Mechanisms of Successful Vaginal Estrogen Prophylaxis for Postmenopausal Women With Recurrent Urinary Tract Infections: Urogenital Microbiota and Host Immune Responses
Phase: PHASE4
Conditions: Recurrent Urinary Tract Infection, Urinary Tract Infections, Cystitis Recurrent
Sponsor: Johns Hopkins University

 
Date: February 13, 2024 
Principal Investigator: Victoria Handa, MD 
Application Number:  IRB00314740 
 
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Study Protocol:  NCT05551949 
Study title:  Mechanisms of Successful Vaginal Estrogen Prophylaxis 
for Postmenopausal Women With Recurrent Urinary Tract 
Infections: Urogenital Microbiota and Host Immune 
Responses 
PI:  Victoria Handa, MD 
Date of this final protocol:  2/13/24 
 

 
Date: February 13, 2024 
Principal Investigator: Victoria Handa, MD 
Application Number:  IRB00314740 
 
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JHM IRB - eForm A – Protocol 
 
 
 Use the section headings to write the JHMIRB eForm A, inserting the appropriate 
material in each. If a section is not applicable, leave heading in and insert N/A. 
 When submitting JHM IRB eForm A (new or revised), enter the date submitted to 
the field at the top of JHM IRB eForm A. 
 
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1. 
Abstract 
Postmenopausal women are disproportionately impacted by urinary tract infection (UTI), 
particularly chronic recurrent UTI (rUTI), defined as UTIs that recur ≥2 times per 6 
months. Presently, the only evidence-based prevention options are daily low dose 
antibiotics and topical vaginal estrogen therapy (VET). Given concerns related to chronic 
antibiotic use, VET is preferred for postmenopausal women. Unfortunately, 50% of 
women experience recurrence despite VET. It is unknown why some women benefit from 
VET while others do not. Also, the mechanism by which VET, when effective, prevents 
rUTI is uncertain. This study seeks to identify mechanisms that explain how VET reduces 
rUTI among postmenopausal women for whom VET is a preferred therapy. 
The purported mechanism is via changes to the vaginal microbiome, possibly related to 
restoration of Lactobacilli. This may be due to production of D-Lactic acid, which 
suppresses vaginal growth of uropathogens such as E. coli. (This increased production 
of lactic acid is reflected by vaginal pH, which is typically reduced with VET use.) It has 
also been suggested that the beneficial effects of VET are mediated by changes in the 
urinary microbiome. Finally, recent studies (mostly in mice) suggest that host immune 
responses in the bladder and urogenital tract are critical to rUTI susceptibility, symptoms, 
and outcomes.  
To investigate the mechanisms by which VET reduces rUTI, we will conduct a single-
arm, open-label clinical trial of conventional therapy with vaginal estrogen therapy for 
postmenopausal women with rUTI. These are women who would be recommended (as 
a part of routine clinical care) to receive VET for rUTI prevention. Among 50 women with 
confirmed rUTI, we will investigate (a) the effects of vaginal estrogen therapy on the 
bladder and vaginal microbiota (as well as D- and L-lactic acid concentrations in the 
vagina) and (b) the effects of vaginal estrogen therapy on immune responses in both 
compartments (including soluble mediators of inflammation (SMI) associated with 
neutrophil and macrophage activity and those associated with Th1, Th2 and Th17 
pathways).  Over 24 weeks, we will then identify the subset of participants who continue 
to experience rUTI versus those who respond to vaginal estrogen therapy. Comparing 
these two groups, we will consider (c) the extent to which changes in microbiota and 
immune responses are associated with successful UTI prevention. 
 
2. 
Objectives (include all primary and secondary objectives) 
The three aims of this proposal are: 
1. To compare the vaginal and urinary microbiota before and after VET in women 
with rUTI. Hypothesis: After VET, vaginal and urinary microbiota will exhibit 

 
Date: February 13, 2024 
Principal Investigator: Victoria Handa, MD 
Application Number:  IRB00314740 
 
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significantly increased relative abundance of key Lactobacillus spp. (L. crispatus, L. 
gasseri, L. jensenii, L. iners). Vaginal D-lactic acid concentration will increase and pH 
will decrease. 
2. To compare host immune responses, by measuring vaginal and urinary soluble 
mediators of inflammation (SMIs), before and after VET in women with rUTI. 
Hypothesis: after VET, vaginal and urinary samples will show decreased SMIs 
associated with neutrophil and macrophage activity and Th2-associated cytokines, 
with concomitant increases in Th1 and Th17 related pathways. 
3. To acquire preliminary data regarding vaginal and urinary markers that 
distinguish women who remain UTI-free after VET versus those who continue to 
experience UTI recurrence   
 
3. 
Background (briefly describe pre-clinical and clinical data, current experience with 
procedures, drug or device, and any other relevant information to justify the research) 
 
Each year in the U.S., urinary tract infection (UTI) is the cause of 8 million ambulatory and 
1 million ED visits. Postmenopausal women are disproportionately impacted: 13% of 
female Medicare beneficiaries experience ≥1 UTI annually. Futhermore, among older 
women who experience UTI, >40% experience chronic recurrent UTI (rUTI) (defined as 
UTIs that recur ≥2 times per 6 months or ≥3 per 12 months). Prevention of UTI recurrence 
is crucial for older women with rUTI, yet effective options are limited. American Urologic 
Association guidelines recommend two options to reduce recurrence: vaginal 
estrogen therapy (VET) or daily low dose antibiotics. While daily antibiotic 
prophylaxis is effective, concerns regarding side effects and emergence of 
antibiotic resistance limit its use. Thus, VET prophylaxis is first line for rUTI 
prevention in postmenopausal women. Several clinical trials demonstrate that 50% of 
women will continue to experience rUTI recurrence despite VET. At present, it is unknown 
why some women benefit while others do not and the mechanisms for treatment success 
are unknown.  
The first aim of this protocol is to investigate the effect of VET on urogenital microbiota. 
The rationale is that changes to the vaginal microbiome are purportedly critical to rUTI 
susceptibility. The vagina is a reservoir for uropathogens (e.g. E. coli). Vaginal lactobacilli 
may protect against rUTI through a variety of mechanisms, including displacement of 
uropathogens by competitive binding and direct inhibition of bacterial growth, likely 
through the bactericidal action of lactic acid. There may be other important functional 
parameters of the microbiome that influence UTI risk (e.g., features that can be best 
understood through metabolomics, proteomics, etc.). 
Measures for Aim 1 are as follows: 
Vaginal microbiota: After menopause, vaginal colonization by lactobacilli declines. There 
is some evidence that VET restores vaginal Lactobacilli. Prospective studies linking a 
lactobacillus-dominant microbiome to UTI prevention are lacking. Also, new data from 
studies using contemporary molecular techniques (e.g., 16S rRNA gene amplicon 
sequencing, shot gun or whole genome metagenomics, RNA-seq) suggest that some 
Lactobacillus species (and certain vaginal “community state types”) may be more likely 
that others to reduce UTI recurrences.  
Vaginal D-Lactic acid and pH: Differences in the vaginal microbiota may be linked to 
production of d-lactic acid.  This isomer is produced more effectively by certain 
lactobacillus species (most notably L. crispatus).  Therefore, for aim 1, we propose to 

 
Date: February 13, 2024 
Principal Investigator: Victoria Handa, MD 
Application Number:  IRB00314740 
 
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compare the vaginal microbiota and d-lactic acid concentrations before and after 12 
weeks of VET among women with rUTI. Vaginal pH will also be examined, as this 
bedside test may prove to be a valuable (bedside) diagnostic test, reflecting d-Lactic 
acid and other markers.  Vaginal pH >5 is typical for menopause and a restoration of 
acidic pH provides additional evidence of adequate estrogenization.   
In addition, we hope to expand our analyses to complement these microbiota analyses 
with additional functional (e.g., metabolomic, proteomic) analyses.  
Vaginal estrogen status: The vaginal maturation index (VMI) is a measure of vaginal 
“estrogenization”, which we will collect at enrollment and after 12 weeks of VET.  This 
is based on a cytologic examination of vaginal epithelial cells, obtained via a swab of 
the vaginal wall.  The VMI is a widely used objective and quantitative measure of 
vaginal estrogen status. Collection of this marker will allow us to establish how these 
conventional measures of estrogenization compare to other study outcomes, such as 
changes to urogenital microbiota and immune response.   
Urinary microbiota: In addition, there is some evidence that the composition of urinary 
microbiota may influence rUTI. For example, a preoperative urinary microbiome 
deficient in lactobacilli and high in uropathogens has been associated with 
postoperative UTI. For aim 1 we also plan to compare the urinary microbiota before 
and after 12 weeks of VET among women with rUTI. 
The second aim of this research is to investigate the effect of VET on the localized 
immune response in the vagina and bladder. Finally, there is evidence (primarily from 
animal models) that the host immune response is critical to rUTI susceptibility. For 
example, bladder invasion by uropathogens is 10–12 fold greater in Toll like receptor 4 
mutant mice versus wild type. Also, in a murine model, severe acute immunopathology 
(with elevated IL-6 and IL-8 in response to UTI), predicts chronic cystitis and rUTI 
susceptibility. Also, importance of Th1 versus Th2 pathway activation is demonstrated by 
IFN-ɣ knockout mice (unable to mount a Th1 response): these mice have an increased 
incidence and severity of UTI, are vulnerable to re-infection, and are less able to clear 
bacteria when re-challenged after initial infection. In contrast IL-4 knockout mice (Th2 
impaired, Th1 uninhibited), appear to be protected from re-infection. Given the apparent 
importance of the host immune response to UTI susceptibility, it is relevant that some 
aspects of immune response may be modified by estrogen. For example, consider gender 
differences in UTI susceptibility: among mice infected via transurethral catheter, males 
develop higher bacterial burdens than females, possibly because males lack a robust 
increase in inflammatory cytokines (notably IL-17). Additional evidence of estrogen’s 
protective effect comes from ovariectomized mice, which show increased bacteriuria, 
IBC’s, and pro-inflammatory (Th2 associated) IL-6 compared with sham-operated 
females. Human data are limited, although it has been shown that serum IL-6 increases 
with menopause and decreases with systemic estrogen therapy.  Also, in non-rUTI 
populations vaginal levels of the pro-inflammatory cytokine TNF-α decreases with VET.  
Therefore, for aim 2, we plan to compare vaginal and urinary fluid from before 
versus after 12 weeks of VET for soluble mediators of inflammation (SMIs), including 
those associated with neutrophil and macrophage activity and those associated with Th1, 
Th2 and Th17 pathways. 
Aims 1 and 2 will identify “biomarkers” that are significantly impacted by VET.  The goal 
of Aim 3 is to compare these biomarkers between women who continue to 
experience rUTI versus those who remain UTI-free on VET.  These comparisons will 
provide preliminary data to support a future RCT of VET in women with rUTI.  Specifically, 
those bio-markers which show the greatest promise to distinguish successful rUTI 

 
Date: February 13, 2024 
Principal Investigator: Victoria Handa, MD 
Application Number:  IRB00314740 
 
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prevention will then be rigorously evaluated in a future larger and adequately powered 
clinical trial to definitively identify the predictors of and the biological conditions associated 
with successful prevention of UTI recurrence among susceptible women. 
 
 
4. 
Study Procedures 
a. Study design, including the sequence and timing of study procedures   
(distinguish research procedures from those that are part of routine care). 
 
All three aims of this proposal will be accomplished via a single-arm, open label 
clinical trial of transvaginal estrogen to reduce UTI recurrence among menopausal 
women with confirmed rUTI (see figure below). Briefly, 24 weeks of vaginal estrogen 
treatment will be administered to 50 eligible postmenopausal women with a history of 
rUTI. Aims 1 and 2 will be accomplished after 12 weeks of VET (because 12 weeks 
may be required for adequate estrogenization. Aim 3 will be accomplished during the 
second 12-week interval of VET.   
 
 
 
 
There is only one arm in this trial -- all participants will receive VET (which meets the 
standard of care for therapy in women with rUTI).  A placebo arm is not considered 
because it would not be relevant to our scientific aims. A strength of the study design 
is that for Aim 1-2 and Aim 4 participants are compared to themselves, minimizing the 
effect of potential confounders.  For Aim 3, the operative question is what distinguishes 
women who respond to VET vs. those who do not. These scientific reasons justify the 
single arm study design. This study meets the NIH definition for “Clinical Trials”, 
defined as a clinical research study (a) in which human participants are assigned to 
an intervention, (b) the study evaluates the effect(s) of the intervention on the 
participants, and (c) the effect being evaluated is a health-related biomedical outcome.   
 
The vaginal estrogen treatment (VET) to be administered in this study is a 
conventional treatment that is commercially available.  In general, VET may be 
administered as a cream, vaginal tablet or silicone ring. This study will use vaginal 
estradiol tablets (10mcg), administered daily for two weeks, followed by twice 
weekly.  
  

 
Date: February 13, 2024 
Principal Investigator: Victoria Handa, MD 
Application Number:  IRB00314740 
 
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For those who enroll, study procedures will include the collection of urinary and 
vaginal specimens (see below) at enrollment (before VET initiation) and after 12 
weeks of therapy.  The primary difference between this study and our routine clinical 
care is specimen collection.  We will also track rUTI episodes during the first 24 
weeks of VET (but the evaluation and treatment of those episodes will follow best 
practices in clinical care and will not be impacted by participation in this study). 
 
b. If your study involves data/biospecimens from participants enrolled under other 
research studies with a written consent or under a waiver of consent, please list the 
IRB application numbers for those studies.  Please note:  Certificate of 
Confidentiality (CoC) protections applied to the data in source studies funded by NIH 
or CDC will extend to this new study if the funding was active in 2016.  If this 
situation applies, Section 36, question 6 in the application will need to be answered 
“Yes” and “Hopkins Faculty” should be selected in question 7. No other documents 
are required. 
 
Not applicable. 
 
c. Study duration and number of study visits required of research participants. 
 
The study will last 24 weeks.  Study procedures will be timed to coincide with 
routine clinical visits (baseline, 12 weeks, 24 weeks).  Participation in this study will 
not require additional visits (outside of what is required for clinical care).   
 
At baseline, women will be screened for eligibility at a routine clinical visit.  Those 
found to be eligible will be consented and enrolled.  Women who initiate VET for 
UTI prevention are typically seen for clinical care 3 and 6 months after VET initiation 
(e.g., 12 and 24 weeks).  For this proposed research, we will collect study 
specimens at the visit prior to VET initiation and at the 12-week follow up visits.  No 
specimens will be collected at the 24 week visit. 
 
d. Blinding, including justification for blinding or not blinding the trial, if applicable. 
 
Not applicable.  All participants and investigators will be aware of the study 
treatment (vaginal estradiol tablets). 
 
e. Justification of why participants will not receive routine care or will have current 
therapy stopped. 
 
Participants will receive the same VET regimen that would be prescribed as part of 
clinical care, including standard dosing.  VET complies with best practices for rUTI 
prevention, as recommended by the American Urologic Association. 
 
f. Justification for inclusion of a placebo or non-treatment group. 
 
A placebo arm is not considered because it would not be relevant to our specific 
aims. The rationale is discussed above (see 4a).  
 
g. Definition of treatment failure or participant removal criteria. 
 

 
Date: February 13, 2024 
Principal Investigator: Victoria Handa, MD 
Application Number:  IRB00314740 
 
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When VET is recommended in clinical practice, a 6-month trial is typical (to assess 
response).  This study is limited to that 6-month period.  Of course, some women 
may elect to stop VET during the observation period, possibly due to intolerance or 
dissatisfaction with the treatment.  (Similarly, women receiving VET in clinical 
practice may elect to stop this Rx.) Participation in this study will not impact a 
decision to stop VET before the 6-month period is completed.  Women who elect to 
stop VET will be encouraged to continue in the trial (to allow data collection as 
proposed). 
 
h. Description of what happens to participants receiving therapy when study ends or if a 
participant’s participation in the study ends prematurely. 
 
At the conclusion of this trial, women will have the opportunity to continue VET as 
part of their clinical care.  They will be informed that their prescription insurance 
coverage may or may not cover this treatment.  Those who are not satisfied with 
VET will be offered alternative prevention options (such as daily antibiotic 
suppression). 
 
i. If biological materials are involved, please describe all the experimental procedures 
and analyses in which they will be used. 
 
Study procedures will be the same for the enrollment and subsequent visits. All study 
specimens will be labeled with a sample ID barcode, the visit type (enrollment, 12-
week) and the study ID assigned to the participant. 
1. Vaginal pH: A mid-vaginal swab will be used to measure pH using Nitrazine pH 
test paper. 
2. Vaginal Maturation Index (VMI): A spatula will be used to collect a specimen 
from the lateral vaginal wall. The tip of the spatula will be placed in a SurePath 
Pap Collection vial and transported to the Pathology department for processing  
3. Specimens to be frozen* and stored for later analysis: 
i. Vaginal microbiota: a mid-vaginal swab will be obtained and placed in 1ml 
stabilizing buffer solution.  
ii. Vaginal SMI and D/L lactic acid: a mid-vaginal swab will be obtained and 
stored dry.  
iii. Urinary microbiota and SMI: A urine specimen will be obtained with a 14F 
catheter. 10cc will be obtained and aliquoted (4ml reserved for microbiota 
and 2ml for SMI analysis).  Note: We do not expect a clinical indication for 
urinary catheterization at the 24 week visit.  Therefore, a catheterized 
urine specimen will not be collected at 24 weeks unless clinically 
indicated. 
 
 
Aim 1: 
MICROBIOTA ANALYSIS OF VAGINAL AND URINARY SPECIMENS:  
The vaginal and urinary microbiota will be characterized through molecular techniques 
(e.g.,  sequencing amplicons of the V3-V4 region of the bacterial 16S rRNA gene, shot 
gun or whole genome metagenomics, RNA-seq, functional analyses including 
metabolomics and proteomic analyses).  
 
 

 
Date: February 13, 2024 
Principal Investigator: Victoria Handa, MD 
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Vaginal D- and L-lactic acid assays: Measuring vaginal L- and D-isomers 
separately allows us to assess the association between VET and the concentration 
of these individual isomers. Vaginal “estrogenization”: This will be assessed with 
the Vaginal Maturation Index, a standard cytologic measure of epithelial cellular 
maturation.  
Aim 2: 
SOLUBLE MEDIATORS OF IMMUNITY 
Concentrations of soluble biomarkers will be determined.  We currently plan to use 
the fluorescent bead based Luminex multiplex system, but specific methods may be 
modified according to laboratory standards.  
 
5. 
Inclusion/Exclusion Criteria 
 
Eligibility: Participants in this study will be postmenopausal women (menopausal for at 
least 1 year) with a minimum age of 55 years. Participants will have documentation of 
recurrent UTI, defined as follows 
 History of treatment for at least 3 UTIs in the past year or 2 episodes within 6 
months AND 
 At least one positive urine culture during an acute symptomatic episode. 
 
Exclusion criteria:  
 Women receiving antibiotic prophylaxis to prevent UTI recurrence; 
 Women with contraindications to vaginal estrogen (as indicated on the FDA-
mandated package insert) and those who have used vaginal or systemic estrogen 
within the past 6 months; 
 Women with an active UTI and those who have received antibiotics within the prior 2 
weeks; 
 Women with complicated rUTI, defined by immune compromise, anatomic or 
functional abnormalities of the urinary tract, indwelling catheterization, those performing 
self-catheterization, and those with neurological disease or illness relevant to the lower 
urinary tract; 
 Women with only asymptomatic bacteriuria (rather than recurrent symptomatic UTI) 
 Women who have had UTI diagnosed only in the setting of institutionalization, 
including hospitalization 
 Women with a blood clotting disorder (e.g., Factor V Leiden, prothrombotic mutation, 
protein C, protein S or antithrombin deficiency) 
 
6. 
Drugs/ Substances/ Devices 
a. The rationale for choosing the drug and dose or for choosing the device to be used. 
b. Justification and safety information if FDA approved drugs will be administered for 
non-FDA approved indications or if doses or routes of administration or participant 
populations are changed. 
c. Justification and safety information if non-FDA approved drugs without an IND will 
be administered.  
 
The vaginal estrogen therapy to be used in this study is vaginal estradiol tablets 
(10mcg), administered daily for two weeks, followed by twice weekly.  This product 
is FDA approved and marketed for treatment of menopausal vaginal atrophy and 
are commonly used in post-menopausal women for a variety of related indications. 

 
Date: February 13, 2024 
Principal Investigator: Victoria Handa, MD 
Application Number:  IRB00314740 
 
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7. 
Study Statistics 
a. Primary outcome variable. 
b. Secondary outcome variables. 
c. Statistical plan including sample size justification and interim data analysis. 
d. Early stopping rules. 
 
For our first aim (to compare the vaginal and urinary microbiota before and after VET in 
women with rUTI), the primary outcome will be the relative abundance of Lactobacilli in 
the vagina and in urine.  We hypothesize that after VET, the vaginal and urinary 
microbiota will exhibit significantly increased relative abundance of Lactobacillus and of 
key Lactobacillus spp. (L. crispatus, L. gasseri, L. jensenii, L. iners). Separately for each 
taxon and species, we will determine whether the pre-to-post change in relative 
abundance is significantly different from zero by paired t-test and Wilcoxon signed-rank 
sum test where appropriate. We will investigate the effect of VET on vaginal and urinary 
microbiota taxa separately. We will repeat these analyses using absolute taxa 
abundances estimated by pan-bacterial 16S qPCR, with a focus on key lactobacilli (e.g. 
L. crispatus and L. iners), and, where possible, for other bacteria of interest, including 
those responsible for most community-acquired UTI (Escherichia, Klebsiella and other 
uropathogens).  
 
Related to the primary aim is the concentration of lactic acid in the vagina, which reflects 
synthesis by Lactobacilli.  Therefore, we will also compare D-lactic acid concentrations in 
the vagina before and after VET in women with rUTI.  We hypothesize that in the vagina, 
D-lactic acid concentration will increase.  We will use similar statistical methods (as 
described above for aim 1) for this additional comparison.  
 
Our second aim is to compare host immune responses, by measuring vaginal and 
urinary soluble mediators of inflammation (SMIs), before and after VET in women with 
rUTI.  The specific SMIs of interest are shown in the table that follows: 
Th1 associated 
(IFN-ɣ, IL-12) 
Th2 associated 
(IL-4, IL-6, IL-10) 
 Th17 associated 
(IL-17, IL-23) 
Inflammation/macrophage 
activating (TNF-α, IL-8, IL-1β) 
 
We hypothesize that after VET, vaginal and urinary samples will show decreased SMIs 
associated with neutrophil and macrophage activity and Th2-associated cytokines, with 
concomitant increases in Th1 and Th17 related pathways. Separately for each SMI, we 
will test whether these pre-to-post VET changes are significantly different from zero 
using paired t-tests or Wilcoxon signed-rank sum tests as appropriate. SMI values will be 
natural log-transformed. SMI values below the lower limit of detection will be imputed 
using the lower limit of detection of the laboratory assay divided by the square root of 2. 
As the SMI expression in the vagina and bladder are not well-characterized, we will also 
perform descriptive and exploratory analyses of the distribution of each SMI, by pre-post 
status, with percentile plots and generalized gamma models using graphical 
approaches. Use of the generalized gamma models will facilitate a more complete 
exploration of these highly regulated SMI markers. 
 
All of these outcomes will then be compared to observed rates of UTI recurrence in the 
study population.  This comparison will provide preliminary data to support a future RCT 
of VET in women with rUTI. For this analysis, observed UTI events will be considered as 
a function of “biomarkers”, including vaginal and urinary microbiota and SMIs, as well as 

 
Date: February 13, 2024 
Principal Investigator: Victoria Handa, MD 
Application Number:  IRB00314740 
 
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vaginal lactic acid.  We will compare women who remain UTI free versus those who 
experience recurrence with respect to differences in microbiota taxa abundances 
(relative and absolute) and SMI concentrations. These comparisons will be performed 
with t-tests, Mann-Whitney test, or Chi-squared tests as appropriate. 
 
We will recruit 50 women for this trial. With loss to follow-up, we conservatively estimate 
that 40-45 women will provide complete data. At 80% power and alpha of 0.05, we 
anticipate that we will have sufficient power to detect a 17% to 19% change in 
Lactobacillus spp relative abundance in the vaginal microbiota pre-to-post VET. Prior 
research suggests that we are likely to observe much larger changes in vaginal samples 
(>30%) with VET. Furthermore, with a sample size of 40 to 50 women, we will be able to 
estimate the mean change in Lactobacillus spp relative abundance from pre-to-post VET 
to within ±11.6% to ±12.9% with 95% confidence interval.   
 
We are not planning interim analyses.  Early stopping rules do not apply. 
 
8. 
Risks 
a. Medical risks, listing all procedures, their major and minor risks and expected 
frequency. 
b. Steps taken to minimize the risks. 
c. Plan for reporting unanticipated problems or study deviations. 
d. Legal risks such as the risks that would be associated with breach of confidentiality. 
e. Financial risks to the participants. 
 
Participation in this study is felt to represent minimal risk to participants.  All women 
enrolled in this trial will be receiving a medication that is commonly prescribed in clinical 
practice.  This medication (vaginal estrogen) is felt to be safe and effective in the 
treatment of postmenopausal vaginal atrophy and is currently recommended by the 
American Urologic Association as a best practice for preventing recurrent UTI.  
 
The collection of specimens (vaginal swabs and urine specimens) represents minimal 
harm to participants.  Such specimens are often collected for clinical care in the setting 
of the evaluation and management of recurrent UTI.   
 
To protect participant privacy and confidentiality, data management will be via Red Cap 
and CRMS.  All collected specimens will be labeled with the participant’s study number.  
The log that links each participant to the assigned study number will be kept 
electronically in CRMS. 
 
Review of the EMR will be required to gather data regarding patients’ clinical course 
and observed UTI recurrences.  Data from chart abstraction will be collected via 
RedCap.  Only IRB-approved members of the study team will have access to these 
data. No identifiable information will be stored on private devices or directly on 
computers or other electronic devices.“Paper documents containing patient information 
(such as signed consent documents) will be uploaded electronically but the original 
hard copies will also be retained in accordance with institutional policy.” 
 
 
9. 
Benefits 
a. 
Description of the probable benefits for the participant and for society. 
 

 
Date: February 13, 2024 
Principal Investigator: Victoria Handa, MD 
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The participants will receive study medications at no cost.  This might represent a 
significant savings to some participants, as out of pocket costs for VET may be up to 
$150 per month.   
 
We anticipate no additional direct benefit to the participants, other than personal 
satisfaction in knowing that they are helping with biomedical research that can potentially 
improve the health of other women.   
 
10. 
Payment and Remuneration 
a. 
Detail compensation for participants including possible total compensation, 
proposed bonus, and any proposed reductions or penalties for not completing the 
protocol. 
 
Participants will receive remuneration to compensate them for the time and effort required 
for compliance and completion of study events. Specifically, we plan to offer each 
participant $100 to compensate her for participating in this study.  Each participant will 
receive $50 at the end of the first 12 weeks of the study and a second $50 payment at the 
conclusion of the study.  Women who cannot complete the study (such as due to 
medication intolerance) will be paid when they drop out of the study, assuming they return 
for specimen collection at that interval. 
In addition, study medications (24 weeks of vaginal estrogen therapy) will be provided at 
no cost to the participants. 
 
11. 
Costs 
a. 
Detail costs of study procedure(s) or drug (s) or substance(s) to participants and 
identify who will pay for them. 
 
The participants will receive study medications at no cost.      
 
 
12. 
Transfer of Materials 
Transfer of biospecimens from Johns Hopkins to another organization for research 
purposes and receipt of biospecimens from an outside organization for your research 
must adhere to JHU policies for material transfer (https://ventures.jhu.edu/faculty-
inventors/forms-policies/ ) and biospecimen transfer 
(https://hpo.johnshopkins.edu/enterprise/policies/176/39187/policy_39187.pdf?_=0.622
324232879).  
 
Please complete this section if your research involves transfer or receipt of biospecimens. 
 
a. Will you receive biospecimens from an external entity for this research? [Yes/No].  
 
If “Yes”, please confirm you will secure an MTA/research agreement from the 
appropriate office  (JHTV/ORA) prior to transfer.  
 
See: https://ventures.jhu.edu/technology-transfer/material-transfer-agreements/ . 
 
We will not receive biospecimens for this research. 
 
b. Will you transfer biospecimens to an external entity as part of this research? [Yes/No] 

 
Date: February 13, 2024 
Principal Investigator: Victoria Handa, MD 
Application Number:  IRB00314740 
 
JHMIRB eFormA  01 
Version 4 Dated:   01/2021 
Page 12 of 13 
 
 
If “Yes”, please address each of the following: 
1) Describe the nature of the research collaboration with the external entity and the 
rationale for the transfer. (Include an explanation of your intellectual contribution to 
the design of the research study, resulting data and sharing, and participation in the 
planned publications.) 
We plan to transfer biospecimens for this research.  Specifically, the microbiome and 
lactic acid analyses will be performed in the laboratory of Dr. Rebecca Brotman at 
the University of Maryland School of Medicine. Specifically, she will supervise these 
analyses in the Microbiome Service Lab of the Institute for Genome Sciences.  Dr. 
Brotman’s laboratory will receive the (de-identified) vaginal and urinary specimens 
and will perform the microbiome analyses. She will then return data to our Johns 
Hopkins team regarding microbiome analyses.  She will not receive data from Johns 
Hopkins.  Dr. Brotman will be included as a co-author on publications and other 
scholarly products from this work. 
 
Until we reach the desired sample size for this research, specimens will be frozen 
and stored at Johns Hopkins Bayview campus in a facility maintained by the division 
of Infectious Disease. 
 
2) Please confirm you will secure an MTA through the appropriate office (JHTV or 
ORA) prior to transfer. 
(See: https://ventures.jhu.edu/technology-transfer/material-transfer-agreements/.) 
  
A material transfer agreement will be obtained prior to transfer. 
 
3) If the biospecimens you intend to transfer were obtained through clinical or research 
procedures at Johns Hopkins and “Other” is selected in Item 4, Section 23, please 
submit the following items in that Section: 
 
a. A pdf version of a completed JHTV Online “Material Transfer Agreement 
Request Form for Outbound Material” https://ventures.jhu.edu/technology-
transfer/material-transfer-agreements/ OR a copy of the COEUS PD (Proposal 
Development Summary). 
b. A completed Biospecimen Transfer Information Sheet 
https://www.hopkinsmedicine.org/institutional_review_board/forms/.   
c. A signed and dated “De-identified Human Subject Certification” 
https://livejohnshopkins-
my.sharepoint.com/:w:/g/personal/sdamare1_jh_edu/ETANthXrGPVBmYs-
_UC59fUBu9b1An7tYUWh4GjiG2fH4Q?rtime=5kjTd-F410g 
d. Approval documents from recipient site, if applicable. 
e. Copies of the consent forms associated with the IRB protocols under which 
the biospecimens were collected, with language appropriate to this transfer 
highlighted.  
f. The name of the specialist you are working with in ORA to complete a 
contract/MTA. 

 
Date: February 13, 2024 
Principal Investigator: Victoria Handa, MD 
Application Number:  IRB00314740 
 
JHMIRB eFormA  01 
Version 4 Dated:   01/2021 
Page 13 of 13 
 
Please see the following website for more information about transferring human biospecimens to 
outside entities: 
https://www.hopkinsmedicine.org/institutional_review_board/news/announcement_transfer_hum
an_biospecimens_outside_entities.html/ .