Effects of a Tissue Selective Estrogen Complex (TESC) on Depression and the Neural Reward System in the Perimenopause
Phase: PHASE4
Conditions: Perimenopausal Disorder, Depression
Sponsor: University of North Carolina, Chapel Hill

 
 
 
 
 
 
Effects of a Tissue Selective Estrogen Complex on Depression and The 
Neural Reward System in the Perimenopause (Duavee) 
 
 
 
 
NCT number NCT03740009 
Document Date 03/10/2021 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

CLINICAL RESEARCH PROTOCOL 
 
 
 
 
 
 
EFFECTS OF A TISSUE SELECTIVE ESTROGEN COMPLEX 
ON DEPRESSION AND THE NEURAL REWARD SYSTEM IN 
THE PERIMENOPAUSE (DUAVEE) 
 
 
 
Regulatory Sponsor: 
David R. Rubinow, MD 
UNC Department of Psychiatry 
10514 Neurosciences Hospital, 101 Manning Drive  
Campus Box 7160  
Chapel Hill, NC  
27599-7160  
919-966-4738  
 
Funding Sponsor: 
Foundation of Hope 
9401 Glenwood Ave 
Raleigh, NC 27617 
Study Product: 
 
Conjugated estrogens/bazedoxifene (Duavee) 
Active ingredients: conjugated estrogens, bazedoxifene 
Chemical name: sodium estrone sulfate and sodium equilin 
sulfate, and sodium sulfate conjugates, 17α-dihydroequilin, 17α-
estradiol, and 17β-dihydroequilin; 1H-Indol-5-ol, 1-[[4-[2-
(hexahydro-1H-azepin-1-yl) ethoxy]phenyl]methyl]-2-(4-
hydroxyphenyl)-3-methyl-, monoacetate 
 
 
Protocol Number: 
18-2129 
IND Number: 
N/A 
 
Initial version: 8/22/18 
Current Version: 3/10/21 
 
 
 
 
 
 
 
 
 
 

 
Table of Contents 
 
 
STUDY SUMMARY ....................................................................................................................................... I 
1 
INTRODUCTION ................................................................................................................................... III 
1.1 
BACKGROUND ................................................................................................................................... III 
1.2 
INVESTIGATIONAL AGENT ................................................................................................................... 4 
1.3 
PRECLINICAL DATA ........................................................................................................................... VI 
1.4 
CLINICAL DATA TO DATE .................................................................................................................... 7 
1.5 
DOSE RATIONALE AND RISK/BENEFITS................................................................................................ 8 
2 
STUDY OBJECTIVES ............................................................................................................................ 8 
3 
STUDY DESIGN ..................................................................................................................................... 9 
3.1 
GENERAL DESIGN .............................................................................................................................. 9 
3.2 
PRIMARY STUDY ENDPOINTS ............................................................................................................ 12 
3.3 
SECONDARY STUDY ENDPOINTS ....................................................................................................... 12 
3.4 
PRIMARY SAFETY ENDPOINTS .......................................................................................................... 12 
4 
SUBJECT SELECTION AND WITHDRAWAL .................................................................................... 12 
4.1 
INCLUSION CRITERIA ........................................................................................................................ 12 
4.2 
EXCLUSION CRITERIA ....................................................................................................................... 12 
4.3 
SUBJECT RECRUITMENT AND SCREENING ......................................................................................... 13 
4.4 
EARLY WITHDRAWAL OF SUBJECTS .................................................................................................. 14 
5 
STUDY DRUG ...................................................................................................................................... 14 
5.1 
DESCRIPTION .................................................................................................................................. 14 
5.2 
TREATMENT REGIMEN ...................................................................................................................... 14 
5.3 
METHOD FOR ASSIGNING SUBJECTS TO TREATMENT GROUPS ........................................................... 15 
5.4 
PREPARATION AND ADMINISTRATION OF STUDY DRUG ....................................................................... 15 
5.5 
SUBJECT COMPLIANCE MONITORING ................................................................................................ 15 
5.6 
PRIOR AND CONCOMITANT THERAPY ................................................................................................ 15 
5.7 
PACKAGING ..................................................................................................................................... 15 
5.8 
BLINDING OF STUDY DRUG (IF APPLICABLE) ...................................................................................... 15 
5.9 
RECEIVING, STORAGE, DISPENSING AND RETURN ............................................................................. 15 
6 
STUDY PROCEDURES ....................................................................................................................... 16 
7 
STATISTICAL PLAN ............................................................................................................................ 17 
7.1 
SAMPLE SIZE DETERMINATION ......................................................................................................... 17 
7.2 
STATISTICAL METHODS .................................................................................................................... 17 
7.3 
SUBJECT POPULATION(S) FOR ANALYSIS .......................................................................................... 17 
8 
SAFETY AND ADVERSE EVENTS ..................................................................................................... 18 
8.1 
DEFINITIONS .................................................................................................................................... 18 
8.2 
RECORDING OF ADVERSE EVENTS .................................................................................................... 18 
8.3 
REPORTING OF SERIOUS ADVERSE EVENTS AND UNANTICIPATED PROBLEMS ..................................... 18 
8.4 
UNBLINDING PROCEDURES ............................................................................................................... 18 
8.5 
STOPPING RULES ............................................................................................................................ 18 
8.6 
MEDICAL MONITORING ..................................................................................................................... 19 
9 
DATA HANDLING AND RECORD KEEPING ..................................................................................... 20 
9.1 
CONFIDENTIALITY ............................................................................................................................ 20 
9.2 
SOURCE DOCUMENTS ...................................................................................................................... 20 
9.3 
CASE REPORT FORMS (AS APPLICABLE) ............................................................................................ 20 

9.4 
RECORDS RETENTION ...................................................................................................................... 20 
10 
STUDY MONITORING, AUDITING, AND INSPECTING ................................................................... 21 
10.1 
STUDY MONITORING PLAN ............................................................................................................. 21 
10.2 
AUDITING AND INSPECTING ............................................................................................................. 21 
11 
ETHICAL CONSIDERATIONS........................................................................................................... 21 
12 
STUDY FINANCES ............................................................................................................................ 21 
12.1 
FUNDING SOURCE ......................................................................................................................... 21 
12.2 
CONFLICT OF INTEREST.................................................................................................................. 21 
12.3 
SUBJECT STIPENDS OR PAYMENTS ................................................................................................. 23 
13 
PUBLICATION PLAN ........................................................................................................................ 23 
14 
REFERENCES ................................................................................................................................... 23 
Appendix A. Data and Safety Monitoring Plan ………………………………………………………………….26 
 
 
 

 
List of Abbreviations  
 
AE 
Adverse Event 
BOLD 
Blood-oxygen-level-dependent 
BRIC 
Biomedical Research Imaging Center 
CHD 
Coronary heart disease 
COVID-19 
Coronavirus Infection 
CRF 
Case report form 
DSMB 
Data and Safety Monitoring Board 
DVT 
Deep vein thrombosis 
EC 
Ethics Committee 
EPDS 
Edinburgh Postnatal Depression Scale 
EPT 
Combined estrogen and progestin treatment (EPT) 
FDA 
Food and Drug Administration 
fMRI 
Functional magnetic resonance imaging 
FSL 
Brain imaging analysis software 
HIPAA 
Health Insurance Portability and Accountability Act 
HRSD 
Hamilton Rating Scale for Depression 
IDAS 
Inventory of Depression and Anxiety Symptoms 
IDS 
Investigational Drug Service 
IRB 
Institutional Review Board  
IVF 
In vitro fertilization 
LH 
Luteinizing hormone 
MASQ-AD 
Mood and Anxiety Symptom Questionnaire – Anhedonic Depression Subscale 
MATLAB 
An interactive environment for numerical computation, visualization, and programming 
MID 
MDD 
Monetary Incentive Delay (fMRI task) 
Major Depressive Disorder 
PHI 
Protected health information 
PPD 
Postpartum depression 
ROI 
Region of interest 
SAE 
Serious Adverse Event 
SCID 
Structured Clinical Interview for DSM-IV-TR Axis-I Disorders 
STRAW 
Stages of Reproductive Aging Workshop 
TSEC 
UNC-CH 
Tissue Selective Estrogen Complex 
University of North Carolina at Chapel Hill  
WHI 
Women’s Health Initiative 
 

Effects of TSECs on Depression in Perimenopause 
 
page i 
Version 1 
Study Summary 
Title 
Effects of a Tissue Selective Estrogen Complex on Depression and the Neural 
Reward System in the Perimenopause 
Short Title 
Duavee 
Protocol Number 
IRB# 18-2129 
Phase 
N/A  
Methodology 
Experimental study  
Study Duration 
12-24 months 
Study Center(s) 
Single-center 
Objectives   
 
There are two practical objectives: 
1. To determine the extent to which TSEC reduces anhedonia and other 
depressive symptoms in PM-MDD. Anhedonia and other depressive 
symptoms will be assessed at baseline and following 3 weeks of TSEC 
administration.  
2. To quantify the effect of TSEC on the neural reward system in PM-
MDD. We will use fMRI at baseline and following TSEC treatment in PM-MDD 
to probe frontostriatal reward circuitry. We also will compare the effects of TSEC 
and ERT in PM-MDD. 
Number of Subjects 
20 
Diagnosis and Main 
Inclusion Criteria 
 
Women with Perimenopausal Depression 
1)The anchor for the staging system is the last menstrual period (LMP) we will 
enroll women who have ≥ 2 skipped cycles and an interval of amenorrhea ≥ 60 
days, consistent with the late menopause transition (stage -1). Women who 
meet these criteria will not require an FSH level. Women who have taken oral 
contraceptives continuously for relief of perimenopausal symptoms and women 
who have had hysterectomies (with ovaries remaining intact) will be exempt from 
our LMP criteria, and their perimenopausal status will be determined by FSH 
level instead (FSH ≥ 14).    
2) 44-55 years old; 
3) current diagnosis of MDD with an onset associated with menstrual cycle 
irregularity. Past mania, psychosis, suicide attempts, and alcohol or drug 
dependence, as determined by the SCID are exclusionary. All other current 
comorbid psychiatric illnesses, as determined by the SCID, will be reviewed with 
our primary investigator (PI) to determine eligibility on a case-by-case basis. 
 
Study Product, Dose, 
Route, Regimen 
 
Study Product 
 
Conjugated estrogens/bazedoxifene (Duavee) 
    Active ingredients: conjugated estrogens, bazedoxifene acetate 
    Chemical name: sodium estrone sulfate and sodium equilin sulfate, and 
sodium sulfate conjugates, 17α-dihydroequilin, 17α-estradiol, and 17β-
dihydroequilin; 1H-Indol-5-ol, 1-[[4-[2-(hexahydro-1H-azepin-1-yl)    
ethoxy]phenyl]methyl]-2-(4-hydroxyphenyl)-3-methyl-, monoacetate 
  
Drug 
Dosage 
Formulation 
Conjugated 
estrogens/bazedoxifene 
0.45 milligrams/20 
milligrams/day 
Oral tablet 
 
Route: 

Drug 
Route of Administration 
Conjugated estrogens/bazedoxifene 
Oral 
 
Regimen: 
Once determined eligible and physically well, participants with perimenopausal 
depression will receive a tissue selective estrogen complex (TSEC) (conjugated 
estrogens/bazedoxifene, 0.45mg/20mg) for 3 weeks. Prior to beginning 
medication, women will have a basic lab panel and serum pregnancy test, pelvic 
exam, breast exam, and PAP smear. Participants who can provide record of a 
pelvic exam and breast exam within the past year and normal pap results within 
the past three years will be permitted to decline the GYN exam. Women will be 
seen in the clinic each week during TSEC administration to assess blood levels 
of estradiol and mood symptoms.  
Duration of 
administration 
3 weeks 
Reference population 
Perimenopausal women, non-depressed  
Statistical 
Methodology: 
 
We will test our H1 hypothesis using a paired t-test of MASQ Anhedonia scores 
at visit 1 (pre-treatment) and visit 6 (post-treatment). We will test our H2 
hypothesis using a paired t-test to compare activity in 3 regions of interest 
(ROIs)—caudate, putamen, and nucleus accumbens—at the pretreatment and 
posttreatment scans. 
 

1 Introduction 
This document is a protocol for a human research study. This study is to be conducted according to 
US and international standards of Good Clinical Practice (FDA Title 21 part 312 and International 
Conference on Harmonization guidelines), applicable government regulations and Institutional research 
policies and procedures.  
1.1 Background 
Despite decades of clinical research, affective disorders continue to affect 20.9 million Americans 
each year and remain the leading cause of disability worldwide1. Unraveling the pathophysiology of affective 
disorders has been uniquely challenging because depressive syndromes are heterogeneous and have 
diverse etiologies2. Attempts to identify genetic and neural biomarkers that would improve the prediction of 
susceptibility, course of illness, and treatment response have yielded inconsistent results. One way to solve 
the problem of etiological diversity and diagnostic heterogeneity is to identify a homogeneous depression 
subtype with an identified etiology. Reproductive affective disorders (i.e., premenstrual dysphoric disorder, 
postpartum depression, and perimenopausal depression) represent more homogeneous subtypes, and a 
clear role for reproductive steroids has been established in these conditions3. Thus, we propose to study 
the pathophysiology of affective dysfunction by examining neural function in women with a specific 
depression subtype, perimenopausal depression. 
Women with perimenopausal depression represent the ideal population in which to study the neural 
biomarkers of reproductive affective dysfunction because the presumptive etiology—ovarian hormone 
withdrawal—is objectively measurable and amenable to manipulation. Evidence supporting the role of 
ovarian hormone withdrawal in the etiology of perimenopausal depression includes the following: 
perimenopausal women show a temporal association between ovarian hormone withdrawal and the onset 
of mood symptoms in the late perimenopause4; treatment with estrogen reduces mood symptoms5; and 
blinded estradiol withdrawal re-precipitates depression in women with a history of perimenopausal 
depression (manuscript in preparation). Thus, perimenopausal depression represents a relatively pure 
phenotype with respect to the presence of hormone sensitive depression. Focusing on a homogeneous 
etiology will increase the likelihood of identifying meaningful neurobiological markers6.  
One of the most powerful tools for understanding the neural mediators of complex behaviors is brain 
imaging7. Although the mechanisms by which reproductive steroids modulate human behavior is relatively 
unknown, the application of both modern imaging techniques and knowledge of the neurocircuitry 
underlying fundamental human and animal behaviors should permit us to define more precisely the means 
by which changes in reproductive steroids elicit depression in some, but not other, individuals. 
A fundamental behavior that is dysregulated in depression is reward responsiveness8. Reduced 
responsiveness to rewards contributes to the clinical phenomenon of anhedonia (i.e., loss of interest or 
pleasure in rewarding activities)5, a cardinal feature of depression9. In individuals with depression, 
anhedonia is associated with frontostriatal hypoactivity during reward processing10. Frontostriatal reward 
circuit dysregulation may be particularly central to perimenopausal depression. Estradiol modulates reward 
responsiveness in rodents11, 12 and a recent human study demonstrated an association between estradiol 
levels and frontostriatal reactivity to reward during the menstrual cycle in healthy women13. Thus, the 
frontostriatal reward system is regulated by estradiol and implicated in major depression. However, the 
effects of estradiol withdrawal and administration on frontostriatal reward circuitry have never been 
examined directly, and the extent to which frontostriatal dysregulation mediates the effects of estradiol 
withdrawal on depressive symptoms remains unknown.  
While estrogen replacement therapy acts as an antidepressant, many women elect not to take 
estrogen and many physicians discourage its use because of the risk of long-term negative health effects, 
including breast and uterine cancer. Estrogens can be paired with selective estrogen receptor modulators 
(SERMs), synthetic non-steroidal agents that have estrogen agonist and antagonist effects in different 
tissues, to block the negative effects of estrogen on non-target tissues, including the reproductive organs 
and cardiovascular system, while allowing estrogen to exert effects on target tissues like the brain [14]. The 
first such tissue selective estrogen complex (TSEC) approved by the FDA is Duavee, which combines 
conjugated estrogens and the SERM bazedoxifene [14]. Bazedoxifene has antiestrogenic effects in the 
endometrium and breast, protecting against uterine and breast cancer, and estrogenic effects in bone, 
making it a potent preventive agent and treatment for osteoporosis. Duavee has been shown to alleviate 
hot flashes and vaginal atrophy and prevent osteoarthritis. As a result, Duavee may be an ideal agent to 
reduce depressive symptoms without the attendant risks of estrogen replacement therapy (ERT) or 

adjunctive progesterone treatment. However, the effects of Duavee on depression and the neural reward 
circuit have never been tested, and one can’t infer that estrogen will have the same antidepressant effects 
in the presence of bazedoxifene (which partially blocks the effects of estrogen in certain tissues). The 
purpose of our additional treatment arm is to 1) test the antidepressant effects of TSEC, and 2) determine 
whether TSEC restores neural reward sensitivity, which is blunted in the absence of estrogen.  
Thus, we will examine the effects on the neural reward system in perimenopausal women. The 
proposed experimental study will allow us to answer the following questions: 1) Does the reward system 
respond to TSEC in those with perimenopausal depression? 2) Does reward system activity at baseline 
predict the antidepressant effects of TSEC women with perimenopausal depression? Our results will 
provide critical information about the neuroendocrine pathophysiology of perimenopausal depression and 
may subsequently contribute to the development of novel pharmacologic interventions.  
The proposed study design will allow us to examine the role of frontostriatal hypoactivity in the 
pathophysiology of perimenopausal depression. It will also allow us to measure frontostriatal responses to 
TSEC treatment in perimenopausal depression, which has not been previously characterized. This 
information is critical for understanding the pathophysiology of perimenopausal depression and the 
mechanisms by which estradiol withdrawal and supplementation have differential effects on mood across 
women (i.e., why some but not all women become depressed in the perimenopause). These aims are of 
central relevance to examine the neural pathophysiology of reproductive mood disorders and conduct 
experimental hormone investigations of the neural circuits contributing to affective illness in women.  
The use of ERT to treat perimenopausal major depressive disorder (PM-MDD) is a relatively nascent 
area of investigation but one of great importance given the large and increasing number of women who 
enter the perimenopause each year [15, 16] and are potentially at risk for depression [17, 18]. Untreated 
mood disorders in perimenopausal women contribute significantly to cardiovascular deaths [19]. 
Perimenopausal women with depressive symptoms seek treatment from gynecologists, psychiatrists, and 
general practitioners, yet there is neither consensus nor practical guidelines for preventing and treating 
perimenopausal depression. Moreover, as mentioned above, many women and physicians do not pursue 
ERT because of the potential adverse consequences and the need for adjunctive treatment with 
progesterone to protect the endometrium, which can have negative mood consequences in women who 
are hormone sensitive. Further, traditional antidepressants are not a viable therapeutic option for PM-MDD 
consequent to limited efficacy [20, 21] and fears regarding side effects and stigma [22, 23]. Because TSEC 
addresses the main potential problems of ERT, this research will provide important information for 1) 
developing new medications for PM-MDD, and 2) understanding the neural mechanisms that contribute to 
depression during periods of reproductive hormone change.  
We will be able to determine whether Duavee can be used to treat PM-MDD and the brain circuits 
involved in depression and its treatment. This research will also provide information essential for 1) 
identifying which patients will benefit most from hormone therapies and 2) developing new medications for 
PM-MDD.  
We have elected not to include a placebo control condition, as many studies in the field of affective 
neuroscience forgo placebo controls when examining the effects of drugs on neural circuitry14, 15. If, 
however, the expense associated with fMRI and sample size were not concerns, the inclusion of a placebo 
condition would allow us to control for the potential variance associated with repeated fMRI and to examine 
the potential placebo effects of medication taking on frontostriatal circuitry. Thus, the proposed study will 
provide pilot data for a larger, randomized, placebo-controlled study with sufficient power to compare 
treatment and placebo responders and non-responders, which will allow us to further elucidate the precise 
relationships between changes in frontostriatal activation, TSEC, and changes in mood. Nevertheless, 
results of the proposed study will provide critical information about the involvement of frontostriatal circuitry 
in the pathophysiology of perimenopausal depression and the antidepressant effects of TSEC treatment. 
1.2 Investigational Agent. 
 
CONJUGATED ESTROGENS/BAZDOXIFENE (DUAVEE) 
Description 
DUAVEE (conjugated estrogens/bazedoxifene) tablets contain conjugated estrogens with bazedoxifene, 
an estrogen agonist/antagonist. Conjugated estrogens are purified from pregnant mares' urine and 

consist of the sodium salts of water-soluble estrogen sulfates blended to represent the average 
composition of material derived from pregnant mares' urine. Conjugated estrogens are a mixture of 
sodium estrone sulfate and sodium equilin sulfate, and also contain as concomitant components, sodium 
sulfate conjugates, 17α-dihydroequilin, 17α-estradiol, and 17β-dihydroequilin.  
Bazedoxifene is supplied as the acetate salt (bazedoxifene acetate) and has the chemical name 1H-
Indol-5-ol, 1-[[4-[2-(hexahydro-1H-azepin-1-yl) ethoxy]phenyl]methyl]-2-(4 hydroxyphenyl)-3-methyl-, 
monoacetate. The empirical formula is C30H34N2O3 • C2H4O2, and the molecular weight is 530.65.  
Bazedoxifene acetate is a white to tan powder. The aqueous solubility of bazedoxifene is pH- dependent. 
Solubility is higher at lower pH. The solubility of bazedoxifene acetate in unbuffered sterile water was 
measured to be 923 microgramsA/mL at pH 5.4. The following represents the chemical structure of 
bazedoxifene acetate:  
 
DUAVEE is available for oral administration as tablets containing 0.45 mg of conjugated estrogens with 
20 mg of bazedoxifene (equivalent to 22.6 mg of bazedoxifene acetate). Each tablet of DUAVEE contains 
the following inactive ingredients: calcium phosphate tribasic, hydroxypropyl cellulose, microcrystalline 
cellulose, powdered cellulose, hypromellose, lactose monohydrate, magnesium stearate, polyethylene 
glycol, sucrose, ascorbic acid, sucrose palmitic acid ester, hydroxyethylcellulose, titanium dioxide, red 
iron oxide, yellow iron oxide, black iron oxide, povidone, polydextrose, maltitol, poloxamer 188, propylene 
glycol, and isopropyl alcohol.  
Pharmacology 
DUAVEE pairs conjugated estrogens with bazedoxifene. Conjugated estrogens and bazedoxifene 
function by binding to and activating estrogen receptors (ER) α and β, which vary in proportion from tissue 
to tissue. Conjugated estrogens are composed of multiple estrogens and are agonists of ER- α and β. 
Bazedoxifene is an estrogen agonist/antagonist that acts as an agonist in some estrogen-sensitive 
tissues and an antagonist in others (e.g., uterus). The pairing of conjugated estrogens with bazedoxifene 
produces a composite effect that is specific to each target tissue. The bazedoxifene component reduces 
the risk of endometrial hyperplasia that can occur with the conjugated estrogens component.  
Pharmacodynamic studies have not been conducted with DUAVEE.  
Summary of Previous Human Experience 
We will enroll perimenopausal women to undergo TSEC supplementation using an existing 
recruitment infrastructure. We currently are assessing the neural reward system in PM-MDD using 
functional magnetic resonance imaging (fMRI) at baseline and following ERT in our “Effects of Neural 
Reward System and Depression in the Perimenopause” study (#13-3572). Over the 45 months of 

recruitment with ads that specify no current depression, 10,721 women were screened, 244 (2%) of whom 
were not eligible based on current MDD symptoms.  
Support for the hypotheses comes from our lab’s own research and that of others, to include: 
1. Estradiol withdrawal precipitates anhedonia in rats, and decreasing estradiol levels are 
associated with increasing negative mood symptoms in women11. These results support our 
ability to conduct successful research in the area of reproductive mood disorders. Our current 
hypotheses are consistent with this prior research and suggest that the results may have 
implications for reproductive mood disorders. 
2. Estradiol withdrawal is associated with the onset of perimenopausal MDD, and estradiol 
treatment reduces perimenopausal MDD symptoms compared with placebo. In a 5-year 
longitudinal study of 29 women, a 14-fold increase in MDD was observed in the 24 months 
surrounding menopause4. In a larger cross sectional study (n=116), depressive episodes were 
significantly more likely during the late perimenopause compared with the pre-, early-, and post-
menopause16. Although estradiol levels are highly variable in regularly cycling women and during 
the pre- and early perimenopause, the average level of circulating estradiol declines dramatically 
during the transition from early to late perimenopause20, which is accompanied by an increased 
incidence in MDD4, 16. Depressive symptoms significantly decreased following 3 weeks of estradiol 
treatment in 34 women with perimenopausal MDD compared with baseline and women taking 
placebo5 (Figure 1c). Moreover, despite comparable ovarian hormone levels in women with 
perimenopausal MDD compared with controls4, 17, women with a history of perimenopausal MDD 
(but not those lacking that history) rapidly experience depression recurrence when blindly 
withdrawn from estradiol. Thus, estradiol withdrawal appears to trigger perimenopausal MDD in 
susceptible women, and three weeks of treatment with estradiol is sufficient to treat 
perimenopausal MDD. 
3. Active MDD symptoms and MDD risk are associated with frontostriatal hypoactivity. 
Individuals at high risk for MDD show reduced frontostriatal activation during the proposed 
monetary incentive delay task, and the degree of activation is associated with the severity of self-
reported rumination among those at high risk for MDD18. 
4. Estradiol levels are associated with increased reward-related neural function during the 
menstrual cycle in non-depressed women. Estradiol levels were positively correlated with 
activation of the dorsolateral and frontopolar cortices19, which is consistent with our hypothesis that 
estradiol supplementation will increase activation in frontal regions. 
5. The proposed monetary incentive delay (MID) task induces frontostriatal activation during 
monetary reward in control women. At baseline, control women enrolled in our R21 study of the 
effects of a scaled down hormonal model of pregnancy and parturition on mood and brain function 
showed increased activity in frontostriatal regions (specifically the nucleus accumbens, caudate, 
thalamus, dorsolateral prefrontal cortex, and frontopolar cortex) during monetary reward. These 
areas were selectively responsive to reward and not activated during non-reward, indicating that 
the task reliably activates the regions of interest associated with reward in previous studies.  
Status of Drug in Other Countries 
To our knowledge, the proposed drugs have not been withdrawn from investigation or marketing in any 
other country. 
1.3 Preclinical Data 
N/A 
1.4 Clinical Data to Date 
We do not expect any adverse side effects associated with the hormonal manipulations outlined in 
this protocol for the following reasons: We will be administering estrogen paired with selective estrogen 
receptor modulators (SERMs) to a subset of women with perimenopausal women. SERMs are synthetic 
non-steroidal agents that have estrogen agonist and antagonist effects in different tissues, to block the 
negative effects of estrogen on non-target tissues, including the reproductive organs and cardiovascular 
system, while allowing estrogen to exert effects on target tissues like the brain, and thus decreasing risk for 
side effects.  
 

Adverse Events Related to Combined Hormone Replacement and the Results of the 
Women's Health Initiative (WHI): The WHI study demonstrated that continuous administration of one 
form of estrogen (conjugated estrogens) in combination with one form of progesterone 
(medroxyprogesterone acetate) is associated with an increased risk of dementia, heart attacks, stroke, 
blood clots, and breast cancer.  TSECs, the form of estrogen that we use in this study, is administered as 
a sole agent and, consequently, we do not expect that it will pose the increased risks observed with the 
chronic combination of the conjugated estrogens and medroxyprogesterone administered in the WHI 
study.  Indeed, while the estrogen alone arm of the WHI trial was shown to be associated with an 
increased risk of stroke, no increased risk of either heart disease or breast cancer was observed55,56. 
Estrogens may precipitate migraine headaches, and depression has also been reported to occur with the 
use of estrogens. In general, considering the dose and duration of treatment that we propose to use in 
this protocol, the risk of developing such side effects is negligible. 
 
Conjugated Estrogens/Bazdoxifene (Duavee): The first such tissue selective estrogen complex 
(TSEC) approved by the FDA is Duavee, which combines conjugated estrogens and the SERM 
bazedoxifene [1]. Bazedoxifene has antiestrogenic effects in the endometrium and breast, protecting 
against uterine and breast cancer, and estrogenic effects in bone, making it a potent preventive agent 
and treatment for osteoporosis. Duavee has been shown to alleviate hot flashes and vaginal atrophy and 
prevent osteoarthritis. The safety of conjugated estrogens/bazedoxifene was evaluated in four Phase 3 
clinical trials (sponsored by Wyeth) ranging from 12 weeks to 24 months in duration and enrolling 6,210 
postmenopausal women age 40 to 75 years (mean age 55 years). A total of 1,224 patients were treated 
with DUAVEE and 1,069 patients received placebo. The incidence of all-cause mortality was 0.0% in the 
DUAVEE group and 0.2% in the placebo group. The incidence of serious adverse reactions was 3.5% in 
the DUAVEE group and 4.8% in the placebo group, and 7.5% of the DUAVEE group and 10.0% of the 
placebo group withdrew [1]. The most common adverse reactions leading to discontinuation were hot 
flashes, upper abdominal pain, and nausea. Other less common adverse reactions included diarrhea, 
dyspepsia, muscle spasms, neck pain, dizziness and oropharyngeal pain [1]. The incidence of 
endometrial hyperplasia was less than 1% in both clinical studies examining the effect of Duavee on the 
endometrium [1, 2, 3, 4]. The SMART study examined safety and efficacy of Duavee and found that 
women reported low incidences of breast pain and high incidences of cumulative amenorrhea, in addition 
to relief of vasomotor symptoms [5].  
1.5 Dose Rationale and Risk/Benefits 
This study will enroll perimenopausal women to undergo TSEC supplementation using their existing 
infrastructure. Many studies have identified perimenopausal women as being at high risk for mood 
disorders, especially during the late menopause transition, but only a few studies have systematically 
assessed this biological vulnerability. The benefits of this study are three-fold: 1) increased knowledge of 
the neuroendocrine mechanisms underlying both the triggering of and susceptibility to depression in 
women, 2) improved identification of perimenopausal women for whom hormone replacement therapy is 
likely to have beneficial neuroregulatory effects, and 3) increased information regarding novel targets for 
pharmacologic intervention. While there are scientific benefits to this study, the benefit to patients will be 
minimal. TSEC administration may reduce depressive symptoms in some of the participants, and this 
information may be helpful to women as they plan their future health care in relation to menopause symptom 
management. 
 
COVID-19 Risks 
Participants may experience the potential risk of COVID-19 transmission during required in-person study 
visits such as at the Biomedical Research Imaging Center (BRIC) and when in close contact with study 
team members during blood draws when study staff will need to maintain less than 6ft distance. The study 
team will be following UNC guidelines and BRIC guidelines to take every possible precaution to protect 
study participants and their staff. Including virtual video or telephone visits when possible, shortening 
duration of in-person contact, requiring masks at all times for study staff and participants, maintaining 6ft 
distance when possible, temperature checks on arrival to BRIC, COVID-19 pre-screening 24 hours in 
advance of any in-person contact and the day of, frequent cleaning with 90% alcohol or 1:10 bleach solution, 
cleaning equipment between each participant, handwashing required every hour and before or after contact 
with any participants. While the study team will be taking every pre-caution possible to participants and the 
study staff there may still be a risk of COVID-19 transmission due to the possibility of the COVID-19 virus 

lingering in enclosed spaces from asymptomatic carriers. However this risk should not be any greater than 
being in an essential public setting such as a grocery store. If a participant or a member of the study team 
has had direct or even secondary contact with any suspected or confirmed cases of COVID, the study team 
will reschedule any upcoming visits until the case is confirmed negative or to quarantine for at least 14 days 
and monitor symptoms. If a participant or study team member experiences any symptoms of COVID-19 
including but not limited to: cough, fever, chest pain, trouble breathing, loss of smell or taste, nausea, 
abdominal pain, vomiting, etc. participants will be asked to notify the study team immediately, contact their 
Primary Care Provider and their local COVID-19 hotline to get tested for COVID-19. 
2 Study Objectives 
 
The long-term research objectives are to 1) advance our understanding of the effects of ovarian 
hormones on the female brain and how these effects contribute to the triggering of and susceptibility to 
mood disorders; and 2) to identify neural and endocrine markers of depression risk, thereby improving our 
ability to prevent affective illness in women. Our central hypothesis is that the neural reward system is 
hypoactive in PM-MDD, and the antidepressant effects of a three-week TSEC intervention will be 
associated with increased activity in the neural reward system, assessed using functional magnetic 
resonance imaging (fMRI). 
 
Aim 1: Determine the extent to which TSEC reduces anhedonia and other depressive symptoms in 
PM-MDD. Anhedonia and other depressive symptoms will be assessed at baseline and following 3 weeks 
of TSEC administration.  
Aim 2 (Exploratory): Quantify the effect of TSEC on the neural reward system in PM-MDD. We will 
use fMRI at baseline and following TSEC treatment in PM-MDD to probe frontostriatal reward circuitry. 
We also will compare the effects of TSEC and ERT in PM-MDD. 
Null hypothesis (H0): TSEC has no salutary effect on depression.  
Alternative hypothesis (H1): TSEC reduces depression as evidenced by 1) a statistically significant 
decrease in average MASQ Anhedonia scale score following 3 weeks of treatment, and 2) a clinically 
significant increase of 1 SD in MASQ Anhedonia scale score.  
We will test this hypothesis using a paired t-test of MASQ Anhedonia scores at visit 1 (pre-treatment) and 
visit 6 (post-treatment). 
Aim 2 (Exploratory): Quantify the effect of TSEC on the neural reward system in PM-MDD. We will 
use fMRI at baseline and following TSEC treatment in PM-MDD to probe frontostriatal reward circuitry. 
We also will compare the effects of TSEC and ERT in PM-MDD. 
Null hypothesis (H0): TSEC has no meaningful effect on activity of the neural reward circuit in response to 
rewards.  
Alternative hypothesis (H1): TSEC reduces increases neural responsiveness to reward in the frontostriatal 
reward circuitry as evidenced by increased activation of the caudate, putamen, and nucleus accumbens 
in PM-MDD in response to reward following TSEC administration (compared with baseline).  
We will test this hypothesis using a paired t-test to compare activity in 3 regions of interest (ROIs)—
caudate, putamen, and nucleus accumbens—at the pretreatment and posttreatment scans. 
 

3 Study Design 
3.1 General Design 
Overview. This is an observational, single-center study using tissue-selectective estrogen complex (TSEC) 
to examine the role of frontostriatal hypoactivity in the pathophysiology or perimenopausal MDD. This study 
will include 6 study visits that will take place over the course of approximately 6 weeks. Out of those 6 visits, 
2 of them will require subjects to come to UNC’s campus for their MRI visits at BRIC, while the rest of the 
appointments will be done virtually through HIPAA compliant Zoom, Webex, or phone when zoom is not 
available. Five visits will require brief in-person contact for phlebotomy, these very brief points of contact 
will be performed outside the subject’s home when possible (i.e. backyard, back porch, or screened porch). 
In the context of COVID-19, all participants and staff will complete the appropriate screening as 
recommended by UNC and BRIC policy prior to any in-person contact. During in person visits participants 
and the study team will be required to wear masks at all times and maintain 6 feet distance when possible 
to minimize the possibility of COVID-19 transmission. Perimenopausal MDD women will receive Duavee, a 
TSEC, for 3 weeks. FMRI sessions will occur at baseline and at the end of the third week of medication 
administration. The procedures that will take place are outlined in Table 1 and detailed below. 
Table 1. Study Procedures and Timeline 
Study Visits 
1 
2 
3 
4 
5 
6 
Maximum duration of in-person visit (hours) 
1 
2 
0.15 
0.15 
2 
Consent 
X 
 
 
 
 
 
OBGYN Exam 
 
X 
 
 
 
 
fMRI 
 
 
X 
 
 
X 
PRT 
 
 
X 
 
 
X 
Venipuncture 
 
X 
X 
X 
X 
X 
SCID 
X 
 
 
 
 
 
SNAP 
 
X 
 
X 
X 
X 
X 
HAM-D 
X 
 
X 
X 
X 
X 
IDAS 
X 
 
X 
X 
X 
X 
GCS 
X 
 
X 
X 
X 
X 
PSQI 
 
 
X 
 
 
X 
HHQ 
 
 
 
 
 
X 
THQ 
 
 
 
 
 
X 
Duavee Rx Provided 
 
 
X 
X 
X 
 
Payment 
$100 
$30 
$150 
$35 
$35 
$150 
 
 

Participants. Participants will include healthy, unmedicated perimenopausal women ages 44-55 with 
(n=20) current major depression. 
 
Hormone Administration.  
Prior to beginning medication, women will have a basic lab panel and serum pregnancy test, pelvic exam, 
breast exam, and PAP smear. Participants who can provide record of a pelvic exam and breast exam within 
the past year and normal pap results within the past three years will be permitted to decline the GYN exam. 
Women will be seen in the clinic each week during medication administration to assess blood levels of 
estradiol and mood symptoms.  
 
Optional Home Visits: In an effort to increase recruitment and retention, the study team will offer home visits 
for Study Visits 1, 4, 5, as well as Baseline Labs.  
 
Clinical Assessments 
The Structured Clinical Interview for DSM-IV-TR Axis-I Disorders (SCID)58 and the Schedule for The SCID1 
will be administered at baseline to determine study eligibility. The following standard measures will be 
administered at baseline, both fMRI sessions, and weekly clinic visits: 
• 
The Positive and Negative Affect Schedule59 is a 20-item questionnaire that measures both positive 
affect (PA) and negative affect (NA) and is sensitive to subtle changes in affect over time. 
• 
The Hamilton Rating Scale for Depression (HRSD)60 is a 21-item researcher-rated standardized 
scale that assesses depressive symptoms and is widely used as a measure of symptom change 
over time.  
• 
The Inventory of Depression and Anxiety Symptoms (IDAS)61 is a 64-item self-report questionnaire 
that comprehensively assesses anxiety and depression symptoms on 10 subscales. The IDAS has 
excellent psychometric properties and has been validated for assessing reproductive mood 
disorders.  
• 
The Mood and Anxiety Symptom Questionnaire – Anhedonic Depression Subscale (MASQ-AD)62 
is a 22-item scale that assesses anhedonia (i.e., loss of interest and low positive affect). MASQ-
AD scores have been associated with blunted striatal response to reward in previous studies of 
patients with depression63.  
• 
The Greene Climacteric Scale (GCS)64 is a 21-item scale that is the gold-standard measure of four 
domains of climacteric symptoms: vasomotor, somatic, anxiety, and depression. 
• 
The Pittsburgh Sleep Quality Index (PSQI)65 is a 9-item questionnaire that measures the quality 
and sleep patterns in older adults. *This measure will only be administered at the two fMRI 
sessions. 
• 
The Hormone History Questionnaire is a 19-item inventory that assesses women's mental and 
physical health and was created for the purpose of this study. 
• 
The Trauma History Questionnaire 14 is a 24-item measure that examines participant's 
experiences with potentially serious or traumatic life events. 
While the SCID and HAM-D are researcher administered, the other measures will be collected through self-
report questionnaires using Qualtrics or paper and pencil questionnaires.  
 
Despite the use of exclusion criteria designed to reduce risk to participants, depressive symptoms are 
monitored closely. Any subject who develops severe depressive symptoms (e.g., suicidal ideation) will be 
discontinued from the study and offered treatment paid for by the study.  If inpatient hospitalization becomes 
necessary as a result of the study, UNC Health Care will cover the cost.  The following language has been 
added to the study consent form to reflect this policy:  
 
“All research involves a chance that something bad might happen to you.  This may include the risk of 
personal injury. In spite of all safety measures, you might develop a reaction or injury from being in 
this study. 
 
“If you become depressed or anxious as a direct result of participating this study, the UNC 
Department of Psychiatry will provide outpatient medical treatment. If vaginal bleeding or any other 
gynecological problem occurs, we will arrange for a visit with a UNC gynecologist. The research study 
will cover the costs of such outpatient exams and treatment at UNC Health Care. 

 
“If you become sick or injured as a direct result of participating in this study, and your condition 
cannot be addressed with outpatient treatment, UNC Health Care will provide all needed inpatient 
medical treatment. UNC Health Care will reimburse you for reasonable and necessary costs of such 
inpatient medical treatment not covered by your insurance company. No other form of reimbursement 
for study-related injury or illness is offered by UNC Health Care. You do not give up any legal rights 
by signing this consent.  
 
“If you receive Medicare benefits, UNC Health Care is required by law to report payments made to 
you for treatment, complications, and injuries that arise from this study. Information that you are 
taking part in this study, medical treatments received, Medicare claims, and other personal 
information about your such as your name, social security number, and date of birth, will be provided 
to the Centers of Medicare and Medicaid Services and its agents and/or contractors for this purpose. 
 
“If you seek treatment outside of UNC Health Care, you will be responsible for the costs of your 
treatment.” 
 
FMRI Tasks 
The following task will be included in each of the two fMRI sessions: 
The Monetary Incentive Delay (MID) Task66 engages the reward circuitry during monetary incentive 
anticipation and outcomes. Each of two MID runs consists of 90 6-second trials during which 
subjects are presented with of one of nine cue shapes, a fixation crosshair (for a variable duration), 
the target, and performance (win/loss/neutral) feedback. The cue indicates whether it is an 
incentive (gain, loss) or non-incentive trial. During incentive trials, participants can either gain or 
lose money by pressing a button during target presentation. Task difficulty is based on participant 
reaction times. This task elicits reliable frontostriatal dysregulation in people with remitted MDD67. 
Resting state scans will also be conducted at the beginning and end of each session.  
 
FMRI Data Acquisition and Image Processing 
Scanning is performed using a Siemens Magnetom 7T TIM Trio scanner. High-resolution, T1-weighted 
anatomical images will be acquired using an MPRAGE sequence. Whole-brain functional images will be 
acquired using a single-shot, gradient recalled echoplanar pulse sequence sensitive to blood-oxygen-level-
dependent (BOLD) contrast. Each of 2 runs will consist of the acquisition of 195 successive brain volumes. 
FMRI image preprocessing, processing, and analysis will be conducted using FSL and custom MATLAB 
scripts. FMRI analyses will include an event-related BOLD response analysis within a priori structurally 
defined frontostriatal regions of interest (ROIs). Contrasts of interest will include win versus non-win 
outcomes68, although the anticipation of wins will also be explored. 
 
Other Tasks 
Probabilistic Reward Task (PRT)69 will be conducted outside of the scanner. This task allows us to test the 
additional hypothesis that perimenopausal depression is characterized by blunted reward learning. During 
this task, correct identifications of two ambiguous stimuli are differentially rewarded. The task will consist of 
300 trials, divided into 3 blocks of 100 trials. Each trial starts with the presentation of a fixation cross for 500 
msec followed by a mouthless face. After a delay of 500 msec, either a short mouth (11.5 mm) or a long 
mouth (13 mm) is presented for 100 msec. Participants will be asked to identify which type of mouth was 
presented. For each block, the long and short mouths are presented equally often in a pseudorandomized 
sequence and 40 correct trials are followed by reward feedback immediately after the correct response. An 
asymmetrical reinforcer ratio will be used in this task, such that for half of the participants, correct 
identification of the short mouth will be associated with three times more positive feedback (30 of 40) than 
correct identification of the long mouth (10 of 40). For the other half of the participants, the contingencies 
will be reversed. 
3.2 Primary Study Endpoints 
1. Frontiostriatal reactivity to reward during the MID fMRI task 
2. Response latency to reward versus non-reward during the MID fMRI task 
3. Depressive symptoms  

3.3 Exploratory Study Endpoints 
1. Neural connectivity measured during resting-state fMRI 
3.4 Primary Safety Endpoints 
N/A 
4 Subject Selection and Withdrawal 
4.1 Inclusion Criteria 
Participants will include healthy, unmedicated perimenopausal women ages 44-55 with (n=20) current 
major depression. Only participants capable of giving informed consent will be enrolled. Participants will 
be compensated upon completion of the study.   
 
Inclusion Criteria. 
1. Perimenopause Status: We will employ the Stages of Reproductive Aging Workshop (STRAW) 
criteria to confirm perimenopausal status. The stages are primarily based on characteristics of the 
menstrual cycle and secondarily on follicle stimulating hormone (FSH) levels. The anchor for the 
staging system is the last menstrual period (LMP). We will enroll women who have ≥ 2 skipped 
cycles with an interval of amenorrhea ≥ 60 days and had a LMP within the last year, consistent 
with the late menopause transition (stage -1). Women who meet these criteria will not require an 
FSH level*. Women who have taken oral contraceptives continuously for relief of perimenopausal 
symptoms and women who have had hysterectomies (with ovaries remaining intact) will be 
exempt from our LMP criteria, and their perimenopausal status will be determined by FSH level 
instead (FSH ≥14)*.  
2. MDD Eligibility Criterion: current diagnosis of MDD with an onset associated with menstrual cycle 
irregularity. Past mania, psychosis, suicide attempts, and alcohol or drug dependence, as 
determined by the Structure Clinical Interview for DSM-IV-TR for Axis I Disorders (SCID) are 
exclusionary. All other current comorbid psychiatric illnesses, as determined by the SCID, will be 
reviewed with our primary investigator (PI) to determine eligibility on a case-by-case basis. 
4.2 Exclusion Criteria 
 
Patients will not be permitted to enter this protocol if they have important clinical or laboratory 
abnormalities including any of the following:  
1. current medication use (i.e., psychotropics, anti-hypertensives, statins,or hormonal preparations). 
Women will be allowed to enroll who take medications without known mood effects (e.g. stable 
thyroid hormone replacement and occasional (< 5 times/month) use of Ambien)*;  
2. pregnant, breastfeeding or trying to conceive;   
3. LMP more than 12 months prior to enrollment**;   
4. history of undiagnosed vaginal bleeding;   
5. undiagnosed enlargement of the ovaries;   
6. polycystic ovary syndrome;   
7. history of breast or ovarian cancer;   
8. first degree relative with ovarian cancer;   
9. first degree relative with premenopausal onset or bilateral breast cancer;  
10. 2+ first degree relatives with breast cancer (regardless of onset);   
11. 3+ relatives with postmenopausal breast cancer;   
12. abnormal finding in a provider breast exam and/or mammogram***;   
13. known carrier of BRCA1 or 2 mutation; 
14. endometriosis; 
15. blood clots in the legs or lungs; 
16. porphyria; 
17. diabetes mellitus; 
18. malignant melanoma; 

19. Hodgkin's disease; 
20. recurrent migraine headaches that are preceded by aura; 
21. gallbladder or pancreatic disease***; 
22. heart or kidney disease***; 
23. liver disease; 
24. cerebrovascular disease (stroke); 
25. current cigarette smoking; 
26. current suicidal ideation, mania, psychosis, or alcohol/drug dependence; 
27. past suicide attempts, mania, alcohol/drug dependence, or psychotic episodes; 
28. chronic depression (i.e., episode(s) lasting 3+ years); 
29. depressive episode(s) within 2 years of enrollment; 
30. self-reported claustrophobia 
31. Allergies to red or yellow dye. 
 
*all reported prescription medications will be reviewed and cleared by a study physician prior to a 
participant's enrollment;  
 
**women who have recently taken oral contraceptives continuously for relief of perimenopausal symptoms 
will be exempt from LMP criteria, and instead, the presence of menstrual irregularity prior to the use of oral 
contraceptives and elevated FSH will be used to determine their perimenopausal status; 
  
***participants will be given the opportunity to describe these conditions in the online screening survey. 
Reported conditions that are acute in nature and/or benign will be reviewed by a study physician and 
exclusions will be decided case-by-case. All chronic conditions will be exclusionary.  
 
There is no evidence for first degree relative with history of MI/CVA as a contraindication for short-term 
ERT, and in our first 6 months of recruitment we have come to find this criterion superfluous for our 
purposes. Per the Endocrine Society Scientific Statement, thrombosis risk in HRT users is substantially 
increased with oral HRT administration and obesity; neither of which applies to our participants. Further, 
the American College of Obstetricians and Gynecologists does not list family history of MI/CVA as a 
contraindication for HRT. In our recruitment to date we have assessed many women with family history of 
MI/CVA who are healthy and otherwise appropriate for the study, and we do not want to continue to exclude 
them unnecessarily.  
 
Santen, R. J., Allred, D. C., Ardoin, S. P., Archer, D. F., Boyd, N., Braunstein, G. D., ... Endocrine Society. 
(2010). Postmenopausal hormone therapy: an Endocrine Society scientific statement. The Journal of 
Clinical Endocrinology and Metabolism, 95(7 Suppl 1), s1–s66. ,  
 
ACOG Practice Bulletin No. 141: management of menopausal symptoms. (2014). Obstetrics and 
Gynecology, 123(1), 202–216. 
4.3 Subject Recruitment and Screening 
 
Methods of recruiting for this study include:  
• 
Letters 
• 
Flyers 
• 
E-mail announcements 
• 
Facebook advertisements 
• 
Instagram advertisements 
• 
Craigslist advertisements 
• 
Newspaper and magazine advertisements  
 
A number of women from our “Effects of Estradiol on Neural Reward System and Depression in the 
Perimenopause” (PEERS) study were ineligible on the basis of current depression. These women will be 
sent a letter as they may qualify for our study and have interest in participating. In addition, participants will 
be self-identified by responding to flyers in the community. A university wide email will also be used to 
recruit participants. 

 
The letters described above will be used to recruit potential subjects. Recruitment materials (e.g., 
advertisements) will also be placed in university buildings and local businesses, and a university wide email 
will be used to recruit participants. Advertisements, including the letter, flyer, and email, will instruct 
participants to call our research lab to complete a phone screen or follow a link to our online eligibility 
survey. The phone screen and online eligibility survey include same questions (see attached).  
 
Eligibility screening will include: 
• An initial phone or online screening that includes questions about past medical and mental health 
history to assess potential participant’s eligibility based on the criteria listed in sections 4.1 and 4.2. 
• Participants will undergo a Clinical and Health Screening process to determine whether they are 
healthy enough to participate in this study. This screening will include past medical and mental health 
history and physical exam. During this evaluation, they will be asked questions about past and present 
psychiatric symptoms. They will also be asked to complete questionnaires about psychiatric 
symptoms. They may choose not to answer any or all of the questions for any reason. 
• Participants will complete a safety questionnaire to determine whether they have any foreign iron or 
steel metal objects in their bodies, such as a pacemaker, shrapnel, metal plate, or metal debris. If they 
have any such objects in their bodies, they cannot participate in the MRI session. 
• All participants will receive a pregnancy test. No pregnant women will be entered into the study, 
because the study drugs (Duavee) may be associated with fetal harm. 
4.4 Early Withdrawal of Subjects 
4.4.1 When and How to Withdraw Subjects 
 
Participants with significant clinical or laboratory abnormalities will be discontinued from the study prior to 
estrogen administration. 
 
Adverse mood symptoms will be monitored by administering the Hamilton Rating Scale for 
Depression (HRSD) at each study visit. If suicidal thoughts or severe mood symptoms are observed at 
any period in the protocol, then the HRSD will be administered on consecutive days for three 
days. Anyone scoring > 20 on the HRSD or expressing concerns about their ability to continue in 
the study, will be considered to have severe mood symptoms and be discontinued from the 
protocol. In the event of the occurrence of severe mood symptoms, the protocol will be terminated. 
Should this step prove to be unsuccessful, conventional medication will be prescribed as needed. Further, 
although we do not anticipate severe adverse reactions, we have arranged for inpatient hospital 
admission in the Psychiatry Department if symptoms are otherwise unmanageable. 
 
Any patient experiencing clinically significant side effects such as nausea, hypertension, vomiting or 
extreme fluid retention from the medication will have the dose titrated to achieve relief of the symptoms. If 
adequate relief cannot be achieved in this manner, drug treatment will be discontinued.  
 
The determination of when and how to withdrawal subjects will be overseen by the study’s principal 
investigator, co-investigators, and research coordinators and will be reported to the UNC Biomedical IRB. 
 
4.4.2 Data Collection and Follow-up for Withdrawn Subjects 
 
Participants who elect to discontinue the hormone protocol or are discontinued for safety reasons will be 
asked to continue to complete self-report ratings through the end of the proposed study period. However, 
fMRIs will not be done if participants discontinue the hormone protocol.  
 

5 Study Drug  
5.1 Description 
Drug 
Dosage 
Formulation 
Conjugated 
estrogens/bazedoxifene 
0.45 milligrams/20 
milligrams/day 
Oral tablet 
 
5.2 Treatment Regimen 
 
Regimen 
 
Once determined eligible and physically well, participants with perimenopausal depression will receive 
TSEC (conjugated estrogens/bazedoxifene, 0.45mg/20mg) for 3 weeks. Prior to beginning medication, 
women will have a basic lab panel and serum pregnancy test, pelvic exam, breast exam, and PAP smear. 
Participants who can provide record of a pelvic exam and breast exam within the past year and normal pap 
results within the past three years will be permitted to decline the GYN exam. Women will be seen in the 
clinic each week during TSEC administration to assess blood levels of estradiol and mood symptoms.  
5.3 Method for Assigning Subjects to Treatment Groups 
N/A 
5.4 Preparation and Administration of Study Drug 
All study drugs will be stored, prepared and dispensed from the UNC Investigational Drug Service (IDS). 
 
Contact: 
Sue Pope, Manager 
Investigational Drug Service 
Department of Pharmacy 
UNC Hospitals 
CB 7600, Room 3001 
101 Manning Drive 
Chapel Hill, NC 27514 
Office: 919-966-1766 
Fax: 919-966-6359 
5.5 Subject Compliance Monitoring 
We will monitor participants’ compliance with the drug regimen by assaying blood levels of medication 
collected at weekly study visits. The drug protocol will be reviewed at each study session, and participants 
who are significantly non-compliant with the study treatment regimen will be discontinued from the study.  
5.6 Prior and Concomitant Therapy 
Women are required to be medication free to enroll in this study; however, prior medication usage will not 
preclude participation in the study. 
5.7 Packaging 
The UNC Investigational Drug Service will receive the active drug from their Pharmacy storeroom. All the 
Duavee tablets will be provided to participants at study visit 3, in its original blister packaging. Duavee 
tablets are to be taken once daily. The remaining tablets will be returned to the study team at the conclusion 
of each subject’s participation in the study, and returned to IDS for appropriate disposal. 
5.8 Blinding of Study Drug (if applicable) 
N/A 

5.9 Receiving, Storage, Dispensing and Return 
The UNC Investigational Drug Service will receive the study drugs from the UNC Pharmacy Storeroom and 
will dispense the drug to the PI or research coordinator to deliver to participants. Any unused drug will be 
returned to the UNC Investigational Drug Service by the PI or research coordinator. 
5.9.1 Receipt of Drug Supplies 
Upon receipt of the of the study treatment supplies, an inventory will be performed and a drug receipt log 
filled out and signed by the person accepting the shipment.  The designated study staff will count and verify 
that the shipment contains all the items noted in the shipment inventory.  Any damaged or unusable study 
drug in a given shipment (active drug) will be documented in the study files.  The investigator will notify the 
UNC Pharmacy Storeroom of any damaged or unusable study treatments that were supplied to the 
Investigational Drug Service. 
5.9.2 Storage 
Duavee will be stored at 20° to 25° C in a temperature-controlled facility.  
5.9.3 Dispensing of Study Drug 
Drugs will be dispensed in the manufacturer’s blister packaging. Regular study drug reconciliation will be 
performed to document drug assigned, drug consumed, and drug remaining at each study visit. This 
reconciliation will be logged on the drug accountability form, and signed and dated by the study team. 
5.9.4 Return or Destruction of Study Drug 
At the completion of the study, there will be a final reconciliation of drug shipped, drug consumed, and drug 
remaining.  This reconciliation will be logged on the drug reconciliation form, signed and dated.  Any 
discrepancies noted will be investigated, resolved, and documented prior to return or destruction of unused 
study drug.  Drug destroyed on site will be documented in the study files. 
6 Study Procedures 
 
The flowchart outlining the procedures at each study visit it attached.  
 
OBGYN Exam 
Prior to beginning medication, women will have a basic lab panel and serum pregnancy test, pelvic 
exam, breast exam, and PAP smear. Participants who can provide record of a pelvic exam and breast 
exam within the past year and normal pap results within the past three years will be permitted to decline 
the GYN exam. Results of the exam will be added to the participants’ UNC Hospital medical record.  
 
Venipuncture 
Participants will undergo venipuncture at 5 study visits. Initial blood tests will include BUN, 
creatinine, ALT, AST, potassium, chloride, calcium, alkaline phosphatase, and a CBCD to rule out 
exclusionary health problems. Lab results will be added to participants’ medical records.  Subsequent 
venipuncture will be for the purpose of assaying estradiol levels to ensure participant compliance. During 
the context of COVID-19 venipuncture will be carried out by fully vaccinated study team members in private 
outdoor settings when possible, such as the subject’s backyard. 
 
 
Drug Administration 
Participants will receive their entire supply of Duavee at study visit 3.  
 
Clinical Assessments 
The Structured Clinical Interview for DSM-IV-TR Axis-I Disorders (SCID)58 and the Schedule for The 
SCID1 will be administered at baseline to determine study eligibility. The following standard measures will 
be administered at baseline, both fMRI sessions, and weekly clinic visits: 
• 
The Positive and Negative Affect Schedule59 is a 20-item questionnaire that measures both positive 
affect (PA) and negative affect (NA) and is sensitive to subtle changes in affect over time. 

• 
The Hamilton Rating Scale for Depression (HRSD)60 is a 21-item researcher-rated standardized 
scale that assesses depressive symptoms and is widely used as a measure of symptom change 
over time.  
• 
The Inventory of Depression and Anxiety Symptoms (IDAS)61 is a 64-item self-report questionnaire 
that comprehensively assesses anxiety and depression symptoms on 10 subscales. The IDAS has 
excellent psychometric properties and has been validated for assessing reproductive mood 
disorders.  
• 
The Mood and Anxiety Symptom Questionnaire – Anhedonic Depression Subscale (MASQ-AD)62 
is a 22-item scale that assesses anhedonia (i.e., loss of interest and low positive affect). MASQ-
AD scores have been associated with blunted striatal response to reward in previous studies of 
patients with depression63.  
• 
The Greene Climacteric Scale (GCS)64 is a 21-item scale that is the gold-standard measure of four 
domains of climacteric symptoms: vasomotor, somatic, anxiety, and depression. 
• 
The Pittsburgh Sleep Quality Index (PSQI)65 is a 9-item questionnaire that measures the quality 
and sleep patterns in older adults. *This measure will only be administered at the two fMRI 
sessions. 
• 
 The Hormone History Questionnaire is a 19-item inventory that assesses women's mental and 
physical health and was created for the purpose of this study. 
• 
The Trauma History Questionnaire 14 is a 24-item measure that examines participant's 
experiences with potentially serious or traumatic life events. 
 
While the SCID and HAM-D are researcher administered, the other measures will be collected through self-
report questionnaires using Qualtrics or paper and pencil questionnaires.  
 
Despite the use of exclusion criteria designed to reduce risk to participants, depressive symptoms are 
monitored closely. Any subject who develops severe depressive symptoms (e.g., suicidal ideation) will be 
discontinued from the study and offered treatment, including inpatient hospitalization. 
 
FMRI Tasks 
The following task will be included in each of the two fMRI sessions: 
The Monetary Incentive Delay (MID) Task66 engages the reward circuitry during monetary incentive 
anticipation and outcomes. Each of two MID runs consists of 90 6-second trials during which 
subjects are presented with of one of nine cue shapes, a fixation crosshair (for a variable duration), 
the target, and performance (win/loss/neutral) feedback. The cue indicates whether it is an 
incentive (gain, loss) or non-incentive trial. During incentive trials, participants can either gain or 
lose money by pressing a button during target presentation. Task difficulty is based on participant 
reaction times. This task elicits reliable frontostriatal dysregulation in people with remitted MDD67. 
Resting state scans will also be conducted at the beginning and end of each session.  
The Hariri Emotional Faces Task is an emotional face-matching task that engages neuronal 
regions implicated in emotional processing, including the amygdala and dorsomedial PFC. This 
block design paradigm consists of 4 blocks of a perceptual face-processing task interleaved with 
5 blocks of a sensorimotor control task. Participants are presented with a target stimulus and 
asked to select one of 2 images, presented on the low half of the screen, which match the target. 
Each face-processing block consists of fear and anger sub-blocks. During the sensorimotor 
control blocks, subjects view a trio of simple geometric shapes.  
FMRI Data Acquisition and Image Processing. Scanning was initially performed using a Siemens 
Magnetom 3T TIM Trio scanner. In July 2016, the scanner was upgraded to a Siemens 3T 
Prisma, and as such, all scanning will be performed on the Prisma system going forward. 
Scanning parameters on the Prima were set to be identical to the Trio in order to minimize the 
effects of scanner on the data. 

High-resolution, T1-weighted anatomical images will be acquired using an MPRAGE sequence. Whole-
brain functional images will be acquired using a single-shot, gradient recalled echoplanar pulse sequence 
sensitive to blood-oxygen-level-dependent (BOLD) contrast. Each of 2 runs will consist of the acquisition 
of 195 successive brain volumes. FMRI image preprocessing, processing, and analysis will be conducted 
using FSL and custom MATLAB scripts. FMRI analyses will include an event-related BOLD response 
analysis within a priori structurally defined frontostriatal regions of interest (ROIs). Contrasts of interest 
will include win versus non-win outcomes9, although the anticipation of wins will also be explored. 
Pizzagalli's Probabilistic Reward Task (PRT) 12 will be conducted outside of the scanner. This task allows 
us to test the additional hypothesis that perimenopausal depression is characterized by blunted reward 
learning. During this task, correct identifications of two ambiguous stimuli are differentially rewarded. The 
task will consist of 1 00 trials, in 1 block. Each trial starts with the presentation of a fixation cross for 500 
msec followed by a mouthless face. After a delay of 500 msec, either a short mouth (11.5 mm) or a long 
mouth (13 mm) is presented for 100 msec. Participants will be asked to identify which type of mouth was 
presented. For each block, the long and short mouths are presented equally often in a pseudorandomized 
sequence and 40 correct trials are followed by reward feedback immediately after the correct response. 
An asymmetrical reinforcer ratio will be used in this task, such that for half of the participants, correct 
identification of the short mouth will be associated with three times more positive feedback (30 of 40) than 
correct identification of the long mouth (10 of 40). For the other half of the participants, the contingencies 
will be reversed. 
 
7 Statistical Plan  
7.1 Sample Size Determination 
The researchers will have 80% power to detect a large effect size (.7) in 20 women. Our recently completed 
study of the effects of transdermal estradiol on mood symptoms in the same population showed a reduction 
in depressive symptoms with the PM-MDD group from pre-treatment to post-treatment (t=4.3, p<0.001 
Cohen's d=1.15). We anticipate the TSEC (the active ingredient of which is estrogen) to have similar effects 
on mood symptoms, and thus, the sample size of 20 is a conservative estimate of the number of subject 
we will need to detect a statistically significant effect.  
 
7.2 Statistical Methods 
 
Aim 1: Determine the extent to which TSEC reduces anhedonia and other depressive symptoms in PM-
MDD. Anhedonia and other depressive symptoms will be assessed at baseline and following 3 weeks of 
TSEC administration. Null hypothesis (H0): TSEC has no salutary effect on depression. Alternative 
hypothesis (H1): TSEC reduces depression as evidenced by 1) a statistically significant decrease in 
average MASQ Anhedonia scale score following 3 weeks of treatment, and 2) a clinically significant 
increase of 1 SD in MASQ Anhedonia scale score. We will test this hypothesis using a paired t-test of 
MASQ Anhedonia scores at visit 1 (pre-treatment) and visit 6 (post-treatment).  
 
Aim 2 (Exploratory): Quantify the effect of TSEC on the neural reward system in PM-MDD. We will use fMRI 
at baseline and following TSEC treatment in PM-MDD to probe frontostriatal reward circuitry. We also will 
compare the effects of TSEC and ERT in PM-MDD. Null hypothesis (H0): TSEC has no meaningful effect 
on activity of the neural reward circuit in response to rewards. Alternative hypothesis (H1): TSEC reduces 
increases neural responsiveness to reward in the frontostriatal reward circuitry as evidenced by increased 
activation of the caudate, putamen, and nucleus accumbens in PM-MDD in response to reward following 
TSEC administration (compared with baseline).We will test this hypothesis using a paired t-test to compare 
activity in 3 regions of interest (ROIs)—caudate, putamen, and nucleus accumbens—at the pretreatment 
and posttreatment scans. 
 

7.3 Subject Population(s) for Analysis 
Given that we are interested in understanding the effect of TSECs on brain function, only data from protocol-
compliant participants will be subjected to the study analysis. 
8 Safety and Adverse Events 
8.1 Definitions 
Unanticipated Problems Involving Risk to Subjects or Others 
Any incident, experience, or outcome that meets all of the following criteria:  
• Unexpected in nature, severity, or frequency  (i.e. not described in study-related documents such 
as the IRB-approved protocol or consent form, the investigators brochure, etc) 
• Related or possibly related to participation in the research (i.e. 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, 
• Serious (as defined below) “Serious” is different than “severe” as reported in the CTC criteria 
that applies a grade to the AE. 
 
Adverse Event 
An adverse event (AE) is any symptom, sign, illness or experience that develops or worsens in severity 
during the course of the study.  Intercurrent illnesses or injuries should be regarded as adverse events.  
Abnormal results of diagnostic procedures are considered to be adverse events if the abnormality: 
• results in study withdrawal 
• is associated with a serious adverse event 
• is associated with clinical signs or symptoms 
• leads to additional treatment or to further diagnostic tests 
• is considered by the investigator to be of clinical significance 
 
Serious Adverse Event 
Adverse events are classified as serious or non-serious.  A serious adverse event is any AE that is:  
• fatal 
• life-threatening 
• requires or prolongs hospital stay 
• results in persistent or significant disability or incapacity 
• a congenital anomaly or birth defect 
• an important medical event 
 
Important medical events are those that may not be immediately life threatening, but are clearly of major 
clinical significance. They may jeopardize the subject, and may require intervention to prevent one of the 
other serious outcomes noted above.  For example, drug overdose or abuse, a seizure that did not result 
in in-patient hospitalization, or intensive treatment of bronchospasm in an emergency department would 
typically be considered serious.  
 
All adverse events that do not meet any of the criteria for serious should be regarded as non-serious 
adverse events.  
 
Adverse Event Reporting Period 
The study period during which adverse events will be reported is normally defined as the period from the 
initiation of any study procedures to the end of the study treatment follow-up.  For this study, the study 
treatment follow-up is defined as 30 days following the last administration of study treatment.  
 
Preexisting Condition 
A preexisting condition is one that is present at the start of the study.  A preexisting condition will be 
recorded as an adverse event if the frequency, intensity, or the character of the condition worsens during 
the study period. 

 
General Physical Examination Findings 
At screening, any clinically significant abnormality will be recorded as a preexisting condition.  At the end 
of the study, any new clinically significant findings/abnormalities that meet the definition of an adverse event 
will also be recorded and documented as an adverse event.  
 
Post-study Adverse Event 
All unresolved adverse events will be followed by the investigator until the events are resolved, the subject 
is lost to follow-up, or the adverse event is otherwise explained.  At the last scheduled visit, the investigator 
will instruct each subject to report any subsequent event(s) that the subject, or the subject’s personal 
physician, believes might reasonably be related to participation in this study.   
 
Abnormal Laboratory Values 
A clinical laboratory abnormality should be documented as an adverse event if any one of the following 
conditions is met:  
• The laboratory abnormality is not otherwise refuted by a repeat test to confirm the abnormality 
• The abnormality suggests a disease and/or organ toxicity 
• The abnormality is of a degree that requires active management; e.g. change of dose, 
discontinuation of the drug, more frequent follow-up assessments, further diagnostic investigation, 
etc. 
 
Hospitalization, Prolonged Hospitalization or Surgery 
Any adverse event that results in hospitalization or prolonged hospitalization will be documented and 
reported as a serious adverse event unless specifically instructed otherwise in this protocol.  Any condition 
responsible for surgery will be documented as an adverse event if the condition meets the criteria for and 
adverse event.  
 
Neither the condition, hospitalization, prolonged hospitalization, nor surgery are reported as an adverse 
event in the following circumstances: 
• Hospitalization or prolonged hospitalization for diagnostic or elective surgical procedures for a 
preexisting condition.  Surgery should not be reported as an outcome of an adverse event if the 
purpose of the surgery was elective or diagnostic and the outcome was uneventful. 
• Hospitalization or prolonged hospitalization required to allow efficacy measurement for the study. 
• Hospitalization or prolonged hospitalization for therapy of the target disease of the study, unless it 
is a worsening or increase in frequency of hospital admissions as judged by the clinical investigator. 
 
COVID-19 
Any participant that develops symptoms of COVID-19 including by not limited to: fever, cough, shortness 
of breath, nausea, abdominal pain, headache, loss of taste or smell, or has known contact with a COVID-
19 positive carrier will be asked to contact their PCP, their local COVID-19 hotline and the study team 
immediately. All study procedures will be put on hold until the participant has received a negative test result 
or has quarantined for 14 days while monitoring their symptoms. If a participant is confirmed positive for 
COVID-19, the appropriate case report forms will be completed in accordance with CDC guidelines and 
UNC Policy. 
8.2 Recording of Adverse Events 
At each contact with the subject, the investigator will seek information on adverse events by specific 
questioning and, as appropriate, by examination.  Information on all adverse events will be recorded 
immediately in the source document, and also in the appropriate adverse event module of the case report 
form (CRF).  All clearly related signs, symptoms, and abnormal diagnostic procedures results will be 
recorded in the source document, though will be grouped under one diagnosis. 
 
All adverse events occurring during the study period will be recorded.  The clinical course of each event will 
be followed until resolution, stabilization, or until it has been determined that the study treatment or 
participation is not the cause.  Serious adverse events that are still ongoing at the end of the study period 
will be followed up to determine the final outcome.  Any serious adverse event that occurs after the study 

period and is considered to be possibly related to the study treatment or study participation will be recorded 
and reported immediately. 
8.3 Reporting of Serious Adverse Events and Unanticipated Problems 
 
Investigators and the protocol sponsor must conform to the adverse event reporting timelines, formats and 
requirements of the various entities to which they are responsible, but at a minimum those events that must 
be reported are those that are: 
• related to study participation, 
• unexpected, and  
• serious or involve risks to subjects or others  
(see definitions, section 8.1).   
 
If the report is supplied as a narrative, the minimum necessary information to be provided at the time of the 
initial report includes: 
• 
Study identifier 
• 
Subject number 
• 
A description of the event 
• 
Date of onset 
• 
Current status 
• 
Whether study treatment was discontinued 
• 
The reason why the event is classified as serious 
• 
Investigator assessment of the association 
between the event and study treatment 
 
8.3.1 Investigator reporting: notifying the study sponsor 
 
Any study-related unanticipated problem posing risk of harm to subjects or others, and any type of serious 
adverse event, will be reported to the PI and IRB by telephone within 24 hours of the event.  To report such 
events, an unanticipated problems (UAP) form will be completed by the investigator, and faxed to the IRB 
within 24 hours.  The investigator will keep a copy of this UAP form on file at UNC.   
 
Within the following 48 hours, the investigator must provide further information on the serious adverse event 
or the unanticipated problem in the form of a written narrative.  This should include a copy of the completed 
UAP, and any other diagnostic information that will assist the understanding of the event.  Significant new 
information on ongoing serious adverse events should be provided promptly to the study sponsor. 
8.3.2 Investigator reporting 
 
For reportable deaths, the initial submission to the UNC IRB may be made by contacting the IRB Director 
or Associate Director. The AE/Unanticipated Problem Form is required as a follow up to the initial 
submission. 
 
Other Reportable events: 
For clinical drug trials, the following events are also reportable to the UNC IRB: 
• Any adverse experience that, even without detailed analysis, represents a serious unexpected adverse 
event that is rare in the absence of drug exposure (such as agranulocytosis, hepatic necrosis, Stevens-
Johnson syndrome). 
• Any adverse event that would cause the investigator to modify the investigators brochure, protocol or 
informed consent form, or would prompt other action by the IRB to assure protection of human subjects. 
• Information that indicates a change to the risks or potential benefits of the research, in terms of severity 
or frequency. For example:  
– An interim analysis indicates that participants have a lower rate of response to treatment than 
initially expected. 
– Safety monitoring indicates that a particular side effect is more severe, or more frequent than 
initially expected. 

– A paper is published from another study that shows that an arm of your research study is of no 
therapeutic value. 
• Change in FDA safety labeling or withdrawal from marketing of a drug, device, or biologic used in a 
research protocol. 
• Breach of confidentiality 
• Change to the protocol taken without prior IRB review to eliminate apparent immediate hazard to a 
research participant. 
• Incarceration of a participant when the research was not previously approved under Subpart C and 
the investigator believes it is in the best interest of the subject to remain on the study. 
• Complaint of a participant when the complaint indicates unexpected risks or the complaint cannot 
be resolved by the research team. 
• Protocol violation (meaning an accidental or unintentional deviation from the IRB approved protocol) 
that in the opinion of the investigator placed one or more participants at increased risk, or affects 
the rights or welfare of subjects. 
8.3.3 Investigator reporting: Notifying UNC if affiliate site 
Investigators are responsible for complying with UNC’s IRB reporting requirements, though must submit 
the required reports to the IRB no later than 10 working days.  Copies of each report and documentation of 
IRB notification and receipt will be kept in the investigator’s study file. 
8.3.4 Sponsor reporting: Notifying the FDA 
 
This study is IND exempt, therefore IND safety reports are not required. 
 
Additional reporting requirements 
N/A 
 
Reporting Process 
N/A 
8.3.5 Sponsor reporting: Notifying participating investigators 
N/A 
8.4 Unblinding Procedures 
N/A 
8.5 Stopping Rules  
The protocol only includes rules for discontinuing individual participant, but not rules for stopping the entire 
study: 
Adverse mood symptoms will be monitored by administering the Hamilton Rating Scale for 
Depression (HRSD) at each study visit. If suicidal thoughts or severe mood symptoms are observed 
at any period in the protocol, then the HRSD will be administered on consecutive days for 
three days. Anyone scoring > 20 on the HRSD or expressing concerns about their ability to 
continue in the study, will be considered to have severe mood symptoms and be discontinued 
from the protocol. In the event of the occurrence of severe mood symptoms, the protocol will be 
terminated. Should this step prove to be unsuccessful, conventional medication will be prescribed as 
needed. Further, although we do not anticipate severe adverse reactions, we have arranged for 
inpatient hospital admission in the Psychiatry Department if symptoms are otherwise unmanageable. 
8.6 Medical Monitoring 
The principal investigator will oversee the safety of the study at her site.  This safety monitoring will include 
careful assessment and appropriate reporting of adverse events as noted above, as well as the construction 

and implementation of a site data and safety-monitoring plan.  Medical monitoring will include a regular 
assessment of the number and type of serious adverse events.  
 
The Principal Investigator’s responsibilities are to: 
 
• 
review the research protocol, informed consent documents, and plans for data safety and 
monitoring; 
 
• 
evaluate the progress of the trial, including periodic assessments of data quality and timeliness, 
participant recruitment, accrual and retention, participant risk versus benefit, performance of the 
trial site, and other factors that can affect study outcome; 
 
• 
consider factors external to the study when relevant information becomes available, such as 
scientific or therapeutic developments that may have an impact on the safety of the participants or 
the ethics of the trial; 
 
• 
protect the safety of the study participants; 
 
• 
report on the safety and progress of the trial; 
 
• 
make recommendations to the UNC-CH IRB,  and the PI, concerning continuation, termination, or 
other modifications of the trial based on the observed beneficial or adverse effects of the treatment 
under study; 
 
• 
if appropriate, conduct interim analysis of efficacy in accordance with stopping rules which are 
clearly defined in advance of data analysis; 
 
• 
ensure the confidentiality of the trial data and the results of monitoring; and, 
 
• 
assist the UNC-CH IRB by commenting on any problems with study conduct, enrollment, and 
sample size and/or data collection. 
 
The principal investigator or one of her trained study staff will be present at all visits to assess psychological 
changes using interviews and scales (i.e. HDRS, SCID, IDAS). If the subject self-reports suicidal ideation, 
this will be immediately communicated to the principal investigator, who will assess each subject on a case-
to-case basis.  
8.6.1 Independent Data and Safety Monitoring Board 
Please see the data and safety monitoring plan in Appendix A. 
9 Data Handling and Record Keeping 
9.1 Confidentiality 
Information about study subjects will be kept confidential and managed according to the requirements of 
the Health Insurance Portability and Accountability Act of 1996 (HIPAA).  Those regulations require a signed 
subject authorization informing the subject of the following:  
• What protected health information (PHI) will be collected from subjects in this study 
• Who will have access to that information and why 
• Who will use or disclose that information 
• The rights of a research subject to revoke their authorization for use of their PHI.  
 
In the event that a subject revokes authorization to collect or use PHI, the investigator, by regulation, retains 
the ability to use all information collected prior to the revocation of subject authorization.  For subjects that 
have revoked authorization to collect or use PHI, attempts should be made to obtain permission to collect 
at least vital status (i.e. that the subject is alive) at the end of their scheduled study period. 

9.2 Source Documents 
Source data is all information, original records of clinical findings, observations, or other activities in a 
clinical trial necessary for the reconstruction and evaluation of the trial.  Source data are contained in source 
documents.  Examples of these original documents, and data records include: hospital records, clinical and 
office charts, laboratory notes, memoranda, subjects’ diaries or evaluation checklists, pharmacy dispensing 
records, recorded data from automated instruments, copies or transcriptions certified after verification as 
being accurate and complete, microfiches, photographic negatives, microfilm or magnetic media, x-rays, 
subject files, and records kept at the pharmacy, at the laboratories, and at medico-technical departments 
involved in the clinical trial. 
9.3 Case Report Forms (as applicable) 
The study case report form (CRF) is the primary data collection instrument for the study.  All data requested 
on the CRF must be recorded.  All missing data must be explained.  If a space on the CRF is left blank 
because the procedure was not done or the question was not asked, write “N/D”.  If the item is not applicable 
to the individual case, write “N/A”.  All entries should be printed legibly in black ink.  If any entry error has 
been made, to correct such an error, draw a single straight line through the incorrect entry and enter the 
correct data above it.  All such changes must be initialed and dated.  DO NOT ERASE OR WHITE OUT 
ERRORS.  For clarification of illegible or uncertain entries, print the clarification above the item, then initial 
and date it. 
9.4 Records Retention 
It is the investigator’s responsibility to retain study essential documents for at least 2 years after the last 
approval of a marketing application in their country and until there are no pending or contemplated 
marketing applications in their country or at least 2 years have elapsed since the formal discontinuation of 
clinical development of the investigational product.  These documents should be retained for a longer period 
if required by an agreement with the sponsor.  In such an instance, it is the responsibility of the sponsor to 
inform the investigator/institution as to when these documents no longer need to be retained.  
 
10 Study Monitoring, Auditing, and Inspecting 
10.1 Study Monitoring Plan 
This study will be monitored according to the monitoring plan in the Attachments.  The investigator will 
allocate adequate time for such monitoring activities.  The Investigator will also ensure that the monitor or 
other compliance or quality assurance reviewer is given access to all the above noted study-related 
documents and study related facilities (e.g. pharmacy, diagnostic laboratory, etc.), and has adequate space 
to conduct the monitoring visit. 
10.2 Auditing and Inspecting 
The investigator will permit study-related monitoring, audits, and inspections by the IRB and University 
compliance and quality assurance groups of all study related documents (e.g. source documents, regulatory 
documents, data collection instruments, study data etc.).  The investigator will ensure the capability for 
inspections of applicable study-related facilities (e.g. pharmacy, diagnostic laboratory, etc.). 
 
Participation as an investigator in this study implies acceptance of potential inspection by government 
regulatory authorities and applicable University compliance and quality assurance offices. 
11 Ethical Considerations 
This study is to be conducted according to US and international standards of Good Clinical Practice (FDA 
Title 21 part 312 and International Conference on Harmonization guidelines), applicable government 
regulations and Institutional research policies and procedures. 
 
This protocol and any amendments will be submitted to a properly constituted independent Ethics 
Committee (EC) or Institutional Review Board (IRB), in agreement with local legal prescriptions, for formal 

approval of the study conduct.  The decision of the EC/IRB concerning the conduct of the study will be 
made in writing to the investigator and a copy of this decision will be provided to the sponsor before 
commencement of this study.  The investigator should provide a list of EC/IRB members and their affiliate 
to the sponsor. 
 
All subjects for this study will be provided a consent form describing this study and providing sufficient 
information for subjects to make an informed decision about their participation in this study.  See Attachment 
for a copy of the Subject Informed Consent Form.  This consent form will be submitted with the protocol for 
review and approval by the EC/IRB for the study.  The formal consent of a subject, using the EC/IRB-
approved consent form, must be obtained before that subject undergoes any study procedure.  The consent 
form must be signed by the subject or legally acceptable surrogate, and the investigator-designated 
research professional obtaining the consent.  
12 Study Finances 
12.1 Funding Source 
This study is financed through a grant from the Foundation of Hope for Research and Treatment of Mental 
Illness.  
12.2 Conflict of Interest 
Any investigator who has a conflict of interest with this study (patent ownership, royalties, or financial gain 
greater than the minimum allowable by their institution, etc.) will have the conflict reviewed by a properly 
constituted Conflict of Interest Committee with a Committee-sanctioned conflict management plan that has 
been reviewed and approved by the study sponsor prior to participation in this study.  All UNC investigators 
will follow the University conflict of interest policy. 
12.3 Subject Stipends or Payments 
Participants will be compensated the amount specified below upon completion of the study for a total of 
$500.00. Payment will be given through the form of a Visa Gift Card, issued inactive and unloaded through 
USPS mail to minimize in-person contact during the COVID-19 pandemic. Upon confirmed arrival of the 
Visa gift card, the card will be loaded with the payment amount and will be able to be activated by the 
participant. If a subject withdraws or is withdrawn from the study as a result of an adverse event, her 
compensation will be prorated based on the following schedule: 
 
Initial evaluation and Psychological Interview (Visit 1; 2.5 hours) $100.00 
Physical Exam & Baseline Labs (Visit 2; 1-2 hours) $30.00 
FMRI Imaging combined with clinic visits (Visits 3 and 6) $150.00/visit -- $300.00 total 
Clinic visits with venipuncture (Visits 4 and 5) $35.00/visit -- $70.00 
 
Payment is processed through the UNC Department of Psychiatry.  
13 Publication Plan 
Neither the complete nor any part of the results of the study carried out under this protocol, nor any of the 
information provided by the sponsor for the purposes of performing the study, will be published or passed 
on to any third party without the consent of the study sponsor.  Any investigator involved with this study is 
obligated to provide the sponsor with complete test results and all data derived from the study. 
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Appendix A. Data and Safety Monitoring Plan 
 
Data and Safety Monitoring Plan  
IRB Study #18-2129 
Title of Study: Effects of a Tissue Selective Estrogen Complex on Depression and the Neural Reward 
System in The Perimenopause (Duavee) 
Principal Investigator: Crystal Schiller, PhD 
Principal Investigator Department: Psychiatry 
Principal Investigator Phone number: (919) 966-4810 
Principal Investigator Email address: crystal_schiller@med.unc.edu   
 
I. 
Overview 
A. Brief description of the purpose of the study and study protocol  
Despite decades of clinical research, affective disorders continue to affect 20.9 million 
Americans each year and remain the leading cause of disability worldwide. Women are 
twice as likely as men to experience depression. Depressive symptoms are particularly 
common during periods of hormone fluctuation, including the transition to menopause. The 
proposed research will help identify the effects of estrogen on brain function and mood 
during the menopause transition. This research will provide important information for 1) 
understanding the triggering of and susceptibility to perimenopausal depression, 2) 
identifying women for whom hormone replacement therapy is likely to have beneficial 
effects, and 3) developing new medications for depression in women.   
 
Using neuroimaging, we will study the effects of tissue selective estrogen complexes 
(TSECs) on mood and brain function in perimenopausal women with depression. 
Participants will include 20 unmedicated, naturally menopausal women who are diagnosed 
with major depressive disorder associated with menstrual cycle irregularity (n=20). An 
initial interview will confirm participants’ presence of depression, and current 
perimenopausal status as well as determine any exclusionary criteria.  
 
Inclusion Criteria. 
 
1. Perimenopause Status: We will employ the Stages of Reproductive Aging Workshop 
(STRAW) criteria to confirm perimenopausal status. The stages are primarily based 
on the characteristics of the menstrual cycle and secondarily on follicle stimulating 
hormone (FSH) levels. The anchor for the staging system is the final menstrual 
period (FMP). We will enroll women who have ≥ 2 skipped cycles and an interval of 
amenorrhea ≥ 60 days, consistent with the late menopause transition (stage -1). 
Women who meet these criteria will not require an FSH level. Women who have 
taken oral contraceptives continuously for relief of perimenopausal symptoms and 
women who have had hysterectomies (with ovaries remaining intact) will be exempt 
from our LMP criteria, and their perimenopausal status will be determined by FSH 
level instead (FSH ≥ 14). Because extremes of body weight (BMI < 18 or > 35 kg/m2) 
or a history of chronic menstrual cycle irregularity can contribute to inaccurate 
reproductive staging, these will serve as additional exclusion criteria; 
2. MDD Group Eligibility Criterion: current diagnosis of MDD with an onset associated 
with menstrual cycle irregularity, and no history of psychiatric illness during the 2 
years before the onset of the current depressive episode as determined by the 
Structure Clinical Interview for DSM-IV-TR for Axis I Disorders (SCID) 
 
Exclusion Criteria. Patients will not be permitted to enter this protocol if they have important 
clinical or laboratory abnormalities including any of the following:  
1. current medication use (i.e., psychotropics, anti-hypertensives, statins, hormonal 
preparations, or frequent use of anti-inflammatory agents (> 10 times/month)). 
Women will be allowed to enroll who take medications without known mood effects 

(e.g. stable thyroid hormone replacement and occasional (< 5 times/month) use of 
Ambien)*;  
2. pregnant, breastfeeding or trying to conceive;   
3. LMP more than 12 months prior to enrollment**;   
4. history of undiagnosed vaginal bleeding;   
5. undiagnosed enlargement of the ovaries;   
6. polycystic ovary syndrome;   
7. history of breast or ovarian cancer;   
8. first degree relative with ovarian cancer;   
9. first degree relative with premenopausal onset or bilateral breast cancer;  
10. 2+ first degree relatives with breast cancer (regardless of onset);   
11. 3+ relatives with postmenopausal breast cancer;   
12. abnormal finding in a provider breast exam and/or mammogram***;   
13. known carrier of BRCA1 or 2 mutation; 
14. endometriosis; 
15. blood clots in the legs or lungs; 
16. porphyria; 
17. diabetes mellitus; 
18. malignant melanoma; 
19. Hodgkin's disease; 
20. recurrent migraine headaches that are preceded by aura; 
21. gallbladder or pancreatic disease***; 
22. heart or kidney disease***; 
23. liver disease; 
24. cerebrovascular disease (stroke); 
25. current cigarette smoking; 
26. current suicidal ideation, mania, psychosis, or alcohol/drug dependence; 
27. past suicide attempts, mania, alcohol/drug dependence, or psychotic episodes; 
28. chronic depression (i.e., episode(s) lasting 3+ years); 
29. depressive episode(s) within 2 years of enrollment; 
30. self-reported claustrophobia 
31. Allergies to red or yellow dye. 
 
*all reported prescription medications will be reviewed and cleared by a study physician prior to a 
participant's enrollment;  
**women who have recently taken oral contraceptives continuously for relief of perimenopausal 
symptoms will be exempt from LMP criteria, and instead, the presence of menstrual irregularity 
prior to the use of oral contraceptives and elevated FSH will be used to determine their 
perimenopausal status; 
***participants will be given the opportunity to describe these conditions in the online screening 
survey. Reported conditions that are acute in nature and/or benign will be reviewed by a study 
physician and exclusions will be decided case-by-case. All chronic conditions will be exclusionary.   
There is no evidence for first degree relative with history of MI/CVA as a contraindication for short-
term ERT, and in our first 6 months of recruitment we have come to find this criterion superfluous 
for our purposes. Per the Endocrine Society Scientific Statement, thrombosis risk in HRT users is 
substantially increased with oral HRT administration and obesity; neither of which applies to our 
participants. Further, the American College of Obstetricians and Gynecologists does not list family 
history of MI/CVA as a contraindication for HRT. In our recruitment to date we have assessed many 
women with family history of MI/CVA who are healthy and otherwise appropriate for the study, and 
we do not want to continue to exclude them unnecessarily.  
Santen, R. J., Allred, D. C., Ardoin, S. P., Archer, D. F., Boyd, N., Braunstein, G. D., ... Endocrine 
Society. (2010). Postmenopausal hormone therapy: an Endocrine Society scientific statement. The 
Journal of Clinical Endocrinology and Metabolism, 95(7 Suppl 1), s1–s66. ,  
ACOG Practice Bulletin No. 141: management of menopausal symptoms. (2014). Obstetrics and 
Gynecology, 123(1), 202–216. 
     B. Adherence statement  

The Data and Safety Monitoring Plan (DSMP) outlined below will adhere to the protocol 
approved by the University of North Carolina at Chapel Hill IRB.  
 
II. 
Adverse Events  
A. Adverse event assessment  
This study defines adverse event as any unfavorable and unintended sign, symptom, or 
disease temporally associated with the subject’s participation.  
 
The estimated level of risk to subjects for this protocol is level 2: minor increase over 
minimal risk.  
 
Potential Risks to Human Subjects and Minimization of those Risks 
 
Psychological Assessment 
 
Clinical interviews and self-report assessments contain questions regarding sensitive 
personal information. As a result, participants may become upset or embarrassed when 
discussing current or past distressing life events. This risk is necessary in order to assess 
depressive symptoms and associated psychopathology. However, we have conducted 
several studies assessing depressive symptoms in women, and participants are unlikely to 
become upset. If participants become upset during an assessment, they will be reminded 
of their right to discontinue participation, suicidal ideation will be assessed, and appropriate 
treatment referrals will be provided. Participants in need of medical follow-up or 
psychological counseling will be referred to the UNC Psychiatry Outpatient Clinic. If a 
participant reports having suicidal thoughts, intent, plans, and means during the course of 
the study, she will be taken to the UNC Emergency Department for evaluation. 
 
MRI 
 
The psychological risks associated with the MRI include the discomfort some subjects 
encounter by the confinement within the bore of the MRI system (i.e., claustrophobia) and 
the loud noise made by the gradients during imaging. These risks occur for all clinical MRI 
exams and are not increased by the proposed research. Nonetheless, the steps taken to 
reduce these risks are described below. 
 
Claustrophobia 
The FDA does not provide guidelines concerning claustrophobia. Some subjects may feel 
uncomfortable or confined once positioned within the MRI system. For some subjects, this 
confinement results in anxiety. The number of subjects who experience claustrophobic 
reactions during MRI is uncertain. Kilborn and Labbe estimated that from 5-10% of patients 
become claustrophobic during clinical MRI scans. Murphy and colleagues reported that 
14.3% of 949 patients undergoing MRI testing in their hospital required sedation to tolerate 
the procedure. The numbers reported in these studies are not representative of our 
experience at BIAC where terminated scans and panic are infrequent. This is not 
surprising, given that our volunteers choose to participate while patients have less choice. 
Also, patients may have additional anxieties about their illness or diagnosis that contribute 
to their discomfort. 
 
We counter the risk of claustrophobia through subject selection and by communication with 
the subjects. We will exclude from study those subjects who state that they are 
claustrophobic. We talk to subjects frequently throughout the scan (particularly at its onset). 
We offer to keep the bore fan running to reduce heat and eliminate any fear of suffocation. 
We also provide an emergency ‘panic’ button so that he or she knows that help can be 
immediately summoned. 
 

We explain to the subjects that the sounds they will hear are a normal part of the scanning, 
and that mild apprehension in enclosed spaces is a normal reaction. Subjects are told that 
if they feel increasingly anxious during the scan, they can ask to stop the scan. 
Experimenters listen for telltale signs of growing anxiety or discomfort, such as the subject 
repeatedly asking how much longer the scan will last. If a subject appears to be more than 
mildly anxious or declares himself or herself to be anxious, then the experimenter removes 
the subject from the scanner immediately. These studies are then reported to the IRB at 
the end of the year as incomplete studies. We have recently constructed a ‘mock scanner’ 
(or MRI simulator) from parts of a decommissioned GE scanner. The mock scanner has a 
bed that moves the subject into its bore, and a spare head coil is used for added realism. 
Recorded scanner noises are played from speakers hidden within the frame. Although 
there are no actual magnetic fields present, the experience of being ‘scanned’ in the mock 
scanner is very realistic. Whenever possible, we familiarize naïve subjects in the mock 
scanner so that they know what to expect during the real study. Although we have no 
objective data yet to report, our expectation is that subjects who experience claustrophobia 
in the mock scanner will identify themselves to the experimenters at that time, and thus will 
be excused from further participation in the experimental protocol. 
 
Acoustic Noise 
 
The FDA guidelines limit the peak unweighted sound pressure level to less than 140 dB. 
The A-weighted root mean square (rms) sound pressure level is limited to 99 dBA with 
hearing protection in place. The rapid rise and fall of currents within the gradient coils in 
the presence of the static magnetic field create strong Lorentz forces that cause the 
gradient coils to move against their mountings. The vibration of the coils and the vibration 
and flexing of their mountings cause the loud tapping and knocking noises during imaging. 
The BRIC scanner was tested for sound intensity during image acquisition and the acoustic 
noise falls within the FDA guidelines. We counter the risks caused by acoustic noise by 
providing hearing protection to all subjects. We require subjects to use Aearo Classic 
earplugs that have an EPA Noise Reduction Rate (NRR) of 29 dB (when properly fit), or 
headphones that are rated for 30 dB of attenuation. We instruct subjects on the proper 
insertion procedure for the earplug and then inspect the fit to make certain that this 
procedure has been followed. Subjects are told to contact an experimenter immediately if 
the scanner is ever uncomfortably or painfully loud. 
 
Confidentiality 
 
A breach of confidentiality could indicate to others a participants’ psychiatric history. Risk 
of breach of confidentiality is minimized by identifying research subjects by a study number 
on all research documents. Study documents that must contain personal information, 
including the informed consent document, and the document that links study ID number to 
personal identifying information are kept in locked filing cabinets in locked rooms. All data 
will be stored in locked cabinets inside locked offices; electronic data will be stored only on 
password-protected computers, and data encryption methods will be used during 
communication between investigators. Only study personnel will have access to these 
data. All study staff participate in annual human subject training that includes education 
about responsibilities to the minimize risk of confidentiality breach. 
 
Duavee Side Effects  
 
We do not expect any adverse side effects associated with the hormonal manipulations 
outlined in this protocol for the following reasons: We will be administering estrogen paired 
with selective estrogen receptor modulators (SERMs). SERMs are synthetic non-steroidal 
agents that have estrogen agonist and antagonist effects in different tissues, to block the 
negative effects of estrogen on non-target tissues, including the reproductive organs and 
cardiovascular system, while allowing estrogen to exert effects on target tissues like the 
brain, and thus decreasing risk for side effects.  

 
Duavee: Nausea is the most common side effect of TSEC administration. At conventional 
replacement doses, higher than those employed in this protocol, this complaint seldom 
interferes with eating, and no weight loss has been reported. Abdominal pain, hot flashes, 
breast engorgement, endometrial hyperplasia and bleeding are also common side effects 
of TSEC administration. Pre-existing fibroid tumors of the uterus may enlarge under the 
effects of TSECs; however, at the dosage and for the duration of estrogen administration 
in this protocol this risk is small.  
 
The relationship between estrogens, both endogenous and exogenous, and the 
development of endometrial carcinoma has been suggested by several different lines of 
investigation. Numerous retrospective case control studies published since 1975 have 
indicated that post menopausal exposure to unopposed estrogens for more than one year 
results in a two to 12 fold increased relative risk for endometrial cancer. A relationship 
between the dose and duration of estrogen use and the risk for endometrial cancer has 
also been shown, the risk being increased after one to four years of estrogen use and rising 
also with the dosage employed. However, the addition of SERMS to estrogen replacement 
therapy appears to decrease the risk of endometrial hyperplasia and endometrial cancer 
to equal or below that of women receiving no hormonal treatment. There is an increased 
risk of thromboembolism in women receiving non-contraceptive estrogen therapy. 
Additionally, some but not all studies report an increase in risk of stroke, in older women 
taking estrogen therapy. However, these complications are unlikely at the dose and 
duration of estrogen replacement employed in this protocol and in the younger age group 
of women who participate in this study. Blood pressure, on average, appears to be 
unaffected by estrogen therapy, although both increases and decreases have been 
reported. In observational studies, post-menopausal estrogen therapy has been observed 
to lower the relative risk of cardiovascular disease in some but not all studies. In contrast, 
recent randomized controlled trials in older postmenopausal women (e.g., Women’s Health 
Initiative [WHI]) report an increased risk of cardiovascular disease. Emerging data suggest 
that these disparities in findings may be related to the timing of initiation of estrogen therapy 
in relation to the proximity of menopause. Additionally, the increased risk of CHD was 
observed in older but not younger perimenopausal women. High doses of oral estrogens 
have been reported to elevate hepatocellular enzyme levels and, less commonly, cause 
cholestatic jaundice. The risk for gall stones and hepatocellular adenomas has been 
reported to be increased in association with oral contraceptive use, and although 
uncommon these complications may also occur with the use of replacement doses of 
estrogen. Estrogen therapy also may increase the risk of urinary incontinence in older 
postmenopausal women. Further, most studies have suggested an increased relative risk 
of breast cancer after four or five years' use, similar to the risk expected if the onset of 
menopause was delayed for a comparablelength of time. Due to the publicity surrounding 
the cancellation of the treatment arm of the Women’s Health Initiative study that involved 
the administration of combined conjugated estrogens and medroxyprogesterone acetate 
(Prempro), we have included the following statement in the consent documents: 
 
Adverse Events Related to Combined Hormone Replacement and the Results of the 
Women's Health Initiative (WHI): The WHI study demonstrated that continuous 
administration of one form of estrogen (estradiol) in combination with one form of 
progesterone (medroxyprogesterone acetate) is associated with an increased risk of 
dementia, heart attacks, stroke, blood clots, and breast cancer. Conjugated estrogens, the 
form of estrogen that we use in this study, is administered with bazedoxifene, a SERM, 
that helps to prevent and, consequently, we do not expect that it will pose the increased 
risks observed with the chronic combination of the conjugated estrogens and 
medroxyprogesterone administered in the WHI study. Indeed, while the estrogen alone 
arm of the WHI trial was shown to be associated with an increased risk of stroke, no 
increased risk of either heart disease or breast cancer was observed. Estrogens may 
precipitate migraine headaches, and depression has also been reported to occur with the 

use of estrogens. In general, considering the dose and duration of treatment that we 
propose to use in this protocol, the risk of developing such side effects is negligible. 
 
 
Potential Benefits to Human Subjects 
 
There is evidence suggesting that estrogens may serve as a therapeutic option for affective 
disorders in perimenopausal women.  Thereby women who participate in the study may 
find that the estrogen therapy yields an improvement in symptoms related to mood or 
physical symptoms, and will have the option to continue hormone replacement after the 
study concludes. If a participant is interested in learning whether she demonstrated a 
differential susceptibility to the hormone replacement used in this study, she will be 
welcome to review the mood and physical symptoms that she experienced during the study 
with the PI. 
 
B. Adverse event reporting  
1. This study defines an unanticipated problem as an incident, experience or outcome 
that is both unexpected (in nature, severity, or frequency) and related or possibly 
related to the research. 
2. This study defines a serious adverse event as fatal or life threatening, requires or 
prolongs hospitalization or results in significant or persistent disability or congenital 
anomaly/birth defect. 
3. Adverse events will be reported to the UNC-CH IRB and to the NIH as required. 
Following UNC-CH Adverse Event guidelines, events that meet the criteria for an 
unanticipated problems involving risks to subjects or others (UPIRSO) and are also 
serious adverse events will be reported to the IRB within one (1) week of the 
investigator becoming aware of the event. Any other events that meet the criteria for 
a UPIRSO will be reported to the IRB within two (2) weeks of the investigator 
becoming aware of the problem. In accordance with the terms of the Federal Wide 
Assurance, the Office for Human Research Protections (OHRP) and the Federal 
Drug Administration (FDA) are notified in a timely manner of 1) serious or continuing 
noncompliance; 2) significant adverse events involving risk to participants or others; 
or 3) suspension or termination of IRB approval for a study. Unexpected problems 
involving risk, unless the event is serious and related to the research, are not 
routinely submitted to the sponsor. 
4. Adverse events will be identified through clinical interviews, laboratory results, safety 
tests, and self-report questionnaires. 
5. Every event will be reported to the principal investigator and Dr. David Rubinow by 
the designated research associates and will be documented. An adverse event report 
will be generated for each even and will include a description of the event, when and 
how it was reported, and any official chart records or documentation to corroborate 
the event.  
6. The adverse event report will also include the severity attribution of the adverse event 
using the Common Toxicity Criteria (CTC) scale: 0 = no adverse event or within 
normal limits; 1 = mild AE, not requiring treatment; 2 = moderate AE, resolved with 
treatment; 3 = severe AE, resulted in inability to carry on normal activities and 
required professional medical attention; 4 = life threatening or disabling AE; 5 = fatal 
AE.  
7. The adverse event report will also include a determination of attribution according to 
the following scale: 0 = definitely not related; 1 = probably not related; 2 = possibly 
related; 3 = probably related; 4 = definitely related.  
 
III. 
Safety Review Plan and Monitoring  
 
Oversight of participant safety includes a review of adverse events as well as study progress, 
data integrity, and study outcomes.  

 
A. Justification of sample size 
We will have 80% power to detect a large effect size (.7) in 20 women. Our recently completed 
study of the effects of transdermal estradiol on mood symptoms in the same population showed 
a reduction in depressive symptoms with the PM-MDD group from pre-treatment to post-
treatment (t=4.3, p<0.001 Cohen's d=1.15). We anticipate the TSEC (the active ingredient of 
which is estrogen) to have similar effects on mood symptoms, and thus, the sample size of 20 
is a conservative estimate of the number of subject we will need to detect a statistically 
significant effect.  
 
B. Safety and study progress reviews  
1. The research coordinator will evaluate the study subjects at appropriate intervals and 
assess laboratory data and clinical signs for potential adverse events. The research 
coordinator will assist the PI with gathering information to help the PI determine 
classification and causality. The research coordinator will also observe and document 
all adverse events, act on the PI’s recommendation, and maintain follow-up until 
reconciliation. 
2. The principal investigator and Dr. David Rubinow will review the adverse events, 
immediately after they occur, with follow-up resolution. The principal investigator and 
Dr. Rubinow will evaluate individual and cumulative participant data when making 
recommendations regarding the safe continuation of the study. The principal 
investigator will be notified within 24 hours of an adverse event.  
3. Specific responsibilities of the principal investigator include:  
a. Review the research protocol, informed consent documents, and plans for data 
safety and monitoring; 
b. Evaluate the progress of the trial, including periodic assessments of data quality 
and timeliness, participant recruitment, accrual and retention, participant risk 
versus benefit, performance of the trial site, and other factors that can affect 
study outcome; 
c. Consider factors external to the study when relevant information becomes 
available, such as scientific or therapeutic developments that may have an 
impact on the safety of the participants or the ethics of the trial;  
d. Protect the safety of the study participants; 
e. Report on the safety and progress of the trial; 
f. Make recommendations to the UNC-CH IRB, and, if required to the Food and 
Drug Administration (FDA) concerning continuation, termination, or other 
modifications of the trial based on the observed beneficial or adverse effects of 
the treatment under study; 
g. If appropriate, conduct interim analysis of efficacy in accordance with stopping 
rules which are clearly defined in advance of data analysis; 
h. Ensure the confidentiality of the trial data and the results of monitoring; and,  
i. Assist the UNC-CH IRB by commenting on any problems with study conduct, 
enrollment, and sample size and/or data collection. 
4. The frequency of the principal investigator’s review is detailed below: 
 
Participant accrual—weekly  
 
Study adherence and dropouts—Weekly  
 
Adverse events—As events occur  
 
Participant confidentiality—As events occur 
5. The annual report will include a list and summary of any adverse events; whether the 
adverse event rates are consistent with pre-study assumptions; a summary of 
recruitment and retention and reason for dropouts; and whether the study is on track 
to be completed and accomplish the stated aims.  
 
C. Stopping Rules—Individual Subject 
 

Participants with significant clinical or laboratory abnormalities will be discontinued from 
the study prior to estrogen administration. Adverse mood symptoms will be monitored by 
administering the Hamilton Rating Scale for Depression (HRSD) at each study visit.  If 
suicidal thoughts or severe mood symptoms are observed at any period in the protocol, 
then the HRSD will be administered on consecutive days for three days. Anyone scoring > 
20 on the HRSD or expressing concerns about their ability to continue in the study, will be 
considered to have severe mood symptoms and be discontinued from the protocol. In the 
event of the occurrence of severe mood symptoms, the protocol will be terminated. Should 
this step prove to be unsuccessful, conventional medication will be prescribed as needed. 
Further, although we do not anticipate severe adverse reactions, we have arranged for 
inpatient hospital admission in the Psychiatry Department if symptoms are otherwise 
unmanageable. 
 
IV. 
Informed Consent 
 
Informed consent will be obtained from each subject at entry into the study. Potential 
participants will complete eligibility screening by telephone/online survey and by laboratory 
tests conducted at the first study visit. Prior to the eligibility screening, potential participants will 
give verbal consent via the phone or will read and agree to a consent statement on an online 
survey before providing any information. No more information will be asked of participants than 
necessary to obtain eligibility information and to contact those who appear eligible. Dr. Crystal 
Schiller, or her trained study staff, will obtain written informed consent from those individuals 
who pass the initial telephone or electronic screening and are interested in participating. During 
the consenting process, all of the applicable consent forms will be reviewed with each 
individual, and they will be given as much time as they would like to discuss their participation 
with their families and decide whether to participate.  
 
V. 
Data Quality and Management  
 
A. Measures to be taken to review data collection  
1. Data will be collected and analyzed as specified in the protocol:  
 
a. Study Design  
 
Once determined eligible and physically well, participants will receive conjugated 
estrogens/bazedoxifene (Duavee) tablets (0.45 μg, 20 mg) for 3 weeks. fMRI 
sessions (described below) will take place at baseline and at the end of the third 
week of Duavee administration. In the first study visit, women will have a basic lab 
panel and serum pregnancy test performed.  Prior to Duavee administration 
women will receive a pelvic exam, breast exam, and Papanicolaou 
test.  Participants who can provide record of a pelvic exam and breast exam within 
the past year and normal pap results within the past 3 years will be permitted to 
decline the GYN exam.  Women will be seen in the clinic each week during Duavee 
administration to assess blood levels of conjugated estrogens/bazedoxifene and 
mood symptoms.  
 
Clinical Assessments. The SCID will be administered at baseline to determine 
study eligibility by Dr. Schiller or her trained study staff. The following standard 
measures will be administered at baseline, both fMRI sessions, and weekly clinic 
visits: The Positive and Negative Affect Schedule is a 20-item questionnaire that 
measures both positive affect (PA) and negative affect (NA) and is sensitive to 
subtle changes in affect over time. 
The Hamilton Rating Scale for Depression (HRSD) is a 21-item researcher-rated 
standardized scale that assesses depressive symptoms and is widely used as a 
measure of symptom change over time. 

The Inventory of Depression and Anxiety Symptoms (IDAS) is a 64-item self-report 
questionnaire that comprehensively assesses anxiety and depression symptoms 
on 10 subscales. The IDAS has excellent psychometric properties and has been 
validated for assessing reproductive mood disorders. 
The Mood and Anxiety Symptom Questionnaire – Anhedonic Depression Subscale 
(MASQ-AD) is a 22-item scale that assesses anhedonia (i.e., loss of interest and 
low positive affect). MASQ-AD scores have been associated with blunted striatal 
response to reward in previous studies of patients with depression. 
The Greene Climacteric Scale (GCS) is a 21-item scale that is the gold-standard 
measure of four domains of climacteric symptoms: vasomotor, somatic, anxiety, 
and depression. 
The Pittsburgh Sleep Quality Index (PSQI) is a 9-item questionnaire that measures 
the quality and sleep patterns in older adults. 
The Hormone History Questionnaire is a 19-item inventory that assesses women's 
mental and physical health and was created for the purpose of this study. 
The Trauma History Questionnaire  is a 24-item measure that examines 
participant's experiences with potentially serious or traumatic life events. 
 
fMRI Task and Protocol. The Monetary Incentive Delay (MID) Task  engages 
reward circuitry during monetary incentive anticipation and outcomes. Each of two 
event-related MID runs consists of 90 6-second trials during which women will be 
presented with a cue shape, a fixation crosshair (for a variable duration), the target, 
and performance (win/loss/neutral) feedback. Cues indicate whether it is an 
incentive (gain, loss) or non-incentive trial. In incentive trials, women can either 
gain or lose money by pressing a button during target presentation, and difficulty 
is based on individual reaction times. This task elicits reliable frontostriatal 
dysregulation in people with remitted MDD8. Resting state scans will also be 
conducted. 
 
FMRI Data Acquisition and Image Processing. Scanning is performed using a 
Siemens Magnetom 3T TIM Trio scanner. High-resolution, T1-weighted 
anatomical images will be acquired using an MPRAGE sequence. Whole-brain 
functional images will be acquired using a single-shot, gradient recalled 
echoplanar pulse sequence sensitive to blood-oxygen-level-dependent (BOLD) 
contrast. Each of 2 runs will consist of the acquisition of 195 successive brain 
volumes. FMRI image preprocessing, processing, and analysis will be conducted 
using FSL and custom MATLAB scripts. FMRI analyses will include an event-
related BOLD response analysis within a priori structurally defined frontostriatal 
regions of interest (ROIs). Contrasts of interest will include win versus non-win 
outcomes, although the anticipation of wins will also be explored. 
 
Probabilistic Reward Task (PRT)  will be conducted outisde of the scanner. This 
task allows us to test the additional hypothesis that perimneopausal depression is 
characterized by blunted reward learning. During this task, correct identifications 
of two ambiguous stimuli are differentially rewarded.The task will consist of 300 
trials, divided into 3 blocks of 100 trials. Each trial starts with the presentation of a 
fixation cross for 500 msec followed by a mouthless face. After a delay of 500 
msec, either a short mouth (11.5 mm) or a long mouth (13 mm) is presented for 
100 msec. Participants will be asked to identify which type of mouth was 
presented. For each block, the long and short mouths are presented equally often 
in a pseudorandomized sequence and 40 correct trials are followed by reward 
feedback immediately after the correct response. An asymmetrical reinforcer ratio 
will be used in this task, such that for half of the participants, correct identification 
of the short mouth will be associated with three times more positive feedback (30 
of 40) than correct identification of the long mouth (10 of 40). For the other half of 
the participants, the contingencies will be reversed. 
 

The table below outlines the procedures that will occur at each study visit: 
Assessments 
1 
2 
3 
4 
5 
6 
Study visits 
X 
X 
X 
X 
X 
X 
Consent 
X 
 
 
 
 
 
OBGYN Exam 
 
X 
 
 
 
 
fMRI 
 
 
X 
 
 
X 
PRT 
 
 
X 
 
 
X 
Venipuncture 
 
 
X 
X 
X 
X 
SCID 
X 
 
 
 
 
 
SNAP 
 
X 
 
X 
X 
X 
X 
HAM-D 
X 
 
X 
X 
X 
X 
IDAS 
X 
 
X 
X 
X 
X 
GCS 
X 
 
X 
X 
X 
X 
PSQI 
 
 
X 
 
 
X 
HHQ 
 
 
 
 
 
X 
THQ 
 
 
 
 
 
X 
Duavee Rx Provided 
 
 
X 
X 
X 
 
Payment 
$100 
$30 
$150 
$35 
$35 
$150 
 
b. Statistical analysis strategy:  
Aim 1: Determine the extent to which TSEC reduces anhedonia and other 
depressive symptoms in PM-MDD. Anhedonia and other depressive symptoms will be 
assessed at baseline and following 3 weeks of TSEC administration.  
Null hypothesis (H0): TSEC has no salutary effect on depression.  
Alternative hypothesis (H1): TSEC reduces depression as evidenced by 1) a statistically 
significant decrease in average MASQ Anhedonia scale score following 3 weeks of 
treatment, and 2) a clinically significant increase of 1 SD in MASQ Anhedonia scale 
score.  
We will test this hypothesis using a paired t-test of MASQ Anhedonia scores at visit 1 (pre-
treatment) and visit 6 (post-treatment). 
Aim 2 (Exploratory): Quantify the effect of TSEC on the neural reward system in PM-
MDD. We will use fMRI at baseline and following TSEC treatment in PM-MDD to probe 

frontostriatal reward circuitry. We also will compare the effects of TSEC and ERT in PM-
MDD. 
Null hypothesis (H0): TSEC has no meaningful effect on activity of the neural reward circuit 
in response to rewards.  
Alternative hypothesis (H1): TSEC reduces increases neural responsiveness to reward in 
the frontostriatal reward circuitry as evidenced by increased activation of the caudate, 
putamen, and nucleus accumbens in PM-MDD in response to reward following TSEC 
administration (compared with baseline).  
We will test this hypothesis using a paired t-test to compare activity in 3 regions of interest 
(ROIs)—caudate,  putamen, and nucleus accumbens—at the pretreatment and 
posttreatment scans. 
 
2. The principal investigator will evaluate the progress of the trial, including periodic 
assessments of data quality and timeliness, participant recruitment, accrual and 
retention, participant risk versus benefit, performance of the trial site, and other 
factors that can affect study outcome. 
 
B. Measures taken to insure data integrity and protection of databases  
 
1. All study personnel are responsible for the collection and storage of data. All study 
staff participate in annual human subject training that includes education about 
responsibilities to minimize risk that confidentiality may be breached. 
2. Participants will be identified by study ID number on all research documents and in 
electronic data files. All data will be stored in locked cabinets inside locked offices, 
and electronic data will be stored only on password-protected file servers only 
accessible from computers in the Psychiatry Department. Only study personnel will 
have access to these data. Qualtrics will be used to collect self-report questionnaire 
data for all participants with internet access. Participants will not enter any personally 
identifying information into the Qualtrics system, and they will be identified by their 
unique study ID only. 
3. All members of the team will have access to the secure file servers on which 
electronic data are stored. It will be therefore unnecessary to send data files between 
investigators 
 
VI. 
Confidentiality  
 
As explained above, research subjects will be identified by their assigned study number on all 
research documents, electronic files, and specimen. Study documents will be stored in locked 
cabinets inside locked offices, and electronic data will be stored on secure servers accessible 
only on password-protected computers.  
 
 
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