Abstract:
A gynecologic composition contains spermidine to treat vulvar vestibulitis syndrome (VVS). In this therapeutic context, spermidine is effective at around one micromole per applied dose in the form of a simple salt or complex, alone or in combination or in conjunction with auxiliary actives such as anaesthetics and estrogens.

Description:
FIELD OF THE INVENTION 
       [0001]    The invention refers to a gynecologic local composition to treat vestibulodynia, best known as vulvar vestibulitis syndrome. 
       BACKGROUND 
       [0002]    Vulvar vestibulitis syndrome (VVS) is one of the most common causes of genital pain and pain with sexual intercourse, affecting up to 15% of women in fertile age. 
         [0003]    This syndrome is characterized by severe pain on vestibular touch or attempted vaginal entry, exquisite tenderness to palpation with a cotton swab, as well as by subtle physical findings confined to vestibular erythema. The etiology of VVS is unknown. Hence, it is probably best to consider VVS as a chronic local inflammatory condition with a wide variety of etiologic causes. 
         [0004]    The heterogeneity of possible causative factors in VVS results in multiple treatment regimens into clinical practice (Goldstein A T et al., Vulvodynia: strategies for treatment; Clin Obstet Gynecol. 2005;48(4):769-85). More common prescription refers to local anaesthetics and systemic antidepressant, the latter maybe also for an ancillary inhibitory effect on mast cells degranulation. 
         [0005]    Innovation under study includes nifedipine and enoxaparin to improve microvascularity; or botulin, capsaicin, pregabalin, and gabapentin with the aim of reducing the sensibility in the affected tissues. 
         [0006]    Scientifically rigorous studies are sorely needed to determine the best approach in VVS. In this frame we have tentatively tested spermidine in sustained delivery system form, which proven effective in in vitro models, as disclosed by co-pending application WO12/017288 and WO12/017290. This therapeutic approach was conceived and is under testing in women&#39;s pathologies of dominant atrophic and senescent nature, such as in vaginal atrophy (VA). 
         [0007]    While the reparative action performed by spermidine was expectedly beneficial in VA, no response could be initially expected in VVS, a predominantly inflammatory condition with a suspected underlying neurogenic component. 
         [0008]    In fact, previous researches disclosed the spermidine pro-inflammaory action. Silva M A in “Role of peripheral polyamines in the development of inflammatory pain” (Biochem Pharmacol. 2011;82(3):269-77) suggested a contribution of Spd and PA in nociception and edema. In this study a local increase in inflammatory sites did correlate to an increase of precursor output, seemingly stimulated by PKC activation. Authors finally stated that limiting PA and Spd level and action could be a method of controlling inflammatory pain. 
       SUMMARY 
       [0009]    It was surprisingly discovered that spermidine represents an effective medical treatment in vulvar vestibulitis syndrome (VVS). 
         [0010]    In an aspect, the invention refers to a local gynecologic composition for the treatment of VVS comprising spermidine, salt, and supramolecular complex thereof. 
         [0011]    In another aspect, the invention refers to a local composition for the treatment of VVS comprising spermidine from about 0.1% to 0.001% w/v of the composition. 
         [0012]    In a further aspect, the invention refers to the afore-mentioned inventive composition comprising spermidine in combination or in conjunction with one or more anesthetic agent and an estrogenic substance in suitable concentration. 
         [0013]    In a yet further aspect, the invention refers to the mentioned inventive composition wherein spermidine is partially or fully substituted with spermine. 
         [0014]    These and other features of the invention are best described herein after. 
     
    
     
       BRIEF DESCRIPTION OF THE DRAWING 
         [0015]      FIG. 1  shows the self-evaluation (subjective score, SS) by weekly questionnaire of a subject with VVS under a 4+4 weeks (W0-W8) treatment protocol with spermidine. 
           [0016]      FIG. 2  shows the clinical evaluation (objective score, OS) at baseline (V1), by a next visit after 4 weeks (V2), and by the final visit after the further 4 weeks of treatment.(V3). 
       
    
    
     DETAILED DESCRIPTION 
       [0017]    The present invention refers to a medicinal, local composition comprising spermidine for the treatment of a gynecologic disorder with prevailing inflammatory and neurogenic signs named Vulvar Vestibulitis Syndrome (VVS). 
         [0018]    The active ingredient of the present invention is spermidine, a substance of structure NH 2 (CH 2 ) 3 NH(CH 2 ) 4 NH 2 , and formula C 7 H 19 N 3 . 
         [0019]    Spermidine is easily incorporated as salt or complex in water-based gynecologic compositions; or as pure amine in water-free or emulsified gynecologic compositions. 
         [0020]    Example of salt form are formed by spermidine with inorganic acid such as HCl, H 2 SO 4 , H 3 BO 3 , H 3 PO 4 , etc., o with organic acid such as acetic, methylsulfonic, ascorbic, lauric, glycolic, lactic, pyruvic, succinic, and citric acid, and the like. 
         [0021]    In case of use of spermidine pure amine, partial or full anion exchange may take place in situ in contact with acidic substances in composition. Analogously, a simple salt such as spermidine 3HCl may undergo acid-base exchange within the composition medium. In a further embodiment, the composition of invention will comprise a supramolecular complex with spermidine for the sustained release thereof. 
         [0022]    The expression “supramolecular complex” as used herein includes polyacid complex formed by polyanionic polymer(s) and spermidine as well as the inclusion complex of spermidine into cyclodextrins. Technical and operative details are enclosed in co-pending applications WO12/017288 and WO12/017290. 
         [0023]    The main inventive object is a topical medicinal composition for treating VVS, wherein “medicinal composition” include drugs, medical devices, and lenitive cosmetics intended for the specific curative purpose. 
         [0024]    The inventive composition will comprise spermidine in concentration from about 1% to 0.0001% w/v, more preferably from about 0.1% to 0.001% w/v, even more preferably around 0.01% w/v of the composition. 
         [0025]    In the inventive composition, the unitary dose of spermidine will be comprised between 1 mmoles and 1 nmoles/unit dose, preferably between 100 μmoles e 10 nmoles/unit dose, even more preferably around 10 μmoles and 100 nmoles/unit dosea. 
         [0026]    The compositions according to the invention, which are administered vaginally, will be presented in semi-fluid forms such as of gel, cream, ointment, etc., or in solid form such as tablets, capsule, pessaries, ovules, etc. for the release of around 1 μmole of spermidine. 
         [0027]    Excipients and auxiliary active ingredients to produce a formulation with proper safety, efficacy, patient compliance, aesthetics, acceptability to regulatory authorities, and cost requires are known. E.g., Garg S et al. in Compendium of Pharmaceutical Excipients for Vaginal Formulations Pharmaceutical Technology, Drug Delivery 2001, 14-24; listed vaginal excipients, the functional classification, allowed concentrations (when available), and regulatory status. 
         [0028]    The inventive composition may be packaged in ordinary Al or plastic tubes for hand application; or as spray, mousse and other means for the application onto female external genitalia without a direct contact with hand, or other device. In general, no vaginal applicator is needed, unless burdens were widely spread out into the vaginal tract. 
         [0029]    In another embodiment, compositions of invention comprise spermidine in combination or in conjunction with an anethetic agent to deliver a fast relief from VVS pain. 
         [0030]    Exemplary anesthetic agents include ester-type like benzocaine, chlorprocaine, cocaine, procaine, tetracaine; and amide-type like lidocaine, prilocaine, mepivacaine, bupivacaine, ropivacaine. For use in combination, spermidine and anesthetic agent may be presented in ratio consistent with the desired effect. In particular, the molar ratio of spermidine to anesthetic agent will suitably be approximately 1 to 300. Preferably, this ratio will be between 0.001 to 3 and 1 to 3, and especially from 0.01:3 to 0.1:3. 
         [0031]    In another embodiment, compositions of invention comprise spermidine in combination or in conjunction with an estrogenic substance to further improve the therapeutic ratio. 
         [0032]    Exemplary estrogenic substances include estrone, estrone esters, estriol esters, estriol, equilin, equilin esters, estradiene, equilenin, ethinyl estradiol, 17β-estradiol, 17β-estradiol esters (i.e. benzoate, cypionate, dienanthate, valerate, etc.), 17α-dihydroequilenin, 17β-dihydroequilenin, 17α-dihydroequilin, 17p-dihydroequilin, 17α-ethynylestradiol, 17α-ethynylestradiol esters, dienestrol, mestranol, mestranol esters, DES, phytoestrogen(s), tibolone, ethynediol and conjugated estrogens. 
         [0033]    Conjugated estrogens refer to estrogenic steroidal substances in which one or more functional groups (typically the OH groups) on the steroid exists as a conjugate (typically a sulfate or glucuronide). The conjugated estrogens may be a single conjugated estrogen, or may consist of mixtures of various conjugated estrogens. 
         [0034]    For administration in combination, spermidine and the estrogenic substance may be presented in a ratio consistent with the desired effect. In particular, the molar ratio of spermidine to estrogenic substance will suitably be approximately 1 to 1. Preferably, this ratio will be between 0.01 to 1 and 100 to 1, and especially from 0.1:1 to 10:1. 
         [0035]    The inventive composition may include other additional active ingredients. Examples include, but not limited to, anti-infective agent such as antibiotics, anti-fungals, antivirals, biocides; calcium antagonists such as nifedipine; heparins such as enoxaparin; botulin; gabaergics such as pregabalin, and gabapentin anti-inflammatories; immuno-suppressant; plant or algal extracts; antihistamines; antioxidants; and a variety of other ingredients such as astringents, fragrances, dyes, vitamins, sunscreens, deodorants, preservatives, and other customary ingredients. 
         [0036]    In another embodiment, spermidine is fully or partially replaced by the PA spermine, a substance of structure NH 2 (CH 2 ) 3 NH(CH 2 ) 4 NH(CH 2 ) 3 NH 2 and formula C 10 H 26 N 4 . 
         [0037]    Other inventive compositions may similarly contain a variety of complementary ingredients as those skilled in the art can select using conventional criteria. 
       EXAMPLES 
     Example 1 
     Test formulation 
       [0038]    An investigational device (ID) for local use was prepared in form of gel having ingredients as set forth below. 
         [0000]    
       
         
               
               
               
             
               
               
               
               
             
               
               
               
             
               
               
               
               
             
           
               
                   
                   
               
               
                   
                 Ingredient 
                 amount per 100 ml 
               
               
                   
                   
               
             
             
               
                   
               
             
          
           
               
                   
                 Spermidine HCl 
                 10 
                 mg 
               
               
                   
                 Sodium hyaluronate 
                 2.0 
                 g 
               
               
                   
                 Sodium benzoate 
                 0.3 
                 g 
               
               
                   
                 Benzyl alcohol 
                 0.3 
                 g 
               
               
                   
                 Phenoxyethanol 
                 0.5 
                 g 
               
             
          
           
               
                   
                 Citric acid 
                 q.b. to pH 5.35 
               
             
          
           
               
                   
                 Purified water 
                 q.b. to 100 
                 ml 
               
               
                   
                   
               
             
          
         
       
     
         [0039]    The resulting transparent gel was packaged in 30 ml Al tube in a GMP/GLP facility. 
       Example 1 
     Pilot Study on VVS 
       [0040]    The general design of clinical protocol is illustrated herein after, with a summary of the key protocol chapter given in brief. 
       Primary Outcome Measures: Efficavy 
       [0041]    Change in physical signs of vestibulitis on physical exam after 4+4 weeks of treatment by gynaecology visit ranked with a vulvoVaginal Health Index (vVHI), whose 1-to-5 score is illustrated in Table I. 
         [0000]    
       
         
               
             
               
               
             
               
               
               
               
               
               
             
               
               
               
               
               
               
             
           
               
                 TABLE I 
               
             
             
               
                   
               
               
                 vVHI by Objective Score (OS) 
               
             
          
           
               
                   
                 SCORE 
               
             
          
           
               
                   
                 1 
                 2 
                 3 
                 4 
                 5 
               
               
                   
                   
               
             
          
           
               
                 Vulvar inflammation 
                 Vivid red 
                 Very red and 
                 Intermediate, 
                 Mostly 
                 Rosy and 
               
               
                 (redness) 
                 with rashes 
                 inflammed 
                 minor spots 
                 rose- 
                 healthy 
               
               
                   
                   
                   
                   
                 colored 
               
               
                 Musculature contraction 
                 Highly overal 
                 Anus or 
                 Intermediate 
                 Fair-to- 
                 Excellent, 
               
               
                   
                 contracted 
                 pelvis 
                   
                 good 
                 fully 
               
               
                   
                   
                 contracted 
                   
                   
                 relaxed 
               
               
                 Pain at speculum 
                 Very strong 
                 Strong 
                 Moderate 
                 Minimal 
                 None 
               
               
                 insertion 
               
               
                 Epithelial integrity 
                 Petechiae, 
                 Bleeds with 
                 Not friable, 
                 Almost 
                 Normal 
               
               
                 (mucosa) 
                 ulcerate 
                 ligh contact 
                 thin 
                 fully 
               
               
                   
                 mucosa 
                   
                 epithelium 
                 trophic 
               
               
                   
               
             
          
         
       
     
         [0042]    Change in self-reported, subjective symptoms (SS) of VVS from baseline to 4+4 weeks by weekly questionnaire, whose 0-to-3 score is illustrated in Table II. 
         [0000]    
       
         
               
             
               
               
               
             
               
               
               
               
               
             
               
               
               
               
               
               
             
           
               
                 TABLE II 
               
             
             
               
                   
               
               
                 Subjective score (SS) 
               
             
          
           
               
                   
                 SCORE 
                   
               
             
          
           
               
                   
                 0 
                 1 
                 2 
                 3 
               
               
                   
                   
               
             
          
           
               
                   
                 Pruritus (Hitching) 
                 None 
                 Mild 
                 Moderate 
                 Severe 
               
               
                   
                 Burning 
                 None 
                 Mild 
                 Moderate 
                 Severe 
               
               
                   
                 Dryness 
                 None 
                 Mild 
                 Moderate 
                 Severe 
               
               
                   
                 Dyspareunia 
                 None 
                 Mildt 
                 Moderate 
                 Severe 
               
               
                   
                   
               
               
                   
                 Meaning 
               
               
                   
                 0 = none (no symptoms during 24 hours); 
               
               
                   
                 1 = light (tolerable symptoms in few, short episode during 24 hours); 
               
               
                   
                 2 = moderate (tolerable symptoms for most 24 hours, with limited impairment of daily tasks); 
               
               
                   
                 3 = severe (hardly tolerable symptoms for most 24 hours, with relevant impairment of daily tasks). 
               
             
          
         
       
     
       Secondary Endpoint: Tolerability and Safety 
       [0043]    Tolerability, scored from excellent to poor, is included on patient&#39;s questionnaire. Safety was monitored from the adverse events (AE) report, that were recorded at all visits from subject experience or by physician controlled, to be reported and described in full length referring to date of beginning, intensity and duration. 
       Inclusion Criteria 
       [0044]    Main inclusion criteria consist of:
       signature of the informed consensus;   women complaining a typical VVS, thereby confirmed by a local gynaecologic visit;   collaborative subjects who are able to follow instruction and protocol schedule.       
 
       Exclusion Criteria 
       [0000]    
       
         
           
             subjects unable to supply a valid informed consensus; 
             subjects using estrogens, or combined estrogens and progestinics; 
             presence of autoimmune diseases, allergies, diabetes and hypertension; 
             presence di cancer or chronic disease with less-then 2 year of life expectancy; 
             therapy with corticosteroids or immuno-modulators within the past 3 weeks; 
             previous or concomitant vulvovaginal laser therapy o crio-therapy; 
             subjects unable to follow the protocol or comprehend scopes and effects; 
             subjects under whatever experimental drug within the past 8 weeks. 
           
         
       
     
       General Design of the Study 
       [0056]    Visit 1 (V1, week 0): Enrolment with baseline assessment, ID delivery and instruction to start treatment by 3 applications per week; 
         [0057]    Visit 2 (V2, week 4): After 4 weeks of treatment, objective assessment and next ID delivery for a new cycle with indication of two applications per week; 
         [0058]    Visit 3 (V3, week 8): End of 4+4 weeks of treatment with final objective assessment and delivery of the questionnaire. 
       Doses and Treatment Regimen 
       [0059]    IP was delivered at V1 and V2 with instruction to apply on vulvar area by hand 3 times per week during the first 4 weeks; followed by 3 times per week during next 4 weeks. 
       Example 3 
     Typical Case Report 
       [0060]    A Caucasian woman aged 38 presented to the ambulatory asking medication for recalcitrant VVS. Beside that, health conditions were good, with no sign of allergy, sensitization, nor immuno-reactivity. She was primipara with regular menstrual cycles. 
         [0061]    History Vulvodynia started 5 years before. Past attempts to treat VVS were various with no significant results. She furthermore reported recurrent vulvovaginitis from candidosis. Patient performed a pap test within past 6 month with negative response. She accepted to enter the pilot study after signing the informed consensus. 
         [0062]    First visit (V1) Upon external exploration, vulva displayed reddish vulvar vestibulus as well as redness on inner labia minora. By inserting speculum, patient experienced strong pain and contracted perineum muscles. Instead, inner vaginal mucosa appeared normal. On SS, patient scored a fair vaginal burning, moderate itching and severe dyspareunia. 
         [0063]    Second visit (V2) After 4 weeks of treatment by 3 weekly applications the patient referred about the increase of itching and burning by week 6, then treated with local anti-fungal. Mucosa looked pink with reduced reddish areas. Speculum insert provoked less pain. Patient avoided sexual intercourses, hence dyspareunia was scored as unchanged. 
         [0064]    Third visit (V3) After second cycle of 4 weeks by 2 weekly applications, examination revealed an almost normalized vulvar mucosa. Patient did not complain nor perceive pain at speculum insertion. During this period an episode of candidosis were medicated with local antibiotic therapy. Dyspareunia was scored as moderate. 
         [0065]    Conclusion Clinical remission was finally attained, as denoted by objective scores (SS) and objective scores (OS) trends, which are plotted in  FIG. 1  and  FIG. 2 , respectively. Interestingly, the improvement already found at visit 2 (V2) by objective examination did not correspond to the perceived symptoms, which persist or even worsened (beside the transient burdens due to candidosis in W4-W5) until a sudden improvement noticed from W6 on. Nonetheless, the two scores converged at the end of the treatment. 
       Example 4 
     Combination Cream with Anesthetic 
       [0066]    An emulsion was prepared by mixing under turbo-emulsifier the oily phase melted at around 70° C. with the water-soluble warmed at the same temperature, which end up with a cream having ingredients as set forth below. 
         [0000]    
       
         
               
               
               
             
               
             
               
               
               
               
             
               
             
               
               
               
               
             
           
               
                   
                   
               
               
                   
                 Ingredient 
                 amount per 100 ml 
               
               
                   
                   
               
             
             
               
                   
               
             
          
           
               
                 Oily phase 
               
             
          
           
               
                   
                 Cetyl alcohol 
                 5.0 
                 g 
               
               
                   
                 Glyceryl stearate 
                 2.5 
                 g 
               
               
                   
                 PEG100 stearate 
                 2.5 
                 g 
               
               
                   
                 Dicaprylyl ether 
                 5.0 
                 g 
               
               
                   
                 Cyclopentaxiloxane 
                 5.0 
                 g 
               
               
                   
                 Lidocaine (base) 
                 2.0 
                 g 
               
             
          
           
               
                 Water phase 
               
             
          
           
               
                   
                 Spermidine HCl 
                 10 
                 mg 
               
               
                   
                 Methylisoxazolidone, 10% sol. 
                 0.1 
                 g 
               
               
                   
                 Benzyl alcohol 
                 0.3 
                 g 
               
               
                   
                 Purified water 
                 q.b. to 100 
                 ml 
               
               
                   
                   
               
             
          
         
       
     
         [0067]    The resulting cream was packaged in 30 ml Al tube under GMP/GLP provisions. It provides an immediate pain relief from the very beginning of the spermidine therapy. 
       Example 5 
     Combination gel with anesthetic 
       [0068]    The emulsion obtained in Example 1 was modified by adding 10 mg g of b-estradiol instead of 2 g of lidocaine. 
         [0069]    The innovation entails the local use of spermidine to treat VVS. It should be understood that the foregoing relates only to preferred embodiments and to applicative examples of the present invention and that numerous modifications or alterations may be made therein without departing from the spirit and the scope of the invention as set forth in the appended claims.