Conditions: Multiple Sclerosis Neurogenic Bladder
Keywords: remyelination urogenital health multiple sclerosis
Allocation: NON_RANDOMIZED | Intervention model: PARALLEL
Enrollment: 21
Healthy volunteers: no

Brief summary:
Study to evaluate the efficiency of vaginal estriol, as a treatment for urogenital symptoms in female patients with RRMS. The secondary objective is to evaluate the potential role of vaginal estriol in re-myelination in RRMS patients.

Detailed description:
Pilot project to determine the effectiveness of 1 mg transvaginal estriol, as an adjunctive therapy for female MS patients. The goal is to recruit 20 patients from the MS clinic in the neurology department of Texas Tech University Health Sciences Center. This study has been planned in collaboration with reproductive endocrinology, endocrinology, gynecology and basic science. The 1mg transvaginal dose was chosen after careful search of the literature and consultation with collaborators.

Single-group pilot study.

Subjects:

Patients with relapsing remitting MS and urogenital symptoms (frequency, urgency, frequent urinary tract infections, incontinence) will be invited to participate in the study. Enrollment will be during their scheduled clinic appointment. Some candidates (patients of the primary investigator) may be contacted by phone and invited to participate in the study.

The clinical trial will be explained to potential participants in detail, reviewing the objectives and methodology of the study. There will be adequate time allotted to answer any questions or concerns from the potential participants. Those patients interested in participating in the study will be asked to sign the consent form. In order to remind patients about their follow-up visits, lab work, etc., they will be contacted routinely. Participants will be instructed to call in case of questions or concerns.

Patients will be evaluated clinically during their scheduled follow up in which a full neurological exam will be performed during each visit. Patients will be instructed by the primary investigator how to correctly use the vaginal cream. This will be done at their enrolment and reinforced by the principal investigator, during their follow up visits.

Arms:
arm 1: To evaluate the efficiency of vaginal estriol, as a treatment for urogenital symptoms in female patients with RRMS. arm 2: To evaluate the potential role of vaginal estriol in re-myelination in RRMS patients.

Interventions: intervention 1: vaginal estriol
Intervention descriptions: intervention 1: Estriol vaginal cream will be formulated by Twin Oaks specialty pharmacy-by the same compound specialist. 30 mg estriol powder will be mixed with 5 mL of propylene glycol and 22 g of vaginal base cream. The product can be stored at room temperature and has a shelf life of up to 4 months. It comes with an applicator.

Protocol document:
ICF_000.pdf: 
Page 1 of 7
Version date: 4.19.2019
This consent form is not valid without a TTUHSC IRB stamp in the lower left corner of 
each page.
CONSENT TO TAKE PART IN A RESEARCH STUDY
This is a research study for people who voluntarily choose to take part.  Please take your time 
to make a decision, and discuss the study with your personal doctor, family and friends if you 
wish.
STUDY TITLE:  Dual benefits of Vaginal Estriol: improved urogenital health and re-myelination 
in relapsing remitting multiple sclerosis (RRMS)?
INVESTIGATORS:   Mirla Avila, MD; Smathorn Thakolwiboon, MD; Alan Peiris MD, PhD; 
Charles Thompson, MD, Dargelis Chi, MD
CONTACT TELEPHONE NUMBERS: 
Neurology Department: 806.743.2391
Clinical Research Institute: 806.743.4222 (Office) or 806.543.8994 (Cell)
You may contact the investigator(s) at the number(s) listed above during normal business hours 
if you develop any of the conditions listed in Question # 7 of this form or if you have any 
unexpected complications.
INSTITUTION:  Texas Tech University Health Sciences Center, Lubbock, TX
1.
Why is this study being done?  
The purpose of this study is to evaluate vaginal estriol as a treatment for urogenital 
symptoms in relapsing remitting multiple sclerosis (RRMS) patients and to see how it 
might help increase the material in the brain that helps transmit signals to other brain 
cells.
2.
How many people will take part in this study? 
About 20 people will take part in this study. 
3.
Why am I being asked to take part in this research study?  
You’re being asked to participate because you are a female RMSS patient.
4.
What will happen during this study?  What will be done that is different from my 
usual care? 
These visits will occur during your regularly scheduled clinic visits.
o
There will be four study visits (today, at 3 months, 6 months and at 9 months). At 
each of these four visits, we’ll be collecting up to a teaspoon of blood via needle 
stick.  We will be measuring your hormone levels with these samples.
o
You’ll be given two noninvasive eye tests at three of the four visits:
 
Visual Evoked Potential (VEP) Test: You will be asked to look a 
checkerboard pattern while a technician is measuring the time it will take 
for the image to reach your brain. To measure this, we will attach an 
electrode to your scalp that will give us this information. 
TEXAS TECH UNIVERSITY HEALTH SCIENCES CENTER
IRB NUMBER: L19-020
IRB APPROVAL DATE: 05/06/2019


Page 2 of 7
Version date: 4.19.2019

Optical coherence tomography (OCT) Test: You will be asked to stay 
still and focus on a small light while we take a picture of your retina with a 
device you will look into.
o
You’ll be asked to complete a questionnaire about your quality of life with MS as 
well as one asking you about your bladder control at this visit, 3-month visit and 
final visit.
o
You will have Magnetic Resonance Imaging (MRI) once at the beginning of the 
study and once at the final visit. A MRI scan will be done by you laying down and 
going into a machine. It will show images of your brain so we can see the status of 
your RRMS. This is performed on your follow up MRI schedule, per your standard 
of care.
o
Today you will be given estriol cream and instructed on how to use the estriol 
cream. You will apply the cream. You will draw 1mg of estriol vaginal cream with 
the provided applicator and apply it intra-vaginally once a day. After application 
you should lay on your back for 30 minutes. You will do this every day until your 
final study visit. 

You will be given more cream at each visit excluding your final visit. We will 
also verify if you’ve been using the cream as instructed.
o
We will collect some data from your medical chart such as demographic data, 
such as age, race and information related to your RRMS.
5.
How much of my time will this study take? How long will I be in the study?
This study will require a minimum of 30 minutes every day. You’ll also have four study 
visits, including today, each will last about 1.5 - 2 hours. These will take place during 
your regularly scheduled clinic visits. The OCT test will be done in the Ophthalmology 
department. 
You’ll be in the study for about nine months. A member of the study team may call or text 
you to remind you of your appointments.
6.
Are there any benefits to me if I take part in this study? 
It is possible that urogenital symptoms or MS symptoms may improve. Sexual function 
could also improve. It is also possible that no improvements in your symptoms may 
occur. 
7.
What are the risks and/or discomforts to me if I join this study? 
Risks associated with venipuncture for blood draws include: discomfort, pain, bleeding, 
bruising, infection where the needle enters the skin; feeling lightheaded or fainting at the 
site of the needle or blood. 
No physical risk with VEP or OCT, these are noninvasive procedures. 
Estriol Cream: There is a low risk of thromboembolism (blood clot). Using the applicator 
or cream may cause vaginal discomfort or infection.
You will be asked about vaginal discomfort or vaginal infections and encouraged to call if 
you are experiencing these symptoms. If you experience these symptoms you may be 
referred to your PCP or Gynecologist for appropriate management. 
TEXAS TECH UNIVERSITY HEALTH SCIENCES CENTER
IRB NUMBER: L19-020
IRB APPROVAL DATE: 05/06/2019


Page 3 of 7
Version date: 4.19.2019
There is a potential loss of confidentiality; we are taking appropriate precautions to 
minimize this risk. 
There may be other risks that are unknown.
8.
Will there be any added risks to me from this study if I am a female?
No.
9.
What other choices do I have if I do not take part in the research study? 
You do not have to take part in this study.
10.
What about confidentiality and the privacy of my records? 
We will keep your involvement in this research study confidential to the extent permitted 
by law.  In addition to the staff carrying out this study, others may learn that you are in 
the study.  This might include federal regulatory agencies such as the Food and Drug 
Administration (FDA) and the Office for Human Research Protection (OHRP), Texas 
Tech University Health Sciences Center (TTUHSC) representatives, representatives 
from any hospital or site where the research takes place, and the TTUHSC Institutional 
Review Board (a committee that reviews and approves research).  These people may 
review and copy records involving your participation in this research.  A copy of this 
document may be placed in your medical record.  
Study results that are used in publications or presentations will not use your name.  
11.
Who is funding this study?  
With assistance from the Laura W. Bush Institute for Women’s Health and University 
Medical Center Women’s Health Research Scholar Fund the department of Neurology is 
providing the space and supplies for this study.  No one on the research staff will receive 
anything of value from other agencies, organizations, or companies to carry out this 
research. 
12.
Will it cost me anything to take part in this research study?  
No. You will not be required to pay for any of the tests conducted solely for purposes of 
the research and the estriol cream will be provided free of charge.
13.
Will I receive anything for taking part in this research study? 
No.
14.
Does anyone on the research staff have a personal financial interest in this study?
No.
15.
What if I am hurt by participating in this study?  
Texas Tech University Health Sciences Center does not offer to pay for or cover the cost 
of medical treatment for research related illness or injury.  No funds have been set aside 
to pay or reimburse you in the event of such injury or illness unless specifically stated.  
TEXAS TECH UNIVERSITY HEALTH SCIENCES CENTER
IRB NUMBER: L19-020
IRB APPROVAL DATE: 05/06/2019


Page 4 of 7
Version date: 4.19.2019
16.
What are my rights as a voluntary participant?  
Taking part in this study is your choice.  If you sign this form, it means that you choose to 
be in the study.  
You may also choose not to be in this study.  If you decide not to be in the study, it will 
not affect any medical care, benefits or rights to which you are entitled.  
If new information becomes available during the study that may affect your willingness to 
take part in the study, you will be told.  
17.
Can I stop being in the study?  
You may leave the study at any time. If you leave the study, we cannot remove any 
information we have collected to that point.  
If you decide to leave the study, discuss it with the investigator who will help you do so in 
the safest way. If you leave the study, your right to standard medical care will continue.
18.
Can someone else end my participation in the study?  
Under certain circumstances, the investigators, TTUHSC, or the study sponsor may 
decide to end your participation in this research study earlier than planned. 
19.
What if I have questions?
For questions about this study, contact the Investigator, Dr. Avila at 806.743. 2391 
If you would like to speak to someone who is not involved in the study about your rights 
as a participant, research-related injuries, or any other matter related to the study, you 
can call the TTUHSC EthicsPoint Hotline:  1-866-294-9352.  Or, you can file an 
EthicsPoint report online: 
https://secure.ethicspoint.com/domain/media/en/gui/12958/index.html.  Please choose the 
“Regulatory Compliance” option when making an online report.   
A description of this clinical trial will be available on https://www.clinicaltrials.gov/ , as 
required by U.S. Law.  This Web site will not include information that can identify you.  At 
most the Web site will include a summary of the results.  You can search this Web site at 
any time.
[SIGNATURE PAGE FOLLOWS]
TEXAS TECH UNIVERSITY HEALTH SCIENCES CENTER
IRB NUMBER: L19-020
IRB APPROVAL DATE: 05/06/2019


Page 5 of 7
Version date: 4.19.2019
Your signature indicates that:
 
this research study has been explained to you;

you have been given the opportunity to ask questions and have received answers;

you accept your responsibility to follow the instructions given to you by the 
research team regarding study participation and, if applicable, research 
medication;

you agree to take part in this study.
You will be given a signed copy of this form.  
Printed Name of Subject
Signature of Subject
Date
Time
Signature of Parent/Guardian
Date
Time
or Authorized Representative 
_____ Subject was unable to read and understand the written consent.
The elements of informed consent required by 45 CFR 46.116 and 21 CFR 50 have been 
presented orally to the subject or the subject’s authorized representative in a language 
understandable to the subject or representative.
                                                                                                                           _ 
Signature of Witness to Oral Presentation                       Date                  Time
I have discussed this research study with the subject and his or her authorized representative, 
using language that is understandable and appropriate.  I believe I have fully informed the 
subject of the possible risks and benefits, and I believe the subject understands this 
explanation.  I have given a copy of this form to the subject.  
Signature of authorized research personnel who
Date
Time
conducted the informed consent discussion
 
TEXAS TECH UNIVERSITY HEALTH SCIENCES CENTER
IRB NUMBER: L19-020
IRB APPROVAL DATE: 05/06/2019


Page 6 of 7
Version date: 4.19.2019
TEXAS TECH UNIVERSITY HEALTH SCIENCES CENTER
AUTHORIZATION TO USE AND/OR DISCLOSE YOUR PROTECTED HEALTH 
INFORMATION for a RESEARCH STUDY
STUDY TITLE: Dual benefits of Vaginal Estriol: improved urogenital health and re-myelination 
in relapsing remitting multiple sclerosis (RRMS)?
This form is intended to tell you about the use and/or disclosure (sharing) of your personal 
Protected Health Information (PHI) if you decide to participate in the research study 
described on the previous pages. The health information about you that may be used or 
disclosed is described below. This information is usually found in your medical records.  Only 
the health information about you that is needed for this research study will be used or disclosed.  
When you consider taking part in this research study, you are also being asked to give your 
permission for your Protected Health Information to be released from your doctors, clinics, and 
hospitals to the research personnel approved for this research study.  This Authorization 
specifically relates to the research study described in the attached Informed Consent document.
1. This Authorization is valid indefinitely or until such time as legal requirements will allow this 
Authorization to be destroyed.
2. If you choose to cancel this Authorization, please give notice in writing to:
Institutional Privacy Officer
Office of Institutional Compliance
3601 4th St MS 8165
Lubbock TX 79430
If you sign this Authorization, the following persons, groups or organizations may rely on this 
Authorization to disclose your Protected Health Information to the Principal Investigator and 
other research personnel who are conducting this Study: 
•
your treating physicians and healthcare providers and their staff,
•
associated healthcare institutions and hospitals where you have or may receive care.
While this research study is in progress, the Principal Investigator or research personnel 
working on this study will inform you whether or not you will be allowed to see the research 
related health information that is created about you or collected by the research personnel prior 
to the end of the study.  After the study is finished you may request this information as allowed 
by the TTUHSC Notice of Privacy Practices.
The Protected Health Information that you authorize to be used or disclosed for research 
purposes may include your current or future health information from some or all of your health 
records, including: 
•
hospital records and reports
•
admission history, and physical examination
•
X-ray films and reports; operative reports
•
laboratory reports, treatment and test results (including 
sexually transmitted diseases, HIV or AIDS)
•
immunizations
•
allergy reports
•
prescriptions
•
consultations
•
clinic notes
TEXAS TECH UNIVERSITY HEALTH SCIENCES CENTER
IRB NUMBER: L19-020
IRB APPROVAL DATE: 05/06/2019


Page 7 of 7
Version date: 4.19.2019
•
any other Protected Health Information needed by the 
research personnel listed above.
(*use separate form for disclosure of psychotherapy notes)
•
mental health records
•
alcohol / substance abuse 
records
For the purposes of this study, your Protected Health Information may need to be reviewed or 
disclosed to individuals or organizations within and/or outside of TTUHSC who sponsor, 
approve, assist with, monitor or oversee the conduct of research studies.  This includes, but is 
not limited to, the TTUHSC Institutional Review Board, TTUHSC compliance reviews, the US 
Food and Drug Administration (FDA) or governmental agencies in other countries. Some of 
these individuals or organizations may share your health information further, and your health 
information may not be protected by the same privacy standards that TTUHSC is required to 
meet.
If you choose to sign this Authorization form, you can change your mind about this later.  If you 
change your mind, send a letter to the person identified above telling us to stop collecting and 
sharing your Protected Health Information.  When we receive your request, you may be asked 
to leave the research study if all the necessary information has not been collected.  We may still 
use the information about you that we have already collected.  We need to know what happens 
to everyone who starts a research study, not just those people who stay in it.
You have the right to refuse to sign this form.  If you choose not to sign 
this form, your regular health care will not be affected.  However, not 
signing this form will prevent you from participating in this research study 
and prevent you from receiving research related health care services 
provided under this study.
I have had the opportunity to review and ask questions regarding this Authorization to use or 
disclose my personal health information, and I will receive a copy of this form.  By signing this 
Authorization, I am confirming that it reflects my wishes.
                                    
Printed Name
Signature of Individual or Authorized Representative
Date
If applicable, Relationship of Authorized Representative 
or Authority to Sign
TEXAS TECH UNIVERSITY HEALTH SCIENCES CENTER
IRB NUMBER: L19-020
IRB APPROVAL DATE: 05/06/2019

Prot_SAP_002.pdf: 
Protocol version: 11.11.2019
1
Protocol
TITLE: Dual benefits of Vaginal Estriol: improved urogenital health and re-myelination in relapsing 
remitting multiple sclerosis (RRMS)?
INVESTIGATORS:
1.      Mirla Avila, MD
2.      Smathorn Thakolwiboon, MD
3.      Charles Thompson, MD
4.      Dargelis Chi, MD
5.      Gyeongmo Sohn, MD
6.      Kenn Freedman, MD, PhD
AIMS:
1.      To evaluate the efficiency of vaginal estriol, as a treatment for urogenital symptoms in female 
          patients with RRMS.
2.      To evaluate the potential role of vaginal estriol in re-myelination in RRMS patients.
The goal of this pilot project is to determine the effectiveness of 1 mg transvaginal estriol, as an 
adjunctive therapy for female MS patients. Our goal is to recruit 20 patients from our MS clinic in the 
neurology department of Texas Tech University Health Sciences Center. This study has been planned in 
collaboration with reproductive endocrinology, endocrinology, gynecology and basic science. The 1mg 
transvaginal dose was chosen after careful search of the literature and consultation with our collaborators.
OBJECTIVES:
Aim 1: Define if transvaginal estriol improves urogenital symptoms (urgency, frequency, intermittent   
incontinence), in female patients with Relapsing Remitting MS (RRMS). Bladder control scale, 
will be given at baseline, 3, 6, and 9 months after starting transvaginal estriol. Quality of life 
questionnaire will be given at baseline and at 9 months after starting vaginal estriol.
Aim 2: Assess for evidence of re-myelination associated to the use of transvaginal estriol in woman with 
MS. Objective measurements for re-myelination will be quantified with brain MRI 3T, Optical 
coherence tomography (OCT) and Visual evoked potentials (VEP). 
INTRODUCTION / BACKGROUND / SIGNIFICANCE:
More than 2.3 million persons suffer from MS worldwide.   Demyelination and axonal loss are the main 
pathological process in MS. Unfortunately remyelination occurs an incomplete fashion (Mallik, Samson, 
Wheeler-Kingshott, & Miller, 2014).  Experimental models of MS have shown that preservation of 
myelin and remyelination of axons can increase neuronal survival.  Until now, treatment for MS may 
decrease the relapse rate and progression, without any significant effect on remyelination.
Urinary issues in MS
Urinary dysfunction includes frequency, incontinence, frequent infections, occurs in about 80-90% of MS 
patients. It causes a major disruption in daily life, imposing economic burdens for patients and their 
families.  Direct costs and indirect costs as psychological distress, loss of productivity are a significant 
burden for the patient, and increase the risk of unemployment.(Moore, 2001)  Besides interfering with 
quality of life, urinary dysfunctions leads commonly to urinary tract infections which can have a direct 
impact on MS, worsening neurologic symptoms, and increasing in the number of relapses, which may 
lead to disability.
TEXAS TECH UNIVERSITY HEALTH SCIENCES CENTER
IRB NUMBER: L19-020
IRB APPROVAL DATE: 12/13/2019


Protocol version: 11.11.2019
2
Estriol for urogenital health
Urinary dysfunction is frequently treated with antimuscarinic agents; side effects from these drugs (dry 
mouth, blurred vision, constipation and difficulty with micturition) make compliance an issue (David 
et.al). Transvaginal estriol decreases urinary symptoms and prevents urinary tract infections.(Rahn et al., 
2014) There is less risk of endometrial hyperplasia and endometrial cancer with estriol treatment 
compared with estradiol treatment (Cody, Jacobs, Richardson, Moehrer, & Hextall, 2012).  Furthermore, 
vaginal delivery offers regional benefits to the lower urogenital tract, it is well absorbed and it is not 
associated with entero-hepatic recirculation as oral estriol, as some of the adverse effects of oral estrogens 
are to produce an increase in thromboembolic events. (Rahn et al., 2014)
Estriol in MS, role in remyelination
Estriol is one of the three main estrogens, produced by fetal placenta. Levels increase significantly in the 
third trimester of pregnancy.  It has been postulated as a possible neuromodulator and neuroprotective 
therapy in multiple sclerosis. (Tiwari-Woodruff & Voskuhl, 2009). Estriol has been studied in animal 
models and has been demonstrated to have distinctly different modulatory actions on the immune system 
than estradiol. Moreover, in 1-chloro-2, 4-dinitrobenzene (DNCB) induced contact dermatitis, estriol 
(Cody, Jacobs, Richardson, Moehrer, & Hextall, 2012)had the strongest suppressive effect when 
compared to estrone and estradiol (Cody et al., 2012). It has been reported that MS patients have a 
decreased annualized relapse rate during pregnancy, with a statistically significant decrease in the third 
trimester.  Additionally, in the 3 months postpartum, the rate of relapse increases significantly. (Avila-
Ornelas, Avila, Stosic, & Robles, 2011)This effect may be mediated at least in part by estriol, which rises 
during the third trimester of pregnancy and then falls precipitously postpartum. Furthermore, Estriol has 
been shown to have a positive effect reducing active brain lesions in multiple sclerosis. Estriol may have a 
role in remyelination.(Harlow, Honce, & Miravalle, 2015) Oligodendrocytes are the myelinating cells of 
the CNS.  The process of re- myelination represents a major form of plasticity in the brain, unfortunately 
this process is not complete, leading to partial remyelination in patients with MS.  (Mallik et al., 2014) 
Previous studies have shown that pregnancy leads to an increase in oligodendrocyte precursor cells (OPC) 
proliferation, oligodendrocyte generation and the number of myelinated axons in the maternal 
CNS.  (Tiwari-Woodruff & Voskuhl, 2009) . If estriol favors remyelination, this could revolutionize 
current treatment options for MS patients.
                                                                                                     
Benefit of vaginal estriol
Oral estriol has been shown to produce a significant decrease in the relapse rate in MS patients(Voskuhl 
et al., 2016) . One of the reasons why vaginal estriol has a better absorption is that oral estriol is 
associated with entero-hepatic recirculation, which prolongs exposure due to recycling. Furthermore, 
vaginal estrogen delivery has a regional benefit to the lower urogenital tract, and is well absorbed at a 
dose of 0.5 mg to 1 mg. In a systematic review of randomized trials comparing vaginal estrogens, it was 
concluded that the 1mg vaginal estriol, was superior to lower doses for the treatment of urogenital 
symptoms.  (Rahn et al., 2014) In animal models, estriol demonstrated to have distinctly different 
modulatory actions on the immune system than other form of estrogens, such as estradiol. Vaginal estriol 
does not increased the risk for heart disease, stroke, or cancer. (Rahn et al., 2014) In summary, patients 
with RRMS may significantly benefit from estriol as an adjunctive therapy to MS, improving quality of 
life and restoring myelin 
HYPOTHESIS:
Transvaginal estriol offers a safe adjunctive therapy for female MS patients, it improves urogenital 
symptoms as well as promotes remyelination.
METHODS:
Type of study: Single-group pilot study.
TEXAS TECH UNIVERSITY HEALTH SCIENCES CENTER
IRB NUMBER: L19-020
IRB APPROVAL DATE: 12/13/2019


Protocol version: 11.11.2019
3
Subjects: Patients with relapsing remitting MS and urogenital symptoms (frequency, urgency, frequent 
urinary tract infections, incontinence) will be invited to participate in the study. Enrollment will be during 
their scheduled clinic appointment. Patients will be screened by a member of the study team during their 
visits to see if they qualify, if so they will be invited to participate in the study. 
The clinical trial will be explained to potential participants in detail, reviewing the objectives and 
methodology of the study.  There will be adequate time allotted to answer any questions or concerns from 
the potential participants. Those patients interested in participating in the study will be asked to sign the 
consent form.   In order to remind patients about their follow-up visits, lab work, etc., they will be 
contacted routinely. Participants will be instructed to call in case of questions or concerns.
Patients will be evaluated clinically during their scheduled follow up. Patients will be instructed by the 
primary investigator how to correctly use the vaginal cream. This will be done at their enrolment and 
reinforced by the principal investigator, during their follow up visits.
Inclusion criteria:
1.      Female patients with RRMS between the ages of 35 to 65. 
A) Being prescribed vaginal estriol to treat their urogenital symptoms.
 B) Patients that had underwent menopause or surgical hysterectomy.
2.      Patients will continue their disease modifying agent for MS during the trial.
Exclusion criteria:
1.
Patients with personal history of breast cancer, uterine or ovarian cancer.
2.
Patients with history of fibrocystic breast disease, heart attack or stroke.
3.
Patients with history of thromboembolism. 
4.   Patients with progressive multiple sclerosis
5.   Patients who are unable to undergo an MRI
6.   Males
7.   Patient is already on vaginal or oral or transdermal estrogens
8.   Pregnant or breast-feeding patients
9.   Patient taking sex hormones eg testosterone for libido
           10.   Patients taking DHEA or OTC related products that could influence the hormonal milieu.
11.  Patient with prolapse uterus or conditions that would impact on transvaginal absorption of 
         estriol
Enrollment in the study will be timed to their follow up brain MRI which will be performed as standard of 
care. Patients that have no baseline MRI or are unable to undergo MRI will be excluded from the study. 
Site of study: The TTUHSC department of Neurology, MS clinic, Lubbock, TX; The TTUHSC 
Department of Ophthalmology and Visual Sciences, Lubbock, TX
Design:
This is a single-group prospective repeated-measures pilot trial. Duration is 12 months
Intervention:
Estriol vaginal cream will be formulated by Twin Oaks Pharmacy’s compounding pharmacy, Regional 
Pharmacy, by the same compound specialist.  30 mg estriol powder will be mixed with 5 mL of propylene 
glycol and 22 g of vaginal base cream.  The product can be stored at room temperature and has a shelf life 
of up to 4 months.  It comes with an applicator.
TEXAS TECH UNIVERSITY HEALTH SCIENCES CENTER
IRB NUMBER: L19-020
IRB APPROVAL DATE: 12/13/2019


Protocol version: 11.11.2019
4
The 1 mg dosing was chosen due to evidence in previous trials, and a systematic review of randomized 
trials comparing vaginal estrogens.  It was concluded that the 1mg vaginal estriol, was superior to lower 
doses for the treatment of urogenital symptoms.  (Rahn et al., 2014).
Study visits/Roles of subjects:
Initial visit:
After the informed consent has been obtained and all questions have been addressed
Potential participants will be screened to ensure they are eligible for the clinical trial. Once eligibility has 
been verified 
1.
Blood will be collected for baseline laboratory studies serum estriol, FSH and LH level. (about 20 
ml of blood)
2.
Baseline urogenital status will be evaluated by 
 
Bladder Control Scale (BLCS) questionnaire
3.
Multiple Sclerosis Quality of Life-54 (l-54) questionnaire will be completed
4.
Baseline Visual Evoked Potential (VEP) within 4 weeks of Initial Visit
5.
Optical Coherence Tomography (OCT) (occurs at the Ophthalmology clinic) within 4 weeks of 
Initial Visit
 
3 Tesla brain MRI will be performed as well. (within 3 months of initial visit)

Dispense vaginal estriol cream once all baselines are complete
The primary investigators will instruct how to correctly use vaginal cream. Patients will be instructed to 
draw 1 mg of estriol vaginal cream with the applicator and apply intravaginally. They will be instructed to 
lay on their back for 30 min after vaginal cream application once a day for the duration of the study. The 
applicator is reusable, cleaning technique will also be given to the patient during their visit and reinforced 
during follow up. The applicator will be washed with regular soap and water and let air dry. 
Patients will be instructed not to start applying vaginal cream until baseline lab work and imaging has 
been performed. 
Three-month visit (90 days +/- 10 days):

BLCS questionnaire will be completed

Blood will be collected for serum estriol, FSH and LH level. (about 20 ml of blood)

VEP and OCT will be also performed. ± 3 weeks of 3 month Visit

Dispense vaginal estriol cream
Six-month visit (180 days +/- 10 days):

BLCS questionnaire will be completed

Blood will be collected for serum estriol, FSH and LH level. (about 20 ml of blood)

VEP and OCT will be also performed. ± 3 weeks of 6 month Visit

Dispense vaginal estriol cream
Nine-month visit (270 days +/- 10 days-FINAL VISIT):

BLCS and MSQOL-54 questionnaires will be completed

Blood will be collected f serum estriol, FSH and LH level. (about 20 ml of blood)

3 Tesla brain MRI will be repeated. ± 3 months of 9 month Visit
During each visit patients will be questioned for adverse events, patients will also have a number to call in 
case of questions, concerns or adverse events. 
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IRB NUMBER: L19-020
IRB APPROVAL DATE: 12/13/2019


Protocol version: 11.11.2019
5
Due to the nature of RRMS there might be acute exacerbations in which the patient will be treated with 
IV methylprednisolone 1gm a day x 3 to 5 days, this is the standard of care for MS exacerbations. 
Schedule of events
Procedures
Screening 
visit
3 month 
visit 
6 month 
visit 
9 month 
visit
FINAL VISIT
Date
ICF
X
I&E
X
Blood work
x
x
x
x
BLCS 
questionnaire
x
x
x
x
MSQOL-54 
questionnaire
x
x
VEP (4 week 
window for 
screening visit or 3 
week window for 3 
and 6 month visits)
x
x
x
OCT (4 week 
window for 
screening visit or 3 
week window for 3 
and 6 month visits))
x
x
x
MRI variables (3 
month window)
x
X
Vaginal cream 
instructions
x
Vaginal cream 
dispensing (once 
baselines 
complete)
x
x
x
Compliance of 
vaginal cream use
x
x
x
Materials, instruments or measurements:
Urogenital measurements:
-         Bladder control scale (BLCS) questionnaire (validated and used for evaluation of MS 
bladder symptoms. {Turnbull et al, 1992}). Raw scores on the 4 items are summed to create a 
Bladder Control Scale (BLCS) total score. Scores can range from 0-22, with higher scores 
indicating greater bladder control problems. See attached document.
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IRB NUMBER: L19-020
IRB APPROVAL DATE: 12/13/2019


Protocol version: 11.11.2019
6
Quality of life:
-         Quality of life questionnaire (Multple Sclerosis Quality of Life-54 {MSQOL-54}. Validated and 
widely used for MS patients. (Vickrey et al, 1995) (Vickrey et al, 1997). The questionnaire includes 54 
questions that provide scores on physical and mental health status. Both scores can range 0-100. See 
attached document.
Blood work:  
Levels of estriol, FSH, LH will be performed in Texas Tech Health Science Laboratory (Dr. Prien’s 
certified lab). The assay used will be the Beckman Coulter Access 2 immunoassay system analyzer. This 
will be run by an established OB/GYN hormone laboratory under the supervision of Dr. Prien and Dr. 
Penrose.
Re-myelinating measurements:
·         Visual evoked potential (VEP) (measurement of the electrical signal recorded at the scalp over the 
occipital cortex in response to light stimulus) VEP/Prolongation of the P100 latency, is an indirect tool for 
remyelination in MS. (The test is non-invasive, patients will be looking at a checkboard pattern while the 
technician is measuring the time it takes to register the image to the brain cortex. This is achieved with 
scalp electrode in the posterior region.)
·         3Tesla brain MRI (performed as standard of care with no extra cost) will be evaluated for possible 
changes in white matter lesions, and Diffusion Tensor Imaging (DTI). This will be read by an expert MD 
collaborator independent from primary investigator.
·         Optical coherence tomography (OCT) (noninvasive scan of the retinal layer which provides 
morphology imagery of the ganglion cell layer which is frequently affected in MS) (Noninvasive test, 
duration of about 5 to 10 min to perform, patient has to stay still and focus on a small light while we take 
a picture of the retina layer with the device.)
Data Sheet: A spreadsheet is attached. We will be gathering demographic data, MRI information, EDSS 
score,  and electrophysiologic information, for details please see the spreadsheet attached. 
Outcome variables:
1- Urogenital symptoms such as frequency, incontinence, frequent urinary tract infections, and BLCS 
questionnaire scores.
2- Remyelination (measured by brain MRI 3 DTI, other measurements include presence of T2 lesions, 
Flair lesions, DWI, T1 black hole, and DTI; Optical coherence tomography (OCT); and visual evoked 
potentials (VEP). 
3- Quality of life, assessed using MSQOL-54 questionnaire.
Analysis:
Patient characteristics will be summarized using frequency (percentage) for categorical variables, and 
mean (SD) or median (interquartile range) for numerical variables as appropriate. Changes in blood work 
variables during the course of the study will be assessed using one-way repeated-measures analysis of 
variance (ANOVA). Compliance assessments will be used as covariate to adjust the differences if 
necessary, using an analysis of covariance model (ANCOVA). Urinary symptoms, and quality of life data 
will be analyzed using mixed-effects linear or logistic regression models for continuous or binary 
outcomes respectively. These models will account for the effect of estriol over time, compliance with 
treatment, and relevant patient characteristics.
Justification for Sample size: 
This is a pilot study. We are planning to include 20 patients. Each patient will be their own control in a 
single-group repeated measures design. Assuming a significance level α = 0.05, and power 1-β = 0.80, a 
TEXAS TECH UNIVERSITY HEALTH SCIENCES CENTER
IRB NUMBER: L19-020
IRB APPROVAL DATE: 12/13/2019


Protocol version: 11.11.2019
7
sensitivity power analysis determined that a moderate effect size (d=0.53 to d=0.66) would be required to 
detect statistically significant changes in the main outcome.
Risks
Studies suggest that when the lower-potency estrogen, estriol, is administered transvaginal, it does not 
increase the risk of hormone-dependent cancers of the breast or endometrium (uterine lining) Therefore 
the risk of breast and endometrial cancer is not increased with vaginal estriol.  (Voojis et.al) Another 
safety concern of estrogens is the risk of thromboembolism.  There is a paucity of prospective studies 
specifically looking at estriol and thromboembolism. Studies have shown that transdermal and 
transvaginal estrogen have a lower rate of thromboembolism. (Scarabin, Oger, & Plu-Bureau, 2003).  
Risks associated with venipuncture for blood draws include: discomfort, pain, bleeding, bruising, 
infection where the needle enters the skin; feeling lightheaded or fainting at the site of the needle or 
blood. No physical risk with VEP or OCT, these are noninvasive procedures.
Using the applicator or cream may cause vaginal discomfort or infection.  Patients will be asked during 
their visits about vaginal discomfort or vaginal infections. Patients will also be encouraged to call if they 
are experiencing these. If the patient does experience these symptoms they may be referred to their PCP 
or Gynecologist for appropriate management. 
Benefits:  
Patients may experience improvement of her urogenital symptoms as well as improvement in their MS 
symptoms. Patient may have improved sexual function.  Subjects could share satisfaction from potential 
benefits to other MS patients. May help revolutionize treatment of MS along with urogenital benefits at 
low cost
Confidentiality:
Patient’s information will be de-identified and identifier information will be kept in a safe place. 
Electronic files will be locked by password which will be known by the principal investigator.
Study documents will be kept at least 3 years then destroyed. 
Study is registered at clinicaltrials.gov
Monitoring
To ensure compliance of the study protocol, GCP guidelines, and TTUHSC Human Research Protection 
Program research policies and procedures during the conduct of the study, a monitor in the Clinical 
Research Institute will conduct the monitoring of the study. The first monitoring visit will be conducted 
within two weeks after the first subject has been enrolled into the study. The succeeding monitoring visits 
will be scheduled periodically, but no less than every 2 months when there is an active study participant, 
at a mutually agreed timeframe by the PI and study monitor. All data collected will be 100% source 
document verified. The study monitor may inspect and audit all study documents, i.e. data collection 
forms, questionnaires, drug accountability, and medical records within the applicable confidentiality 
regulations.
Reimbursement:
           No reimbursement for the participants
Funding: Laura W. Bush Institute for Women's Health and University Medical Center Women's Health 
Research Scholar Fund and the TTUHSC Department of Neurology. 
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IRB NUMBER: L19-020
IRB APPROVAL DATE: 12/13/2019


Protocol version: 11.11.2019
8
Acknowledgements:
           The investigators would like to express our sincere gratitude to the Clinical Research Institute and 
Department of Neurology at TTUHSC, Lubbock, Texas for assistance.
References:
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Corticosteroids in the Prevention of. International Journal of MS Care, 13, 91–93.
Cody, J. D., Jacobs, M. L., Richardson, K., Moehrer, B., & Hextall, A. (2012). Oestrogen therapy for urinary 
incontinence in post-menopausal women. In Cochrane Database of Systematic Reviews. 
https://doi.org/10.1002/14651858.CD001405.pub3
Harlow, D. E., Honce, J. M., & Miravalle, A. A. (2015). Remyelination therapy in multiple sclerosis. 
Frontiers in Neurology, 6(DEC), 1–13. https://doi.org/10.3389/fneur.2015.00257
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Rahn, D. D., Carberry, C., Sanses, T. V., Mamik, M. M., Ward, R. M., Meriwether, K. V., … Murphy, M. 
(2014). Vaginal estrogen for genitourinary syndrome of menopause. Obstetrics and Gynecology, 
124(6), 1147–1156. https://doi.org/10.1097/AOG.0000000000000526
Scarabin, PY, et al.  Differential association of oral and transdermal oestrogen-replacement therapy with 
venous thromboembolism risk.  Lancet, 2003; 362: 428-32
Tiwari-Woodruff, S., & Voskuhl, R. R. (2009). Neuroprotective and anti-inflammatory effects of estrogen 
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https://doi.org/10.1016/j.jns.2009.04.023
Vooijs, GP and Geurts, TBP.  Review of the endometrial safety during intravaginal treatment with estriol.    
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Voskuhl, R. R., Wang, H. J., Wu, T. C. J., Sicotte, N. L., Nakamura, K., Kurth, F., … Elashoff, R. (2016). 
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randomised, placebo-controlled, phase 2 trial. The Lancet Neurology, 15(1), 35–46. 
https://doi.org/10.1016/S1474-4422(15)00322-1
TEXAS TECH UNIVERSITY HEALTH SCIENCES CENTER
IRB NUMBER: L19-020
IRB APPROVAL DATE: 12/13/2019