Efficacy and Safety of Hyaluronic Acid Injection on Symptoms of Vulvovaginal Atrophy in Postmenopausal Women

DESIRIAL® is a CE-marketed hyaluronic acid gel intented to rehydrate vaginal and vestibular mucous membranes by mucosal injections. In this study, 121 postmenopausal women of minimum age 45 with symptoms associated with vulvovaginal atrophy, refusing estrogen therapies for treatment of symptoms or with contraindications for such therapies, with at least one moderate to severe vulvovaginal symptom among dryness sensation, dyspareunia, itching / irritation and pain, who have given her informed consent and met all the eligibility criteria, will be enrolled. Patients will randomly receive 1 injection of DESIRIAL® or placebo (ratio 2:1) in the vaginal mucosa at Day 0. If still eligible 12 weeks after, patients receiving placebo at Day 0 will be treated with DESIRIAL®. Patients will come to a total of 6 to 8 visits depending on the product injected at Day 0 over a period of 11 up to 12 months. Phone interview will be performed between 3 and 5 days after injection. Variation of vulvovaginal symptomatology, sexual function, vaginal pH and safety will be assessed.

This is a prospective, international, multicenter study performed in 2 steps:

* From 0 to 12 weeks: randomized, single-blind, placebo-controlled study;
* From 12 to 52 weeks: open label, treatment only study.

The study will assess the efficacy of DESIRIAL® in reducing the vulvovaginal symptomatology after a single injection. One hundred twenty one postmenopausal women of minimum age 45, with symptoms associated with vulvovaginal atrophy, refusing estrogen therapies for treatment of symptoms or with contraindications for such therapies, with at least one moderate to severe vulvovaginal symptom among dryness sensation, dyspareunia, itching / irritation and pain, who have given her informed consent and met all the eligibility criteria, will be enrolled. Patients will randomly (2:1 ratio) receive a 1mL-injection of DESIRIAL® (Desirial Only group, DO) or placebo (Placebo and Desirial group, PAD) in the vestibular and vaginal mucosa using the multi-puncture and/or retrolinear technique at D0. If still eligible 12 weeks after, patients from PAD group receiving placebo at Day 0 will be treated with DESIRIAL®. Group DO will be followed up at 4, 12, 24, 36 and 52 weeks timepoints.Group PAD will be followed up at 4, 12, 16, 24, 36 and 48 weeks timepoints. Phone interview will be performed between 3 and 5 days after injection to check safety. Variation of vulvovaginal symptomatology, sexual function and vaginal pH will be measured using vulvovaginal symptomatology questionnaire, Female Sexual Function Index (FSFI) and vaginal pH indicator strip respectively. Safety will also be assessed through collection of adverse events.

Eligibility Criteria:
Inclusion Criteria:

* ≥ 45 years of age at inclusion;
* With postmenopausal status: at least 12 months of spontaneous amenorrhea or 6 weeks postsurgical bilateral oophorectomy with or without hysterectomy at the time of inclusion. Hormone-dependent breast cancer survivors previously treated with long-term anti-estrogen treatment tamoxifene, in complete remission of breast cancer, and with a post-menopause diagnosis after tamoxifene discontinuation are eligible;
* Refusing estrogen therapies for treatment of vulvovaginal symptomatology or with contraindications for such therapies;
* With at least one of the following vulvovaginal symptoms, as moderate to severe, self-assessed: Dryness sensation, Dyspareunia, Itching / irritation, Pain. Possible scores are 0 - none, 1 - mild, 2 - moderate, 3 - severe;
* Subject affiliated to a health social security system (if applicable according to national regulation);
* Informed consent signed by the patient for study enrolment.

Exclusion Criteria:

Women with the following conditions:

* General:

  * Pregnancy;
  * Breast feeding;
  * With a known tendency to develop hypertrophic or keloid scars;
  * Participating at the same time in another clinical trial;
  * Deprived of their freedom by administrative or legal decision or under trusteeship/guardianship;
  * With a known and documented hypernatremia;
  * With a known and documented hyperchloremia;
  * With a severe case of hydric inflation and hydro-sodic retention, particularly in case of decompensated heart failure, decompensated liver failure (cirrhosis with oedema and ascites), and pre-eclampsia / eclampsia.
* Linked to genital status: With a stage 2 upper genital tract prolapse indicated for surgery.
* Linked to inflammatory or immune status:

  * With a known hypersensitivity to one of DESIRIAL®'s components (hyaluronic acid, mannitol), to the antiseptic solution, to amide local anesthetics or to one of the components of anesthesia products planned to be used;
  * Presence of clinical signs of inflammation in or close to the area of interest or treatment for these affections;
  * History of or ongoing autoimmune disease.
* Linked to infection:

  * Presence of bacterial, fungal or viral infection in or close to the area of interest or treatment for these affections;
  * With previous history of streptococcal illness (such as recurrent sore throat or acute articular rheumatism);
  * History of Toxic Shock Syndrome.
* Linked to neoplasia:

  * Ongoing or history of cancer in areas close to the injection site (vulvar, vaginal or cervical cancers);
  * Ongoing cancer distant from the injection site. Hormone-dependent breast cancer survivors must be in complete remission after anti-estrogen treatment (tamoxifen, aromatase inhibitor) to be eligible.
* Linked to previous or ongoing treatments:

  * Anti-estrogen treatment (tamoxifen, aromatase inhibitor) for hormone-dependent breast cancer within 1 year prior to inclusion;
  * Treatment with a trophically targeted electromagnetic treatment of the vaginal mucosa (pulsed CO2 laser, LED, radiofrequency, etc.) within 6 months prior to inclusion;
  * Treatment with anticoagulant, antiplatelet agents, NSAIDs or Vitamin C within 1 week prior to inclusion;
  * Local hyaluronic acid-like hydrating treatment within 4 weeks prior to inclusion;
  * Under hormonal treatment: Local vaginal estrogen alone including phytoestrogen, or estrogen-progestogen (rings, creams, ovules, gels) therapy within 1 week prior to inclusion; transdermal estrogen alone or estro-progestogen therapy within 4 weeks prior to inclusion; Tibolone within 4 weeks prior to inclusion; Oral estrogen alone including phytoestrogen, progestogen alone, or estro-progestogen therapy within 8 weeks prior to inclusion; Androgen therapy (including oral or vaginal DHEA) within 8 weeks prior to inclusion; Intrauterine progestogen therapy within 8 weeks prior to inclusion; Progestogen implants or estrogen alone injectable therapy within 3 months prior to inclusion; Estrogen pellet therapy or progestogen injectable therapy within 6 months prior to inclusion;
  * Selective estrogen receptor modulator (SERM) treatment targeted against vaginal dryness (Ospemifene, etc) within 4 weeks prior to inclusion;
  * Antidepressant agents within 4 weeks prior to inclusion;
  * History of vulvovaginal treatment with DESIRIAL® or similar indication implants (resorbable or slowly resorbable) within 1 year prior to inclusion;
  * History of vestibular and/or vaginal treatment with non resorbable implants;
  * Total injection volume of cross-linked hyaluronic acid \>19 mL within 1 year prior to inclusion.