Conditions: Perimenopausal Disorder Stress, Emotional
Keywords: perimenopause menopause transition estrogen stress mood
Allocation: RANDOMIZED | Intervention model: PARALLEL
Enrollment: 82
Healthy volunteers: yes

Brief summary:
Women in the menopause transition ('perimenopause') are exposed to extreme hormone variability, tend to experience a unique set of severe stressors (e.g., divorce, death of loved ones), and are also at substantially elevated risk to suffer from mood and anxiety disorders. The purpose of this research is to understand the mechanisms by which variability in estradiol (E2) is associated with the symptoms of anxiety and anhedonia (loss of interest and pleasure - a common symptom of depression). By stabilizing E2 variability with a hormonal manipulation, this research will determine the degree to which the E2 variability (or E2 levels) plays a causal role in perimenopausal anxiety and anhedonia symptoms and whether it does so by affecting biological responses to stress.

Detailed description:
Framed within a diathesis-stress model, the primary objective of this research is to determine the pathophysiological mechanisms of estradiol (E2) in the clinical anxiety and anhedonia seen in the menopause transition (MT). Specifically whether E2 variability or E2 levels predict exaggerated hypothalamic-pituitary-adrenal (HPA) axis reactivity and impaired recovery to stress and, in turn, deficits in behavioral indices of threat responsivity and approach motivation and symptoms of anxiety and anhedonia. The secondary objective of the research is to use a hormonal manipulation as a mechanistic probe to stabilize E2 variability in premenopausal ranges and determine if: a) HPA axis reactivity/recovery represents a biomarker of behavioral and symptom responses to E2 stabilization; b) whether recent severe life stress predicts the HPA axis response to hormone stabilization.

A total of 170 women in the early or late MT who are eligible for the hormonal probe will be recruited to reflect the full continuum of anxiety and anhedonia symptoms based on self-report to the State-Trait Anxiety Inventory and the Snaith-Hamilton Pleasure Scale, respectively. However, the investigators will over-represent the clinically impairing end of the anxious and anhedonic phenotype (75% of the sample). Over an 8-week baseline, anxiety and anhedonia symptoms and serum E2 measured by liquid chromatography-tandem mass spectrometry (LC-MS/MS) will be assessed on a weekly basis. At baseline week 8, HPA axis (plasma cortisol and ACTH) response to the Trier Social Stress Test and behavioral measures of threat responsivity (via Dot-Probe task) and approach motivation (Effort Expenditure for Rewards Task 'EEfRT') will be determined. Using transdermal E2 as a pharmacological probe to stabilize variability of E2 in premenopausal ranges, women will then be randomized to transdermal E2 (0.10 mg) or placebo for 16 weeks. This is not a clinical efficacy trial. The investigators will use an randomized control trial (RCT) design with a hormonal manipulation in order to investigate the pathophysiologic role of E2 variability (or E2 levels) in HPA axis dysregulation and, in turn, threat responsivity and approach motivation. Serum E2 will be assessed weekly during weeks 9-16, and HPA axis reactivity to stress and behavioral responses to the Dot-Probe and EEfRT tasks will be assessed every four weeks during the 16 week probe.

Arms:
arm 1: Placebo patches worn for 16 weeks. On the 9th week of patch, oral placebo capsule taken daily for 12 days. Following the 16 weeks of patch use oral placebo capsule taken daily for 12 days. arm 2: Estradiol patches worn for 16 weeks. On the 9th week of patch, oral progesterone capsule taken daily for 12 days. Following the 16 weeks of estradiol patch use oral progesterone capsule taken daily for 12 days.

Interventions: intervention 1: Estradiol Patch, 0.1 Mg/24 Hours Weekly Transdermal Film, Extended Release intervention 2: Placebo Patch intervention 3: Progesterone Capsule intervention 4: Placebo Oral Capsule
Intervention descriptions: intervention 1: Transdermal Estradiol worn daily for 16 weeks (patch changed every 7 days). intervention 2: Matching placebo patches to be worn every day for 16 weeks (patch changed every 7 days). intervention 3: Micronized progesterone (200 mg) will be administered every day for 12 days during the 9th week of randomization and again following randomization at the 17th week intervention 4: Matching placebo capsules will be administered orally every day for 12 days during the 9th week of randomization and again following randomization at the 17th week.

Protocol document:
Prot_SAP_000.pdf: 
 
The Menopause Transition: Estrogen Variability, HPA Axis and 
Affective Symptoms 
 
 
 
NCT number NCT03003949 
Document Date 02/15/2021 
 


  
UNC Changes Study 
The Menopause Transition: Estrogen Variability, HPA Axis and Affective Symptoms 
UNC IRB #16-1731 
National Clinical Trial (NCT) Identified Number:  NCT03003949 
Principal Investigator: Dr. Susan Girdler, PhD. 
Funded by NIH 1R01MH108690 
Version Number:  v.1.0 
15 February 2021 
 
 


  
 
 
Table of Contents 
STATEMENT OF COMPLIANCE ............................................................................................................................. 1 
1 
PROTOCOL SUMMARY ............................................................................................................................... 1 
1.1 
Synopsis ................................................................................................................................................ 1 
1.2 
Schema ................................................................................................................................................. 3 
1.3 
Schedule of Activities (SoA) ............................................................................................................... 4 
2 
INTRODUCTION ............................................................................................................................................ 4 
2.1 
Study Rationale .................................................................................................................................... 4 
2.2 
Background ........................................................................................................................................... 5 
2.3 
Risk/Benefit Assessment .................................................................................................................... 7 
2.3.1 
Known Potential Risks ..................................................................................................... 7 
2.3.2 
Known Potential Benefits .............................................................................................. 10 
2.3.3 
Assessment of Potential Risks and Benefits .............................................................. 10 
3 
OBJECTIVES AND ENDPOINTS .............................................................................................................. 11 
4 
STUDY DESIGN ........................................................................................................................................... 12 
4.1 
Overall Design .................................................................................................................................... 12 
4.2 
Scientific Rationale for Study Design .............................................................................................. 12 
4.3 
Justification for Dose ......................................................................................................................... 12 
4.4 
End of Study Definition ..................................................................................................................... 13 
5 
STUDY POPULATION ................................................................................................................................ 13 
5.1 
Inclusion Criteria ................................................................................................................................ 13 
5.2 
Exclusion Criteria ............................................................................................................................... 13 
5.3 
Lifestyle Considerations .................................................................................................................... 14 
5.4 
Screen Failures .................................................................................................................................. 14 
5.5 
Strategies for Recruitment and Retention ...................................................................................... 14 
6 
STUDY INTERVENTION ............................................................................................................................ 15 
6.1 
Study Intervention(s) Administration ............................................................................................... 15 
6.1.1 
Study Intervention Description ..................................................................................... 15 
6.1.2 
Dosing and Administration ............................................................................................ 16 
6.2 
Preparation/Handling/Storage/Accountability ................................................................................ 16 
6.2.1 
Acquisition and accountability ...................................................................................... 16 
6.2.2 
Formulation, Appearance, Packaging, and Labeling ................................................ 17 
6.2.3 
Product Storage and Stability ....................................................................................... 17 
6.2.4 
Preparation ...................................................................................................................... 17 
6.3 
Measures to Minimize Bias: Randomization and Blinding ........................................................... 17 
6.4 
Study Intervention Compliance ........................................................................................................ 17 
6.5 
Concomitant Therapy ........................................................................................................................ 17 
6.5.1 
Rescue Medicine ............................................................................................................ 17 
7 
STUDY INTERVENTION DISCONTINUATION AND PARTICIPANT 
DISCONTINUATION/WITHDRAWAL .................................................................................................................... 17 
7.1 
Discontinuation of Study Intervention ............................................................................................. 17 
7.2 
Participant Discontinuation/Withdrawal from the Study ............................................................... 18 
7.3 
Lost to Follow-Up ............................................................................................................................... 18 
8 
STUDY ASSESSMENTS AND PROCEDURES ...................................................................................... 19 


  
8.1 
Efficacy Assessments ....................................................................................................................... 19 
8.2 
Safety and Other Assessments ....................................................................................................... 19 
8.3 
Adverse Events and Serious Adverse Events ............................................................................... 20 
8.3.1 
Definition of Adverse Events (AE) ............................................................................... 20 
8.3.2 
Definition of Serious Adverse Events (SAE) .............................................................. 20 
8.3.3 
Classification of an Adverse Event .............................................................................. 21 
8.3.4 
Time Period and Frequency for Event Assessment and Follow-Up ....................... 22 
8.3.5 
Adverse Event Reporting .............................................................................................. 23 
8.3.6 
Serious Adverse Event Reporting ............................................................................... 23 
8.3.7 
Reporting Events to Participants ................................................................................. 23 
8.3.8 
Events of Special Interest ............................................................................................. 23 
8.3.9 
Reporting of Pregnancy ................................................................................................ 23 
8.4 
Unanticipated Problems .................................................................................................................... 23 
8.4.1 
Definition of Unanticipated Problems (UP) ................................................................. 23 
8.4.2 
Unanticipated Problem Reporting ................................................................................ 24 
8.4.3 
Reporting Unanticipated Problems to Participants ................................................... 25 
9 
STATISTICAL CONSIDERATIONS .......................................................................................................... 25 
9.1 
Statistical Hypotheses ....................................................................................................................... 25 
9.2 
Sample Size Determination .............................................................................................................. 26 
9.3 
Populations for Analyses .................................................................................................................. 26 
9.4 
Statistical Analyses ............................................................................................................................ 26 
9.4.1 
General Approach .......................................................................................................... 27 
9.4.2 
Analysis of the Primary Efficacy Endpoint(s) ............................................................. 27 
9.4.3 
Analysis of the Secondary Endpoint(s) ....................................................................... 28 
9.4.4 
Safety Analyses .............................................................................................................. 28 
9.4.5 
Baseline Descriptive Statistics ..................................................................................... 28 
9.4.6 
Planned Interim Analyses ............................................................................................. 28 
9.4.7 
Sub-Group Analyses ..................................................................................................... 29 
9.4.8 
Tabulation of Individual participant Data .................................................................... 29 
9.4.9 
Exploratory Analyses ..................................................................................................... 29 
10 
SUPPORTING DOCUMENTATION AND OPERATIONAL CONSIDERATIONS .............................. 29 
10.1 
Regulatory, Ethical, and Study Oversight Considerations ........................................................... 29 
10.1.1 
Informed Consent Process ........................................................................................... 29 
10.1.2 
Study Discontinuation and Closure ............................................................................. 30 
10.1.3 
Confidentiality and Privacy ........................................................................................... 30 
10.1.4 
Future Use of Stored Specimens and Data ............................................................... 31 
10.1.5 
Key Roles and Study Governance .............................................................................. 31 
10.1.6 
Safety Oversight ............................................................................................................. 32 
10.1.7 
Clinical Monitoring .......................................................................................................... 32 
10.1.8 
Quality Assurance and Quality Control ....................................................................... 32 
10.1.9 
Data Handling and Record Keeping ............................................................................ 33 
10.1.10 
Protocol Deviations ........................................................................................................ 33 
10.1.11 
Publication and Data Sharing Policy ........................................................................... 34 
10.1.12 
Conflict of Interest Policy .............................................................................................. 34 
10.2 
Additional Considerations ................................................................................................................. 35 
10.3 
Abbreviations ...................................................................................................................................... 36 
10.4 
Protocol Amendment History .............................................................. Error! Bookmark not defined. 


  
11 
REFERENCES ............................................................................................................................................. 37 
 


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STATEMENT OF COMPLIANCE 
 
The trial will be carried out in accordance with International Conference on Harmonisation Good 
Clinical Practice (ICH GCP) and the following:  
 
• 
United States (US) Code of Federal Regulations (CFR) applicable to clinical studies (45 CFR 
Part 46, 21 CFR Part 50, 21 CFR Part 56, 21 CFR Part 312, and/or 21 CFR Part 812)  
 
National Institutes of Health (NIH)-funded investigators and clinical trial site staff who are 
responsible for the conduct, management, or oversight of NIH-funded clinical trials have 
completed Human Subjects Protection and ICH GCP Training. 
 
The protocol, informed consent form(s), recruitment materials, and all participant materials will 
be submitted to the Institutional Review Board (IRB) for review and approval.  Approval of both 
the protocol and the consent form must be obtained before any participant is enrolled.  Any 
amendment to the protocol will require review and approval by the IRB before the changes are 
implemented to the study.  In addition, all changes to the consent form will be IRB-approved; a 
determination will be made regarding whether a new consent needs to be obtained from 
participants who provided consent, using a previously approved consent form.] 
1 
 
PROTOCOL SUMMARY 
1.1 
SYNOPSIS  
Title: 
The Menopause Transition: Estrogen Variability, HPA axis and Affective 
Symptoms 
Study Description: 
Women in the menopause transition ('perimenopause') are exposed to 
extreme hormone variability, tend to experience a unique set of severe 
stressors (e.g., divorce, death of loved ones), and are also at substantially 
elevated risk to suffer from mood and anxiety disorders. The purpose of 
this research is to understand the mechanisms by which variability in 
estradiol (E2) is associated with the symptoms of anxiety and anhedonia 
(loss of interest and pleasure - a common symptom of depression). By 
stabilizing E2 variability with a hormonal manipulation, this research will 
determine the degree to which the E2 variability (or E2 levels) plays a 
causal role in perimenopausal anxiety and anhedonia symptoms and 
whether it does so by affecting biological responses to stress. 
Objectives: 
 
Primary Objectives: 
1. Change over time in anxiety score from State-Trait Anxiety Inventory 
[Time Frame: Baseline (Week 8), Weeks 16, 20 and 24] 
2. Change over time in anhedonia score from the Snaith-Hamilton 
Pleasure Scale [Time Frame: Baseline (Week 8), Weeks 16, 20 and 24] 
 
Secondary Objectives: 
1. Change over time in AUC cortisol stress response [Time Frame: 
Baseline (Week 8), Weeks 16, 20 and 24] 
2. Change over time in threat reactivity from Dot Probe behavioral 
task [Time Frame: Baseline (Week 8), Weeks 16, 20 and 24] 


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3. Change over time in measure of effort for motivation and 
anhedonia from Effort Expenditure for Reward Task [Time Frame: 
Baseline (Week 8), Weeks 16, 20 and 24] 
 
 
Endpoints: 
Primary Endpoints: 
1. Change in STAI score [Time Frame: Baseline (Week 8), Weeks 16, 20 
and 24] 
2. Change in SHAPS score [Time Frame: Baseline (Week 8), Weeks 16, 20 
and 24] 
Secondary Endpoints: 
1. Change in AUC cortisol response [Time Frame: Baseline (Week 8), 
Weeks 16, 20 and 24] 
2. Change in “threat bias” score from Dot Probe task [Time Frame: 
Baseline (Week 8), Weeks 16, 20 and 24] 
3. Change in “hard choice” score from EEfRT [Time Frame: Baseline 
(Week 8), Weeks 16, 20 and 24] 
Study Population: 
250 medically healthy female volunteers aged 45-60 undergoing natural 
menopause transition who meet STRAW+10 criteria for early or late 
menopause transition and are candidates for transdermal E2 and have had 
a normal mammogram in the previous 12 months. 
Phase: 
N/A 
Description of 
Sites/Facilities Enrolling 
Participants: 
Subjects are recruited from the area surrounding Chapel Hill, North 
Carolina and will be enrolled at the UNC-CH laboratory site located at 2218 
Nelson Highway, Suite 1, Chapel Hill, NC 27517. Medical screening, 
including the gynecological exam and screening mammogram will occur at 
the UNC Medical Center on the UNC-CH campus. This study is not 
intended to include sites outside of the United States. 
Description of Study 
Intervention: 
Subjects randomized to the active treatment arm will wear a transdermal 
estradiol patch (0.1mg) every day for 16 weeks, changing the patch every 7 
days. They will also take 200mg of micronized progesterone oral capsules 
every day for 12 days 8 weeks after randomization to estradiol and again 
at the end of the 16th week of randomization to estradiol. Subjects 
randomized to the placebo arm will follow the same regimen using 
matching placebo transdermal patches and placebo capsules. 
Study Duration: 
Enrollment will occur for approximately 54 months and data analysis will 
occur for 6 months following the close of enrollment. Estimated total 
study duration is 60 months. 
Participant Duration: 
Following medical screening, individual participation study duration is 6 
months (24 weeks). Randomization to active/placebo treatment arm 
occurs at week 8, and subjects will be in the intervention phase for a total 
duration of 16 weeks. 
 
 
 
 
 
 
 
 


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Medical Screening and Enrollment 
• 
Obtain informed consent 
• 
Screen potential participants by inclusion and exclusion criteria with online, phone, and medical 
screening via gynecological exam and mammogram 
• 
Obtain history, document 
1.2 
SCHEMA 
 
 
 
 
 
 
Lab Session- Baseline Assessments 
• 
Administer STAI and SHAPS questionnaires 
• 
Administer Dot Probe and EEfRT behavioral tasks 
• 
Administer Trier Social Stress Test (TSST) and collect serum to measure cortisol at the end of 
baseline rest and at minutes 20, 30, and 45 of recovery post-TSST 
• 
Urine HCG test to confirm subject is not pregnant prior to randomization 
 
Randomization 
• 
Active Intervention Group (0.10mg transdermal estradiol (E2))  
• 
Placebo (matching inactive patch) 
• 
Administer initial dose of study drug intervention  
Lab Session- Study Intervention, Side Effect & Compliance Checks 
• 
Administer STAI and SHAPS questionnaires 
• 
Administer Dot Probe and EEfRT behavioral tasks 
• 
Administer Trier Social Stress Test (TSST) and collect serum to measure cortisol at the end of 
baseline rest and at minutes 20, 30, and 45 of recovery post-TSST 
• 
Administer oral micronized progesterone (200mg daily)/matching placebo capsules for subjects to 
take for twelve days starting on Week 17 for the same treatment arms as E2/placebo 
randomization 
Week 8 
Week 16 
Week 20 
Lab Session- Study Intervention, Side Effect & Compliance Checks 
• 
Administer STAI and SHAPS questionnaires 
• 
Administer Dot Probe and EEfRT behavioral tasks 
• 
Administer Trier Social Stress Test (TSST) and collect serum to measure cortisol at the end of 
baseline rest and at minutes 20, 30, and 45 of recovery post-TSST 
• 
Continued administration of transdermal E2/placebo patch 
Week 24 
Final Lab Session- Study Intervention, Side Effect & Compliance Checks 
• 
Administer STAI and SHAPS questionnaires 
• 
Administer Dot Probe and EEfRT behavioral tasks 
• 
Administer Trier Social Stress Test (TSST) and collect serum to measure cortisol at the end of 
baseline rest and at minutes 20, 30, and 45 of recovery post-TSST 
• 
Administer oral micronized progesterone (200mg daily)/matching placebo capsules for subjects to 
take for twelve days starting on Week 25 for the same treatment arms as E2/placebo 
randomization 
• 
Discontinue use of transdermal E2/placebo patch 
Week 0 


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1.3 
SCHEDULE OF ACTIVITIES (SOA) 
 
 
 
 
 
 
 
Procedures 
Medical Screening 
and Enrollment 
Week 0 
Lab Session- Baseline 
Assessments & 
Randomization 
Week 8 
Lab Session- Study 
Intervention, Side 
Effects, and Compliance 
Checks 
Week 16 
Lab Session- Study 
Intervention, Side 
Effects, and Compliance 
Checks 
Week 20 
Final Lab Session- 
Study Intervention, 
Side Effects, and 
Compliance Checks 
Week 24 
Informed consent  
X 
 
 
 
 
Demographics 
X 
 
 
 
 
Medical history 
X 
 
 
 
 
Physical and gynecological 
exam (including height and 
weight) 
X 
 
 
 
 
Screening mammogram  
X 
 
 
 
 
Pregnancy test a 
 
X 
 
 
 
Randomization 
 
X 
 
 
 
Administer transdermal 
estradiol/placebo 
 
X 
X 
X 
 
Administer micronized 
progesterone/placebo 
 
 
X 
 
X 
Discontinue transdermal 
estradiol/placebo 
 
 
 
 
X 
Administer STAI and SHAPS 
questionnaires 
 
X 
X 
X 
X 
Administer Dot Probe and 
EEfRT behavioral tasks 
 
X 
X 
X 
X 
Administer Trier Social 
Stress Test (TSST) and 
collect serum to measure 
cortisol b 
 
X 
X 
X 
X 
Adverse event review and 
evaluation 
 
X 
X 
X 
X 
a: urine pregnancy test (women of childbearing potential) 
b: serum collected at the end of baseline rest and at minutes 20, 30, and 45 of recovery post-TSST 
 
 
2 
 
INTRODUCTION 
 
2.1 
STUDY RATIONALE  
 
Vulnerability to the deleterious mood effects of normal changes in reproductive hormones is a likely 
underpinning to reproductive mood disorders. The menopause transition (MT) is associated with 
pronounced hormonal variability (within the context of relative E2 deprivation) and substantially 
increased risk for clinically impairing anxiety and anhedonia. Anxiety is characterized by cognitive bias to 


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interpret ambiguous stimuli in a threat-related manner. Anhedonia can be defined by decreased 
motivation to approach rewards. The neurobiologically-based constructs of ‘threat reactivity’ and 
‘approach motivation’ provide a framework for studying the pathophysiology of the clinical impairment 
experienced by 25% of women in the MT. Although the causes of affective symptoms in the MT remain 
unknown, severe life stress proximate to the MT is a strong predictor. Framed within a diathesis-stress 
model, the primary objective of this research is to determine the pathophysiological mechanisms of 
estradiol (E2) in the clinical anxiety and anhedonia seen in the MT. Specifically whether E2 variability or 
E2 levels predict exaggerated hypothalamic-pituitary-adrenal (HPA) axis reactivity and impaired recovery 
to stress and, in turn, deficits in behavioral indices of threat responsivity and approach motivation and 
symptoms of anxiety and anhedonia. The secondary objective of the research is to use a hormonal 
manipulation as a mechanistic probe to stabilize E2 variability in premenopausal ranges and 
determine if HPA axis reactivity/recovery represents a biomarker of behavioral and symptom responses 
to E2 stabilization. 
 
A total of 250 women in the early or late MT who are eligible for the hormonal probe will be recruited to 
reflect the full continuum of anxiety and anhedonia symptoms based on self-report to the State-Trait 
Anxiety Inventory and the Snaith-Hamilton Pleasure Scale, respectively. At baseline week 8, HPA axis 
(plasma cortisol) response to the Trier Social Stress Test and behavioral measures of threat responsivity 
(via Dot-Probe task) and approach motivation (Effort Expenditure for Rewards Task ‘EEfRT’) will be 
determined. Using transdermal E2 as a pharmacological probe to stabilize variability of E2 in 
premenopausal ranges, women will then be randomized to transdermal E2 (0.10 mg) or placebo for 16 
weeks. This is not a clinical efficacy trial. We will use an RCT design with a hormonal manipulation to 
investigate the pathophysiologic role of E2 variability (or E2 levels) in HPA axis dysregulation and, in 
turn, threat responsivity and approach motivation. HPA axis reactivity to stress and behavioral 
responses to the Dot-Probe and EEfRT tasks, as well as self-report symptoms on the STAI and SHAPS 
measures will be assessed at weeks 8, 12, and 16 during the 16-week probe. 
 
2.2 
BACKGROUND  
 
Clinical, basic, and epidemiologic research indicates that reproductive events provide an endocrine 
context of vulnerability for the emergence of mood and anxiety disorders and impairment in women1.  
Though the causes of affective disorders tied to reproductive events are unknown, studies in menstrual 
mood disorders and postpartum depression suggest that a vulnerability to normal changes in ovarian 
steroid hormones is etiologic 2,3.  The menopause transition (‘perimenopause’) is a reproductive stage 
associated with pronounced hormone variability and risk for psychiatric illness.  The menopause 
transition (MT) is an ideal model for studying the etiologic role of ovarian hormone changes in affective 
illness.  
 
During the MT (average duration = 5 years), the risk of major depressive disorder (MDD) increases two 
to three-fold 4, in addition to the two to four-fold increase in risk of clinically significant depressive 
symptoms, affecting 26-33% of women in the MT 5-8. A parallel increase in suicide ideation and attempts 
emerges in perimenopausal compared with pre- or postmenopausal women or age-matched men. While 
the causes of perimenopausal affective disorders are unknown, stressful life events are a strong 
predictor of the development of depression in the MT 4-6.   
 
The Phenotype of Perimenopausal Depression:  Women in the MT with impairing mental health 
symptoms typically present with an anxious and anhedonic phenotype 9-11.  Common to all anxiety 


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disorders is an exaggerated neurobiological sensitivity to threat, indexed by cognitive biases to regard 
ambiguous stimuli as threatening 12,13.  The brain regions involved in processing threat information (e.g., 
hippocampus) activate stress-responsive systems, including the hypothalamic-pituitary-adrenal (HPA) 
axis.  Perceived threat is a feature of stress that elicits cortisol increases14. Anhedonia (loss of pleasure 
or interest) has emerged as an endophenotype in depressive disorders15.  Patients with anhedonia 
exhibit diminished sensitivity and attentional bias towards positively valanced stimuli and reduced 
behavioral and neurobiological responsiveness to reward cues15.  Anhedonia can be defined as reduced 
motivation to approach rewards (reward “wanting”).  
 
This research will employ a more fine-grained approach to defining impairment in perimenopausal 
women by focusing on anxiety and anhedonia symptoms.  This will allow for more precise integration of 
a particular psychopathology with underlying biological mechanisms (E2 regulation of HPA axis 
reactivity) and fundamental constructs (threat responsivity and approach motivation), and therefore 
advance our knowledge of the causes of the clinical impairment experienced by 25% of women in the 
MT. 
 
Endocrinology of the Menopause Transition: While there are individual differences in the hormonal 
trajectory during the MT 16,17, most women experience the following changes beginning in the early and 
progressing to the late MT 18,19.  First, cycle length becomes increasingly variable, with long cycles 
becoming more common as the transition progresses. While short cycles are due to early follicular 
recruitment by intermittently high FSH, long cycles can be due to anovulation or a delayed ovarian 
response to FSH stimulation, resulting in an extended (low-E2) early follicular phase. Second, luteal 
progesterone (P4) also declines, resulting from declining dominant follicle quality. Third, appearing in 
the early and continuing into the late MT are cycles in which E2 levels are elevated compared to 
premenopausal levels, due to high FSH and ovarian hyperstimulation 20. The late MT is marked by more 
anovulatory cycles, characterized by low P4 and erratic E2.  In sum, most women in the MT are exposed 
to erratic hormonal flux. Anovulatory cycles results in fewer increases in P4, but variable FSH causes 
periods of both hypo- and hyper-estrogenism 21. 
 
The Hormone Milieu and Affective Symptoms in the Menopause Transition:  While women in the MT are 
exposed to periods of relative hyper-estrogenism, mean levels of E2 are lower than in premenopausal 
women 22,23, especially in late MT.   Whether the clinical symptomatology experienced during the MT is 
consequent to E2 deprivation or E2 variability has not been empirically tested.  Estradiol: 1) 
“beneficially” modulates systems implicated in depressive illness (e.g., neurotransmitters, 
neuroplasticity)24-27; 2) displays anti-depressant effects in animals 28-31; 3) regulates brain circuits 
important for emotional processing32 and fear conditioning33 and protects against fear and anxiety34.  
While the planned research will test whether alterations in the neurobiologically based constructs of 
threat reactivity and approach motivation underlying anxiety and anhedonia is best explained by E2 
variability or E2 levels, most evidence supports the variability hypothesis 35-45. Schmidt et al.,46 placed 
euthymic perimenopausal women (CES-D = 3) on three weeks of transdermal E2 (100 ug/day) then 
blindly and abruptly withdrew half of the women.  Those with a history of perimenopausal depression 
(PMD) had an increase in depressive symptoms (CESD = 12) within 1-3 weeks, an effect not seen in 
unaffected controls or in those maintained on E2. The specific symptoms that increased with abrupt E2 
withdrawal were only: anxiety, excessive worry, anhedonia, motivation, and social avoidance – 
supporting an etiologic role for E2 in the clinical anxiety and anhedonia experienced in the MT. 
However, that study did not measure E2, limiting conclusions about the mechanism underlying 
emergence of symptoms (i.e., withdrawal from E2 stabilization or induction of E2 deprivation). Our prior 
research strongly implicates E2 variability, not levels47. 


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E2 regulation of the HPA axis as a Candidate Mechanism in the Psychopathology of the MT: Impairment 
in HPA axis regulation is implicated in human affective illness48.  Gonadal steroid hormones play a vital 
role in modulating HPA axis function.  Estrogens stimulate the HPA-axis through an interaction of 
estrogen receptors (ERs) in the promoter region of the human CRH gene 49.  ERs are expressed 
throughout the brain 50, including the paraventricular nucleus of the hypothalamus.  The genomic action 
of E2 is mediated by ERα and ERß.   E2 also has rapid cellular effects by inducing changes in second 
messenger pathways and intracellular Ca+ 51,52.  Although ERs are abundant in regions involved in affect 
regulation53, 54,55, E2 regulatory control of the HPA axis may be most relevant to understanding anxiety 
and anhedonia in the MT, particularly in the context of stressful life events. 
 
In rodents, ovariectomy reduces stress-induced corticosterone (CORT) and ACTH secretion, an effect 
reversed by systemic E2 treatment 56, 57,58.  Acute stress increases production of E2 in the PVN59 and its 
presence is associated with enhanced responsiveness of the HPA axis to stress, mediated by E2-induced 
impairment in glucocorticoid negative feedback57.  The effect of E2 depends on the ER signaling 
pathways60 since stimulation of ERα and ERß, exerts opposite effects on the CORT and ACTH stress 
response 56,59-61.  Consequently, alternations between hyper- and hypo-estrogenism, characteristic of the 
MT, could exert a destabilizing effect on the regulatory control of the HPA axis.  Testing HPA stress 
reactivity as a mediator in the relationship of E2 variability (or levels) to threat responsivity and 
approach motivation, and clinical symptoms, in perimenopausal women represents a novel contribution 
of this research.  
 
The significance and impact of the proposed research is in delineating the role of E2 variability versus E2 
levels in the clinical symptoms seen in a substantial proportion of women in the MT and testing a 
candidate physiologic mediating mechanism (HPA axis) of E2.  This research will advance a diathesis-
stress model of affective state change involving E2 (variability or levels) as the diathesis for HPA axis 
dysregulation and affective symptoms, in the context of severe life stress.   
 
2.3 
RISK/BENEFIT ASSESSMENT   
 
2.3.1 KNOWN POTENTIAL RISKS  
 
The most frequent side effects associated with estradiol use include: 
 
• 
breast tenderness (occurs in 29% of patients) 
• 
abdominal cramps (occurs in 16% of patients) 
• 
headache (occurs in 13% of patients) 
• 
edema (swelling) (occurs in 10% of patients) 
• 
nausea (occurs in 6% of patients) 
• 
depression, nervousness (occurs in 11% of patients) 
• 
acne (occurs in 3 – 12% of patients) 
• 
skin rash or irritation may also occur at site where the patch is placed (occurs in 3 - 12% of 
patients) 
 
Less frequent side effects associated with estradiol use include: 
 
• 
jaundice (yellowing of skin) 


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• 
increased blood pressure 
• 
worsening of migraines or asthma 
• 
enlargement of uterine fibroids 
• 
intolerance to contact lenses 
• 
dizziness 
• 
changes in appetite and weight 
 
The most common side effects associated with progesterone use include: 
 
• 
breast tenderness (occurs in 16% of patients) 
• 
dizziness (occurs in 24% of patients) 
• 
abdominal cramping (occurs in 20% of patients) 
• 
headache (occurs in 16% of patients) 
• 
viral infection (occurs in 12% of patients) 
• 
joint pain (occurs in 12% of patients) 
• 
diarrhea (occurs in 8% of patients) 
• 
menstrual bleeding, sometimes consistent with a heavy menstrual period (occurs in 20-30% of 
patients) 
• 
drowsiness (occurs in 9% of patients) 
 
Less common side effects associated with progesterone use include: 
 
• 
vaginal discharge 
• 
chest pain 
• 
abdominal bloating 
 
Rare yet Serious Risks Associated with Perimenopausal Hormone Use: 
 
The Women’s Health Initiative (WHI) study results will be summarized here to provide a context for 
understanding risk and the current expert opinions about hormone administration to women in the 
menopausal transition. 
 
The WHI enrolled > 27,000 women aged 50-79 years old (mean=63 years).  They were randomized to 
either oral Estrogen Replacement therapy (ERT, for those without a uterus), Hormone Replacement 
Therapy (HRT, conjugated equine estrogen), or placebo. The HRT arm was terminated after 5 years due 
to an increased incidence of breast cancer; the results also suggested an increase in non-fatal MI and 
stroke. Two years later, although there appeared to be reduced risk of cardiovascular disease (CVD) 
among 50–59-year-old women who were on ERT, the NIH also terminated the ERT arm based on overall 
risk/benefit ratios for all age groups. These findings appropriately ended the routine prescription of HRT 
for CVD prophylaxis, a practice formerly based on observational studies demonstrating a 50% reduction 
in CVD in women taking HRT. 
 
Cardiovascular Risk.  In the intervening years, two ”white paper” reviews by the North American 
Menopause Society and the Endocrine Society (representing the work of 30 leading experts and four 
levels of review) as well as reports of subgroup analyses and one surrogate endpoint study from the WHI 
all concluded that the effects of HRT on CVD are modified by the timing of its initiation, with beneficial 
or neutral effects on CVD in women who initiate therapy close to the menopause onset (during the fatty 


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streak to uncomplicated plaque stage of atherosclerosis) and harmful effects in women who are older or 
initiate therapy with a long latency after onset of menopause (presumably in the stage of plaque 
necrosis and inflammation). These data are compatible with those from cynomolgus monkeys 
demonstrating that, E2’s atheroprotective effects decrease with prolonged E2 deficiency; ERT or HRT 
reduces coronary atherosclerosis by 50-70% if initiated immediately after ovariectomy, while no benefit 
is observed if delayed for years. 
 
Breast Cancer.  The increase in breast cancer observed in the WHI reflects the prior use of HRT in 25% of 
the study sample; the hazard ratio for breast cancer in the remaining 75% of the sample was 1.02.  Data 
from the Endocrine Society Scientific Statement report a worst-case scenario increased risk of breast 
cancer in a 50–54-year-old woman with five years of unopposed estrogen from 13/1000 women (no 
ERT) to 14.94/1000 women.  Thus, the risk of exposure to 16 weeks of E2, especially given our plans to 
screen out individuals at risk for heritable breast cancer, would be insubstantial. 
 
Venous Thromboembolism (VTE).  The risk of VTE is clearly increased with hormone use, with the risk 
influenced by age and hormone preparation. In the WHI, the risk of VTE was greater with combined 
estrogen + progestin (HRT) (HR 2.06) than with conjugated equine estrogen alone (HR 1.32), with both 
risk rates reduced in the 50–59-year-old subjects (estimated excess events 9-10/1,000 for HRT and 3-
4/1000 for ERT). Notably, the risk for VTE is significantly reduced using transdermal E2 in case control 
studies (HR 0.9 compared with HR 4.2 in those taking oral estrogen). 
 
Stroke.  It is possible that ERT increased the risk of stroke, but this is age dependent.   ERT increased risk 
of stroke in the Women' Health Initiative study in 50 - 59-year-old women by an additional 1 case per 
5000 women. 
 
In sum, the Endocrine Society concludes that “Data from the various Women’s Health Initiative studies, 
which involved women of average age 63, cannot be appropriately applied to calculate risks and 
benefits of menopausal hormone therapy in women starting shortly after menopause”.  In fact, there is 
substantial evidence for the safety of E2, particularly if administered to women within 10 years of their 
final menstrual period and if administered as the transdermal form (e.g., lower risk of VTE).  Given our 
plans to administer transdermal E2 to women: 1) for only 16 weeks, 2) no older than 60 years of age, 3) 
who are within 1 year of their final menstrual period, and 4) who are at no greater than average risk for 
CVD, breast cancer or VTE, the risk of serious adverse events are exceedingly low. 
 
Endometrial Cancer - Exposure to estrogen by itself increases the risk of endometrial cancer two-fold.  
However, use of a progesterone prevents the increased risk of endometrial cancer.  Although giving a 
small dose of progesterone every day or giving a larger dose for 12 days every month are the most 
common clinical practices to protect against endometrial cancer when using estrogen, there have been 
no research studies specifically designed to determine which is the most protective type of 
progesterone and which is the most protective frequency of administration.   In the current research 
study, we plan to give a progesterone (200 mg/day) for 12 days every two months.  In a prior study of 
Dr. Girdler’s, that used the same enrollment criteria as in this study (medically healthy women 45 – 60 
years of age in the menopause transition), progesterone was given at a dose of 200/mg day for 12 days 
every two or three months. Of the 86 women who received the active estrogen and this regimen of 
progesterone, one woman (1% of the women) developed endometrial hyperplasia.  Endometrial 
hyperplasia is a risk factor for the development of endometrial cancer.  However, in this case, the cells 
were not atypical, meaning that the cells were not characteristic of cancer cells.   Only 1.6% of patients 
diagnosed with hyperplasia without atypical cells develop endometrial cancer, while 22% of patients 


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who have the atypical cells go on to develop endometrial cancer.  This research participant was 
withdrawn from the study and treated clinically with progesterone which was effective in eliminating 
the endometrial hyperplasia.       
 
Risks Associated with Discontinuation of Hormones. For women who were experiencing menopausal 
vasomotor symptoms and/or vaginal dryness and are randomized to the active estradiol, there is the 
risk that these menopausal symptoms may return once hormones are discontinued.  Over a sixteen-
week interval of treatment, we would rate this as a likely possibility in those who were experiencing 
symptoms at baseline.  These risks are minimal as it simply returns the woman to the pre-randomized 
hormone state.  There is no evidence in the literature or clinical practice that abruptly discontinuing 
hormone replacement therapy is associated with negative clinically meaningful sequelae. 
 
Risks Associated with the Vaginal Exam and Endometrial Biopsy:  There are no significant risks associated 
with the vaginal ultrasound of the uterus, though the insertion of the ultrasound probe and speculum to 
be associated with a sensation of increased pressure but immediately terminated when the probe and 
speculum are removed.  Endometrial biopsies may cause cramping both during the procedure and 
afterwards.  There may also be temporary spotting. Rare complications include excessive uterine 
bleeding and uterine perforation (0.1-1.3% risk). 
 
Risks Associated with Mammography:  The amount of radiation to the breast from one mammogram is 
43 mrem which is equivalent to the radiation exposure that everyone receives in 52 days from natural 
background radiation. There is the risk that a mammogram will falsely indicate an abnormality that 
could cause unnecessary anxiety and/or extra procedures to be performed.  There may be some 
discomfort by the compression of the breast tissue. 
 
Other Risks:  Venipuncture (the needle stick) may result in syncope (light headedness), discomfort, 
nausea, and bruising. 
 
 
2.3.2 KNOWN POTENTIAL BENEFITS  
 
The benefit to subjects includes study-related medical evaluations, including a gynecological exam and 
screening mammogram. Subjects may also benefit by knowing that they are contributing to research 
aimed at enhancing our understanding of the causes of clinically significant anxiety and anhedonia 
symptoms in women in the menopause transition. 
 
2.3.3 ASSESSMENT OF POTENTIAL RISKS AND BENEFITS  
 
Minimizing these risks. The risk are minimized as much as possible by the following:  1) young age (45-60 
years of age); 2) careful medical evaluations, including normal mammogram and endometrial exam, to 
ensure no greater risk for these side effects than the average population of women 45 - 60 years of age; 
3) the use of intermittent micronized progesterone (200 mg/day for 12 days every 2 months)  and close 
monitoring of bleeding patterns will substantially minimize the likelihood of developing endometrial 
hyperplasia and virtually eliminate any increased risk of endometrial cancer; 4) exposure to estradiol for 
only 16 weeks since short-term exposure (< 3 years) has not been shown to be associated with an 
increased risk of breast cancer; 5) the frequent assessment of side effects; 6) the provision of 
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report to the study personnel; 7) endometrial biopsies (if needed) performed in a UNC gynecology clinic 
by a board certified gynecologist; 8)The level of radiation used by modern mammography systems does 
not significantly increase the risk for breast cancer.  Scientific data has shown that doses 100-1000 times 
greater than those used for mammography are required to show any statistical increase in breast cancer 
frequency. There is no significant risk of radiation damage to breast tissue from mammography; and 9) 
there is an independent safety board made up of a cardiologist, gynecologist, psychiatrist, and 
statistician that will be closely monitoring this study for side effects and risks. 
 
Special Considerations for Cancer Risk.  To minimize any possible risks associated with exposure to E2, 
we will obtain a comprehensive family history of cancer in each of our subjects to ensure that women 
enrolled into the present study would meet clinical criteria for average risk (i.e., risk seen in the female 
population at large) for breast and ovarian cancer.  This is the approach Dr. Girdler has used in her most 
recent study using transdermal E2 in perimenopausal women.  A review of the accuracy of self-reported 
patient history found that for breast cancer specifically, the comparison of patient reports with first 
degree relative medical records or first degree relative self-report yielded 95% sensitivity and 97% 
specificity. Thus, patient self-report of family medical history is a valid, reliable approach and continues 
to be the approach recommended for determining the clinical management not only of breast cancer 
risk, but of all common diseases.  Moreover, as in our eligibility criteria for subjects to have ‘average 
cancer risk profile’, each will also be required to have a negative mammogram within one year of 
enrollment. 
 
Risks of loss of confidentiality will be minimized using subject codes linked to all data and by maintaining 
the file linking the subject code to the name in separate secured locations.  All databases will be stored 
on a secure, HIPAA compliant network.  The server is backed up nightly.  The backup tapes reside in a 
separate location from the server off site.  The database is also protected by logins and passwords 
required to open the system.  Different levels of privileges are granted to different users.  This study will 
use a web-based, secure, password protected access to the database.  Passwords will be changed every 
90 days. 
 
3 
OBJECTIVES AND ENDPOINTS 
 
OBJECTIVES 
ENDPOINTS 
JUSTIFICATION FOR 
ENDPOINTS 
Primary 
 
 
The primary objective of this study 
is use transdermal estradiol to 
determine the pathophysiologic 
role of estradiol in clinically 
significant symptoms of anxiety 
and anhedonia in the menopausal 
transition.  
 
The primary endpoints are changes in 
mean levels from week 8 (baseline) to 
weeks 16, 20, and 24 in validated 
questionnaires for symptoms of 
anxiety and anhedonia. Specifically, 
the validated State-Trait Anxiety 
Inventory and the Snaith-Hamilton 
Pleasure Scale (SHAPS) will be 
assessed. 
The goal is to establish 
whether there is a 
causal role of estradiol 
in the clinically relevant 
anxiety and anhedonia 
symptoms seen in 
perimenopausal 
women. 
Secondary 
 
 
The secondary objectives of this 
study are to use transdermal 
estradiol to determine i) the role of 
The secondary endpoints are changes 
from week 8 (baseline) to weeks 16, 
20, and 24 in i) mean levels of 
The goal is to establish 
whether there is a 
causal role of estradiol 


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OBJECTIVES 
ENDPOINTS 
JUSTIFICATION FOR 
ENDPOINTS 
estradiol in anxiety and anhedonia 
related behaviors and ii) if HPA 
stress activation is a biomarker of 
estradiol-related behavior and 
symptomatology. 
behavioral measures of anxiety (Dot 
Probe task) and anhedonia (EEfRT 
task) and ii) in serum cortisol stress-
reactivity, as a marker of HPA stress 
activation 
 
in the clinically relevant 
anxiety and anhedonia 
related behaviors and 
stress physiology in 
perimenopausal 
women. 
 
 
 
4 
STUDY DESIGN  
 
4.1 
OVERALL DESIGN 
 
• 
Hypothesis: Our central hypothesis is that stabilization of E2 variability, not increasing E2 levels, 
will modify HPA axis stress activation and in turn, beneficially modify cognitive bias towards 
perceived threat and approach motivation, thereby decreasing anxiety and anhedonia. 
• 
Phase: N/A 
• 
Design of trial: randomized, placebo-controlled, double-blinded parallel design. 
• 
Study arms: 2 (active and placebo) 
• 
Single site study 
• 
Methods to minimize bias: Under double-blind procedures, subjects will be randomized to 
receive transdermal E2 or placebo for 16 weeks. The study biostatistician will create the 
randomization scheme and UNC Investigational Drug Services will manage the randomization 
and dispensing of hormones in blinded form. 
• 
Intervention and Dosing: Subjects randomized to active treatment arm will wear a patch deliver 
0.10mg of E2 over 24 hours and will take oral micronized progesterone (200mg/daily) for 12 
days at two points in the intervention. Subjects randomized to placebo arm will wear placebo 
patches and take placebo pills matching in appearance. 
• 
Planned Interim Analysis: Data and Safety Monitoring Board will monitor the safety of the study 
every six months. The DSMB will evaluate issues of participant safety as well as enrollment 
information and the adequacy and integrity of accumulating data 
 
4.2 
SCIENTIFIC RATIONALE FOR STUDY DESIGN 
 
THIS IS NOT A CLINICAL EFFICACY TRIAL. However, we will employ an RCT design to study the 
pathophysiologic role of E2 variability [or levels] in the clinical symptoms of women in the MT. Under 
double-blind procedures, subjects will be randomized to receive 17β- E2 or placebo for 16 weeks.  The 
study biostatistician will create the randomization scheme and UNC Investigational Drug Services will 
manage the randomization and dispensing of hormones in blinded form. For those randomized to 
transdermal E2 (n=60), each will wear a patch (generic for Climara®) delivering 0.10 mg E2/24 hours. 
Those randomized to placebo (n=60), will wear a patch identical in appearance (3M Pharmaceuticals). 
 
4.3 
JUSTIFICATION FOR DOSE 
 


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By avoiding the first-pass metabolic effects of oral estrogen, transdermal E2 creates stable, 
premenopausal follicular phase E2 blood levels; and a physiologic profile of E2 relative to its metabolites 
estrone and estriol 136-138. Transdermal E2 also has a superior thromboembolic and metabolic safety 
profile than oral estrogen. 139-141 A 7-day transdermal system provides significantly more stable 
concentrations and better patch adherence than twice weekly patches.142 We have chosen (generic 
version) Climara® 7 day patches because the adhesive layer of the matrix distributes E2 molecules to 
continuously release E2, which is transported across skin leading to sustained levels of E2.136 Because 
of the dynamic changes in the reproductive axis during the MT and the possibility that, over 24 weeks, 
some women may transition from one STRAW stage to another, placebo will control for effects of 
reproductive aging, per se, on measures of interest and for habituation effects to repeat testing. 
Progesterone Administration: To prevent E2-induced endometrial hyperplasia, women randomized to 
active E2 will take 200 mg micronized progesterone/day x 12 days during weeks 17-18 (after 2 months 
of drug intervention) and at the end of the study (weeks 25-26; after 4 months of drug intervention). 
Exposure to a progestin every 2 months is sufficient for endometrial protection.143 Under double-blind 
procedures, women randomized to placebo-E2 will take placebo P4; those randomized to active E2 will 
take active P4. We have chosen to give P4 in a discontinuous fashion instead of using Climara Pro® (a 
transdermal system that delivers both E2 and a progestin) because progestins antagonize E2 effects. 
144,145 
 
 
4.4 
END OF STUDY DEFINITION 
A participant is considered to have completed the study if he or she has completed all phases of the 
study including the last visit or the last scheduled procedure shown in the Schedule of Activities (SoA), 
Section 1.3. 
 
5 
STUDY POPULATION 
 
5.1 
INCLUSION CRITERIA 
 
To be eligible to participate in this study, an individual must meet all of the following criteria: 
1. Provision of signed and dated informed consent form. 
2. Stated willingness to comply with all study procedures and availability for the duration of the 
study.  
3. Female aged 45-60 
4. In good general health as evidenced by medical history 
5. Ability to take oral medication and be willing to adhere to the study intervention regimen. 
6. Negative HCG urine pregnancy test results administered at Baseline lab session prior to 
randomization. 
7. Normal screening mammogram results within 12 months of enrollment 
8. Meet STRAW+10 criteria for early or late MT. 
 
 
5.2 
EXCLUSION CRITERIA 
 
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1. Any history of CVD, including coronary artery disease, arteriosclerosis, heart attack, or stroke. 
2. Type I or II diabetes 
3. Stage I or greater hypertension based on 3 stethoscopic measures at enrollment. 
4. Personal or family history suggesting elevated risk for E2-related cancer or thrombotic events. 
5. Sensitivities to any ingredient in transdermal E2 or micronized P4 
6. Use of psychotropics, statins, or hormonal preparations. 
7. Use of herbal supplements that may affect mood or menopause symptoms (e.g., Black Cohosh 
or St. John’s Wort) 
8. Nicotine use of greater than 10 cigarettes per day. 
9. BMI of greater than or equal to 36 
10. History of migraine headaches in current smokers 
11. History of migraine with aura within the last 3 years 
12. History of psychotic disorders, bipolar disorder, or severe substance use disorder (within 10 
years of enrollment) 
13. History of suicide attempts, or current suicide ideation with intent 
14. History gall bladder disease, liver dysfunction, or other disorders for which E2 or P4 is 
contraindicated 
15. History or signs of endometrial disorder (based on gynecological exam) 
16. Pregnancy or lactation 
17. Known allergic reactions to components of the <study intervention>, <specify 
components/allergens> 
 
5.3 
LIFESTYLE CONSIDERATIONS 
 
During this study, prior to laboratory stress testing sessions, participants are asked to: 
• 
Refrain from consumption of alcohol for 24 hours prior to session 
• 
Refrain from marijuana use for 48 ours prior to session 
• 
Limit caffeine consumption to 1 cup (8 oz.) before 9AM on the day of session 
• 
Refrain from consumption of anti-inflammatory agents (e.g., ibuprofen) 24 hours prior to 
session 
 
 
5.4 
SCREEN FAILURES 
Participants who are consented to participate in the clinical trial, who do not meet one or more criteria 
required for participation in the trial during the screening procedures, are considered screen failures. 
Screen failures will be withdrawn from participation and offered referrals to the UNC Women’s Mood 
Disorder Clinic upon request.  
 
Individuals who do not meet criteria for participation (screen failure) because they are too earlier in the 
menopause transitions (i.e., pre-menopausal; experiencing regular menstrual cycles) may be rescreened 
when menstrual cycles become irregular. Rescreened participants will be assigned the same participant 
number as for initial screening. 
 
5.5 
STRATEGIES FOR RECRUITMENT AND RETENTION 
 
In carrying out this recruitment we will partner with UNC's the North Carolina Translational 


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and Clinical Science Institute (NC TraCS). Established in 2008 by UNC's Clinical and 
Translational Science Award (CTSA) from the NIH, NC TraCS includes the following programs that we will 
utilize: 1) The Research Recruitment Office (RRO), which will assist the project in 
developing subject recruitment plans, identifying enrollment barriers specific to the targeted 
population, and monitoring recruitment statistics; and 2) The Community Engagement Core, 
which will assist the project in building community relationships, using research navigators – 
UNC faculty leaders in clinical and translational research who have dedicated time to work with 
research projects such as this one.  
 
We intend to make use of the UNC Health Care System's (UNCHCS's) enterprise-wide patient data base, 
the Carolina Data Warehouse for Health (CDW-H), to identify and enroll eligible subjects. The CDW-H is a 
central repository of clinical, research and administrative data on all patients seen since July 2004 by the 
UNCHCS. Updated every 24 – 48 hours from its source systems, this research portal is a user-friendly 
web-based tool that allows researchers to identify patients as potential research subjects and to 
estimate subject pools. 
 
We will also recruit using advertisements on social media platforms (e.g., Facebook and Instagram), 
which will target females aged 45-60 within a specified geographical radius surrounding Chapel Hill. 
Interested subjects will click on a link within the advertisements to the study’s website and Qualtrics 
screening survey.  
 
Inclusion of Minorities:  There is no evidence to suggest that estradiol variability would influence the 
mechanisms to be studied in this project (HPA axis activation, and threat responsivity and approach 
motivation) differently in different races or ethnic groups.  Since the primary analyses involve within-
subject change in E2 variability, minorities will be enrolled in numbers proportional to our regional 
distribution (African American = 23%; Hispanic = 5%; American Indian/Alaskan Native = 1.2%; Asian = 
1%, or Native Hawaiian/Pacific Islander = 0.8%).  African American race will be examined, however, in 
covariate analyses and controlled for if indicated. 
 
Recruitment Plan: We realize, however, that specialized efforts will be needed to meet these goals.  Dr. 
Girdler has a long-standing track record of successful recruitment of African Americans (our largest 
minority population) into clinical research studies.  In our current study of perimenopausal women, of 
those enrolled, 30% identify as African American.   We will employ the strategies that have proven 
successful in prior studies.  The single most effective strategy involves the use of minority research staff 
in the recruitment and retention process.  Other strategies involve the use of culturally sensitive 
language in advertisements, including assurances that the study involves no experimental drugs or 
devices.  We will also advertise in periodicals targeting African American populations and work with 
community-based minority programs.  Statistics will be kept throughout the study documenting 
recruitment strategy and enrollment rates, allowing the PIS to adjust initiatives accordingly.  Should 
additional initiatives be necessary, we will work directly with leaders from the African American 
community. 
 
6 
STUDY INTERVENTION 
 
6.1 
STUDY INTERVENTION(S) ADMINISTRATION 
 
6.1.1 STUDY INTERVENTION DESCRIPTION 


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Study drugs will be provided and stored at 36-46°F in Neurosciences IDS pharmacy refrigerator.  
• 
Estradiol 0.1mg topical patch, 4 patches/box 
• 
Progesterone 100mg capsules, 100 capsules/bottle 
• 
Placebo capsules, 100 capsules/bottle (Capsugel Orange, Size AA, DB Capsules) 
• 
Placebo patches (provided by study) 
6.1.2 DOSING AND ADMINISTRATION 
 
Under double-blind procedures, women randomized to placebo-E2 will take placebo P4; those 
randomized to active E2 will take active P4. 
 
By avoiding the first-pass metabolic effects of oral estrogen, transdermal E2 creates stable, 
premenopausal follicular phase E2 blood levels; and a physiologic profile of E2 relative to its metabolites 
estrone and estriol. 35-37  Transdermal E2 also has a superior thromboembolic and metabolic safety 
profile than oral estrogen.38-40 A 7-day transdermal system provides significantly more stable 
concentrations and better patch adherence than twice weekly patches.41  We have chosen generic 
estradiol 7 day patches because the adhesive layer of the matrix distributes E2 molecules to 
continuously release E2, which is transported across skin leading to sustained levels of E2.35 Because of 
the dynamic changes in the reproductive axis during the MT and the possibility that, over 24 weeks, 
some women may transition from one STRAW stage to another, placebo will control for effects of 
reproductive aging, per se, on measures of interest and for habituation effects to repeat testing. 
 
Progesterone Administration: To reduce the risk of E2-induced endometrial hyperplasia, women 
randomized to active E2 will take 200 mg micronized progesterone/day x 12 days during weeks 17-18 (8 
weeks after randomization) and again eight weeks later at the end of the study (weeks 25-26).  Although 
in clinical settings progesterone tends to be given either every day or for 12 days once per month, the 
literature is inconclusive regarding the precise regimen that provides the best protection against 
endometrial hyperplasia or endometrial cancer.   
 
We have chosen to give P4 in a discontinuous fashion instead of using a transdermal system that 
delivers both E2 and a progestin because progestins not only antagonize E2 effects 43,44 but because the 
metabolites of progesterone (e.g., allopregnanolone) are potent modulators of the HPA axis response to 
stress.   Thus, this would introduce a confound and mitigate against our ability to examine the role of E2 
variability on the HPA axis stress response. 
 
 
6.2 
PREPARATION/HANDLING/STORAGE/ACCOUNTABILITY 
 
6.2.1 ACQUISITION AND ACCOUNTABILITY 
 
The study coordinator will notify the IDS Pharmacy of a patient’s enrollment by the presentation of a 
pre-printed prescription. The prescription will contain the patient’s name, medical record number, 
patient number, study visit week, informed consent, allergies, quantity of drug to be dispensed, date, 
and signature of an authorized prescriber. Dispensed study drugs are labeled with Vestigo outpatient 
prescription labels. All study drug returns may be discarded following documentation. 
 


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6.2.2 FORMULATION, APPEARANCE, PACKAGING, AND LABELING 
 
Active: Alvogen brand estradiol 0.1mg topical patch and generic prometrium progesterone 100mg 
capsules 
Control: Placebo patches supplied by PI. Placebo capsules from Capsugel, orange, size AA, DB.  
All patches will be dispensed in individually wrapped packages without manufacturer branding. Pills will 
be contained in Capsugel capsules and active/control capsules will be identical in appearance. 
 
6.2.3 PRODUCT STORAGE AND STABILITY 
 
Drugs will be stored in the Neurosciences IDS Pharmacy refrigerator at 36-46°F. 
 
 
6.2.4 PREPARATION 
Addressed in 6.2.2 above. 
 
6.3 
MEASURES TO MINIMIZE BIAS: RANDOMIZATION AND BLINDING 
 
Under double-blind procedures, subjects will be randomized to receive E2 or placebo for 16 weeks. The 
study biostatistician will create the randomization scheme and UNC Investigational Drug Services will 
manage the randomization and dispensing of hormones in blinded form. For those randomized to 
transdermal E2 (n=60), each will wear a patch delivering 0.10 mg E2/24.  Those randomized to placebo 
(n=60), will wear a patch similar in appearance. 
 
6.4 
STUDY INTERVENTION COMPLIANCE 
 
Compliance checks will occur at every study visit. Subjects will: 
1. Be educated on the importance of replacing their patches every 7 days and we will develop an 
individualized behavior strategy to enhance compliance. 
2. Record date of patch application, reviewed at each visit 
3. Bring used an unused patches to each visit. 
4. Be giving extra patches for replacement if necessary. 
 
6.5 
CONCOMITANT THERAPY 
Not applicable 
 
6.5.1 RESCUE MEDICINE 
Not applicable. 
 
7 
STUDY INTERVENTION DISCONTINUATION AND PARTICIPANT 
DISCONTINUATION/WITHDRAWAL 
 
7.1 
DISCONTINUATION OF STUDY INTERVENTION 
 


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At six-month intervals, the Biostatistician on the study will test whether there are significant differences 
between those in the active E2 versus placebo E2 for moderate or severe AEs. The statistical analysis 
method will be a two-sided Fisher exact Test, with alpha = 0.05. These results will be provided to the 
Data Safety and Monitoring Board (DSMB) along with the summary report of enrollment and other 
safety data. The DSMB will consider stopping the study based on the results of the statistical tests and 
other safety data. 
 
7.2 
PARTICIPANT DISCONTINUATION/WITHDRAWAL FROM THE STUDY 
 
1. In the case of mood deterioration, Dr. Dichter (licensed clinical psychologist) will determine the next 
course of action, including a reassessment more frequently or more urgently if deemed to be clinically 
required. Participants will be withdrawn and referred for treatment to the UNC Center for Women’s 
Mood Disorders if, in the opinion of Dr. Dichter the mood disturbance warrants pharmacological or 
other intervention and is rated Grade III or higher. 
 
2. Any participant with emergent suicide ideation with intent or suicide behaviors will be removed from 
the study. Based on the clinical assessment by Dr. Dichter, she will either be taken to the emergency 
room or referred for treatment.  
 
3. Development of a VTE, breast carcinoma, Stage 2 hypertension, or other medical conditions for which 
E2 is contraindicated. 
 
4. Development of endometrial hyperplasia.   
 
5. Start of an exclusionary prescription medication or herbal supplement (e.g., psychotropics)  
 
6.  Failure or inability to comply with study procedures as determined by study staff and ultimately by 
Dr. Girdler. 
 
7. For participants who report experiencing current migraines (with or without aura) at the initial 
enrollment, staff will incorporate additional protocol to monitor all headaches they experience 
throughout the study protocol. Staff will document this headache assessment during each weekly visit, 
both before and after randomization. Should a participant report experiencing migraine with aura prior 
to randomization, they will not be randomized and complete the baseline visits only.  If a participant 
reports a migraine with aura post-randomization, they will discontinue use of HRT immediately and be 
withdrawn from the study. If a participant reports an increase in frequency or severity of migraine 
without aura post-randomization, they will be referred to Dr. Munoz for further assessment. 
 
7.3 
LOST TO FOLLOW-UP 
 
The following actions must be taken if a participant fails to return to the clinic for a required study visit: 
• 
The site will attempt to contact the participant and reschedule the missed visit within 7 days and 
counsel the participant on the importance of maintaining the assigned visit schedule and 
ascertain if the participant wishes to and/or should continue in the study. 
• 
Before a participant is deemed lost to follow-up, the investigator or designee will make every 
effort to regain contact with the participant. These contact attempts will be documented in the 
participant’s medical record or study file.  


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• 
Should the participant continue to be unreachable, he or she will be considered to have 
withdrawn from the study with a primary reason of lost to follow-up. 
 
 
8 
STUDY ASSESSMENTS AND PROCEDURES 
8.1 
EFFICACY ASSESSMENTS  
 
This is not a clinical efficacy trial. 
 
8.2 
SAFETY AND OTHER ASSESSMENTS 
 
Safety Screening prior to randomization: 
• 
Physical examination: height and weight will be measured to determine eligibility based on 
BMI. Gynecological exam by Investigator gynecologist will determine if subjects have any signs 
or history of endometrial disorder, abnormal uterine anatomy, or abnormal ovarian anatomy 
(confirmed by endometrial ultrasound and/or biopsy). 
• 
Vital signs Three stethoscopic blood pressure readings will be measured at enrollment to rule 
out hypertension. 
• 
Radiographic assessments. Subjects will be required to have normal results from a screening 
mammogram within 12 months prior to enrollment. 
 
The Snaith-Hamilton Pleasure Scale (SHAPS): 104 assesses anhedonia. SHAPS scores range from 14-56, 
with higher scores corresponding to higher levels of anhedonia. This scale has shown adequate overall 
psychometric properties in clinical and student samples 105. The SHAPS has satisfactory test-retest 
validity in healthy participants (intraclass correlation coefficient = 0.70, p < 0.001 106. 
 
The State-Trait Anxiety Inventory (STAI): the state measure of anxiety from the STAI consists of items 
such as “I am worried” or “I feel calm” and participants complete the items as to how they currently 
feel. A higher score indicates higher anxiety. While there are no standard clinical cut-offs for the STAI, 
past research indicates scores ≥ 40 are clinically significant. 107,108 The scale has good median alpha 
reliability (.92). 109 
 
Dot-probe (DP) task (15 min): will measure attentional bias to threat (threat responsivity)119. An angry 
and a neutral face of the same individual are presented vertically simultaneously (trials with neutral 
faces are controls). Immediately following the face pair, a probe letter replaces either the angry face 
(threat congruent trial) or the neutral face (threat incongruent trial). Participants indicate the probe 
letter via button press. The task consists of 144 trials (48 threat congruent, 48 threat incongruent, 48 
neutral). Trials are separated by a variable length inter-stimulus interval (900 - 1300 ms). Bias scores are 
calculated by subtracting the reaction time on threat congruent from threat incongruent trials. Positive 
scores reflect a bias towards threat and negative scores reflect a bias away from threat. Attention bias 
calculations exclude trials with incorrect responses, trials with reaction times <150 ms or >2000 ms or 
>2.5 SD outside the mean. 
 
Effort Expenditure for Rewards Task (“EEfRT”) (20 min) will measure approach motivation that indexes 
the willingness to expend effort to obtain monetary rewards under varying conditions of reward 
probability and magnitude 120. On each trial, participants choose between an “easy task” and a “hard 


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task” and are presented with information about the probability of winning (i.e., 12%, 50%, or 88%), and 
the magnitude of the potential reward if they complete the button-press task successfully (range:$1.24 - 
$4.12). Completion of the easy task requires 30 button presses in 7 seconds using the dominant index 
finger, whereas completion of the hard task requires 100 presses with the non-dominant “pinky” finger 
in 21 seconds. The % of hard task choices is the dependent measure. We have experience with this task 
in clinical studies of reward processing deficits 121. 
 
The Trier Social Stress Test (TSST) involves social evaluation of speech and serial subtraction stress and 
induces large HPA axis responses 122-125. Baseline Rest (30 mins): The subject will rest for 30 minutes. 
Instructions: (5 min) Subjects are introduced to a 2-person committee. The 
subject will assume the role of a job applicant who is invited for a personnel interview with the 
committee. Anticipation: The subject prepares for 10 min. Speech: The committee asks the subject to 
deliver her talk for 5 mins. The committee responds with prepared questions to ensure that the talk 
lasts for 5 mins. Serial Subtraction: The subject is given a number to start from and asked to subtract a 
number from that original number as fast and as accurately as possible for 5 mins. For each mistake, the 
subject restarts at the original number. Stress Recovery: The subject rests alone for 45 mins. The 
characteristics of the TSST that elicit large HPA axis response include: 1) lack of controllability; 2) 
creation of a context of forced failure; and 3) social evaluative threat28. Thus, the TSST provides a 
physiologic unit of analysis for the construct of threat responsivity. To minimize habituation, we will use 
the second TSST at baseline week 8 as the comparison for all analyses (the first TSST will be used to 
eliminate the novelty effect). Modifications with each TSST will minimize habituation:126 1) a different 
speech topic, such as modifying the job; describing one’s positive and negative personality attributes 
and impact on likeability126; 2) different numbers in the serial subtraction; 3) different, opposite sex 
committee members each time. With these modifications, some novelty is maintained even with repeat 
exposure, ensuring a significant HPA response. 
 
Neuroendocrine Sampling during Stress Testing: Plasma cortisol will be taken at the end of baseline rest 
and again during Recovery at minutes 20, 30, and 45, wince HPA-axis reactivity is reliably seen 10-30 
minutes after cessation of the TSST 22,26. 
   
8.3 
ADVERSE EVENTS AND SERIOUS ADVERSE EVENTS 
 
8.3.1 DEFINITION OF ADVERSE EVENTS (AE) 
 
Adverse event means any untoward medical occurrence associated with the use of an intervention in 
humans, whether or not considered intervention-related (21 CFR 312.32 (a)). 
 
8.3.2 DEFINITION OF SERIOUS ADVERSE EVENTS (SAE)  
An adverse event (AE) or suspected adverse reaction is considered "serious" if, in the view of either the 
investigator or sponsor, it results in any of the following outcomes: death, a life-threatening adverse 
event, inpatient hospitalization or prolongation of existing hospitalization, a persistent or significant 
incapacity or substantial disruption of the ability to conduct normal life functions, or a congenital 
anomaly/birth defect. Important medical events that may not result in death, be life-threatening, or 
require hospitalization may be considered serious when, based upon appropriate medical judgment, 
they may jeopardize the participant and may require medical or surgical intervention to prevent one of 
the outcomes listed in this definition. 
 


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8.3.3 CLASSIFICATION OF AN ADVERSE EVENT 
8.3.3.1 SEVERITY OF EVENT 
 
The following guidelines will be used to describe severity of AEs.  
 
• 
Mild –is defined as having no effect on activities of daily living such as transient light 
headedness or sweating with venipuncture; breast tenderness, mild skin irritation; or something 
of equal significance that requires no medical intervention and is of marginal clinical relevance. 
• 
Moderate – would be associated with temporary (minutes to a few days) disruption in activities 
of daily living such as temporary loss of consciousness with venipuncture; a worsening of 
migraines or headache that require bed rest, an increase in anxiety or anhedonia symptoms 
consistent with clinically meaningful levels, emergent suicide intent without specific plan 
(severity level 4 on the C-SSRS), excess sleepiness or fatigue that resolves with additional rest, or 
something of equal significance.  
• 
Severe – would cause serious disruption in daily activities of living and may or may not require 
hospitalization. Examples of such events would include a thromboembolic event, breast 
carcinoma, an increase in blood pressure consistent with Stage 2 hypertension, any 
cardiovascular event, any event that is permanently disabling, any event requiring 
hospitalization or is life threatening, severe mood impairment or emergent suicide ideation with 
specific plan (severity level 5 on the C-SSRS) or any suicidal behavior (actual attempt, 
interrupted attempt, aborted attempt, or preparation towards imminent suicide attempt),  or 
something of equal significance.  The development of endometrial hyperplasia with or without 
atypia would also be consistent with a severe AE. 
 
8.3.3.2 RELATIONSHIP TO STUDY INTERVENTION 
 
• 
Definitely Related – There is clear evidence to suggest a causal relationship, and other possible 
contributing factors can be ruled out. The clinical event, including an abnormal laboratory test 
result, occurs in a plausible time relationship to study intervention administration and cannot be 
explained by concurrent disease or other drugs or chemicals.  
• 
Probably Related – There is evidence to suggest a causal relationship, and the influence of other 
factors is unlikely. The clinical event, including an abnormal laboratory test result, occurs within 
a reasonable time after administration of the study intervention, is unlikely to be attributed to 
concurrent disease or other drugs or chemicals, and follows a clinically reasonable response on 
withdrawal. Rechallenge information is not required to fulfill this definition. 
• 
Not Related – The AE is completely independent of study intervention administration, and/or 
evidence exists that the event is definitely related to another etiology. 
• 
Unknown – based on the temporal relationship and clinical judgment of medical monitor, the 
relationship between the AE and study intervention cannot be determined. 
 
 
8.3.3.3 EXPECTEDNESS  
 
The Investigator gynecologist, PI, and study clinical psychologist will be responsible for determining 
whether an adverse event (AE) is expected or unexpected.  An AE will be considered unexpected if the 


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nature, severity, or frequency of the event is not consistent with the risk information previously 
described for the study intervention. 
 
8.3.4 TIME PERIOD AND FREQUENCY FOR EVENT ASSESSMENT AND FOLLOW-UP 
 
The study coordinator will monitor side effects and AEs related to the pharmacological E2 probe at all 
study visits (on a weekly basis initially and then monthly for two months) and report all side effects as 
well as any significant deterioration in anxiety or anhedonic symptoms (see below) directly to Dr. Girdler 
following study visits.  Side effects consistent with moderate or severe AEs or that are troublesome to 
the subject, or evidence of mood deterioration reported by telephone, will also be immediately 
reported to Dr. Girdler.  Based on the clinical skill required not only to assess but to act on emergent 
suicidality, a licensed clinical psychologist or psychiatry resident will conduct the suicide assessments at 
each laboratory session (weeks 8, 16, 20 and 24) or more frequently if indicated (e.g., every two weeks 
for those with a history of suicide intent).  Investigator licensed clinical psychologist, Dr. Dichter, will 
oversee the fellows and residents in this responsibility.   
 
Bleeding patterns and severity will be assessed at every study visit.   Moreover, subjects will be 
instructed to contact us whenever they start a menstrual bleed.  Staff will follow up to determine the 
amount and duration of bleeding.  For any woman with profuse bleeding (defined as more than 3 
tampons or pads for more than 5 days OR more than 1 tampon or pad per hour on any given day), Dr. 
Munoz will be contacted, and she will decide whether to evaluate if clinically indicated.  The timing of 
the bleeding with respect to the timing of the progesterone will contribute to that determination.  Any 
unscheduled or prolonged bleeding (> 10 days) will be followed by an ultrasound or an endometrial 
biopsy or both.  If ultrasound reveals the vaginal the stripe thickness to be more than 3 mm, then an 
endometrial biopsy will be performed. If the pathology report indicates hyperplasia, the subject will be 
withdrawn from the study, estrogen discontinued, and Dr. Munoz will prescribe a stronger progestin.  If 
the subject has hyperplasia, a follow-up biopsy would be performed at 3 months to make sure it is 
cured.   The research study will pay for all biopsies required, including the follow-up biopsy.   
 
Dr. Girdler will ensure that Dr. Dichter or Dr. Munoz are consulted within 24-hours of any severe AE.  
Moderate AEs will prompt a follow-up evaluation of the subject within one week.   If the condition has 
not resolved or has worsened, Dr. Dichter or Dr. Munoz will be contacted to determine the next course 
of action. Staff will be specifically trained to monitor the STAI-S and the SHAPS for > 50% increase in 
symptom severity from baseline and an increase in stratification (e.g., from a low symptom group to a 
medium group or from a medium group to a high symptom group).  If the subject is already in a high 
anhedonia or anxiety strata, then any increase above 50% will be reviewed by Dr. Girdler.  Staff will be 
specifically trained to monitor the STAI-S and the SHAPS for > 50% increase from baseline levels in 
symptom severity.  In the case of elevations in anxiety and anhedonia symptoms Dr. Dichter will 
determine the next course of action, including more frequent assessment of mood if deemed to be 
clinically required.  In the case of emergent suicide ideation with intent or any suicide-related behavior, 
the individual will be withdrawn from the study and the blind broken.  If the participant appears to need 
immediate treatment, she will be escorted to the UNC emergency department.  Otherwise, Dr. Dichter 
will meet with the participant to evaluate her safety and administer the C-SSRS.   He will then determine 
the appropriate next steps, including referral to the UNC Center for Women’s Mood Disorders or a 
community provider for further evaluation and treatment.  Dr. Munoz will be the responsible physician 


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to determine the next course of action involving medical side effects (e.g., continue in protocol, exclude, 
and refer for treatment).  
 
 
8.3.5 ADVERSE EVENT REPORTING  
 
The PI Dr. Girdler will review all protocol data at monthly meetings, including enrollment and retention 
statistics and aggregate reports of side effects/AEs.  Dr. Girdler will be the responsible one to report any 
individual occurrence of an AE to the Chair of the DSMB according to the guidelines established at the 
initial DSMB meeting (e.g., the DSMB may require the reporting of any serious adverse event on an 
individual basis and in an on-going fashion).  She will also report all severe AEs to the IRB and DSMB 
within 1 week.  Since we are employing a marketed pharmaceutical product (i.e., a non-IND study), 
unexpected Severe AEs will also be reported to the FDA MedWatch Program. The NIMH program officer 
will be notified of any study modifications or suspension imposed by the DSMB or local IRB in response 
to an AE. 
 
 
8.3.6 SERIOUS ADVERSE EVENT REPORTING  
 
Dr. Girdler will also report all AEs graded as severe to Investigator Dr. Munoz.  Dr. Munoz will maintain a 
secured, password protected file linking subject ID to subject name.  Dr. Munoz will also receive the 
randomization code by subject ID from Investigational Drug Services. If it is medically necessary to 
become unblinded to treatment assignment, Dr. Munoz will be able to do so very quickly. 
 
8.3.7 REPORTING EVENTS TO PARTICIPANTS  
Not applicable. 
 
8.3.8 EVENTS OF SPECIAL INTEREST  
Not applicable. 
 
8.3.9 REPORTING OF PREGNANCY  
Since perimenopausal women may still become pregnant, especially those in the early menopause 
transition, we will assess pregnancy status by point of care urine pregnancy test for all participants 
under the age of 55.  Pregnancy status will be tested via the use of urine hCG test (SA Scientific, San 
Antonio). Urine hCG is a rapid (results within minutes) qualitative test to detect the presence of hCG in 
urine to aid in the early detection of pregnancy. The SA urine hCG rapid test will be conducted in Dr. 
Girdler's lab using a small urine sample taken prior to the week 8 baseline laboratory session that 
precedes randomization to confirm that subjects are not pregnant.    Women who are pregnant at this 
time will be withdrawn from the study. Dr. Girdler's lab has a CLIAA waiver certification from the NC 
Dept of Health to perform this assay at Carolina Crossing which expires September 02, 2021. 
 
8.4 
UNANTICIPATED PROBLEMS 
 
8.4.1 DEFINITION OF UNANTICIPATED PROBLEMS (UP) 
 


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The Office for Human Research Protections (OHRP) considers unanticipated problems involving risks to 
participants or others to include, in general, any incident, experience, or outcome that meets all the 
following criteria: 
 
• 
Unexpected in terms of nature, severity, or frequency given (a) the research procedures that are 
described in the protocol-related documents, such as the Institutional Review Board (IRB)-
approved research protocol and informed consent document; and (b) the characteristics of the 
participant population being studied. 
• 
Related or possibly related to participation in the research (“possibly related” means there is a 
reasonable possibility that the incident, experience, or outcome may have been caused by the 
procedures involved in the research); and 
• 
Suggests that the research places participants or others at a greater risk of harm (including 
physical, psychological, economic, or social harm) than was previously known or recognized. 
 
Corrective actions to be considered in response to an UP include: 
 
• 
Modification of inclusion or exclusion criteria to mitigate the newly identified risks 
• 
Implementation of additional safety monitoring procedures 
• 
Suspension of enrollment of new participants or halting of study procedures for enrolled 
participants  
• 
Modification of informed consent documents to include a description of newly recognized risks 
• 
Provision of additional information about newly recognized risks to previously enrolled 
participants. 
 
 
8.4.2  UNANTICIPATED PROBLEM REPORTING  
 
The investigator will report unanticipated problems (UPs) to the reviewing Institutional Review Board 
(IRB) and to the Data Coordinating Center (DCC)/lead principal investigator (PI). The UP report will 
include the following information: 
 
• 
Protocol identifying information: protocol title and number, PI’s name, and the IRB project 
number. 
• 
A detailed description of the event, incident, experience, or outcome.  
• 
An explanation of the basis for determining that the event, incident, experience, or outcome 
represents an UP.  
• 
A description of any changes to the protocol or other corrective actions that have been taken or 
are proposed in response to the UP. 
 
To satisfy the requirement for prompt reporting, UPs will be reported using the following timeline:   
 
• 
UPs that are serious adverse events (SAEs) will be reported to the IRB and to the DCC/study 
sponsor within 1 week of the investigator becoming aware of the event.  
• 
Any other UP will be reported to the IRB and to the DCC/study sponsor within 1 week of the 
investigator becoming aware of the problem.  
• 
All UPs should be reported to appropriate institutional officials (as required by an institution’s 
written reporting procedures), the supporting agency head (or designee), and the Office for 


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Human Research Protections (OHRP) within the timeline in accordance with policy of the IRB’s 
receipt of the report of the problem from the investigator. 
 
 
8.4.3 REPORTING UNANTICIPATED PROBLEMS TO PARTICIPANTS  
 
Corrective actions to be considered in response to an UP include: 
 
• 
Modification of inclusion or exclusion criteria to mitigate the newly identified risks 
• 
Implementation of additional safety monitoring procedures 
• 
Suspension of enrollment of new participants or halting of study procedures for enrolled 
participants  
• 
Modification of informed consent documents to include a description of newly recognized risks 
• 
Provision of additional information about newly recognized risks to previously enrolled 
participants. 
 
9 
STATISTICAL CONSIDERATIONS  
 
NOTE: There will not be a formal Statistical Analysis Plan (SAP) attached to this protocol. Rather, details 
on all analysis plans are to be found in this section under the specific subheadings. We will test whether 
there are any differences between related population means (time effect, within-subject) and whether 
mean levels change across time based on the treatment group the participants were randomized to 
(time x treatment effect, within and between-subject). 
 
9.1 
STATISTICAL HYPOTHESES 
 
• 
Primary Efficacy Endpoint(s):  
o 1. Change in State-Trait Anxiety Inventory score [Time Frame: Baseline (Week 8), Weeks 
16, 20 and 24] 
 
H0: The mean scores of the State-Trait Anxiety Inventory are the same at 
baseline (week 8), and weeks 16, 20, and 24, both, in those randomized to 
active treatment and in those randomized to placebo. 
 
H1: The mean scores of the State-Trait Anxiety Inventory will significantly 
change from baseline (week 8) to weeks 16, 20, and 24 in those randomized to 
active treatment, but not in those randomized to placebo. 
o 2. Change in SHAPS score [Time Frame: Baseline (Week 8), Weeks 16, 20 and 24] 
 
H0: The mean scores of the SHAPS will not change from baseline (week 8) to 
weeks 16, 20, and 24, both, in those randomized to active treatment and in 
those randomized to placebo. 
 
H1: The mean scores in the SHAPS score will significantly change from baseline 
(week 8) to weeks 16, 20, and 24 in those randomized to active treatment, but 
not in those randomized to placebo. 
 
• 
Secondary Efficacy Endpoint(s): 
o 1. Change in AUC cortisol response [Time Frame: Baseline (Week 8), Weeks 16, 20 and 
24] 


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 
H0: The cortisol AUC will not change from baseline (week 8) to weeks 16, 20, 
and 24, both, in those randomized to active treatment and in those randomized 
to placebo. 
 
H1: The cortisol AUC will significantly change from baseline (week 8) to weeks 
16, 20, and 24 in those randomized to active treatment, but not in those 
randomized to placebo. 
o 2. Change in “threat bias” score from Dot Probe task [Time Frame: Baseline (Week 8), 
Weeks 16, 20 and 24] 
 
H0: The mean score in the Dot Probe task will not change from baseline (week 
8) to weeks 16, 20, and 24, both, in those randomized to active treatment and in 
those randomized to placebo. 
 
H1: The mean score in the Dot Probe task will significantly change from baseline 
(week 8) to weeks 16, 20, and 24 in those randomized to active treatment, but 
not in those randomized to placebo. 
o 3. Change in “hard choice” score from EEfRT [Time Frame: Baseline (Week 8), Weeks 16, 
20 and 24] 
 
H0: The mean score in the EEfRT task will not change from baseline (week 8) to 
weeks 16, 20, and 24, both, in those randomized to active treatment and in 
those randomized to placebo. 
 
H1: The mean score in the EEfRT task will significantly change from baseline 
(week 8) to weeks 16, 20, and 24 in those randomized to active treatment, but 
not in those randomized to placebo. 
 
 
9.2 
SAMPLE SIZE DETERMINATION 
 
Sample size calculations were performed for the primary outcome measures. Correlation and effect size 
estimations were based on previously published literature 173,174. With a sample size of N=120 and 
performing hypothesis tests at two-sided alpha=.05 and a correlation of >.25 among repeated measures, 
we have >90% power to detect a small effect size of .15. 
 
The G*power software was used to determine the sample size 175, based on a repeated measures 
ANOVA with within-between interaction 173,174. We conservatively account for 15% (n =18) withdrawal 
following randomization, yielding 138 women who complete the protocol (powered for 120). This 
sample size will provide sufficient power to address secondary endpoints. No exploratory analyses will 
be performed.  
 
By using proc mixed (not GLM), we will apply an analysis which is relatively robust to missing data. 
Before applying proc mixed, we will check for the randomness of missing data. 
 
9.3 
POPULATIONS FOR ANALYSES 
 
We will use an Intention-to-Treat (ITT) Analysis Dataset, including all randomized participants (either to 
transdermal estradiol patch and micronized progesterone pill, or placebo patch and placebo pill. 
 
9.4 
STATISTICAL ANALYSES 
 


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9.4.1 GENERAL APPROACH 
 
Descriptive statistics of continuous data will be presented as adjusted means (least squared means) 
and standard errors. A two-tailed p-value of ≤ .05 will be considered as statistical significance. 
Examinations of residual normality, linearity, homogeneity of variance, and influential outliers will 
be performed using the SAS Macro Mixed DX 176. Outliers at 2 SD’s or more above or below the 
mean will be winsorized. For cortisol, the distribution of the values before and after every Trier 
Social Stress Test will be visually inspected and, in the case of skewness, a log-transformation will be 
performed.  
 
We will use two-way repeated measures analyses with between-subject factors. Our models will 
test whether there is a mean value change in the primary and secondary outcomes from week 8 to 
weeks 16, 20, and 24 (within-subject analyses) and based on the treatment arm (between-subject 
analyses of transdermal estradiol vs. placebo treatment groups). We expect a significant change 
over time in the primary and secondary outcome measures in those randomized to active 
transdermal estradiol, but not in those randomized to placebo. Data will be analyzed using proc 
mixed in SAS. All models will use an auto-regressive covariance structure to account for the 
repeated assessments of primary and secondary outcomes in the same participants.  
 
9.4.2 ANALYSIS OF THE PRIMARY EFFICACY ENDPOINT(S) 
 
For each primary endpoint: 
 
1.Change in the Anxiety score from State-Trait Anxiety Inventory 
State anxiety will be assessed using the validated State-Trait Anxiety Inventory. The State-Trait Anxiety 
Inventory consists of 20 questions on a 4-point force-choice Like-type response scale (scores 0 - 3). The 
20 questions are summed together for a final score. The score can range from 0 to 60 with higher scores 
representing higher levels of anxiety. Continuous, interval scaled sum scores will be calculated and 
treated as a repeated measure (assessed at weeks 8, 16, 20, and 24). Change in State-Trait anxiety 
inventory will be analyzed using two-way repeated-measures analysis for a time and treatment effect 
(proc mixed in SAS). Models will use an auto-regressive covariance structure to account for the repeated 
assessments in the same participants. Outliers at 2 SD’s or more above or below the mean will be 
winsorized. Missing data will not be imputed, as the statistical procedures we will apply (proc mixed) are 
robust to randomly distributed missing data. Before applying proc mixed, we will check for the 
randomness of missing data. Results of the statistical procedures will be presented as adjusted means 
(least squared means) with standard errors.  
 
2. Change in anhedonia score from Snaith-Hamilton Pleasure Scale  
Anhedonia will be assessed using the validated Snaith-Hamilton Pleasure Scale (SHAPS). Scores range 
from 0-14, with higher scores corresponding to higher levels of anhedonia. The questionnaire will be 
applied at weeks 8, 16, 20 and 24. Continuous, interval scaled sum scores will be calculated and treated 
as a repeated measure (assessed at weeks 8, 16, 20, and 24). Change in the SHAPS will be analyzed using 
two-way repeated-measures analysis for treatment x week (proc mixed in SAS). Models will use an auto-
regressive covariance structure to account for the repeated assessments of primary and secondary 
outcomes in the same participants. Outliers at 2 SD’s or more above or below the mean will be 
winsorized. Missing data will not be imputed, as the statistical procedures we will apply (proc mixed) are 
robust to randomly distributed missing data. Before applying proc mixed, we will check for the 


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randomness of missing data. Results of the statistical procedures will be presented as adjusted means 
(least squared means) with standard errors. 
 
9.4.3 ANALYSIS OF THE SECONDARY ENDPOINT(S) 
 
All analyses of the secondary endpoints are independent of the primary endpoints. 
 
For each secondary endpoint: 
 
1. Changes in Cortisol stress response 
The cortisol response will be presented as Area Under the Curve (AUC) with respect to ground and 
calculated using the trapezoid formula described by Pruessner 177. At weeks 8, 16, 20, and 24, cortisol 
was assessed around a standardized psychosocial stress test – the Trier Social Stress Test. Before the 
stress test, a baseline, pre-stress serum sample was taken. After the end of the stress test, reactivity 
serum samples were taken at 10-, 20-, 30-, and 45-minutes post-stress. The distribution of the values at 
every single timepoint, at every week will be visually inspected and, in case of skewness, log-
transformed before calculating the AUC. All AUC’s will be treated as continuous, interval scaled 
measures and treated as repeated measure (assessed at weeks 8, 16, 20, and 24). Results of the 
statistical procedures will be presented as adjusted means (least squared means) with standard errors. 
Outliers at 2 SD’s or more above or below the mean will be winsorized. In case of missing values for one 
or more single timepoints around the stress task, the AUC will not be calculated and as a consequence 
treated as missing data. The statistical procedures we will apply (proc mixed) are robust to randomly 
distributed m missing data. 
 
2.&3. Changes in the EEfRT and Dot Probe task 
Continuous, interval scaled sum scores will be used for statistical models testing changes in the EEfRT 
and the Dot probe task. Both scores will be treated as repeated measures (assessed at weeks 8, 16, 20, 
and 24). Results of the statistical procedures will be presented as adjusted means (least squared means) 
with standard errors. Outliers at 2 SD’s or more above or below the mean will be winsorized. Missing 
data will not be imputed, as the statistical procedures we will apply (proc mixed) are robust to randomly 
distributed missing data. 
 
9.4.4 SAFETY ANALYSES 
At six-month intervals, the Biostatistician on the study will test whether there are significant differences 
between those in the active E2 versus placebo E2 for moderate or severe AEs. The statistical analysis 
method will be a two-sided Fisher exact Test, with alpha = 0.05. These results will be provided to the 
Data Safety and Monitoring Board (DSMB) along with the summary report of enrollment and other 
safety data. The DSMB will consider stopping the study based on the results of the statistical tests and 
other safety data. 
 
9.4.5 BASELINE DESCRIPTIVE STATISTICS 
 
The two intervention arms will be compared on baseline (week 8) characteristics in the SHAPS score, the 
State-Trait Anxiety Inventory score, the EEfRT and Dot Probe scores, and the Cortisol AUC. Differences 
between the two groups will be compared using inferential statistics (student t-Tests). 
 
9.4.6 PLANNED INTERIM ANALYSES  


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See section 9.4.4 for details on safety analysis.  
 
9.4.7 SUB-GROUP ANALYSES 
 
The study intervention (transdermal estradiol patch and micronized progesterone pill) is only for use in 
women. Therefore, no sub-group analyses will be performed. 
 
9.4.8 TABULATION OF INDIVIDUAL PARTICIPANT DATA 
 
Not applicable 
 
9.4.9 EXPLORATORY ANALYSES 
 
Not applicable 
 
10 SUPPORTING DOCUMENTATION AND OPERATIONAL CONSIDERATIONS 
 
 
10.1 REGULATORY, ETHICAL, AND STUDY OVERSIGHT CONSIDERATIONS 
 
 
10.1.1 INFORMED CONSENT PROCESS 
 
10.1.1.1 CONSENT/ASSENT AND OTHER INFORMATIONAL DOCUMENTS PROVIDED TO 
PARTICIPANTS 
 
Consent forms describing in detail the purpose of the study, study intervention, study procedures, and 
risks are given to the participant and written documentation of informed consent is required prior to 
starting intervention/administering study intervention. 
 
 
10.1.1.2 CONSENT PROCEDURES AND DOCUMENTATION 
 
Informed consent is a process that is initiated prior to the individual’s agreeing to participate in the 
study and continues throughout the individual’s study participation. Consent forms will be Institutional 
Review Board (IRB)-approved and the participant will be asked to read and review the document. The 
investigator will explain the research study to the participant and answer any questions that may arise. 
A verbal explanation will be provided in terms suited to the participant’s comprehension of the 
purposes, procedures, and potential risks of the study and of their rights as research participants.  
Participants will have the opportunity to carefully review the written consent form and ask questions 
prior to signing. The participants should have the opportunity to discuss the study with their family or 
surrogates or think about it prior to agreeing to participate. The participant will sign the informed 
consent document prior to any procedures being done specifically for the study. Participants must be 
informed that participation is voluntary and that they may withdraw from the study at any time, without 
prejudice. A copy of the informed consent document will be given to the participants for their records. 


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The informed consent process will be conducted and documented in the source document (including the 
date), and the form signed, before the participant undergoes any study-specific procedures. The rights 
and welfare of the participants will be protected by emphasizing to them that the quality of their 
medical care will not be adversely affected if they decline to participate in this study. 
10.1.2 STUDY DISCONTINUATION AND CLOSURE 
 
This study may be temporarily suspended or prematurely terminated if there is sufficient reasonable 
cause.  Written notification, documenting the reason for study suspension or termination, will be 
provided by the suspending or terminating party to study participants, investigator, funding agency, and 
regulatory authorities.  If the study is prematurely terminated or suspended, the Principal Investigator 
(PI) will promptly inform study participants, the Institutional Review Board (IRB), and sponsor and will 
provide the reason(s) for the termination or suspension.  Study participants will be contacted, as 
applicable, and be informed of changes to study visit schedule. 
  
Circumstances that may warrant termination or suspension include, but are not limited to: 
• 
Determination of unexpected, significant, or unacceptable risk to participants 
• 
Demonstration of efficacy that would warrant stopping    
• 
Insufficient compliance to protocol requirements 
• 
Data that are not sufficiently complete and/or evaluable 
• 
Determination that the primary endpoint has been met 
• 
Determination of futility 
 
Study may resume once concerns about safety, protocol compliance, and data quality are addressed, 
and satisfy the sponsor, IRB and/or Food and Drug Administration (FDA). 
 
 
10.1.3 CONFIDENTIALITY AND PRIVACY  
 
Participant confidentiality and privacy is strictly held in trust by the participating investigators, their 
staff, and the sponsor(s) and their interventions. This confidentiality is extended to cover testing of 
biological samples and genetic tests in addition to the clinical information relating to participants. 
Therefore, the study protocol, documentation, data, and all other information generated will be held in 
strict confidence. No information concerning the study, or the data will be released to any unauthorized 
third party without prior written approval of the sponsor.  
 
All research activities will be conducted in as private a setting as possible. 
 
The study monitor, other authorized representatives of the sponsor, representatives of the Institutional 
Review Board (IRB), regulatory agencies or pharmaceutical company supplying study product may 
inspect all documents and records required to be maintained by the investigator, including but not 
limited to, medical records (office, clinic, or hospital) and pharmacy records for the participants in this 
study. The clinical study site will permit access to such records. 
 
The study participant’s contact information will be securely stored at each clinical site for internal use 
during the study. At the end of the study, all records will continue to be kept in a secure location for as 
long a period as dictated by the reviewing IRB, Institutional policies, or sponsor requirements. 


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Study participant research data, which is for purposes of statistical analysis and scientific reporting, will 
be transmitted to and stored in the study database. This will not include the participant’s contact or 
identifying information. Rather, individual participants and their research data will be identified by a 
unique study identification number. The study data entry and study management systems used by 
clinical sites and by research staff will be secured and password protected. At the end of the study, all 
study databases will be de-identified and archived at the research site. 
 
To further protect the privacy of study participants, a Certificate of Confidentiality will be issued by the 
National Institutes of Health (NIH).  This certificate protects identifiable research information from 
forced disclosure. It allows the investigator and others who have access to research records to refuse to 
disclose identifying information on research participation in any civil, criminal, administrative, legislative, 
or other proceeding, whether at the federal, state, or local level. By protecting researchers and 
institutions from being compelled to disclose information that would identify research participants, 
Certificates of Confidentiality help achieve the research objectives and promote participation in studies 
by helping assure confidentiality and privacy to participants. 
 
 
10.1.4 FUTURE USE OF STORED SPECIMENS AND DATA  
 
Data collected for this study will be analyzed and stored at the research site. After the study is 
completed, the de-identified, archived data will be transmitted to and stored at the research site, for 
use by other researchers including those outside of the study. Permission to transmit data will be 
included in the informed consent.  
 
With the participant’s approval and as approved by local Institutional Review Boards (IRBs), de-
identified biological samples will be stored at the research site with the same goal as the sharing of data 
with biospecimen repository. These samples could be used to research the factors that cause or 
contribute to the development of mood disorders in the menopause transition, its complications, and 
other conditions for which individuals in the menopause transition are at increased risk, and to improve 
treatment. The repository will also be provided with a code-link that will allow linking the biological 
specimens with the phenotypic data from each participant, maintaining the blinding of the identity of 
the participant. 
 
During the conduct of the study, an individual participant can choose to withdraw consent to have 
biological specimens stored for future research. However, withdrawal of consent with regard to 
biosample storage may not be possible after the study is completed.  
 
When the study is completed, access to study data and/or samples will be provided through the only 
personnel approved by the study investigator. 
 
 
10.1.5 KEY ROLES AND STUDY GOVERNANCE 
 
Principal Investigator 
Medical Monitor 
Susan Girdler, Ph.D. 
Maria Munoz, MD. 


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UNC SOM - Psychiatry  
UNC OB/GYN 
101 Manning Dr. CH, 27514 
101 Manning Dr., CH, 27514 
(919) 966-2544 
(650) 815-9041 
Susan_girdler@med.unc.edu 
Cris_munoz@med.unc.edu 
 
 
10.1.6 SAFETY OVERSIGHT 
 
The safety of the study will be monitored by a Data and Safety Monitoring Board (DSMB). This will 
ensure the independent oversight of issues related to safety and adverse events. The North Carolina 
Translational and Clinical Sciences (NC TraCS) Data and Safety Monitoring Board (NC TraCS DSMB) will 
be used for this purpose.  The Board is composed of MDs from a variety of disciplines, an R.N. from the 
UNC School of Nursing, a Biostatistician, a Regulatory Expert, and for purposes of this study, a 
psychiatrist or clinical psychologist will serve as an ad hoc member. 
 
The NC TraCS DSMB will monitor for AEs, including medical events (e.g., VTEs) and psychological events 
(e.g., significant deterioration in anxiety or anhedonia symptoms and emergent suicidal intent or 
behavior).  The DSMB will specify the tables and data it wishes to have presented to it at all meetings, 
including but not limited to, all side effects and symptoms recorded at the study visits (see Adverse 
Events Form) and all interim phone calls initiated by research subjects to report AEs or concerns.  DSMB 
review of this study will occur every six months (or more frequently if specified by the DSMB).  At these 
meetings, the DSMB will also review data from subjects who have withdrawn or dropped out of the 
study and the reasons for drop out.  The DSMB will evaluate issues of participant safety as well as 
enrollment information and the adequacy and integrity of accumulating data.  The DSMB will also 
identify if any study procedures should be altered or stopped in the event of an indication of harm to 
participants attributable to the study interventions. 
 
10.1.7 CLINICAL MONITORING 
Not applicable. 
 
10.1.8 QUALITY ASSURANCE AND QUALITY CONTROL 
The research site will perform internal quality management of study conduct, data and biological 
specimen collection, documentation and completion.  An individualized quality management plan will be 
developed to describe a site’s quality management. 
 
Quality control (QC) procedures will be implemented beginning with the data entry system and data QC 
checks that will be run on the database will be generated. Any missing data or data anomalies will be 
communicated to the site for clarification/resolution. 
 
Following written Standard Operating Procedures (SOPs), the monitors will verify that the clinical trial is 
conducted and data are generated and biological specimens are collected, documented (recorded), and 
reported in compliance with the protocol, International Conference on Harmonisation Good Clinical 
Practice (ICH GCP), and applicable regulatory requirements (e.g., Good Laboratory Practices (GLP), Good 
Manufacturing Practices (GMP)).  
 


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The investigational site will provide direct access to all trial related sites, source data/documents, and 
reports for the purpose of monitoring and auditing by the sponsor, and inspection by local and 
regulatory authorities. 
 
10.1.9 DATA HANDLING AND RECORD KEEPING  
 
10.1.9.1 DATA COLLECTION AND MANAGEMENT RESPONSIBILITIES  
Data collection is the responsibility of the clinical trial staff at the site under the supervision of the site 
investigator. The investigator is responsible for ensuring the accuracy, completeness, legibility, and 
timeliness of the data reported. 
 
All source documents should be completed in a neat, legible manner to ensure accurate interpretation 
of data.   
 
Hardcopies of the study visit worksheets will be provided for use as source document worksheets for 
recording data for each participant enrolled in the study.  Data recorded in the electronic case report 
form (eCRF) derived from source documents should be consistent with the data recorded on the source 
documents.  
 
Clinical data (including adverse events (AEs), concomitant medications, and expected adverse reactions 
data) and clinical laboratory data will be entered into Microsoft Access and Qualtrics, a 21 CFR Part 11-
compliant data capture system provided by UNC. The data system includes password protection and 
internal quality checks, such as automatic range checks, to identify data that appear inconsistent, 
incomplete, or inaccurate. Clinical data will be entered directly from the source documents. 
 
10.1.9.2 STUDY RECORDS RETENTION  
 
Study documents should be retained for 5 years after the last publication. At that point, all paper data 
will be shredded. Biological samples will be destroyed according to OSHA procedures. The linkage file 
will also be destroyed. 
 
 
10.1.10 
PROTOCOL DEVIATIONS  
 
A protocol deviation is any noncompliance with the clinical trial protocol, International Conference on 
Harmonisation Good Clinical Practice (ICH GCP), or Manual of Procedures (MOP) requirements. The 
noncompliance may be either on the part of the participant, the investigator, or the study site staff. As a 
result of deviations, corrective actions are to be developed by the site and implemented promptly.  
 
These practices are consistent with ICH GCP:  
• 
4.5 Compliance with Protocol, sections 4.5.1, 4.5.2, and 4.5.3  
• 
5.1 Quality Assurance and Quality Control, section 5.1.1  
• 
5.20 Noncompliance, sections 5.20.1, and 5.20.2.  
 
It is the responsibility of the site investigator to use continuous vigilance to identify and report 
deviations.  All deviations must be addressed in study source documents and reported to NIH Program 
Official per NIH guidelines. Protocol deviations must be sent to the reviewing Institutional Review Board 


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(IRB) per their policies. The site investigator is responsible for knowing and adhering to the reviewing 
IRB requirements.  
 
10.1.11 
PUBLICATION AND DATA SHARING POLICY 
 
National Institutes of Health (NIH) Public Access Policy, which ensures that the public has access to the 
published results of NIH funded research. It requires scientists to submit final peer-reviewed journal 
manuscripts that arise from NIH funds to the digital archive PubMed Central upon acceptance for 
publication. 
 
This study will comply with the NIH Data Sharing Policy and Policy on the Dissemination of NIH-Funded 
Clinical Trial Information and the Clinical Trials Registration and Results Information Submission rule. As 
such, this trial will be registered at ClinicalTrials.gov, and results information from this trial will be 
submitted to ClinicalTrials.gov. In addition, every attempt will be made to publish results in peer-
reviewed journals.   
 
Consistent with NOT-MH-14-015, we will submit data to the RDoC database.  This database is built on the 
infrastructure of the National Database for Autism Research (NDAR). The project coordinator will work 
closely with the PIs and the data manager and be responsible for data preparation and submission to 
RDoCdb.  We will use appropriate informed consent language to inform potential participants of the 
sharing of their data through RDoCdb.  We commit to use RDoCdb template language during recruitment 
and to augment the informed consent process as necessary.  To accomplish this objective, we will 
formulate an enrollment strategy that will obtain the information necessary to generate a GUID for each 
participant.  We will build in procedures to be able to capture the personally identifiable information 
needed to create a valid GUID.  We will utilize data structures already defined by RDoCdb as much as 
possible to ease the process of data submission and sharing.  Where data structures have not yet been 
defined in RDoCdb, we will work with RDoCdb staff to define data structures for any data being collected 
as part of the study.  Immediately upon award of this grant, we will complete and share the necessary 
RDoCdb Data Submission Documents so others can see what kind of research we are conducting.  We 
commit to submit descriptive data two times per year and will provide supporting documentation as 
necessary for others to more fully understand the manner in which data were collected.  We will submit 
cumulative data each submission cycle and will review the data to look for any personally identifiable 
information and ensure that data are loaded correctly.  We commit to sharing data within 4 months after 
submission (both descriptive and experimental data) and will submit experimental data within 12 months 
after the study completion.  We commit to create an RDoCdb Study for each publication related to the 
grant and to submit a link to the RDoCdb study along with any publications so readers of articles can link 
back to the data used in RDoCdb.   
 
10.1.12 
CONFLICT OF INTEREST POLICY 
 
The independence of this study from any actual or perceived influence, such as by the pharmaceutical 
industry, is critical.  Therefore, any actual conflict of interest of persons who have a role in the design, 
conduct, analysis, publication, or any aspect of this trial will be disclosed and managed. Furthermore, 
persons who have a perceived conflict of interest will be required to have such conflicts managed in a 
way that is appropriate to their participation in the design and conduct of this trial.  The study 
leadership in conjunction with the NIMH has established policies and procedures for all study group 


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members to disclose all conflicts of interest and will establish a mechanism for the management of all 
reported dualities of interest. 
 
10.2 ADDITIONAL CONSIDERATIONS 
Not applicable. 
 
 
 


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10.3 ABBREVIATIONS 
 
AE 
Adverse Event 
AUC 
Area Under the Curve 
ACTH 
Adrenocorticotropic Hormone 
CFR 
Code of Federal Regulations 
CLIA 
Clinical Laboratory Improvement Amendments 
COC 
Certificate of Confidentiality 
CORT 
Cortisol 
CRF 
Case Report Form 
CVD 
Cardiovascular Disease 
DHHS 
Department of Health and Human Services 
DSMB 
Data Safety Monitoring Board 
E2 
Estradiol 
EEfRT 
Effort Expenditure for Reward Task 
ER 
Estrogen Receptor 
ERT 
Estrogen Replacement Therapy 
FDA 
Food and Drug Administration 
GCP 
Good Clinical Practice 
GWAS 
Genome-Wide Association Studies 
HIPAA 
Health Insurance Portability and Accountability Act  
HPA-Axis 
Hypothalamic-Pituitary-Adrenal Axis 
ICH 
International Conference on Harmonisation  
ICMJE 
International Committee of Medical Journal Editors 
IND 
Investigational New Drug Application 
IRB 
Institutional Review Board 
ITT 
Intention-To-Treat 
LSMEANS 
Least-squares Means 
MDD 
Major Depressive Disorder 
MI 
Myocardial Infarction 
MT 
Menopause Transition 
NIH  
National Institutes of Health 
NIH IC 
NIH Institute or Center 
OHRP 
Office for Human Research Protections 
P4 
Progesterone 
PI 
Principal Investigator 
QA 
Quality Assurance 
QC 
Quality Control 
RCT 
Randomized Controlled Trial 
SAE 
Serious Adverse Event 
SAP 
Statistical Analysis Plan 
SHAPS 
Snaith-Hamilton Pleasure Scale 
SOA 
Schedule of Activities 
SOP 
Standard Operating Procedure 
STAI 
State-Trait Anxiety Inventory 
STRAW+10 
Staging of Reproductive Aging Workshop 
UP 
Unanticipated Problem 
US 
United States 
WHI 
Women’s Health Initiative 
VTE 
Venous Thromboembolism 


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NIH-FDA Clinical Trial Protocol Template – v1.0 7 Apr 2017 
 
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