining that the event, incident, experience, or outcome 
represents an UP;  
• 
A description of any changes to the protocol or other corrective actions that have been taken or 
are proposed in response to the UP. 
 
To satisfy the requirement for prompt reporting, UPs will be reported using the following timeline:   
 
• 
UPs that are serious adverse events (SAEs) will be reported to the IRB within 7 days of the 
investigator becoming aware of the event.  
• 
Any other UP will be reported to the IRB within 14 days of the investigator becoming aware of 
the problem.  
• 
All UPs should be reported to appropriate institutional officials (as required by an institution’s 
written reporting procedures), the supporting agency head (or designee), and the Office for 
Human Research Protections (OHRP) within 31 days of the IRB’s receipt of the report of the 
problem from the investigator. 
 
9 
STATISTICAL CONSIDERATIONS  
 
9.1 
STATISTICAL HYPOTHESES 
Aim 1. Assess whether T2D alters cognitive response to 8 weeks of transdermal estrogen. Composite z-
scores will be calculated by calculating a z-score for each cognitive task and summing z-scores for the 
tasks designated as Short-Term Memory (STM Composite) and Executive Function (EF Composite). We 
will assess differences in follow-up scores between intervention groups using ANCOVA after covariate 
adjustment for baseline scores using SAS software.61 Because age, BMI, and education may influence 
changes in cognition over time (e.g. learning effects), we will assess whether including these as 

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covariates affects results. The primary outcomes will be the composite scores. Secondary analyses will 
examine individual components. 
 
Aim 2. Assess whether T2D alters estrogen effects on brain uptake of glucose and ketone bodies in 
whole brain and Alzheimer’s disease (AD) related regions of interest. FDG and AcAc PET scan data will 
be analyzed with PMOD® Software using methods described by our collaborators.32 Briefly, imaging data 
are co-registered to T1 structural MRI data to conduct region of interest (ROI)-based analyses. This will 
quantify absolute global and regional uptake of FDG and AcAc to determine uptake, as well as uptake of 
AcAc relative to FDG to find potential areas of compensatory ketone use. T1 MRI images will be 
processed using publically available software in a customized workflow, primarily ANTs due to evidence 
of superior performance.62 Average values for ROI will be calculated for the posterior 
cingulate/precuneus, temporal lobe, and prefrontal cortices, as these are regions of observed decreases 
in FDG uptake in AD and are relevant for development and progression of dementia. Inference will be 
based the same approaches as for cognitive data for 1) whole-brain glucose uptake, 2) whole-brain 
ketone uptake, 3) regional glucose uptake, 3) regional ketone uptake, 4) whole-brain ratio of 
ketone/glucose uptake, and 5) regional ratio of ketone/glucose uptake. We will assess inter-
relationships among changes in these outcomes and with changes in cognitive function using principal 
components and canonical correlation. 
 
Alternate hypotheses. In addition to its effects on cellular bioenergetics, estrogen can affect vascular 
health.63, 64 A recent finding that women with T2D were at increased dementia risk saw increased risk for 
vascular dementia.2 Thus, the interaction between T2D and estrogen may be mediated through vascular 
effects, or through an interaction between metabolic and vascular effects. Therefore, we have included 
two MRI scans to assess vascular brain health: 1) a T2-weighted FLAIR image to assess white matter 
hyperintensities, an indicator of small-vessel disease correlated with diabetes status and 
hypertension,65-67 and 2) a susceptibility-weighted image to assess for microbleeds.68  
 
The 3 City Study18 found interactions between T2D status and endogenous estrogen levels. The WHIMS 
study observed an interaction between T2D and women randomized to oral estrogen treatment.19, 20 We 
will examine exploratory cross-sectional associations between estrogen levels before estrogen 
administration and PET and cognitive testing to assess for differences due to endogenous estrogen.  
 
Both the WHIMS and 3 City studies statistically adjusted for BMI. To minimize any potential influence of 
BMI that may persist after BMI adjustment, we plan to limit participants’ BMI range and match for BMI. 
We will also examine whether changes in BMI or diabetes treatment over follow-up affect results. 
Cortisol may be elevated in older adults with T2D, even after controlling for BMI69 and the presence of 
cortisol may modify the effects of estrogen on cognition.36 Therefore, serum cortisol will be assayed to 
test for potential interactions between estrogen and cortisol. Due to the cyclical nature of cortisol 
secretion, all blood draws will occur between 8AM-10AM. OGTT data will allow us to use glucose and 
insulin levels as covariates as needed. Drs. Mintz and Hughes are currently collecting pilot data on 
methods that may enhance the sensitivity of the [11C]AcAc scans. If these methods are successful, they 
will be incorporated into the final study. 
 
9.2 
SAMPLE SIZE DETERMINATION 
This is a small, proof-of-concept study to determine whether it is feasible to measure effects of estrogen 
on brain metabolism using novel PET methods. For ethical (exposure to radiation) and financial reasons, 
it is not uncommon to limit sample size for PET studies. Previous work specifically examining the effects 

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of small sample size on PET outcomes observed that in sample sizes comparable to this study, false 
negatives began to increase, but no increase was seen in false positives. In addition, they concluded 
good replicability could be achieved in samples of 10-20 PET.70 
 
9.3 
POPULATIONS FOR ANALYSES 
All participants who complete the experimental estrogen administration will be included in the analysis. 
If a participant discontinues, withdraws, or is lost to follow-up after beginning the study, all efforts will 
be made to replace that participant and reach the final sample size. 
 
9.4 
STATISTICAL ANALYSES 
 
9.4.1 GENERAL APPROACH 
For all analyses, statistical significance will be defined as p<0.05. For all data, distributions will be 
viewed,  assessed for normality, and transformed if needed to conform to the requirements of the 
selected statistical test.  
 
10 SUPPORTING DOCUMENTATION AND OPERATIONAL CONSIDERATIONS 
 
10.1 REGULATORY, ETHICAL, AND STUDY OVERSIGHT CONSIDERATIONS 
 
10.1.1 INFORMED CONSENT PROCESS 
 
10.1.1.1 CONSENT/ASSENT AND OTHER INFORMATIONAL DOCUMENTS PROVIDED TO 
PARTICIPANTS 
Consent forms describing in detail the study intervention, study procedures, and risks are given to the 
participant and written documentation of informed consent is required prior to starting 
intervention/administering study intervention.   
 
10.1.1.2 CONSENT PROCEDURES AND DOCUMENTATION 
Informed consent is a process that is initiated prior to the individual’s agreeing to participate in the 
study and continues throughout the individual’s study participation. The participant will be asked to 
read and review the IRB-approved consent form. Study staff will explain the research study to the 
participant and answer any questions that may arise. A verbal explanation will be provided in terms 
suited to the participant’s comprehension of the purposes, procedures, and potential risks of the study 
and of their rights as research participants.  Participants will have the opportunity to carefully review the 
written consent form and ask questions prior to signing. The participant will sign the informed consent 
document prior to any procedures being done for the study. A copy of the informed consent document 
will be given to the participants for their records.  
10.1.2 STUDY DISCONTINUATION AND CLOSURE 
This study may be temporarily suspended or prematurely terminated if there is sufficient reasonable 
cause.  Written notification, documenting the reason for study suspension or termination, will be 
provided by the suspending or terminating party to study participants, the investigator, the NIA and 
regulatory authorities.  If the study is prematurely terminated or suspended, the Principal Investigator 
(PI) will promptly inform study participants, the Institutional Review Board (IRB), and the NIA and will 

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provide the reason(s) for the termination or suspension.  Study participants will be contacted, as 
applicable, and be informed of changes to study visit schedule. 
  
Circumstances that may warrant termination or suspension include, but are not limited to: 
• 
Determination of unexpected, significant, or unacceptable risk to participants 
• 
Insufficient compliance to protocol requirements 
• 
Determination of futility 
 
The study may resume once concerns about safety, protocol compliance, and data quality are 
addressed, and satisfy the IRB. 
 
10.1.3 CONFIDENTIALITY AND PRIVACY  
Every effort is made by the investigators, study staff, sponsor(s) and their agents to maintain 
confidentiality of protected health information collected in the study. All of the materials collected are 
for research purposes only and will be held in strictest confidence. All WFSM faculty and staff receive 
annual trainings in privacy, protection of personally identifiable information, and HIPAA regulations. 
Confidentiality of data is maintained by using research identification numbers that uniquely identify 
each individual.  Data other than demographic information will not use names as an identifier; research 
ID numbers will be used.  Data will be used only in aggregate and no identifying characteristics of 
individuals will be published or presented.  
 
Written records will be kept in locked cabinets in the Sticht Center on Aging. Files matching participants' 
names and demographic information with the research ID numbers are kept in a separate room and 
locked file with a different key from for all other files. Files may be obtained from the research unit only 
by authorized study personnel. After the study is completed, local data will be stored with other 
completed research studies in a secured storage area. 
 
Digital records, including brain imaging data, will be stored on password protected, network drives 
behind the WFSM firewall. These drives are routinely backed up and access to the drives is limited to 
necessary personnel. Brain imaging data are stored using subject number and date of acquisition as 
identifiers. The study PI regulates access to the drives used for brain imaging data. Data other than brain 
imaging data will be entered into REDCap, which allows the PI to control who has access to viewing and 
downloading data.  
 
No information concerning the study or the data will be released to any unauthorized third party 
without prior written approval of the sponsor. The study monitor or other authorized representatives of 
the sponsor may inspect all study documents and records required to be maintained by the investigator, 
including but not limited to, medical records (office, clinic, or hospital) for the study subjects.  The 
clinical study site will permit access to such records. 
 
Certificate of Confidentiality 
To further protect the privacy of study participants, a Certificate of Confidentiality will be issued by the 
National Institutes of Health (NIH).  This certificate protects identifiable research information from 
forced disclosure. It allows the investigator and others who have access to research records to refuse to 
disclose identifying information on research participation in any civil, criminal, administrative, legislative, 
or other proceeding, whether at the federal, state, or local level. By protecting researchers and 
institutions from being compelled to disclose information that would identify research participants, 

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Certificates of Confidentiality help achieve the research objectives and promote participation in studies 
by helping assure confidentiality and privacy to participants. 
 
10.1.4 FUTURE USE OF STORED SPECIMENS AND DATA  
Data collected for this study will be analyzed and stored at Wake Forest School of Medicine. With the 
participant’s approval and as approved by the Institutional Review Boards (IRB), de-identified biological 
samples may be stored at Wake Forest School of Medicine. These samples could be used for future 
related research with the permission of the PI. During the study, an individual participant can choose to 
withdraw consent to have biological specimens stored for future research. However, withdrawal of 
consent with regard to biosample storage may not be possible after the study is completed.  When the 
study is completed, access to study data and/or samples will be provided through permission from the 
PI and IRB. 
 
10.1.5 KEY ROLES AND STUDY GOVERNANCE 
Principal Investigator    Christina Hugenschmidt, PhD 
Sticht Center on Healthy Aging and Alzheimer’s Prevention 
Wake Forest School of Medicine 
Medical Center Boulevard 
Winston-Salem, NC 27157 
Email: chugensc@wakehealth.edu 
Phone: +1-336-713-4190 
Fax: +1-336-713-8588 
 
Study Physician 
Jantira Thomas, DO 
 
 
 
Assistant Professor of Internal Medicine,  
 
 
 
Medical Director, Acute Care for the Elderly (ACE) Unit 
 
 
 
Gerontology and Geriatric Medicine 
 
 
 
Wake Forest School of Medicine 
 
 
 
Email: janthoma@wakehealth.edu  
 
 
 
Phone: +1-336-713-8583 
 
Statistician 
 
Mark Espeland, PhD 
 
 
 
Professor, Department of Public Health Sciences 
 
 
 
Wake Forest School of Medicine 
 
 
 
Email: mespelan@wakehealth.edu 
 
 
 
Phone:  +1-336-716-2826 
 
10.1.6 SAFETY OVERSIGHT 
Safety oversight will be monitored by the PI and the study physician, as well as the study team. Any 
safety concerns should be reported immediately to the PI and/or study physician or proxy for the study 
physician. Safety concerns will also be addressed at monthly study team meetings. AEs will be reported 
as described above. 
 
10.1.7 QUALITY ASSURANCE AND QUALITY CONTROL 
Quality control metrics for non-imaging data will be generated from computerized reports generated 
from the database after data entry. Monthly reports will identify missing data, values that are out of 
range, and track attendance, as well as show plots of primary outcome measures to identify outliers that 

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may signify data entry errors. These metrics can be generated by REDCap. A study staff member will be 
identified who will routinely generate these measures in REDCap approximately 24 hours prior to the 
monthly study meeting. The study staff member will present the data to the study team and data errors 
will be agreed upon by the team. During the meeting, a study staff member will be assigned an action to 
correct the data entry error. This will be documented in the meeting minutes as an action item and 
follow-up will be added to the next month’s agenda. When data are corrected in REDCap, REDCap 
software automatically tracks the date, time, and user who modified the database.  
 
At the end of the study, histograms of the data distribution for each variable will be generated to 
identify outliers that may signify errors in acquisition or data entry. Many variables in the study will be 
acquired at 2 or 3 time points. For these variables, histograms of differences will be generated. This 
additional step can identify data acquisition or entry errors through unusual amounts of change.    
 
Quality assessment will performed on MRI and PET data at 3 time points on all data sets and results will 
be recorded in a REDCap form accessible by all study team members. First, raw data will be viewed after 
being transferred from the scanner and converted into nifti format to ensure completeness and assess 
for imaging ghosting and reconstruction errors. After preprocessing, data will be viewed again to assess 
for errors and residual motion. Finally, data will be viewed to assess any errors during processing. All 
image processing steps will be verified before summary metrics are extracted for the final statistical 
analyses. All data quality questions will be referred to the PI. 
 
10.1.8 DATA HANDLING AND RECORD KEEPING  
 
10.1.8.1 DATA COLLECTION AND MANAGEMENT RESPONSIBILITIES  
As this is a single-site study, all data will be collected by study staff at this site. The header of all data 
collection forms includes a unique numerical study identifier (study ID number), a unique alphabetical 
identifier (“acrostic”), the date the form was collected, the initials of the study staff who completed the 
form, the study name, and the study visit (e.g., baseline visit 1). The footer for all data collection forms 
includes version number and page.  
 
Types of data collected include 1) paper forms, 2) electronic data, and 3) neuroimaging data. All data 
collection will be performed by trained study staff. Every effort is made by the investigators, study staff, 
sponsor(s) and their agents to maintain confidentiality of protected health information collected in the 
study. All of the materials collected are for research purposes only and will be held in strictest 
confidence. All WFSM faculty and staff receive annual trainings in privacy, protection of personally 
identifiable information, and HIPAA regulations. 
 
Written records will be kept in locked cabinets in the Sticht Center on Healthy Aging and Alzheimer’s 
Prevention. Files matching participants' names and demographic information with the research ID 
numbers are kept in a separate room and locked file with a different key from for all other files. Files 
may be obtained from the research unit only by authorized study personnel. After the study is 
completed, local data will be stored with other completed research studies in a secured storage area. 
After data collection on paper forms, data will be entered into a REDCap database that is password 
protected and accessible only by study staff in 0-14 days after data are collected. Only the PI will have 
permission to download identifying information from the REDCap database and the PI will assign data 
access for all study staff.  
 

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Digital records, including brain imaging data, will be stored on password protected, network drives 
behind the WFSM firewall. These drives are routinely backed up and access to the drives is limited to 
necessary personnel. Brain imaging data are stored using subject number and date of acquisition as 
identifiers. The study PI regulates access to the drives used for brain imaging data.  
 
No information concerning the study or the data will be released to any unauthorized third party 
without prior written approval of the sponsor. The study monitor or other authorized representatives of 
the sponsor may inspect all study documents and records required to be maintained by the investigator, 
including but not limited to, medical records (office, clinic, or hospital) for the study subjects.  The 
clinical study site will permit access to such records. 
 
10.1.8.2 STUDY RECORDS RETENTION  
Study documents should be retained for a minimum of 2 years after the last approval of a marketing 
application in an International Conference on Harmonisation (ICH) region and until there are no pending 
or contemplated marketing applications in an ICH region or until at least 2 years have elapsed since the 
formal discontinuation of clinical development of the study intervention. These documents should be 
retained for a longer period, however, if required by local regulations. No records will be destroyed 
without the written consent of the sponsor, if applicable. It is the responsibility of the sponsor to inform 
the investigator when these documents no longer need to be retained. 
 
10.1.9 PROTOCOL DEVIATIONS  
A protocol deviation is any noncompliance with the study protocol, International Conference on 
Harmonisation Good Clinical Practice (ICH GCP), or Manual of Procedures (MOP) requirements. The 
noncompliance may be either on the part of the participant, the investigator, or the study site staff. As a 
result of deviations, corrective actions are to be developed by the site and implemented promptly. All 
deviations must be addressed in study source documents and must be sent to the reviewing Institutional 
Review Board (IRB) per their policies. 
 
A computerized tracking system will be used to document participant attendance, generate quality 
control reports for identifying protocol deviations and to assess protocol adherence. Any unanticipated 
problems, serious and unexpected adverse events, deviations or protocol changes will be promptly 
reported by the principal investigator or designated member of the research team to the IRB and 
sponsor or appropriate government agency if appropriate. The study team will generate Study Reports 
for the DSMB and will provide information on the overall status and timeline of the study including 
enrollment status, recruitment, subject status (i.e., number completed), safety events, and protocol 
deviations. Study Report tables will be generated only from aggregate (not by group assignment) 
baseline and safety data for the study population. Study team meetings will occur at least twice a 
month, and quality control metrics will be reviewed once a month.  
 
10.1.10 
PUBLICATION AND DATA SHARING POLICY 
National Institutes of Health (NIH) Public Access Policy, which ensures that the public has access to the 
published results of NIH funded research. It requires scientists to submit final peer-reviewed journal 
manuscripts that arise from NIH funds to the digital archive PubMed Central upon acceptance for 
publication. 
 
10.1.11 
CONFLICT OF INTEREST POLICY 

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31 
The independence of this study from any actual or perceived influence, such as by the pharmaceutical 
industry, is critical.  Therefore, any actual conflict of interest of persons who have a role in the design, 
conduct, analysis, publication, or any aspect of this trial will be disclosed and managed. Furthermore, 
persons who have a perceived conflict of interest will be required to have such conflicts managed in a 
way that is appropriate to their participation in the design and conduct of this trial.   
 
10.2 ABBREVIATIONS 
 
AE 
Adverse Event 
ANCOVA 
Analysis of Covariance 
CFR 
Code of Federal Regulations 
CLIA 
Clinical Laboratory Improvement Amendments 
COC 
Certificate of Confidentiality 
CRF 
Case Report Form 
HIPAA 
Health Insurance Portability and Accountability Act  
IRB 
Institutional Review Board 
MOP 
Manual of Procedures 
MRI 
Magnetic resonance imaging 
NIH  
National Institutes of Health 
OHRP 
Office for Human Research Protections 
PET 
Positron Emission Tomography 
PI 
Principal Investigator 
QA 
Quality Assurance 
SAE 
Serious Adverse Event 
UP 
Unanticipated Problem 
 
 

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32 
10.3 PROTOCOL AMENDMENT HISTORY 
 
Version 
Date 
Description of Changes  
Brief Rationale 
2.0 
03/13/19 
Section 2.31 Add language regarding 
Genetic testing 
Genetic testing was not 
included in the original IRB 
approved protocol 
2.0 
03/13/19 
Section 5.1 Inclusion Criteria: 
remove number 7 regarding 
transportation. 
Transportation is available if 
necessary. 
2.0 
03/13/19 
Section 5.2 Add exclusionary 
medications to List of Exclusions 
Exclusionary medications were 
outlined in original protocol 
under concomitant medications 
but not in the Exclusion List. 
2.0 
03/13/19 
Section 8.1 Assessments:  Add “For 
non-diabetic women” to bullet 
regarding OGTT 
OGGT is unnecessary for 
participants with a diagnosis of 
diabetes. 
2.0 
03/13/19 
Section 8.1 Add language to V2 and 
V4 to indicate the participants must 
be fasting for the PET scans 
The PET scan requires the 
participants to fast for 6-7 
hours prior to the scan. 
3.0 
05/06/19 
Section 1.3 Add fasting blood draw 
to V2 and V4 since blood is being 
drawn at various points of PET scan 
The PET scan includes fasting 
blood draws that were not 
identified on the Schedule of 
Assessments 
3.0 
05/06/19 
Section 8.1 Remove fasting blood 
draw for genetic assessment ad to 
assess ketone bodies  
from SV  
The blood draw for genetic 
assessment is done at V3 and 
the blood draws to assess for 
ketone bodies are done during 
the PET Scan at V2 and V4, not 
at the SV 
3.0 
05/06/19 
Section 8.1 Add fasting blood draw 
to assess for ketone bodies to V2 
This was erroneously included 
in the SV in the previous 
protocols. 
3.0 
05/06/19 
Section 8.1 Add blood draw for 
genetic assessment to V3 
This was erroneously included 
in the SV in the previous 
protocols. 
3.0 
05/06/19 
Section 8.1 Add fasting blood draw 
to assess for ketone bodies to V4 
This was erroneously included 
in the SV in the previous 
protocols. 
4.0 
09/05/19 
Section 1.1 Change study population 
age range to 60-80 
Lowering the inclusion age to 
60 should allow for a greater 
number of participants to 
qualify 
4.0 
09/05/19 
Section 5.1 Expand BMI range up to 
35 
Increasing the BMI range 
should allow a greater number 
of participants to qualify 
4.0 
09/05/19 
Section 5.1 Change Inclusion Criteria 
age range to 60-80 
Lowering the inclusion age to 
60 should allow for a greater 

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33 
number of participants to 
qualify 
5.0 
 
12/09/19 
5.1 Add Inclusion Criteria #8 to now 
include prediabetic women to 
participate 
Prediabetic women will now 
be eligible to participate 
where, in the past, were 
excluded. 
5.0 
12/09/19 
5.2 Modify wording of Exclusion 
Criteria #8 to clarify necessary 
ranges for cutoff measurements for 
prediabetic women. 
Prediabetic women were all 
excluded in the past and now 
are included if measurements 
fall into this specific range. 
6.0 
01/28/2020 
1.3 Expand length of time between 
SV1 and SV2 to 1-30 days. 
Increasing the span of time 
allows for more flexibility for 
scheduling basesd on 
participant, equipment and 
staff availability. 
6.0 
01/28/2020 
8.1 Expand length of time between 
SV1 and SV2 to 1-30 days 
Increasing the span of time 
allows for more flexibility for 
scheduling basesd on 
participant, equipment and 
staff availability. 
7.0 
08/14/2020 
10.1.9 Remove reference to DSMB. 
There is no Data Safety 
Monitoring Board for this 
study. 
 

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34 
REFERENCES  
1.Prevention, C.f.D.C.a., National Diabetes Statistics Report: Estimates of Diabetes and Its Burden in the United 
States, 2014, U.D.o.H.a.H. Services, Editor 2014: Atlanta, GA. 
2.Chatterjee, S., et al., Type 2 Diabetes as a Risk Factor for Dementia in Women Compared With Men: A Pooled 
Analysis of 2.3 Million People Comprising More Than 100,000 Cases of Dementia. Diabetes Care, 2016. 39(2): p. 
300-7. 
3.Cunnane, S.C., et al., Can ketones compensate for deteriorating brain glucose uptake during aging? Implications 
for the risk and treatment of Alzheimer's disease. Ann N Y Acad Sci, 2016. 
4.Brinton, R.D., et al., Perimenopause as a neurological transition state. Nat Rev Endocrinol, 2015. 11(7): p. 393-
405. 
5.Thies, W., L. Bleiler, and A. Alzheimer's, 2013 Alzheimer's disease facts and figures. Alzheimers Dement, 2013. 
9(2): p. 208-45. 
6.James, B.D., et al., Contribution of Alzheimer disease to mortality in the United States. Neurology, 2014. 
7.Di Carlo, A., et al., Incidence of dementia, Alzheimer's disease, and vascular dementia in Italy. The ILSA Study. J 
Am Geriatr Soc, 2002. 50(1): p. 41-8. 
8.Fratiglioni, L., et al., Very old women at highest risk of dementia and Alzheimer's disease: incidence data from the 
Kungsholmen Project, Stockholm. Neurology, 1997. 48(1): p. 132-8. 
9.Letenneur, L., et al., Are sex and educational level independent predictors of dementia and Alzheimer's disease? 
Incidence data from the PAQUID project. J Neurol Neurosurg Psychiatry, 1999. 66(2): p. 177-83. 
10.Miech, R.A., et al., Incidence of AD may decline in the early 90s for men, later for women: The Cache County 
study. Neurology, 2002. 58(2): p. 209-18. 
11.Ott, A., et al., Incidence and risk of dementia. The Rotterdam Study. Am J Epidemiol, 1998. 147(6): p. 574-80. 
12.Hebert, L.E., et al., Alzheimer disease in the United States (2010-2050) estimated using the 2010 census. 
Neurology, 2013. 80(19): p. 1778-83. 
13.Alzheimer's, A., 2015 Alzheimer's disease facts and figures. Alzheimers Dement, 2015. 11(3): p. 332-84. 
14.Carter, C.L., et al., Sex and gender differences in Alzheimer's disease: recommendations for future research. J 
Womens Health (Larchmt), 2012. 21(10): p. 1018-23. 
15.Artero, S., et al., Risk profiles for mild cognitive impairment and progression to dementia are gender specific. J 
Neurol Neurosurg Psychiatry, 2008. 79(9): p. 979-84. 
16.Barnes, L.L., et al., Sex differences in the clinical manifestations of Alzheimer disease pathology. Arch Gen 
Psychiatry, 2005. 62(6): p. 685-91. 
17.Fleisher, A., et al., Sex, apolipoprotein E epsilon 4 status, and hippocampal volume in mild cognitive impairment. 
Arch Neurol, 2005. 62(6): p. 953-7. 
18.Carcaillon, L., et al., High plasma estradiol interacts with diabetes on risk of dementia in older postmenopausal 
women. Neurology, 2014. 82(6): p. 504-11. 
19.Espeland, M.A., et al., Impact of Type 2 Diabetes and Postmenopausal Hormone Therapy on Incidence of 
Cognitive Impairment in Older Women. Diabetes Care, 2015. 38(12): p. 2316-24. 

FEMME 
Protocol – V8.0 03/16/2021 
 
35 
20.Espeland, M.A., et al., Postmenopausal hormone therapy, type 2 diabetes mellitus, and brain volumes. 
Neurology, 2015. 85(13): p. 1131-8. 
21.Laffel, L., Ketone bodies: a review of physiology, pathophysiology and application of monitoring to diabetes. 
Diabetes Metab Res Rev, 1999. 15(6): p. 412-26. 
22.Morris, A.A., Cerebral ketone body metabolism. J Inherit Metab Dis, 2005. 28(2): p. 109-21. 
23.Pan, J.W., et al., Measurement of beta-hydroxybutyrate in acute hyperketonemia in human brain. J Neurochem, 
2001. 79(3): p. 539-44. 
24.Wootton-Gorges, S.L., et al., Detection of cerebral {beta}-hydroxy butyrate, acetoacetate, and lactate on proton 
MR spectroscopy in children with diabetic ketoacidosis. AJNR Am J Neuroradiol, 2005. 26(5): p. 1286-91. 
25.Blomqvist, G., et al., Effect of acute hyperketonemia on the cerebral uptake of ketone bodies in nondiabetic 
subjects and IDDM patients. Am J Physiol Endocrinol Metab, 2002. 283(1): p. E20-8. 
26.Pan, J.W., et al., Human brain beta-hydroxybutyrate and lactate increase in fasting-induced ketosis. J Cereb 
Blood Flow Metab, 2000. 20(10): p. 1502-7. 
27.Mahendran, Y., et al., Association of ketone body levels with hyperglycemia and type 2 diabetes in 9,398 Finnish 
men. Diabetes, 2013. 62(10): p. 3618-26. 
28.Avogaro, A., et al., High blood ketone body concentration in type 2 non-insulin dependent diabetic patients. J 
Endocrinol Invest, 1996. 19(2): p. 99-105. 
29.Harano, Y., et al., Ketone bodies as markers for type 1 (insulin-dependent) diabetes and their value in the 
monitoring of diabetic control. Diabetologia, 1984. 26(5): p. 343-8. 
30.Robertson, D.A., et al., Metabolic abnormalities in obese patients with impaired glucose tolerance. Diabet Med, 
1990. 7(1): p. 45-9. 
31.Nugent, S., et al., Relationship of metabolic and endocrine parameters to brain glucose metabolism in older 
adults: do cognitively-normal older adults have a particular metabolic phenotype? Biogerontology, 2016. 17(1): p. 
241-55. 
32.Nugent, S., et al., Brain glucose and acetoacetate metabolism: a comparison of young and older adults. 
Neurobiol Aging, 2014. 35(6): p. 1386-95. 
33.Castellano, C.A., et al., Lower brain 18F-fluorodeoxyglucose uptake but normal 11C-acetoacetate metabolism in 
mild Alzheimer's disease dementia. J Alzheimers Dis, 2015. 43(4): p. 1343-53. 
34.Asthana, S., et al., High-dose estradiol improves cognition for women with AD: results of a randomized study. 
Neurology, 2001. 57(4): p. 605-12. 
35.Asthana, S., et al., Cognitive and neuroendocrine response to transdermal estrogen in postmenopausal women 
with Alzheimer's disease: results of a placebo-controlled, double-blind, pilot study. Psychoneuroendocrinology, 
1999. 24(6): p. 657-77. 
36.Baker, L.D., et al., Cognitive response to estradiol in postmenopausal women is modified by high cortisol. 
Neurobiol Aging, 2012. 33(4): p. 829 e9-20. 
37.Moses-Kolko, E.L., et al., Estradiol effects on the postmenopausal brain. Am J Psychiatry, 2004. 161(11): p. 2136; 
author reply 2136. 

FEMME 
Protocol – V8.0 03/16/2021 
 
36 
38.Loucks, T.L. and S.L. Berga, Does postmenopausal estrogen use confer neuroprotection? Semin Reprod Med, 
2009. 27(3): p. 260-74. 
39.Shumaker, S.A., et al., Conjugated equine estrogens and incidence of probable dementia and mild cognitive 
impairment in postmenopausal women - Women's Health Initiative Memory Study. Jama-Journal of the American 
Medical Association, 2004. 291(24): p. 2947-2958. 
40.Shumaker, S.A., et al., Estrogen plus progestin and the incidence of dementia and mild cognitive impairment in 
postmenopausal women - The Women's Health Initiative Memory Study: A randomized controlled trial. Jama-
Journal of the American Medical Association, 2003. 289(20): p. 2651-2662. 
41.Pinkerton, J.V., et al., The 2017 hormone therapy position statement of The North American Menopause Society. 
Menopause-the Journal of the North American Menopause Society, 2017. 24(7): p. 728-753. 
42.Rasgon, N.L., et al., Prospective Randomized Trial to Assess Effects of Continuing Hormone Therapy on Cerebral 
Function in Postmenopausal Women at Risk for Dementia. Plos One, 2014. 9(3). 
43.Troy, S.M., et al., Differences in Pharmacokinetics and Comparative Bioavailability between Premarin(R) and 
Estratab(R) in Healthy Postmenopausal Women. Current Therapeutic Research-Clinical and Experimental, 1994. 
55(4): p. 359-372. 
44.Levrant, S. and R. Barnes, Pharmacology of estrogens., in Treatment of the postmenopausal women: basic and 
clinical aspects., R. Lobo, Editor. 1994, Raven Press: New York. p. 57-68. 
45.Engler-Chiurazzi, E.B., M. Singh, and J.W. Simpkins, From the 90's to now: A brief historical perspective on more 
than two decades of estrogen neuroprotection. Brain Research, 2016. 1633: p. 96-100. 
46.Emmerzaal, T.L., A.J. Kiliaan, and D.R. Gustafson, 2003-2013: a decade of body mass index, Alzheimer's disease, 
and dementia. J Alzheimers Dis, 2015. 43(3): p. 739-55. 
47.Ishii, M. and C. Iadecola, Adipocyte-derived factors in age-related dementia and their contribution to vascular 
and Alzheimer pathology. Biochim Biophys Acta, 2016. 1862(5): p. 966-74. 
48.Pedditizi, E., R. Peters, and N. Beckett, The risk of overweight/obesity in mid-life and late life for the 
development of dementia: a systematic review and meta-analysis of longitudinal studies. Age Ageing, 2016. 45(1): 
p. 14-21. 
49.Roberts, J.S. and W.R. Uhlmann, Genetic susceptibility testing for neurodegenerative diseases: ethical and 
practice issues. Prog Neurobiol, 2013. 110: p. 89-101. 
50.Espeland, M.A., et al., Conjugated equine estrogens and global cognitive function in postmenopausal women - 
Women's Health Initiative Memory Study. Jama-Journal of the American Medical Association, 2004. 291(24): p. 
2959-2968. 
51.Rapp, S.R., et al., Effect of estrogen plus progestin on global cognitive function in postmenopausal women - The 
Women's Health Initiative Memory Study: A randomized controlled trial. Jama-Journal of the American Medical 
Association, 2003. 289(20): p. 2663-2672. 
52.Wharton, W., et al., Short-term Hormone Therapy with Transdermal Estradiol Improves Cognition for 
Postmenopausal Women with Alzheimer's Disease: Results of a Randomized Controlled Trial. Journal of Alzheimers 
Disease, 2011. 26(3): p. 495-505. 
53.Henderson, V.W., Alzheimer's disease: Review of hormone therapy trials and implications for treatment and 
prevention after menopause. Journal of Steroid Biochemistry and Molecular Biology, 2014. 142: p. 99-106. 

FEMME 
Protocol – V8.0 03/16/2021 
 
37 
54.Rigaud, A.S., et al., No additional benefit of HRT on response to rivastigmine in menopausal women with AD. 
Neurology, 2003. 60(1): p. 148-150. 
55.American Diabetes, A., 2. Classification and Diagnosis of Diabetes: Standards of Medical Care in Diabetes-2018. 
Diabetes Care, 2018. 41(Suppl 1): p. S13-S27. 
56.Sperling, R.A., et al., Toward defining the preclinical stages of Alzheimer's disease: recommendations from the 
National Institute on Aging-Alzheimer's Association workgroups on diagnostic guidelines for Alzheimer's disease. 
Alzheimers Dement, 2011. 7(3): p. 280-92. 
57.Bentourkia, M., et al., PET study of 11C-acetoacetate kinetics in rat brain during dietary treatments affecting 
ketosis. Am J Physiol Endocrinol Metab, 2009. 296(4): p. E796-801. 
58.Nugent, S., et al., Glucose hypometabolism is highly localized, but lower cortical thickness and brain atrophy are 
widespread in cognitively normal older adults. Am J Physiol Endocrinol Metab, 2014. 306(11): p. E1315-21. 
59.Pifferi, F., et al., Mild experimental ketosis increases brain uptake of 11C-acetoacetate and 18F-
fluorodeoxyglucose: a dual-tracer PET imaging study in rats. Nutr Neurosci, 2011. 14(2): p. 51-8. 
60.Tremblay, S., et al., Automated synthesis of 11C-acetoacetic acid, a key alternate brain fuel to glucose. Appl 
Radiat Isot, 2007. 65(8): p. 934-40. 
61.Fitzmaurice, G.M., N.M. Laird, and J.H. Ware, Applied Longitudinal Analysis. 2012, New York: John Wiley. 
62.Klein, A., et al., Evaluation of 14 nonlinear deformation algorithms applied to human brain MRI registration. 
Neuroimage, 2009. 46(3): p. 786-802. 
63.Vitale, C., M.E. Mendelsohn, and G.M. Rosano, Gender differences in the cardiovascular effect of sex hormones. 
Nat Rev Cardiol, 2009. 6(8): p. 532-42. 
64.Duckles, S.P. and D.N. Krause, Mechanisms of cerebrovascular protection: oestrogen, inflammation and 
mitochondria. Acta Physiol (Oxf), 2011. 203(1): p. 149-54. 
65.Brown, W.R., et al., Vascular dementia in leukoaraiosis may be a consequence of capillary loss not only in the 
lesions, but in normal-appearing white matter and cortex as well. J Neurol Sci, 2007. 257(1-2): p. 62-6. 
66.Brown, W.R. and C.R. Thore, Review: cerebral microvascular pathology in ageing and neurodegeneration. 
Neuropathol Appl Neurobiol, 2011. 37(1): p. 56-74. 
67.Shim, Y.S., et al., Pathological correlates of white matter hyperintensities on magnetic resonance imaging. 
Dement Geriatr Cogn Disord, 2015. 39(1-2): p. 92-104. 
68.Liu, C., et al., Susceptibility-weighted imaging and quantitative susceptibility mapping in the brain. J Magn Reson 
Imaging, 2015. 42(1): p. 23-41. 
69.Chiodini, I., et al., Cortisol secretion in patients with type 2 diabetes: relationship with chronic complications. 
Diabetes Care, 2007. 30(1): p. 83-8. 
70.Andreasen, N.C., et al., Sample size and statistical power in [15O]H2O studies of human cognition. J Cereb Blood 
Flow Metab, 1996. 16(5): p. 804-16.