Conditions: Suicidal Ideation
Keywords: steroid hormones estradiol estrogen progesterone depression suicide
Allocation: RANDOMIZED | Intervention model: CROSSOVER
Enrollment: 60
Healthy volunteers: no

Brief summary:
This within-person, crossover, 3-condition, placebo-controlled study compares the impact of three perimenstrual conditions on severity of suicidal symptoms in females with past-month suicidality but minimal risk of imminent suicide attempt. The three conditions are (1) perimenstrual withdrawal from estradiol only (during progesterone stabilization), (2) perimenstrual withdrawal from progesterone only (during estradiol stabilization), and (3) perimenstrual withdrawal from both estradiol and progesterone during placebo.

Detailed description:
Previous work from our group demonstrates that perimenstrual worsening of suicidal thoughts in females is caused by normal perimenstrual withdrawal from the ovarian steroids estradiol (E2) and progesterone (P4), since perimenstrual stabilization of E2+P4 prevented the perimenstrual worsening of suicidal ideation observed under placebo. In the present study, we follow up on that work with an additional mechanistic trial in which E2 and P4 will be stabilized in separate arms of the study.

60 (30 completers) female outpatients, with past-month suicidal ideation but minimal imminent risk for attempt, will complete self-reports and clinical interviews measuring presence and severity of suicidal ideation in each of three conditions (A, B, C: order randomized across three menstrual cycles): (A) perimenstrual E2/P4 withdrawal (under placebo), (B) perimenstrual P4 withdrawal (exogenous stabilization of E2 only), and (C) perimenstrual E2 withdrawal (exogenous stabilization of P4 only). A washout cycle will separate conditions. Analyses will compare the perimenstrual trajectories of symptoms and suicidality across the three conditions.

Arms:
arm 1: .1mg per 24 hours transdermal estradiol applied to the skin weekly, and sugar pill manufactured to mimic the progesterone pills taken twice daily by mouth, for 14 days. arm 2: 100 mg oral micronized progesterone pill taken twice daily by mouth, and clear patch manufactured to mimic the E2 patch applied to the skin weekly, for 14 days. arm 3: Sugar pill designed to mimic the P4 pills taken twice daily by mouth, and clear patch manufactured to mimic the E2 patch applied to the skin weekly, for 14 days.

Interventions: intervention 1: Transdermal Estradiol + Placebo intervention 2: Oral Micronized Progesterone + Placebo intervention 3: Placebos
Intervention descriptions: intervention 1: .1mg/24hr transdermal estradiol for 14 days starting day 7 after positive urine luteinizing hormone test, plus twice daily placebo pills during the same time frame. intervention 2: 100mg oral micronized progesterone twice daily for 14 days starting day 7 after positive urine luteinizing hormone test, plus weekly application of a placebo patch during the same time frame. intervention 3: Twice daily placebo pills for 14 days starting day 7 after positive urine luteinizing hormone test, plus weekly application of a placebo patch during the same time frame.

Protocol document:
Prot_SAP_000.pdf: 
CLEAR 2 Study Protocol: Hormones and Suicide Risk, Version 9,  07-02-20, Page 1 of 64 
 
Ovarian Hormone Withdrawal and Suicide Risk: 
An Experimental Approach 
 
Protocol Identifying Number: IRB # 2018-1089 
Principal Investigator: Tory Eisenlohr-Moul, Ph.D. 
IND/IDE Sponsor: Not applicable 
Funded by: NIMH (R00, Number 109667) 
Draft or Version Number:  v.9 
2 July 2020 
 


CLEAR 2 Study Protocol: Hormones and Suicide Risk, Version 9,  07-02-2020, Page 2 of 64 
 
Table of Contents 
LIST OF ABBREVIATIONS ............................................................................................. 0 
STATEMENT OF COMPLIANCE .................................................................................... 0 
PROTOCOL SUMMARY ................................................................................................. 0 
SCHEMATIC OF STUDY DESIGN ................................................................................. 3 
1 
KEY ROLES .......................................................................................................... 5 
2  
INTRODUCTION: BACKGROUND INFORMATION AND SCIENTIFIC 
RATIONALE .................................................................................................................... 5 
2.1 
Background Information ................................................................................. 6 
2.2 
Rationale ........................................................................................................ 6 
2.3 
Potential Risks and Benefits ........................................................................ 10 
2.3.1 
Known Potential Risks .................................................................. 10 
2.3.2 
Known Potential Benefits .............................................................. 12 
3 
OBJECTIVES AND PURPOSE ........................................................................... 12 
4 
STUDY DESIGN AND ENDPOINTS .................................................................... 12 
4.1 
Description of the Study Design ................................................................... 12 
4.2.1 
Primary Endpoint ........................................................................... 14 
4.2.2 
Secondary Endpoints .................................................................... 15 
4.2.3 
Exploratory Endpoints ................................................................... 15 
5 
STUDY ENROLLMENT AND WITHDRAWAL ..................................................... 15 
5.1 
Participant Inclusion Criteria ........................................................................ 15 
5.2 
Participant Exclusion Criteria ....................................................................... 15 
5.3 
Strategies for Recruitment and Retention .................................................... 24 
5.4 
Participant Withdrawal or termination .......................................................... 26 
5.4.1 
Reasons for Withdrawal or Termination ........................................ 26 
5.4.2 
Handling of Participant Withdrawals or termination ....................... 26 
5.5 
Premature Termination or Suspension of Study .......................................... 27 
6 
STUDY AGENT ................................................................................................... 27 
6.1 
Study Agent(s) and Control Description ....................................................... 27 
6.1.1 
Acquisition ..................................................................................... 27 
6.1.2 
Formulation, Appearance, Packaging, and Labeling ..................... 27 
6.1.3 
Product Storage and Stability ........................................................ 27 
6.1.4 
Preparation ................................................................................... 27 
6.1.5 
Dosing and Administration ............................................................ 28 
6.1.6 
Route of Administration ................................................................. 28 
6.1.7 
Starting Dose and Dose Escalation Schedule ............................... 28 
6.1.8 
Dose Adjustments/Modifications/Delays ....................................... 28 
6.1.9 
Duration of Therapy ...................................................................... 28 
6.1.10 
Tracking of Dose ........................................................................... 28 
6.1.11 
Device Specific Considerations ..................................................... 28 
6.2 
Study agent Accountability Procedures ....................................................... 29 
7 
STUDY PROCEDURES AND SCHEDULE ......................................................... 29 
7.1 
Study Procedures/Evaluations ..................................................................... 29 
7.1.1 
Study specific procedures ............................................................. 29 
7.1.2 
Standard of care study procedures ............................................... 30 
7.2 
Laboratory Procedures/Evaluations ............................................................. 30 


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7.2.1 
Clinical Laboratory Evaluations ..................................................... 31 
7.2.2 
Other Assays or Procedures ........... Error! Bookmark not defined. 
7.2.3 
Specimen Preparation, Handling, and Storage ............................. 31 
7.2.4 
Specimen Shipment ...................................................................... 32 
7.3 
Study Schedule ............................................................................................ 32 
7.3.1 
Screening ...................................................................................... 32 
7.3.2 
Enrollment/Baseline ...................................................................... 32 
7.3.3 
Follow-up ...................................................................................... 32 
7.3.4 
Final Study Visit ............................................................................ 34 
7.3.5 
Early Termination Visit .................................................................. 34 
7.3.7 
Schedule of Events Table ............................................................. 34 
7.4 
Justification for Sensitive Procedures .......................................................... 35 
7.5 
Concomitant Medications, Treatments, and Procedures ............................. 36 
7.5.1 
Precautionary Medications, Treatments, and Procedures ............. 36 
7.6 
Prohibited Medications, Treatments, and Procedures ................................. 36 
7.7 
Prophylactic Medications, Treatments, and Procedures .............................. 36 
7.8 
Rescue Medications, Treatments, and Procedures ..................................... 36 
7.9 
Participant Access to Study Agent At Study Closure ................................... 36 
8 
ASSESSMENT OF SAFETY ............................................................................... 37 
8.1 
Specification of Safety Parameters .............................................................. 37 
8.1.1 
Definition of Adverse Events (AE) ................................................. 37 
8.1.2 
Definition of Serious Adverse Events (SAE) ................................. 37 
8.1.3 
Definition of Unanticipated Problems (UP) .................................... 37 
8.2 
Classification of an Adverse Event .............................................................. 38 
8.2.1 
Severity of Event ........................................................................... 38 
8.2.2 
Relationship to Study Agent .......................................................... 38 
8.2.3 
Expectedness................................................................................ 39 
8.3 
Time Period and Frequency for Event Assessment and Follow-Up ............. 39 
8.4 
Reporting Procedures .................................................................................. 40 
8.4.1 
Adverse Event Reporting .............................................................. 40 
8.4.2 
Serious Adverse Event Reporting ................................................. 40 
8.4.3 
Unanticipated Problem Reporting ................................................. 41 
8.4.4 
Events of Special Interest ............................................................. 41 
8.4.5 
Reporting of Pregnancy ................................................................ 41 
8.5 
Study Halting Rules ..................................................................................... 41 
8.6 
Safety Oversight .......................................................................................... 42 
9 
CLINICAL MONITORING..................................................................................... 42 
10 
STATISTICAL CONSIDERATIONS ..................................................................... 42 
10.1 
Statistical and Analytical Plans .................................................................... 42 
10.2 
Statistical Hypotheses.................................................................................. 42 
10.3 
Analysis Datasets ........................................................................................ 42 
10.4 
Description of Statistical Methods ................................................................ 43 
10.4.1 
General Approach ......................................................................... 43 
10.4.2 
Analysis of the Primary Efficacy Endpoint(s) ................................. 43 
10.4.3 
Analysis of the Secondary Endpoint(s) ......................................... 43 
10.4.4 
Safety Analyses ............................................................................ 43 


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10.4.5 
Adherence and Retention Analyses .............................................. 45 
10.4.6  
Baseline Descriptive Statistics ...................................................... 45 
10.4.7 
Planned Interim Analyses ............................................................. 45 
10.4.9 
Multiple Comparison/Multiplicity .................................................... 46 
10.4.10 
Tabulation of Individual Response Data ........................................ 46 
10.4.11 
Exploratory Analyses .................................................................... 46 
10.5 
Sample Size ................................................................................................. 46 
10.6 
Measures to Minimize Bias .......................................................................... 46 
10.6.1 
Enrollment/ Randomization/ Masking Procedures......................... 46 
10.6.2 
Evaluation of Success of Blinding ................................................. 47 
10.6.3 
Breaking the Study Blind/Participant Code ................................... 47 
11 
SOURCE DOCUMENTS AND ACCESS TO SOURCE DATA/DOCUMENTS .... 47 
12 
QUALITY ASSURANCE AND QUALITY CONTROL ........................................... 47 
13 
ETHICS/PROTECTION OF HUMAN SUBJECTS................................................ 47 
13.1 
Ethical Standard .......................................................................................... 48 
13.2 
Institutional Review Board ........................................................................... 48 
13.3 
Informed Consent Process .......................................................................... 48 
13.3.1 
Consent/assent and Other Informational Documents Provided to 
Participants 
48 
13.3.2 
Consent Procedures and Documentation ..................................... 48 
13.4 
Participant and data Confidentiality ............................................................. 48 
13.4.1 
Research Use of Stored Human Samples,Specimens or Data ..... 49 
13.5 
Future Use of Stored Specimens ................................................................. 50 
14 
DATA HANDLING AND RECORD KEEPING ...................................................... 50 
14.1 
Data Collection and Management Responsibilities ...................................... 50 
14.2 
Study Records Retention ............................................................................. 50 
14.3 
Protocol Deviations ...................................................................................... 50 
14.4 
Publication and Data Sharing Policy ............................................................ 51 
15 
STUDY ADMINISTRATION ................................................................................. 51 
15.1 
Study Leadership ......................................................................................... 52 
16 
CONFLICT OF INTEREST POLICY .................................................................... 52 
17  
LITERATURE REFERENCES ............................................................................. 52 
APPENDIX .................................................................................................................... 64 
 


CLEAR 2 Study Protocol: Hormones and Suicide Risk, Version 9,  07-02-2020, Page 0 of 64 
 
LIST OF ABBREVIATIONS 
 
E2 
17-beta-estradiol 
P4 
progesterone 
RCT 
Randomized controlled trial 
SITBI 
Self-Injurious Thoughts and Behaviors Interview 
UWRAP/LRAP University of Washington Risk Assessment and Management 
Protocol/Linehan Risk Assessment and Management Protocol 
EXP 
Experimental 
PL 
Placebo 
EMA 
Ecological Momentary Assessment 
CESD 
Center for Epidemiologic Studies Depression Scale 
BHI 
Beck Hopelessness Inventory 
STAI 
State-Trait Anxiety Inventory 
UPPS-P 
An Impulsivity Scale measuring Urgency, lack of Premeditation, lack of 
Perseverance, Sensation seeking, and Positive Urgency. 
SSES 
State Self-Esteem Scale 
FT-IRAP 
Future-Thinking Implicit Relational Assessment Procedure (Hopelessness 
Task) 
SAR-IAT 
Social Acceptance and Rejection Implicit Association Test (Negative Social 
Appraisals Task) 
SST 
Stop-Signal Task (Inhibitory Control Task) 
DPT 
Dot Probe Task (Threat Sensitivity Task) 
SCID 
Structured Clinical Interview for Diagnosis 
IDS 
Investigational Drug Services 
 
STATEMENT OF COMPLIANCE 
 
The trial will be conducted in accordance with the ICH E6, the Code of Federal Regulations on 
the Protection of Human Subjects (45 CFR Part 46), and the NIMH Terms of Award. The 
Principal Investigator will assure that no deviation from, or changes to the protocol will take 
place without prior agreement from the sponsor and documented approval from the Institutional 
Review Board (IRB), except where necessary to eliminate an immediate hazard(s) to the trial 
participants. All personnel involved in the conduct of this study have completed Human Subjects 
Protection Training.  
 
PROTOCOL SUMMARY 
Title: 
Ovarian Hormone Withdrawal and Suicide Risk: An Experimental 
Approach 
 
Précis: 
60 female outpatients with suicidal ideation but minimal1,2 imminent 
risk for attempt will complete behavioral tasks measuring 
hopelessness, social appraisals, inhibitory control, and threat 
sensitivity as well as clinical interviews measuring suicidality in each 
of three conditions (A, B, C: order randomized across three 
menstrual cycles): (A) perimenstrual E2/P4 withdrawal (under 
placebo), (B) perimenstrual P4 withdrawal (exogenous 
stabilization of E2 only), and (C) perimenstrual E2 withdrawal 


CLEAR 2 Study Protocol: Hormones and Suicide Risk, Version 9,  07-02-2020, Page 1 of 64 
 
(exogenous stabilization of P4 only). A washout cycle will separate 
conditions. Analyses will compare the perimenstrual trajectories of 
symptoms and suicidality across the three conditions.  
Objectives: 
 
Test the hypothesis that key suicide risk pathways will be 
heightened during conditions involving P4 withdrawal (conditions A 
and B above) relative to the E2 withdrawal condition (condition C), 
and that this greater risk will be mediated by a steeper slope of 
withdrawal from ALLO during P4 withdrawal and natural (placebo) 
E2/P4 withdrawal conditions relative to E2 withdrawal condition 
(where P4 is stabilized). We will also examine the role of inflammatory 
gene expression in explaining the associations between E2, P4, 
ALLO, and suicidality.   
 
 
 
 
 
Endpoint 
Primary:  
 
(1) Mean Within-Person Condition Differences (7 final placebo 
days – 7 final stabilization days) of SITB Suicidal Ideation 
subscale score (operationalization of suicidal desire) across 
the three conditions 
 
(2) Mean Within-Person Condition Differences (7 final placebo 
days – 7 final stabilization days) of SITB Suicidal Planning 
subscale score (operationalization of suicidal action capacity) 
across the three conditions 
 
Secondary: 
 
(1) Mean Within-Person Condition Differences (7 final placebo 
days – 7 final stabilization days) of BHI Hopelessness Score  
 
(2) Mean Within-Person Condition Differences (7 final placebo 
days – 7 final stabilization days) of CES-D Depression Total 
Score  
 
(3) Mean Within-Person Condition Differences (7 final placebo 
days – 7 final stabilization days) of UPPS-P Lack of 
Premeditation Impulsivity subscale 
 
(4) Mean Within-Person Condition Differences (7 final placebo 
days – 7 final stabilization days) of PROMIS Anxiety Total 
Score 
 
(5) Mean Within-Person Condition Differences (7 final placebo 
days – 7 final stabilization days) of SSES Social Evaluation/ 
Rejection Sensitivity subscale 
 
Population: 
60 female outpatients with suicidal ideation but minimal1,2 imminent 
risk for attempt 
Phase: 
II 


CLEAR 2 Study Protocol: Hormones and Suicide Risk, Version 9,  07-02-2020, Page 2 of 64 
 
Number of Sites 
enrolling 
participants: 
1 
Description of Study 
Agent : 
(1) Transdermal Estradiol .1mg/24hr weekly for two weeks, (2) Oral 
Micronized Progesterone 200mg (100mg each morning, 100mg 
each evening) for two weeks 
Study Duration: 
24 months  
Participant Duration: 
~3 active menstrual cycles (1 menstrual cycle lasts, on average, ~28 
days) plus 1 baseline cycle and 2 washout cycles between 
conditions (i.e., 6 menstrual cycles total). Therefore, average 
participant participation will last roughly 6-7 months. 
 
 
 


CLEAR 2 Study Protocol: Hormones and Suicide Risk, Version 9,  07-02-2020, Page 3 of 64 
 
 
SCHEMATIC OF STUDY DESIGN 
 
Screening and  
Enrollment 
 
 
 
 
 
 
 
 
 
 
 
Visits 1-3  
(COND 1) 
 
 
 
 
 
 
Visits 4-6 
(COND 2) 
 
 
 
 
 
Visits 7-9 
(COND 3) 
Perform initial telephone screen of potential subjects by inclusion and exclusion criteria, schedule enrollments as 
appropriate. At Enrollment, obtain informed consent if eligible and interested. Administer SCID, SITBI.Train 
participants in ovulation testing. 
Days 7, 14, and 22 Following 1st positive Ovulation test:  
Administer Condition 1 Intervention (Placebo or Experimental).  
Complete Interview Assessment of suicidiality (SITBI). 
Complete Computerized Tasks Measuring Inhibitory Control, Hopelessness, Rejection 
Sensitivity, and  Threat Sensitivity. Assess side effects.  
Final Visit to Debrief, Evaluate 
Suicide Risk and Facilitate 
Appropriate Referrals as Needed  
 
Days 7, 14, and 22 Following 2nd positive Ovulation test:  
Administer Condition 2 Intervention (Placebo or Experimental).  
Complete Interview Assessment of suicidiality (SITBI). 
Complete Computerized Tasks Measuring Inhibitory Control, Hopelessness, Rejection 
Sensitivity, and  Threat Sensitivity. Assess side effects.  
Days 7, 14, and 22 Following 3nd positive Ovulation test:  
Administer Condition 2 Intervention (Placebo or Experimental).  
Complete Interview Assessment of suicidiality (SITBI). 
Complete Computerized Tasks Measuring Inhibitory Control, Hopelessness, Rejection 
Sensitivity, and  Threat Sensitivity. Assess side effects.  
BASELINE CYCLE WITH DAILY MOOD MONITORING 
WASHOUT  CYCLE WITH DAILY MOOD MONITORING 
WASHOUT  CYCLE WITH DAILY MOOD MONITORING 
Randomized Subject to a Condition Order: 
(ABC, ACB, BAC, BCA, CAB, or CBA) 


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Overview of the Three Within-Person Counterbalanced, Crossover Study Conditions 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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1 
KEY ROLES 
 
Tory Eisenlohr-Moul, Ph.D. – Primary Investigator, Illinois-Licensed Clinical Psychologist, Clinician 
Responsible for Suicide Risk Assessment and Management; University of Illinois at Chicago, 912 S Wood St.,  
Rm 335, Chicago, IL 60612. Email: t.eisenlohr.moul@gmail.com; moul@med.unc.edu.  Phone: 859-317-0503.  
 
Melissa Wagner-Schuman, M.D./Ph.D. (Primary Medical Expert) – Medical Monitor, Supervising 
Physician Psychiatrist Regarding Hormone Administration; University of Illinois at Chicago, Women’s 
Mental Health Research Program, 912 S Wood St., Chicago, IL 60612. Email: mwagner9@uic.edu. Phone:  
(414) 303-0495 
 
Madeline Divine, Project Manager – University of Illinois at Chicago, Women’s Mental Health Research 
Program, 912 S Wood St., Chicago, IL 60612. Email: mdivine@uic.edu. Phone: (314) 315-3848.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
2  
INTRODUCTION: BACKGROUND INFORMATION AND SCIENTIFIC RATIONALE  


CLEAR 2 Study Protocol: Hormones and Suicide Risk, Version 9,  07-02-2020, Page 6 of 64 
 
 
2.1 
BACKGROUND INFORMATION  
 
Suicide is the second leading cause of death among females of reproductive age, yet we cannot reliably 
predict when an individual will attempt suicide. Suicide accounts for 13% of all deaths among reproductive-
age American females21. Although existing models of suicide risk provide information about long-term, stable 
risk stemming from factors such as depression, interpersonal sensitivity, anxiety, or impulsivity, little is known 
about when these factors will translate into acute risk for attempt19,22,23. By directly studying suicidal 
individuals24 and focusing on biologic triggers and cognitive/behavioral mediators of acute changes in suicide 
risk, the proposed research responds to public calls from the U.S. President, Congress, Surgeon General, and 
the NIMH-co-sponsored Suicide Research Prioritization Agenda23, to identify strong predictors of acute suicide 
risk19. Such work is imperative in developing targeted interventions for stabilizing and reducing suicidal behavior, 
and will improve the precision and effectiveness of critical efforts to block suicide attempts.  
 
Perimenstrual (around menses) withdrawal from estradiol (E2) and progesterone (P4) may represent a 
time-varying biological mechanism of acute suicide risk. The perimenstrual period, which is characterized 
by rapid withdrawal from E2 and P4, is associated with more hospitalization for suicide attempts1-3,25, more 
lethal attempts2, and suicide deaths4. The rationale for studying perimenstrual hormone withdrawal as a 
predictor of suicidality also comes from work showing that changes in normal levels of E2/P4, rather than 
absolute levels, precipitate affective symptoms and impulsivity in susceptible individuals26,27. Preliminary results 
of the PI’s recently-completed similar experiment, described in the preliminary data section below), have 
provided the first evidence that perimenstrual E2/P4 withdrawal is responsible for perimenstrual exacerbation of 
suicide risk. 
 
Theoretical Underpinning for Mediating Constructs. Selection of mediating constructs (Fig 1) through which 
ovarian steroid withdrawal is most likely28,29 to 
influence suicide risk was informed by the 
Interpersonal Theory of Suicide8,30, which posits 
that suicidal behavior arises from two acute risk 
factors: Suicidal Desire—a wish to die, and 
Suicidal Action Capacity—a readiness to act on 
urges. Suicidal desire is strongly predicted by 
hopelessness and negative social appraisals 
(thwarted 
belongingness, 
perceived 
burdensomeness)8,31. Suicidal action capacity is 
predicted by poor inhibitory control32 and threat 
sensitivity—a tendency toward detection and 
reactions to threats (fostered by extreme stress 
exposure)10,32. Because this is an integrative 
theory, the constructs measured here will allow 
testing of a variety of theories (e.g., Neurocognitive 
Theory7).  
 
Ovarian Steroid Changes Robustly Modulate Key Mediators of Suicidal Desire and Action Capacity 
 
1. Hopelessness repeatedly emerges as the most robust prospective predictor of suicidal desire in 
inpatients33 and outpatients6. Furthermore, hopelessness5 and suicide7,9,34 share functional alterations of the 
dorsomedial prefrontal cortex, supporting a central role of hopelessness in suicidality. 
Ovarian steroid withdrawal may increase hopelessness (and associated symptoms of depression). In 
animals, ovarian steroid withdrawal increases depressive behavior via GABAergic75 and serotonergic76,77 
mechanisms, whereas E2 specifically is known to exert antidepressant effects.78  
2. Negative social appraisals predict suicidal desire. Relationships are central to our ability to survive and 
thrive35. Perceptions of social rejection are experienced as painful36,37 and increase suicidal desire8—
particularly in reproductive-age females38,39. Additionally, suicidality is associated with altered function of 
brain regions associated with experiences of social exclusion and rejection7.  
Ovarian steroid withdrawal may increase negative social appraisals (and associated symptoms of rejection 
sensitivity). In animals, E2 and P4 facilitate social motivation and behavior40-42, and ovarian steroid withdrawal 


CLEAR 2 Study Protocol: Hormones and Suicide Risk, Version 9,  07-02-2020, Page 7 of 64 
 
precipitates social withdrawal15. In females, elevated luteal P4 correlates with social motivation43  and attention 
to social-affiliative opportunities44. The PI’s longitudinal work indicates that ovarian steroid withdrawal predicts 
increased daily appraisals of social rejection in females at elevated suicide risk12,16.  
3. Poor inhibitory control enables suicidal desire to escalate into suicidal action10,45. Suicidal ideation alone 
is a poor predictor of suicidal behavior19; however, the addition of poor inhibitory control robustly predicts 
suicide attempts, suggesting its relevance for suicidal action capacity11,46,47. Suicide attempters and victims 
show deficiencies in the functioning of inhibitory circuits10,48-52.  
Ovarian steroid withdrawal may reduce inhibitory control (and increase associated symptoms of 
impulsivity). Cyclical E2/P4 withdrawal predicts poorer inhibitory control, greater impulsivity,12,53-55  and 
decreased frontal cortex inhibitory activity56, while high, stable ovarian steroids increase frontal cortex inhibitory 
activation57,58. Cyclical reductions in inhibition are particularly marked in females with low prefrontal dopamine, 
which corresponds to the greater impulsivity found in suicide victims7,59. In animals, baseline impulsive behavior 
is a risk factor for greater sensitivity to ovarian steroid withdrawal60,61.  
4. Threat sensitivity, (defined as increased attention and reflexive responses to threats), predicts suicidal 
behavior10,39,62. Repeated engagement of physiological stress systems also leads to HPA axis dysregulation, 
which prospectively predicts suicide attempts among chronically suicidal individuals (preliminary work by PI 
under review)63. Other research in suicide victims indicates that generalized threat sensitivity and reactivity 
to stimuli in daily life are acutely elevated prior to fatal suicidal behavior62. 
Ovarian steroid withdrawal may increase threat sensitivity (and associated symptoms of anxiety). In 
animals, E2/P4 withdrawal increases threat sensitivity and reactivity13 and causes threat-sensitizing alterations 
in associated brain circuitry, including the amygdala64-66, the bed nucleus of the stria terminalis66,67, and the 
periaqueductal grey68,69, mediated by increased expression of GABAA receptor subunits that elicit anxiogenic 
effects of P4-derived neurosteroids64,70-76. In females, correlates of suicidality including social stress77, social 
isolation78, lifetime abuse16, impulsivity60, and PTSD 79,80, predict greater effects of ovarian steroid withdrawal on 
threat sensitivity. Cyclical reductions in E2/P4 correlate with morphological and functional changes in CNS fear 
and anxiety circuitry, especially amygdala sensitivity28,81,82.  
 
Despite robust animal and correlational human evidence that E2/P4 withdrawal modulates key mediators of 
suicide risk, the PI’s recently-completed, K99-funded experimental study (referred to as “the preceding 
study” throughout this document) was the first to experimentally test a pathophysiologic role for steroid 
hormone withdrawal on suicide risk factors in at-risk females. The PI’s recently-completed similar 
experiment (hypothesized model in Fig 1) tested a model in which perimenstrual E2/P4 withdrawal increases 
acute risk for suicidality by modulating mediating cognitive behavioral constructs (hopelessness, social 
appraisals, inhibitory control, threat sensitivity) and parallel clinical symptoms (depression, impulsivity, rejection 
sensitivity, anxiety) toward increased risk. To maximize both safety and generalizability, we studied females with 
suicidal ideation but minimal17,18 imminent risk for suicide attempt. Preliminary results (n = 25) are outlined below. 
Additional planned analyses will delineate the within-person effects of ovarian steroid withdrawal on suicidal 
desire (via mediators hopelessness and social appraisals), and suicidal action capacity (via inhibitory control and 
threat sensitivity). 
 
 
Safety and Feasibility Information. In a recently-completed similar experimental study by the PI (the 
K99-funded study), no serious adverse events have been recorded. Just two participants were 
withdrawn (by the study team; 0 dropouts) after randomization, supporting protocol feasibility. Missing 
data were minimal; participants completed 90% of daily symptom surveys, 97% of blood draws, and 
100% of lab visits.  
 


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Results from Previous Experiment (Fig 2, above): E2/P4 withdrawal causes perimenstrual worsening of 
daily self-reported suicidality in at-risk females, and EXPERIMENTAL STABILIZATION REDUCES THIS 
RISK. Analyses of daily self-report data from the 
previous 
study 
(n 
= 
30) 
indicates 
that 
perimenstrual hormone stabilization in the active 
condition prevented the robust perimenstrual 
increase in suicidal ideation observed under 
placebo (E2/P4 natural withdrawal). Results are 
identical for suicidal planning, suggesting the 
applicability of these results to suicidal behavior 
as well as suicidal thoughts. Further, as 
predicted, perimenstrual risk was shifted to the 
“withdrawal week” of the active condition (not 
significantly 
different 
from 
natural 
perimenstrual levels of risk under placebo—
i.e., the risk is not higher, but simply 
experimentally shifted to 2 weeks later), further 
demonstrating the causal role of ovarian steroid 
withdrawal 
in 
perimenstrual 
worsening 
of 
suicidality. When results were standardized to 
reflect subject-specific means and standard 
deviations (as in Fig 2 at right), the average 
impact of stabilization was roughly a 1 person-
standard-deviation condition difference in suicide 
outcomes. This suggests clinical significance. 
Additional analyses using task and interview data are planned to identify the specific cognitive and behavioral 
constructs that account for experimental effects on suicidality outcomes.  
 
 
 
 
2.2 
RATIONALE  
 
The rationale for the upcoming experiment is to build on the results of the previous experiment to disentangle 
the relative effects and mechanisms of E2 and P4 withdrawal on suicide risk, testing a mediational model 
in which P4 withdrawal is the primary driver of perimenstrual changes in behavioral constructs relevant to suicide 
risk, and ultimately, suicidal desire and action capacity, due to associated rapid withdrawal from P4-derived 
neuroactive steroids, particularly allopregnanolone (ALLO)83-87. ALLO, via positive allosteric modulation of 
GABAA receptors, exerts anxiolytic, antidepressive, and anticonflict effects88,89. P4 from the corpus luteum is the 
primary source of ALLO flux across the cycle.  This fluctuation has important implications at the GABAA receptor, 
which is composed of a responsive combination of subunits that are up- or down-regulated to maintain 
homeostasis in the face of changing ALLO70-72,90,91. This ability of the GABAA receptor to change composition is 
important in times of considerable ALLO flux (e.g., perimenstrually72,92,93). Insufficient plasticity or maladaptive 
changes to the GABAA receptor in response to ALLO flux can cause paradoxical anxiogenic, despressogenic 
effects71,75,90,91,94.  
 
Therefore, the rationale for considering ALLO specifically stems from the following evidence: blocking conversion 
of P4 to ALLO ameliorates mood symptoms, including hopelessness87, by blocking ALLO fluctuations and 
associated changes in GABAA receptor subunit expression83.  ALLO also facilitates social behavior42 and 
downregulates negative appraisals relevant to social cognition95. Finally, in a recent landmark paper from Dr. 
Leslie Morrow’s lab, ALLO has recently been found to regulate inflammatory gene expression, a process that 
has been demonstrated to be heightened among suicide victims.   
 
In sum, the rationale for the experiment is based on the need to disentangle effects of E2 and P4 withdrawal 
on suicide risk, and to identify a pathophysiological mediators (i.e., ALLO withdrawal, inflammatory gene 
expression) of the deleterious effect of perimenstrual E2/P4 withdrawal on suicidal risk in vulnerable females, 
Fig 2: Preceding Study - Experimental Effects on Suicidality 


CLEAR 2 Study Protocol: Hormones and Suicide Risk, Version 9,  07-02-2020, Page 9 of 64 
 
thereby beginning to clarifying the pathophysiology of acute suicidality. The long-term impact of this work is to 
identify targets for pharmacological and behavioral interventions to prevent suicide. 
 
Design Overview: 40 female patients (up to 60 enrolled to allow for dropout) with recent suicidal ideation but 
minimal17,18 imminent risk for suicide attempt will complete behavioral tasks and clinical risk assessments in 
three conditions: (A) perimenstrual E2/P4 withdrawal (under placebo), (B) perimenstrual P4 withdrawal 
(during exogenous perimenstrual stabilization of E2 only) and (C) perimenstrual E2 withdrawal (during 
exogenous perimenstrual stabilization of P4 only). Mediation by degree of perimenstrual ALLO withdrawal will 
be explored for significant condition contrasts.  
 
 
CENTRAL HYPOTHESIS: Test the hypothesis that key suicide risk pathways will be heightened during 
conditions involving P4 withdrawal (conditions A and B above) relative to the E2 withdrawal condition (condition 
C), and that this greater risk will be mediated by a steeper slope of withdrawal from ALLO during P4 withdrawal 
and natural (placebo) E2/P4 withdrawal conditions relative to E2 withdrawal condition (where P4 is stabilized).    
 
JUSTIFICATION OF E2/P4 DOSING AND SCHEDULE 
 
Chosen formulations are bioidentical to human E2 and P4 and were selected to mimic luteal phase 
concentrations or E2 and P4. Results from the PI’s recently-completed similar experiment indicate that these 
doses were effective in stabilizing (rather than increasing) luteal phase levels.  
 
Rationale for Route and Dose of E2 and P4. We will use Climara® 7 day transdermal E2 patches. Peak levels 
of E2 with Climara (~45 pg/mL), achieved within 24 hrs., correspond to luteal E2 levels102. No transdermal P4 is 
available. Although transdermal synthetic progestins are available, these molecules have a high affinity for 
androgen and mineralocorticoid receptors, limiting their usefulness for testing hypotheses. Thus, oral prometrium 
will be dosed b.i.d. to achieve luteal P4 levels (~13 ng/dL)102 to create steady-state levels.  
 
Rationale for Duration of E2/P4. Administration for 14 days starting 7 days after ovulation will span the range 
of time in which natural perimenstrual withdrawal would occur and prevent natural withdrawal of either E2 or P4. 
 
Compliance: Pills are dispensed in a double-blind manner. Patches will be placed by CTSA staff at UIC. All 
study staff will remain blinded. Analyses of blinding data from the previous experiment revealed that the blinding 
was successful; participants were not more likely to report believing they were on active treatment in the active 
condition relative to the placebo condition (p = .58). Participants will: 1) be educated on the importance of 
compliance; 2) be asked about compliance on each daily call; and 3) have steroid levels measured to confirm 
compliance. 
 
Route and Dose of Estradiol (E2). By avoiding the first-pass metabolic effects of oral estrogen, transdermal 
E2 creates more stable blood levels and a more physiologic profile of E2 relative to its metabolites estrone and 
estriol120-122. Transdermal E2 also has a superior safety profile than oral estrogen for thromboembolic and 
metabolic risk123-125. The use of a 7 day transdermal system provides significantly more stable concentrations 
and fewer patch adherence problems than twice weekly patches126. Climara® 7 day patches will be employed 
because the adhesive layer of the matrix patch (vs. reservoir systems) consists of polymeric acrylate or vinyl 
acetate in which the E2 molecules are distributed to continuously releases E2, which is transported across the 
skin leading to sustained circulating levels of E2 during each 7-day period. Levels of E2 achieved in 
pharmacological studies with Climara patches (around 45 pg/mL) corresponds roughly to normative luteal levels 
of E2 (reference range: 40-200 pg/mL) of E2102. Climara achieves peak levels of E2 within 24 hours.  
 
Route and Dose of Progesterone (P4). No transdermal P4 is available. Although transdermal synthetic 
progestins are available, these molecules have a high affinity not only for the progesterone receptor but also for 
the androgen and mineralocorticoid receptors, limiting their usefulness for testing our hypotheses. Therefore, 
oral micronized progesterone will be dosed daily to achieve luteal levels P4 (about 13 ng/dL)102 given on a 
b.i.d. schedule to create more steady-state levels and minimize the greater variability (peaks and troughs) that 
can occur with the oral route. Prometrium peaks within 3 hours and declines throughout the next 24 hours.  


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Duration of E2/P4 Administration in experimental conditions. Administration of either E2 or P4 for 14 days 
starting 7 days following ovulation will span the range of time in which natural perimenstrual withdrawal from E2 
and P4 naturally occur, and will therefore prevent natural perimenstrual withdrawal from E2 or P4. 
 
 
2.3 
POTENTIAL RISKS AND BENEFITS  
 
2.3.1 KNOWN POTENTIAL RISKS  
 
1) Psychological Symptom Assessment. Clinical interviews and self-report assessments contain questions 
regarding sensitive personal information, including severe psychological symptoms such as suicidal and other 
impulsive behaviors (e.g., substance abuse). As a result, participants may become upset or embarrassed 
when discussing current or past distressing life events and behaviors. On the other hand, recent evidence 
suggests that research questions pertaining to potentially distressing topics such as psychiatric symptoms, 
suicidality, and sexual or physical abuse do not significantly increase distress or acute suicide risk in females 
who report these issues24,116. The chance of increased distress is necessary in order to assess how symptoms 
change in response to perimenstrual hormone withdrawal (vs. stabilization). 
 
2) Effects of the Ovarian Hormone Stabilization Protocol on Mood/Anxiety and Behavior.  
 
Mood/Anxiety. As the population being studied in this protocol will have elevated psychiatric symptoms, and 
as ovarian hormone changes are implicated in depressive symptoms in some females27,97, it is possible that 
adverse mood reactions may occur (1) during the administration of ovarian hormones in the stabilization 
condition or (2) naturally during the placebo (natural) perimenstrual withdrawal condition. However, because 
the proposed hormone manipulation mimics (i.e., stabilizes) the luteal hormone levels that females 
naturally experience102, the proposed study is not expected to pose any greater risk to participants 
than what they experience in daily life. Furthermore, although the slow taper at the end of the withdrawal 
prevention, luteal hormone stabilization conditions could elicit negative mood changes, these would not be 
expected to be any more severe than those that would otherwise have arisen from normal perimenstrual 
hormone withdrawal—that is, we will have simply delayed the normal withdrawal process. 
 
Suicidality. As detailed above, the population will be recruited to achieve a population of females that is 
simultaneously: (1) experiencing recent suicidal ideation, yet (2) at acceptably low17,18,100 current risk for 
suicidal crisis/attempt based on an assessment conducted during a screening visit (see Table 1). Because 
ovarian hormone changes are implicated in psychiatric symptoms in some females27,97, and because such 
symptoms may increase suicide risk, it is possible that increases in suicidality may occur (1) during the 
administration of ovarian hormones in stabilization conditions or (2) naturally during the placebo (natural) 
perimenstrual withdrawal condition. However, because the proposed hormone manipulations mimic (i.e., 
stabilizes) the normal physiologic range of luteal hormone levels102 that females naturally experience, 
the proposed studies are not expected to expose participants to greater risk for suicidality than what 
they experience in daily life.  This notion is borne out by the results of the preceding experiment by the PI, 
which suggest a beneficial effect of the active hormone stabilization condition on symptoms. The results also 
indicate that the “shifted” risk during active hormone patch/pill withdrawal does not represent an net increase in 
risk, because (1) typical perimenstrual increase in risk is prevented, and (2) the experimental withdrawal-
related symptoms are not significantly different in magnitude from the natural withdrawal-related symptoms that 
are prevented earlier in the condition (as observed under placebo).  
 
3) Hormone Side Effects. We do not expect any serious adverse mood or other side effects associated with 
the hormonal manipulations for the following reasons: First, we will be administering the physiologically 
relevant steroid hormones (estradiol and/or progesterone) and not the substituted steroids (such as ethinyl 
estradiol or norethindrone) present in many oral contraceptives and which have been reported to have a 
potentially more serious profile of side effects127-130. Second, prior exogenous hormonal studies (or E2, P4, or a 
combination) conducted in Dr. Rubinow’s lab at the NIH that induced substantially more elevated hormone 


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concentrations and a more precipitous hormone withdrawal.  In those studies in females with histories of 
reproductive mood disorders (whom are excluded in the present study), although hormone induction and 
withdrawal was associated with increased mood symptoms, symptoms were transient and no subjects 
experienced a mood-related adverse event defined by meeting criteria for MDD or developing imminent risk for 
suicide. During the the PI’s recently-completed similar study, no physical or mental adverse events 
were sufficient to lead the medical supervisor to recommend unblinding or termination of participation.  
 
Possible Side Effects of Estradiol. Nausea is the most common side effect of estrogen administration. At 
conventional hormone doses, this complaint seldom interferes with eating, and no weight loss has been 
reported as a result of nausea. Breast engorgement and bleeding are also common side effects of estrogen 
administration. Pre-existing fibroid tumors of the uterus may enlarge under the effects of estrogen; however, at 
the dosage and for the duration of estrogen administration in this protocol this risk is extremely small. 
Numerous retrospective case control studies published since 1975 have indicated that post-menopausal 
exposure to unopposed estrogens for more than one year results in a two to 12 fold increased relative risk for 
endometrial cancer. A relationship between the dose and duration of estrogen use and the risk for endometrial 
cancer has also been shown, the risk being increased after one to four years of estrogen use and rising also 
with the dosage employed. In the upcoming experiment, however, the length of E2-only administration in the 
P4 withdrawal condition (see Research Strategy) is only 14 days, which is not sufficient to cause endometrial 
hyperplasia131.  There is an increase in thromboembolism in females receiving non-contraceptive estrogen 
therapy132-135, but this risk is most evident in obese females and in those who smoke (exclusionary factors in 
the present research).  
 
It may be important to note that there were numerous concerns about increased risk for breast cancer and 
cardiovascular events related to the use of hormone replacement therapy (estrogen plus a progestin) that 
stemmed from the initial results of the Women’s Health Initiative (WHI), which randomized 27,000 
postmenopausal females to HRT or placebo.  Critical reviews subsequent to the initial WHI reports showing an 
increased incidence of non-fatal breast cancer and cardiovascular events have argued that the discordant 
findings between the WHI and the observational studies finding benefit of HRT for all cause and cardiovascular 
mortality reflected problems in the design of the WHI, the most important of which may have been the age and 
condition of the study subjects136.  As the risk of breast cancer, heart disease and metabolic dysregulation 
increase with age; the likelihood of adverse events upon exposure to E2 should also increase with age. Recent 
reports from the North American Menopause Society137 and the Endocrine Society138 confirm that the risk of 
CVD in the WHI was observed in older but not younger females. Additionally, data suggest that the formulation 
of E2 (conjugated equine estrogen) used in the WHI is associated with an increased profile of risk compared 
with transdermal E2, and the progestin used in the WHI (medroxy progesterone acetate) is particularly 
antagonistic (among progestins) to the beneficial cardiovascular effects of E2139,140.  The Endocrine Society 
concludes that “Data from the various Women’s Health Initiative studies, which involved participants of average 
age 63, cannot be appropriately applied to calculate risks and benefits of menopausal hormone therapy in 
females starting shortly after menopause”138.  In fact, there is substantial evidence for the safety of E2, 
particularly if administered to females within 10 years of their final menstrual period and if administered as the 
transdermal form (e.g., lower risk of VTE)137,138.  
 
Given our plans to administer transdermal E2 to participants: (1) for only 14 days, (2) no older than 45 years of 
age, (3) who are currently regularly menstruating and medically healthy, and (4) who are at no greater than 
average risk for CVD, breast cancer or VTE, the risk of serious adverse events is exceedingly low. 
 
Possible Side Effects of Progesterone. Progesterone and the synthetic progestins are widely prescribed, 
with indications including dysfunctional uterine bleeding, endometriosis, mastodynia, galactorrhea, and 
precocious puberty131. In a recent study, a dose of 300 mg of oral micronized progesterone (100mg higher than 
the dose proposed) was given to a sample of females with premenstrual mood disturbance and was well 
tolerated by this sample141. Side effects reported included lightheadedness and fatigue; these were very mild 
and caused no dropouts. 
 
4) Confidentiality. A breach of confidentiality could indicate to others a participants’ history of suicidality. 


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5) Venipuncture. Standard risks associated with venipuncture are present during the laboratory testing 
sessions. 
 
2.3.2 KNOWN POTENTIAL BENEFITS  
 
This is a mechanistic study to determine the role of ovarian hormone changes in constructs that are 
relevant to suicidality. There is no direct benefit to the participants other than the benefit of knowing 
that they are contributing to research on the causes of suicidality.   
 
3 
OBJECTIVES AND PURPOSE 
 
The purpose of this mechanistic study is to experimentally test a pathophysiologic mediational model in 
which late luteal (perimenstrual) ovarian steroid withdrawal increases suicidal desire (via increased 
hopelessness and negative social appraisals) and suicidal action capacity (via reduced inhibitory control and 
increased threat sensitivity). We predict that natural P4 withdrawal (compared to the two conditions in which P4 
is stabilized) will increase reports of suicidal desire (partially mediated by task performance indicating increased 
hopelessness and negative social appraisals) and action capacity (partially mediated by task performance 
indicating decreased inhibitory control and increased threat sensitivity). Therefore, we predict that administration 
of P4 will reduce suicide risk by buffering the deleterious impact of perimenstrual withdrawal from P4. We predict 
that administration of E2 will have some mild protective effects, but not to the same extent as P4. 
 
4 
STUDY DESIGN AND ENDPOINTS 
 
4.1 
DESCRIPTION OF THE STUDY DESIGN 
 
This is a single-center study; there is no phase designation because it is a mechanistic experiment 
with agents (E2,P4) that is commonly used in clinical practice. 
 
Participants: 60 female outpatients (recruited to achieve a targed N of 40 completers) with a with past-month 
suicidal ideation but low17,18 imminent suicide risk (see Human Subjects) receiving treatment as usual. 
Participants must: be 18 to 45 years of age, have normal menstrual cycles (21-35 days), not pregnant, 
breastfeeding, or trying to get pregnant, not taking hormones, no history of serious medical illness, normal weight 
(BMI 18-29.99), and low risk for thrombotic events (factor V Leiden mutation based on family history). Most 
outpatients with suicidality take medications; therefore, to increase feasibility/generalizability, medication use will 
be measured and covaried in analyses (as in the similar study recently completed by the PI).  
 
Psychiatric Diagnoses. The SCID-I and SCID-II. History of manic episode, psychosis, or substance abuse 
disorder will be exclusionary due to risk of suicidal crises17,100. Additionally, self-report history of postpartum 
depression or premenstrual dysphoric disorder are exclusionary, since reproductive mood disorders may be 
characterized by a different pattern of sensitivity101. Based on data from the preceding study, we expect 90% of 
our sample to have lifetime depressive disorder, 50% to meet criteria for BPD, and 50% to have lifetime anxiety 
disorder.  
 


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Study Design (Fig 2). THIS IS NOT A CLINICAL EFFICACY 
TRIAL.  However, an RCT design with transdermal 17β-E2 
and oral micronized P4 will investigate the unique roles of 
perimenstrual withdrawal from E2 and P4 in acute suicidality 
(Fig 1). Participants will be trained in the protocol, including 
urine ovulation testing (LH surge preceding ovulation 24h), 
daily phone assessment, and patch/pill schedule. Using a 
double-blind, counterbalanced, within-subject cross-over 
design, participants will receive each of three, 2-week  
perimenstrual phase conditions (see Fig 3 at right) with 
washout cycles in between: (CONDITION A): E2/P4 
withdrawal during placebo patches/pills, (CONDITION B): P4 
withdrawal during E2 stabilization with active E2 patch and 
placebo pills, and (CONDITION C): E2 withdrawal during P4 
stabilization with active P4 pills and placebo patch. The UIC 
Investigational Drug Service will manage randomization and 
dispensing. During the stabilization conditions, participants 
will wear weekly E2 patches (Climara®) delivering 0.10 mg 
E2 per day for seven days and will take oral progesterone 
(Prometrium®) at a dose of 100mg b.i.d. These doses were 
tolerated by 100% of participants in the preceding similar 
experiment. These doses will achieve (stabilize) luteal E2 or 
P4 levels102.  
 
Timing of Hormone Administration. Based on urine 
testing, participants will begin medications seven days after 
ovulation (+7 in Fig 3) to coincide with a time in the cycle 
when E2/P4 are elevated. The goal of the active E2 or P4 
manipulations are to extend and maintain the mid-luteal 
phase hormone profile of either E2 or P4 beyond the point 
in the cycle that would normally be associated with natural 
withdrawal (as in Condition A under placebo). In the active 
conditions, the luteal phase hormone profile of either E2 
(Condition B) or P4 (Condition C) will be maintained for 14 days by applying a new patch on day +14 (extended 
luteal phase levels  spanning +7 to +21), preventing natural withdrawal and stabilizing E2 or P4 in physiologic102 
luteal range. In the prior study, this dosing schedule resulted in a stabilized, slower hormone taper as both 
endogenous hormones were naturally falling during the perimenstrual experimental time period, with exogenous 
hormone slowing/buffering this decline during the active phase. Of note, the placebo condition uses the same 
patch/pill schedule.  
 
Assessment of Outcomes. In addition to daily surveys, participants will complete phone measures starting at 
ovulation and ending 5 days following the last patch/pill. Three lab sessions will assess serum E2, P4, and ALLO, 
and behavioral outcomes. 
 
Lab Construct Measures. Each computerized task is scored using within-task comparisons, controlling for 
training-related changes in response time. Hopelessness will be measured via the Future Thinking Implicit 
Relational Assessment Procedure (FT-IRAP)103; participants respond with true or false to pairings between “I 
expect” and “I don’t expect” with sets of negative (e.g., worry, sadness) and positive (e.g., enjoyment, happiness) 
events. Greater latency to optimistic/hopeful, and lower latency to pessimistic/hopeless pairings indicate implicit 
hopelessness103. Performance predicts clinical hopelessness and depression103. Negative Social Appraisals 
will be measured using the Social Acceptance-Rejection Implicit Association Test (SAR-IAT)104, in which 
participants respond to pairings of self words (e.g., I, me) and other words (e.g., them, you) with words indicating 
social acceptance (e.g., included) or social rejection (e.g., rejected). Response times to pairings indicate the 
strength of implicit self-with-acceptance or self-with-rejection associations. Performance predicts explicit social 


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appraisals and negative affect in social interactions104. Inhibitory Control will be measured using the Stop-
Signal Task (SST)105; participants withhold a prepotent response. Performance predicts prefrontal cortex 
activation and lower impulsive clinical outcomes105. Threat Sensitivity will be measured as attentional bias for 
threat pictures on a Dot Probe Task (DPT)106. Attentional bias to threat on this task is linked to anxiety disorders107 
and multimodal indices of threat sensitivity in daily life106,108. Parasympathetic influences on the heart will be 
quantified using electrocardiogram, which will be collected and cleaned according to established evidence-based 
protocols. Respiratory Sinus Arrhythmia (RSA) will measure of parasympathetic (vagal) influence, and will be 
calculated using the well-validated peak-valley method.  Greater RSA values reflect greater parasympathetic 
activity. RSA will be evaluated for a 10-minute baseline. Concurrent Suicidal Desire and Action Capacity will 
be estimated with the Suicidal Ideation, Thoughts, and Behavior Interview (SITBI)112. Validity will also be 
examined with a wide variety of well-validated self report laboratory measures of the above constructs; all items 
of these measures are provided in the appendix. 
 
Daily Online Symptom Measures: A variety of items intended to capture a wide array of symptoms related to 
the above constructs; all items are provided in the appendix.   
 
Daily Safety and Suicidality Telephone Call: Suicidal desire and action capacity will be measured with a 
daily telephone call during active condition days using a shortened version of the SITBI112. Items are provided in 
the appendix. 
 
Participant Safety: As in the preceding experiment, emergent changes in suicidality will be managed using the 
structured University of Washington Risk Assessment and Management Protocol (UWRAP)24,116. However, 
because the manipulation mimics luteal E2/P4 levels that females naturally experience, the manipulation is not 
expected to pose greater risk than a normal102 cycle—the risk will simply be shifted during P4 stabilization. This 
is supported by the results of the prior experiment. 
 
Primary Windows of Comparison for Hypothesis Testing. To test whether prevention of P4 withdrawal (in 
Condition C) reduces the perimenstrual increase in suicide risk, primary hypothesis tests will compare degree 
of suicide risk (as measured with self-report, tasks, and interviews) during the perimenstrual weeks of each 
condition (days +7 to +22). Secondary analyses will examine Condition C, testing whether tapered withdrawal 
from exogenous P4 around days +16 to +22 causes “shifted”/”postponed” perimenstrual risk.  
 
Hypotheses/Analytic Plan. It is hypothesized that Condition A (E2/P4 withdrawal under placebo) and Condition 
B (P4 withdrawal under E2 stabilization) will BOTH be associated with heightened perimenstrual suicidality, but 
that Condition C (E2 withdrawal under P4 stabilization) will significantly reduce perimenstrual increases in 
suicidality. We also hypothesize that a steeper slope of ALLO withdrawal, calculated across the lab ALLO 
measures in each condition, will mediate the more deleterious effects of P4 withdrawal conditions. Multilevel 
models will be used (repeated observations nested within individuals) to predict daily or weekly repeated 
suicidality and mediator outcomes from a within-person condition factor (and, if appropriate, the interaction of 
condition and day). Mediation by degree of ALLO withdrawal will be tested by estimating a 95% CI for the indirect 
effect of condition (focal predictor) on suicide risk outcomes (dependent variable) via the slope of ALLO change 
across the perimenstrual phase (mediator). Power Analysis. For primary hypothesis tests, 80% power to detect 
a conventionally medium-sized effect of condition (f = .25) is achieved with 24 participants117. To allow for attrition 
and improve generalizability and power, we propose to include 30 participants.  
 
 
4.2.1 PRIMARY ENDPOINT 
 
The primary endpoints (described below) of this mechanistic study are suicidal ideation and planning score 
differences between placebo condition and stabilization conditions on the SITBI measure. These were chosen 
given their strong predictive validity in epidemiological studies.  
 
(1) Mean Within-Person Condition Differences (7 final placebo days – 7 final stabilization days) of SITB 
Suicidal Ideation subscale score  


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(2) Mean Within-Person Condition Differences (7 final placebo days – 7 final stabilization days) of SITB 
Suicidal Planning subscale score  
 
 
4.2.2 SECONDARY ENDPOINTS 
 
The secondary endpoints of this study include the daily telephone measures as follows:  
 
(6) Mean Within-Person Condition Differences (7 final placebo days – 7 final stabilization days) of BHI 
Hopelessness Score  
 
(7) Mean Within-Person Condition Differences (7 final placebo days – 7 final stabilization days) of CES-D 
Depression Total Score  
 
 
(8) Mean Within-Person Condition Differences (7 final placebo days – 7 final stabilization days) of UPPS-P 
Lack of Premeditation Impulsivity subscale 
 
(9) Mean Within-Person Condition Differences (7 final placebo days – 7 final stabilization days) of PROMIS 
Anxiety Total Score 
 
(10) 
Mean Within-Person Condition Differences (7 final placebo days – 7 final stabilization days) of 
SSES Social Evaluation/ Rejection Sensitivity subscale 
 
 
4.2.3 EXPLORATORY ENDPOINTS 
 
None. 
 
5 
STUDY ENROLLMENT AND WITHDRAWAL 
 
5.1 
PARTICIPANT INCLUSION CRITERIA 
 
In order to be eligible to participate in this study, an individual must meet all of the following general criteria:  
• 
Provision of signed and dated informed consent form  
• 
Stated willingness to comply with all study procedures and availability for the duration of the study  
• 
Ability to take oral medication and be willing to adhere to the medication regimen  
 
To be eligible for participation in the proposed study, an individual must meet all of the following criteria. 
 
1. Must be biologically female and between the ages of 18-45 years.  
o Justification: Females younger than 18 or older than 45 may have inconsistent menstrual 
cycles or may be postmenopausal and therefore no longer cycling. 
 
2. Must have normal menstrual cycles between 21 and 35 days. 
o Justification: Abnormal menstrual cycle lengths or variability in lengths could introduce error 
variance into the experiment, and could reduce confidence regarding the timing of the 
experimental manipulation to cycle events. 
 
3. Must be under the current care of an outpatient mental health provider, whom they report seeing at 


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least once every 3 months. 
o Justification: Because we intend to recruit females with current suicidality, engagement with a 
mental health provider is required as a protective measure to ensure that participants have 
access to treatment if needed. 
 
4. If the woman has children, she must be at least 1 year postpartum. 
o Justification: The postpartum period can be characterized by altered hormone levels and 
changes; therefore, postpartum females may introduce error variance into the experiment. 
 
5. Must not be pregnant, breastfeeding, or trying to become pregnant. Pregnancy status will be 
confirmed using urine pregnancy test at the enrollment visit and again at the first visit of the second 
condition. Participants will be encouraged to use a barrier method of birth control during the study. 
o Justification: Administration of ovarian hormones to a pregnant woman could negatively 
influence the pregnancy in a variety of ways, including risks to the health of the fetus. 
 
6. Must not be taking any form of exogenous hormones or IUD, and must have ended previous use of 
hormonal preparations at least one month prior to the study. 
o Justification: The use of additional exogenous hormones poses safety risks and would 
undermine experimental control of hormones.  
 
7. Must be of normal weight (BMI between 18.00-29.99 kg/m2); measured at the enrollment visit. 
o Justification: Responses to doses of hormones may vary by BMI and risk for thromboembolic 
events with hormone use increases in obese females. 
 
8. Must report no personal history of any chronic medical condition, including but not limited to 
metabolic or autoimmune disease, epilepsy, endometriosis, cancer, diabetes, cardiovascular, 
gastrointestinal, hepatic, renal, or pulmonary disease, and no personal or first degree family history of 
thromboembolic events. 
o Justification: Administration of exogenous hormones to females with these chronic medical 
conditions may increase the risk of an adverse health-related response to hormones. Further, 
the purpose of the present study is to determine the impact of hormonal stabilization (vs. natural 
withdrawal) in otherwise physically healthy females.  
 
9. Must not report 2 or more first degree relatives with hormone dependent cancers (ovarian, uterine, 
breast, colon, prostate) or a known genetic predisposition (BRCA1, BRCA2, PTEN, or Tp53) to those 
cancers 
o Justification: Administration of exogenous hormones might increase cancer risk in individuals 
with genetic predisposition.  
 
 
10. Must not currently smoke cigarettes. 
o Justification: Administration of ovarian hormones to females who smoke may increase the risk 
of thromboembolic events.  
 
11. Must not report a history of clinical diagnosis of postpartum depression or premenstrual dysphoric 
disorder (Note: PMDD diagnosis must have been made based on prospective daily ratings).  
o Justification: Some evidence would suggest that the pattern of perimenstrual symptoms that 
have been linked with these reproductive mood disorders could differ meaningfully27 from that 
which we be expect in the more general clinical population of females with suicidality12. Because 
these distinctions are not yet clear, females with a self-reported history of clinical diagnosis with 
these disorders will be excluded.  
 
12. Must not report any history of manic episode, psychotic symptoms, or substance use disorder.  
o Justification: These factors are known sources of variability in suicidality and would therefore 
introduce error into our models as well as increasing the risk that a participant would experience 


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a suicidal crisis during the study17,100. Use of opioids, methamphetamine, and cocaine will be 
screened at the enrollment visit to validate self-report measures of substance use.  
 
13. Must report at least some recent suicidal ideation (in the past month) at enrollment. 
 
• 
Justification: As reviewed in the research strategy, the purpose of the study is to examine the 
impact of natural perimenstrual hormone withdrawal (vs. prevention of either E2 or P4 
withdrawal) on within-person changes in suicide risk. The present sampling strategy ensures 
generalizability24 of our findings to clinical populations of interest and will also prevent a floor 
effect (i.e., zero-inflation of daily outcome measures and associated limitations in power to 
detect effects) on primary daily outcome measures (e.g., mediating behavioral constructs, 
suicidality).  
 
14. Must be categorized as having acceptably low imminent risk for suicidal crisis/attempt according 
to established clinical and research guidelines100 (see Suicide Experimental Eligibility Table), which 
have been adapted for the K99/R00 studies (the preceding experiment and the present experiment) in 
collaboration with Dr. Prinstein, the suicide-focused co-mentor on the K99 training grant. As Dr. 
Prinstein notes in his 2014 methodological paper on research-based suicide risk assessment18, 
evaluation of imminent risk of suicidal crisis/attempt is a complex clinical task, requiring integrative 
consideration of a variety of factors (including: general clinical presentation, ideation severity, 
frequency, recency, and associated consideration/intent; access to suicidal means; previous attempts 
and gestures; presence of suicidal planning, recent stressors, frequency of contact with mental health 
provider; and presence of social support). Therefore, our specific criteria for delineating whether a 
participant is eligible are based on an evidence-based determination18,100 that the participant is at 
acceptably low imminent risk of suicidal crisis/attempt. These decisions will be based on 
responses to a variety of questions from the SITBI and Severity of Suicidal Ideation Interview (clinical 
interviews at the beginning of an enrollment visit). 
 
o Justification: Individuals with current suicidality are not necessarily at imminent risk for 
suicidal crises/attempt (i.e., their risk is manageable on an outpatient basis through frequent 
clinical contact, such as the daily calls in the present study). Because the proposed hormone 
protocol simply prolongs the physiologic luteal hormone profile of E2 or P4, it is not expected to 
expose participants to additional risk of suicidal crisis beyond what they would naturally 
experience during their typical monthly menstrual cycles. However, out of an abundance of 
caution, we will exclude females with elevated imminent risk for suicidal crisis/attempt 
(determined by structured interview and established guidelines18,100). Individuals with histories of 
suicidality often have ongoing, habitual thoughts about death or suicide that are highly 
distinguishable from imminent risk for suicide attempt17,100,118. In further support of this notion 
and of the feasibility of recruiting this population, it should be mentioned that up to 1/3 of the 
American population experiences suicidal ideation at some point in their lives118, yet less than 
.01% die by suicide each year100,118.  Data from the preceding similar experiment (K99 
experiment) provide clear evidence of the safety of this protocol; no participant was 
hospitalized for imminent risk or attempted suicide during the study.  
 
 
SPECIFICS OF SUICIDE RISK-RELATED ELIGIBILITY CRITERIA  
 
The proposed study will include only participants with current suicidal ideation (past-month endorsement 
of suicidal ideation) in order to maximize generalizability to our clinical population of interest. We hypothesize 
that natural perimenstrual withdrawal from ovarian hormones will be associated with significant but transient 
shifts in continuously-estimated suicide risk that are not expected to escalate to the level of suicidal 
crisis/attempt (due to the exclusion of certain females at highest risk for attempt, as noted below). In order to 
minimize the risk of suicidal crises during the study, we will exclude females who meet evidence-based 
criteria18,100 for imminent risk of acute suicidal crisis/attempt. 
 


CLEAR 2 Study Protocol: Hormones and Suicide Risk, Version 9,  07-02-2020, Page 18 of 64 
 
The goal of these exclusion/inclusion criteria is to minimize the risk that a participating woman will 
demonstrate imminent risk of suicidal crisis/attempt during the study. The determination of acceptably low 
current risk of suicidal crisis/attempt will be carried out in multiple steps, as follows: 
 
1. First, potential participants must pass a phone screen in which they will report on their previous 
psychiatric diagnoses and recent history of suicide attempts. At that juncture, the following criteria will 
be applied:      
a. A woman will be excluded if she reports a suicide attempt or any concrete suicidal planning in 
the past 3 months, as the majority of repeated attempts occur within the first three months 
following an initial attempt17,100. 
b. A woman will be excluded if she reports a history of more than one suicide attempt, as multiple 
attempts represent a uniquely potent risk factor for additional suicidal crises/attempts17,100. 
c. A woman will be excluded (and referred) if she reports that she does not currently visit a mental 
health provider (psychiatrist, therapist) at least once every 3 months17.  
d. A woman will be excluded if she reports any extreme external stressors (e.g., death of a loved 
one, loss of employment) in the past month, as extreme stressors drastically increase the risk of 
suicidal crisis17,100. 
e. A woman will be excluded if she reports a history of clinical diagnosis with manic episode, 
psychotic symptoms, or substance use disorder, as these disorders reduce predictability and 
increase likelihood of suicidal crises/attempt100.  
 
2. Second, potential participants must pass an in-person eligibility screening at the beginning of an 
enrollment visit, in which they will complete a clinical interview designed to more thoroughly assess the 
risk factors described in 1a-1e above, as well as additional determinants of suicide risk outlined in 
Table 1 below. 
a. Eligibility criteria in 1a-1e above will again be re-assessed and applied.  
b. Using a clinical interview based on the SITBI interview112 and the Scale for Suicidal Ideation 
interview119, the PI will evaluate each woman on a variety of risk factors for suicidal crisis and 
evaluate whether a woman has acceptably low17,18,100 imminent risk of suicidal crisis/attempt 
using the decision rules described in the leftmost column in Table 1 and summarized below: 
• 
The evidence-based determination of acceptably low risk17,18,100 of suicidal 
crisis/attempt will be based on the count of positive findings in each Row of Table 
1 (see next page), as follows: No positive findings in Row 5; No greater than 1 
positive finding in Row 4; No greater than 2 total positive findings in Rows 3 + 4; 
No greater than 3 total positive findings in Rows 2, 3, and 4. 
 
3. Note that ongoing participant suicide risk monitoring and management is described in later sections. 


CLEAR 2 Study Protocol: Hormones and Suicide Risk, Version 9,  07-02-2020, Page 19 of 64 
 
SUICIDE-RELATED EXPERIMENTAL ELIGIBILITY TABLE 
 
The goal of the suicide-related exclusion/inclusion criteria (outlined below) for the proposed set of studies is to minimize the risk that a participant 
will experience an acute suicidal crisis or attempt suicide during the study. Evidence-based criteria were developed in collaboration with mentors at 
UNC Chapel Hill During the K99 Phase of the Grant17,18,100. History of mania, psychosis, or substance abuse disorder will also be exclusionary. 
Table notes: Recent = In the past month. MHP = Mental Health Provider. 1SITBI items 3a, 3b, 4a, 4b, 4c. 2SITBI items 1a, 1b, 1c, 1f, 2c. 3SITBI 
items 2a, 2b. 
 
ROW 
Suicide 
Attempts1 
Suicidal Thoughts2 
Recency 
of Last 
Suicidal 
Planning3 
Current 
Access to 
Means 
Recent 
Stressors/
Loss 
Current 
Frequency 
of MHP 
Contact 
Current 
Social 
Support 
Number 
Recency 
 
Recency 
 
Recent 
Frequency 
Recent 
Severity 
Recent 
Intent 
 
 
 
 
 
1 
Never 
Never 
In past 
year 
Less than 
monthly 
1f=1 
2c=1 
Never 
No Access 
to Means 
None 
>1x/ 
month 
Multiple 
Strong 
Supporter
s 
2 
No more than 3 
total positive 
findings allowed 
in Rows 2,3, +4 
Any 
gesture 
or NSSI, 
no 
attempt 
In past 2 
years 
In past 
month 
~1x/ 
month 
1f=2 
2c=2 
>2 years 
ago 
 
Extreme 
Stressors in 
past year 
~1x/ 
month 
One 
Strong 
Supporter 
or multiple 
supports 
3 
No more than 2 
total positive 
findings allowed 
in Rows 3 + 4 
1 
aborted 
attempt 
in past 
year 
In past 
week 
~1x/ week 
1f=3 
2c=3 
1-2 years 
ago 
Access to 
Nonspecific 
or  
Unfeasible 
means 
Extreme 
Stressors in 
last 3 
months 
~1/ 
2 months 
Very 
Limited 
Support 
4 
No more than 1 
positive finding 
allowed in Row 4 
1-3 
attempts 
In past 6 
months 
Now 
>1x/ 
week 
1f=4 
2c=4 
3 months 
to 1 year 
ago 
Access to 
Specific, 
Feasible 
Means 
Extreme 
Stressors in 
last 1-2 
months 
~1x/ 
3 months 
No 
Support 
5  
No positive 
findings allowed 
in Row 5 
>3 
attempts 
In past 3 
months 
 
 
 
 
<3 months 
ago 
 
Extreme 
Stressors in 
last month 
<1x/ 
3 months 
 


 
CLEAR 2 Study Protocol: Hormones and Suicide Risk, Version 9,  07-02-2020, Page 23 of 64 
 
5.2 
PARTICIPANT EXCLUSION CRITERIA 
 
Any individual meeting any of the following exclusion criteria at baseline will be 
excluded from the study: 
 
1. Must not be pregnant, breastfeeding, or trying to become pregnant. Pregnancy 
status will be confirmed using urine pregnancy test at the enrollment visit and again at 
the first visit of the second and third conditions. Participants will be instructed to use a 
barrier method of birth control during the study. 
o Justification: Administration of ovarian hormones to a pregnant woman could 
negatively influence the pregnancy in a variety of ways, including risks to the 
health of the fetus. 
 
2. Must not be taking any form of exogenous hormones or IUD, and must have ended 
previous use of hormonal preparations at least one month prior to the study. Potential 
participants who were previously taking oral contraceptives or other hormonal 
medications must have one normal menstrual cycle (menstrual period) prior to 
enrollment in the study.  
o Justification: The use of additional exogenous hormones poses safety risks and 
would undermine experimental control of hormones.  
o Participants will be required to use licensed barrier methods of 
contraception during study participation; if they are unable to commit to 
this responsibility, they will not be eligible for participation. 
 
3. Must report no personal history of any chronic medical condition, including but not 
limited to metabolic or autoimmune disease, epilepsy, endometriosis, cancer, diabetes, 
cardiovascular, gastrointestinal, hepatic, renal, or pulmonary disease, and no personal 
or multiple first degree family history of thromboembolic events. 
o Justification: Administration of exogenous hormones to females with these 
chronic medical conditions may increase the risk of an adverse health-related 
response to hormones. Further, the purpose of the present study is to determine 
the impact of hormonal stabilization (vs. natural withdrawal) in otherwise 
physically healthy females.  
 
4. Must not currently smoke cigarettes. 
o Justification: Administration of ovarian hormones to females who smoke may 
increase the risk of thromboembolic events.  
 
5. Must not report a history of clinical diagnosis of postpartum depression or premenstrual 
dysphoric disorder (Note: PMDD diagnosis must have been made based on prospective 
daily ratings).  
o Justification: Some evidence would suggest that the pattern of perimenstrual 
symptoms that have been linked with these reproductive mood disorders could 
differ meaningfully39 from that which we be expect in the more general clinical 
population of females with suicidality8. Because these distinctions are not yet 
clear, females with a self-reported history of clinical diagnosis with these 
disorders will be excluded.  
 
6. Must not report any history of manic episode, psychotic symptoms, or substance use 
disorder.  


 
CLEAR 2 Study Protocol: Hormones and Suicide Risk, Version 9,  07-02-2020, Page 24 of 64 
 
o Justification: These factors are known sources of variability in suicidality and 
would therefore introduce error into our models as well as increasing the risk that 
a participant would experience a suicidal crisis during the study1,149.  
 
7. Must not test positive for opioid use, cocaine use, or methamphetamine use at the 
enrollment visit.  
o Justification: Use of these drugs are indicative of either a chronic medical 
condition or increased risk of suicidal crisis, both of which are exclusionary in the 
present study.149 
 
 
 
5.3 
STRATEGIES FOR RECRUITMENT AND RETENTION 
 
Recruitment and Informed Consent 
 
We will utilize the same strategies for recruitment as were used in the similar preceding 
experiment: (1) social media advertisements with links to a qualtrics eligibility survey, and (2) 
community flyers with contact information. 
 
Potential participants will complete initial eligibility screening by telephone and a secure online 
questionnaire. 
 
No more information will be asked of participants than necessary to obtain eligibility information 
and to contact those who appear to be eligible to schedule a screening/enrollment visit. At this 
initial visit, the PI (Dr. Eisenlohr-Moul) will obtain written informed consent for further screening 
regarding suicidality from those individuals who pass the initial telephone and questionnaire 
screenings and are interested in participating. This consent will inform participants regarding the 
nature of the questions to be asked. If the participant consents, the Self-Injurious Thoughts and 
Behaviors Interview160 and the Scale for Suicidal Ideation Interviews168 will be administered. If 
the participant is not eligible for the study following the screening (see details above), they will 
be dismissed and referred for treatment as necessary. If they are eligible, Dr. Eisenlohr-Moul 
will obtain additional written informed consent for participation in the larger study (i.e., the 
screening visit will become the enrollment visit). During the consenting process for the larger 
study, all of the applicable consent forms will be reviewed with each individual, and they will be 
given as much time as they would like to discuss their participation with their significant others 
and decide whether to participate.  
 
INCLUSION OF WOMEN AND MINORITIES 
 
Men will not be included in this study, given the stated purpose of examining ovarian 
hormone withdrawal as a mechanism of suicidal risk in females. With respect to ethnic and 
racial diversity, The University of Illinois at Chicago (UIC) Women’s Mental Health Research 
Program (WMHRP) has a strong commitment to the enrollment of racial minority women in 
research projects, and this commitment will be reflected in the proposed work. The WMHRP has 
extensive experience with recruitment and retention of diverse samples in women’s mental 
health studies that reflect Chicago demographics. We plan to recruit proportions of ethnic and 
racial minorities for the proposed work that are as consistent with the demographics of Chicago 
(per 2016 data) as possible. We have conservatively estimated our ability to recruit a sample 
(N=30) that is 60% Caucasian (n = 18), 32% Black or African American (n=9), 5% Asian (n = 2), 


 
CLEAR 2 Study Protocol: Hormones and Suicide Risk, Version 9,  07-02-2020, Page 25 of 64 
 
and with 3% identifying as more than one race (n = 1). With regard to ethnicity, we estimate that 
25% (n = 7) will identify as Hispanic, and 75% (n = 23) will identify as non-Hispanic.   
 
 
JUSTIFICATION FOR INCLUSION OF INDIVIDUALS WITH CURRENT SUICIDALITY 
 
As reviewed in the study background and rationale, the purpose of the study is to examine the 
impact of natural perimenstrual hormone withdrawal (vs. prevention of hormone 
withdrawal/stabilization of E2 or P4) on within-person changes in suicide risk. The present 
sampling strategy ensures generalizability3 of our findings to clinical populations of interest 
(i.e., not simply depressed females, but those with suicidality) and will also prevent a floor 
effect (i.e., zero-inflation of daily outcome measures and associated limitations in power to 
detect effects) on primary daily outcome measures (e.g., mediating behavioral constructs, 
suicidality).  
 
Individuals with current suicidality are not necessarily at imminent risk for suicidal 
crises/attempt (i.e., their risk is manageable on an outpatient basis through frequent clinical 
contact, such as the daily calls in the present study). Because the hormone protocol simply 
prolongs the physiologic luteal hormone profile, it is not expected to expose participants to 
additional risk of suicidal crisis beyond what they would naturally experience during their typical 
monthly menstrual cycles. However, out of an abundance of caution, we will exclude females 
with elevated imminent risk for suicidal crisis/attempt (determined by structured interview 
and established guidelines). Individuals with histories of suicidality often have ongoing, habitual 
thoughts about death or suicide that are highly distinguishable from imminent risk for suicide 
attempt. In further support of this notion and of the feasibility of recruiting this population, it 
should be mentioned that up to 1/3 of the American population experiences suicidal ideation at 
some point in their lives, yet less than .01% die by suicide each year.  
 
RETENTION OF INDIVIDUALS WITH SUICIDALITY 
 
Although a variety of exclusion criteria will be applied, the PIs recent work has prepared her to 
recruit, retain, and maintain the safety of participants and potential participants with suicidal 
ideation but low imminent risk of attempt. Furthermore, the majority of individuals with suicidal 
ideation do not evidence imminent risk for suicide attempt, supporting the feasibility of recruiting 
from this population. With regard to retention, the PI has demonstrated the capacity to recruit and 
retain females with BPD with suicidal ideation, and participants with BPD in her recent study have 
completed 85% of daily email surveys; given larger incentives for shorter daily contacts, we expect 
a higher response rate. In the recently-completed experimental study, the PI and her team were 
successful in retaining 30 participants with suicidality through a similar 4-month study. 
 
Empirically-supported strategies for retention will include study branding, frequent contact, 
monetary rewards, and graduated compensation schedules.  
 
 
Study subjects will receive the following monetary incentives: 
 
Participants who complete the protocol in full will receive $2650, paid in installments over 6-7 
months of participation following the completion of the enrollment visit and folling each of three 
conditions.  
 
Study participants will receive the following monetary incentives: 


 
CLEAR 2 Study Protocol: Hormones and Suicide Risk, Version 9,  07-02-2020, Page 26 of 64 
 
- 
$150 pay for one enrollment visit  
- 
$150 pay for each laboratory testing session x 9 laboratory sessions (= $1350 total) 
- 
$250 for completing daily online symptom surveys in each condition (=total $750) 
- 
$100 for completing daily phone calls in each condition (=total $300) 
- 
$100 for debriefing visit 
 
Rationale for Pay: The compensation structure utilized here is identical to that used for the 
previous iteration of this experiment (the K99-funded experiment) at the PI’s previous institution 
(UNC Chapel Hill). It is critical that the compensation structure remain identical in order to 
prevent any possible change to the protocol that may affect participant investment or attitudes 
toward completion of surveys and laboratory visits. The extended nature of the protocol (6-7 
months) and the intensive requirements of participation coincide with the level of incentive we 
are providing. Given the intensive nature of the study and the long time-span over which 
compensation will be provided, we believe that this compensation structure is NOT likely to be 
coercive. 
 
5.4 
PARTICIPANT WITHDRAWAL OR TERMINATION 
 
5.4.1 REASONS FOR WITHDRAWAL OR TERMINATION 
Participants are free to withdraw from participation in the study at any time upon 
request. An investigator may terminate participation in the study if:  
• 
Any clinical adverse event (AE), or other medical condition or situation occurs such that 
continued participation in the study would not be in the best interest of the participant 
(severe mood deterioration, severe changes in suicidality, severe hormonal side effects), 
as determined by Dr. Eisenlohr-Moul in collaboration with Dr. Wagner (or the DSMB).  
 
• 
The participant meets an exclusion criterion (either newly developed or not previously 
recognized) that precludes further study participation. 
 
 
5.4.2 HANDLING OF PARTICIPANT WITHDRAWALS OR TERMINATION 
 
PROTOCOL FOR DISCONTINUATION AND REFERRAL 
 
If a participant shows emergence of severe mood symptoms or greater than low risk of suicide 
attempt, the URWAP protocol for assessing and managing suicide risk will be closely followed 
(see Appendix for UWRAP). In particular, if a participant appears to need immediate treatment, 
our offices are in close proximity to UIC emergency department, and participants requiring 
immediate emergency care can easily be escorted there. The blind will be broken for the 
participant and their study participation will be discontinued. If it is revealed that the participant 
was currently in the placebo condition, they will simply be referred to their mental health 
provider (or, as necessary, to the emergency department) for treatment. However, if it is 
revealed that the participant was currently in an active hormone stabilization condition, the 
supervising physician (Dr. Wagner) will oversee a gradual tapering of the hormonal intervention 
and the patient will be referred to their mental health provider (or, as necessary, the emergency 
department) for treatment.  
 


 
CLEAR 2 Study Protocol: Hormones and Suicide Risk, Version 9,  07-02-2020, Page 27 of 64 
 
5.5 
PREMATURE TERMINATION OR SUSPENSION OF STUDY 
 
Administration of study agent will be halted when three serious AEs* determined to be 
“probably related” (i.e., with new onset during study patches/pills) are observed. The PI 
will immediately notify the DSMB when this occurs. The DSMB will notify the study sponsor and 
investigators immediately when the third severe event is reported and enrollment screens will 
stop accepting new study participants. The DSMB will request the statistical analyses and 
tables that they wish to review, and these will be prepared by an unblinded biostatistician 
associated with the study. All requested documentation will be provided to the DSMB. The 
DSMB will convene an ad hoc meeting by teleconference or in writing as soon as possible. The 
DSMB will provide recommendations for proceeding with or terminating the study to the PI and 
the NIH. The study sponsor will inform all appropriate regulatory agencies of the temporary halt 
and the disposition of the study (i.e., terminate, continue). 
 
*Statistically, the most likely examples of serious adverse events in the present study 
include development of a venous thromboembolism or a suicide attempt during an 
experimental phase of the study.  
 
 
6 
STUDY AGENT 
 
6.1 
STUDY AGENT(S) AND CONTROL DESCRIPTION 
 
6.1.1 ACQUISITION 
 
Both Climara patches (transdermal E2) and Prometrium pills (oral micronized P4) will be 
acquired through UIC Investigational Drug Services from their respective manufacturers.  
 
IDS will order climara + prometrium as well as appropriate placebo materials.  
 
6.1.2 FORMULATION, APPEARANCE, PACKAGING, AND LABELING 
 
Please see attached inserts for information about active Climara patches (transdermal E2) and 
Prometrium (oral micronized P4). Both transdermal E2 and oral micronized P4 are readily 
commercially available. Placebo patches and pills (both in stock at UIC IDS) are formulated and 
designed to be identical in appearance to these agents; all packaging and blinding will be 
accomplished via UIC Investigational Drug Services.  
 
6.1.3 PRODUCT STORAGE AND STABILITY 
 
Both Climara and Prometrium can be stored at room temperature for the duration of an 
individual’s study participation. Participants will be instructed to avoid exposing study 
drugs to extreme temperatures or humidity. More specific information about storage and 
stability can also be found in the attached inserts for Climara and Prometrium.  
 
6.1.4 PREPARATION 
 


 
CLEAR 2 Study Protocol: Hormones and Suicide Risk, Version 9,  07-02-2020, Page 28 of 64 
 
All preparation will be handled by UIC Investigational Drug Services (IDS), who will blind and 
mask the study drugs. No further preparation will be required by study staff or participants.  
 
6.1.5 DOSING AND ADMINISTRATION 
 
Dosages of E2 and P4 will be fixed. Dosages will not be tied to meals, but will be 12 hours apart 
in the morning and evening. 
 
6.1.6 ROUTE OF ADMINISTRATION 
 
E2 will be administered via transdermal patch. Micronized P4 will be administered orally in pill 
form. 
 
6.1.7 STARTING DOSE AND DOSE ESCALATION SCHEDULE 
 
In the experimental conditions of the study, the dosages will be fixed and not changed.  
 
6.1.8 DOSE ADJUSTMENTS/MODIFICATIONS/DELAYS 
 
If the PI determines that a participant must be discontinued from the protocol (see Section 
5.4.2), The PI and Dr. Wagner will be unblinded via IDS. If the participant was on active E2/P4, 
Dr. Wagner will supervise the subject’s discontinuation of E2/P4. Regardless of the condition 
the participant was in, the PI and Dr. Wagner will continue to follow the participant until 
resolution via appropriate clinical care (e.g., hospitalization for suicidality). 
 
6.1.9 DURATION OF THERAPY 
 
The planned duration of active treatment is 14 days. All days in which participants use patches 
and pills will be utilized in multilevel modeling analyses, which accommodate 
unbalanced/missing data.  
 
6.1.10 TRACKING OF DOSE 
 
For patches (E2): E2 patches will be applied (day +7 following ovulation) and changed (day 
+14 following ovulation) in the laboratory; therefore, no compliance issues are anticipated for 
E2.  One extra patch will be given to each participant in the case that the patch falls off. All used 
patches will be brought to the lab so that use of patches can be monitored. 
For pills (P4): at the first lab visit, study staff will work with participants to develop individualized 
methods for reminding the participant to take twice-daily study pills, including but not limited to 
email reminders, phone call reminders, text reminders, app-based reminders (with data stored 
locally only), pill charts, calendar reminders, and stimulus control (e.g., putting study medication 
on bedside table. Participants will bring in pill bottles to each visit so compliance can be 
monitored.  
6.1.11 DEVICE SPECIFIC CONSIDERATIONS 
 
Not applicable.  


 
CLEAR 2 Study Protocol: Hormones and Suicide Risk, Version 9,  07-02-2020, Page 29 of 64 
 
 
6.2 
STUDY AGENT ACCOUNTABILITY PROCEDURES 
 
Research staff pick up agents from IDS and distribute to subjects as outlined in the 
study schedule below. All unused pills and patches will be returned to study staff, who 
will return them to IDS. IDS will dispose of unused materials according to regulations. 
 
7 
STUDY PROCEDURES AND SCHEDULE 
 
7.1 
STUDY PROCEDURES/EVALUATIONS 
7.1.1 STUDY SPECIFIC PROCEDURES  
 
PHONE SCREENING 
 
Variable 
Interview 
Measure 
Self-Report 
Measure 
Task Measure 
Inclusion/Exclusion Criteria 
x 
- 
- 
Psychiatric Diagnosis 
Self-
reported 
Previous 
Diagnosis 
- 
- 
Suicidality 
Abbreviated 
SITBI 
- 
- 
 
 
ENROLLMENT VISIT – 1 VISIT @ 4 HRS 
• Timing: Can occur at any time provided that it allows for the participant to 
complete the protocol in the term of IRB approval. 
• Assessments Administered (see section 4.1 for Abbreviations): 
 
Variable 
Interview 
Measure 
Self-Report 
Measure 
Task Measure 
Vitals 
- 
Height/Weight 
- 
Inclusion/Exclusion Criteria 
x 
 
 
Psychiatric Diagnosis 
SCID 
- 
- 
Suicidality 
Full SITBI 
- 
- 
Depression 
- 
CESD 
- 
Hopelessness 
- 
BHI 
- 
Inhibitory Control 
- 
UPPS-P 
- 
Threat Sensitivity 
- 
STAI 
- 
Negative Social Appraisals 
- 
SSES 
- 
 
LABORATORY TESTING VISITS – 9 VISITS @ 1.5-2 HRS 
• Timing: The nine laboratory visits for each condition will occur on days +7, +14, 
and +22 following positive ovulation test (day 0) in each condition. The 


 
CLEAR 2 Study Protocol: Hormones and Suicide Risk, Version 9,  07-02-2020, Page 30 of 64 
 
acceptable windows will be +/- 2 days in either direction for each visit.  
 
• Assessments Administered (see section 4.1 for Abbreviations): 
 
Variable 
Interview 
Measure 
Self-Report 
Measure 
Task Measure 
Urine Pregnancy Screen 
(1st lab visit of each 
condition) 
- 
- 
x 
Urine Drug Testing  
X 
X 
x 
Vitals (1st lab visit of each 
condition) 
- 
- 
Height/Weight 
Blood Sample (48 ml) 
- 
- 
E2/P4/ALLO/Inflammatory 
Gene Expression 
Suicidality 
Full SITBI 
- 
- 
Depression 
- 
CESD 
- 
Hopelessness 
- 
BHI 
FT-IRAP 
Inhibitory Control 
- 
UPPS-P 
SST 
Threat Sensitivity 
- 
STAI 
DPT 
Negative Social Appraisals 
- 
SSES 
SAR-IAT 
Side Effects and 
Compliance Monitoring 
X 
- 
- 
Parasympathetic Activity 
- 
- 
Respiratory Sinus 
Arrhythmia 
 
DEBRIEFING VISIT – 1 HOUR 
 
• Timing: Debriefing will occur within a 15 day window following completion of the 
second condition.  
• Individual results will not be reported to the patient. 
• Referral to original care provider will be facilitated as necessary. 
• Assessments Administered (see section 4.1 for Abbreviations): 
 
Variable 
Interview 
Measure 
Self-Report 
Measure 
Task Measure 
Final Suicide Risk 
Assessment 
Full SITBI 
- 
- 
 
7.1.2 STANDARD OF CARE STUDY PROCEDURES  
 
Although the LRAP/UWRAP dictates the provision of basic supportive conversation and other 
simple interventions to reduce imminent risk in the context of increased suicidality, participants 
are expected to utilize their mental health provider for any treatment needs that arise during the 
course of the study.  
 
7.2 
LABORATORY PROCEDURES/EVALUATIONS 
 


 
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7.2.1 CLINICAL LABORATORY EVALUATIONS  
 
A point-of-care urine pregnancy test will be completed in our laboratory on site at the first visit 
of all three conditions. A positive pregnancy test will result in termination of participation and will 
be managed by Dr. Wagner. 
 
At the beginning of each experimental condition,  we will also collect a urine sample and 
perform rapid urine toxicology screens for cocaine, opioids, cannabis, and methamphetamine 
on-site through the CRC nursing staff using Ten Panel Integrated EZ Split Key Drug Test Cup 
with temperature-sensitive strips. A positive result for cocaine, opioids, or methamphetamine will 
result in exclusion. THC use will be allowed as long as the participant does not meet criteria for 
a substance use disorder on the SCID-I.  
 
At all 9 laboratory assessments during active treatment with placebo or E2/P4, participants will 
provide 48ml of blood to be assayed for E2/P4, ALLO, and inflammatory gene expression, to 
evaluate the success of the hormone in achieving stable luteal phase levels of E2/P4/ALLO, as 
well as more stable inflammatory markers. Storage onsite will be handled by the CTSA CRC 
staff. 
 
7.2.2 OTHER ASSAY PROCEDURES  
 
Gene Expression Measurement and Coding. Total RNA will be extracted using a Qiacube 
automated nucleic acid preparation system (Qiagen, Valencia, CA). Resulting RNA samples will 
be tested for suitable mass (Nanodrop ND1000) and integrity (Agilent Bioanalyzer), and converted 
to fluorescent cRNA for hybridization to human HT-12 BeadChips (Illumina, San Diego, CA). 
Expression values for all human gene transcripts will be determined, with individual samples 
subject to quantile normalization and log2-transformation to stabilize variance for linear model-
based analyses of differential gene expression and subsequent interpretive bioinformatics.  
Genomic data will be included in analyses using composite measures of a priori-defined gene 
sets involved in inflammation, Type I interferon-related antiviral responses, and antibody 
production. From a specific set of 53 genes, we will form composites of 19 pro-inflammatory 
genes, 31 Type I interferon-related genes, and 3 antibody-related genes. Composites will be 
formed by averaging standardized values of each (log2-transformed, quantile normalized) gene 
transcript. Cronbach’s alpha reliability coefficients for such transcript composites are typically in 
excess of .80, and we expect similarly reliable composites in this study. In addition, we will 
complete a “bottom-up” analysis of all sets of genes that are systemically up- or down-regulated 
across the perimenstrual weeks as a result of our experimental conditions (E2, P4) relative to 
placebo. 
 
7.2.3 SPECIMEN PREPARATION, HANDLING, AND STORAGE 
 
48 ml of blood will be collected using: (1)  one 20-ml red-top tube (no additive), (2) one 20-ml 
lavender-top tube (EDTA additive), and (3) one 8-ml PaxGene RNA tube. 20ml of blood (red-top 
tube) will be centrifuged and serum will be aliquoted into storage tubes and stored in a -80F 
freezer in the Clinical Research Center. These will be transported to the core laboratory in 
batches for estrogen and progesterone assay. Following assay, any additional serum will be 
stored by the CRC. The other 20 ml tube of blood (lavender-top tube) will be transferred to Dr. 
Graziano Pinna’s laboratory within 48 hours of the draw, and will be centrifuged and separated 
into plasma aliquots (for measurement of GABAergic neurosteroids using GC-MS) and 


 
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lymphocyte aliquots (for use in gene expression assays related to neurosteroid synthesis and 
function), then stored in a -80 F freezer in the Dr. Pinna’s Laboratory. Standard freezer-proof 
labels will indicate participant ID and study session. A PaxGene RNA blood tube will be utilized 
to collect an additional 8ml of blood for use in gene expression assays related to inflammation. 
Following analysis, the PaxGene RNA blood samples will also be destroyed. 
 
7.2.4 SPECIMEN SHIPMENT 
 
Serum transport will be handled by Clinical Research Center staff. Serum samples will 
analyzed in batches when there are enough aliquots to support purchase of RIA kits.  
Lavender top tubes will be transported to Dr.Pinna’s lab by CLEAR Lab staff members. 
PaxGene tubes will be stored until assay at the conclusion of the experiment, and will 
be analyzed in a single batch. 
 
7.3 
STUDY SCHEDULE 
 
7.3.1 SCREENING 
 
The screening procedures described below must take place prior to the enrollment visit; 
because all information about eligibility obtained during the phone screen is confirmed at the 
enrollment visit, there is no expiration of screening procedures after which they must be 
repeated. 
 
Following verbal consent, verbal phone screening will include verbal assessment of all 
inclusion/exclusion criteria described above, including assessment of recent suicidality using the 
shortened SITBI.  
 
The study will be conducted without accessing protected health information (PHI). We will NOT 
seek access to any medical records. 
 
 
7.3.2 ENROLLMENT/BASELINE 
 
Following recruitment screening via telephone, interested individuals will schedule and attend 
an enrollment visit at which they will provide informed consent and be further assessed for 
eligibility, which includes assessment of self-reported inclusion/exclusion criteria (including 
appropriate level of suicide risk on the SITBI-- see information in section 5.1). If ineligible, they 
will be referred back to their mental health provider and receive payment for the enrollment visit. 
If eligibility is confirmed, they will be further characterized using the SCID-I and SCID-II and 
complete various psychosocial questionnaires. In addition, they will be trained in the protocol for 
urine ovulation testing, daily telephone assessments, and the patch/pill administration schedule. 
Participants will be randomized to one of six possible condition orders at that time.  
 
The study agent will not be administered until Lab assessment 1 (i.e., not at this enrollment 
visit).  
 
7.3.3 FOLLOW-UP  
 


 
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Following the baseline/enrollment visit, participants will remain in contact with study staff 
and will begin ovulation testing as instructed. When ovulation testing is positive (day 0), 
the participant will contact the study staff to schedule the first three laboratory 
assessment visits (visits for condition 1) on days +7, +14, and +22. All laboratory 
assessment visits are identical in structure and content, with the singular exception that 
the first laboratory visit of each condition will include: (1) a pregnancy test that must be 
negative prior to dispensing study medication, (2) a urine drug screen, and (3) 
assessment of height and weight (BMI). Between conditions, participants will again remain 
in contact with study staff to schedule ovulation testing in the next menstrual cycle. 
Once again, when ovulation is confirmed (day 0), the final 3 laboratory assessments (for 
condition 2) will be scheduled on days +7, +14, and +22. These visits may be scheduled 
up to +/-2 days in either direction. 
 
• Follow-Up Assessments Administered (see section 4.1 for Abbreviations): 
 
Variable 
Interview 
Measure 
Self-Report 
Measure 
Task Measure 
Vitals (first lab of each 
condition) 
- 
- 
Height/Weight 
Urine Pregnancy Screen 
(first lab of each condition) 
- 
- 
x 
Urine Drug Screen (first lab 
of each condition) 
x 
x 
x 
Blood Sample (48 ml) 
- 
- 
E2/P4/ALLO/Inflammatory 
Gene Expression 
Suicidality 
Full SITBI 
- 
- 
Depression 
- 
CESD 
- 
Hopelessness 
- 
BHI 
FT-IRAP 
Inhibitory Control 
- 
UPPS-P 
SST 
Threat Sensitivity 
- 
STAI 
DPT 
Negative Social Appraisals 
- 
SSES 
SAR-IAT 
Side Effects, AEs, and 
Compliance Monitoring 
X 
- 
- 
Parasympathetic Activity 
- 
- 
Respiratory Sinus 
Arrhythmia 
 
Follow-Up Timeline: 
 
Condition 1 (Follow-Up Visits 1-3):  
 
- Ovulation Testing  
- Positive Ovulation Test #1= Day 0 
- Study Followup Visits 1-3 Scheduled for days +7, +14, +22 
- Study Followup Visit 1 (Day +7): Assessments, pregnancy test, drug test, vitals, administration 
of study agent patch A and dispensation of pills (Condition 1) 
- Study Followup Visit 2 (Day +14): Assessments, replacement of study agent patch A with 
patch B (Condition 1) 
- Removal of study patch and end of pills on day +21 
- Study Followup Visit 3 (Day +22): Assessments 


 
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Condition 2 (Follow-Up Visits 4-6):  
 
- Ovulation Testing  
- Positive Ovulation Test #2= Day 0 
- Study Followup Visits 4-6 Scheduled for days +7, +14, +22 
- Study Followup Visit 4 (Day +7): Assessments, pregnancy test, drug test, vitals, administration 
of study agent patch A and dispensation of pills (Condition 2) 
- Study Followup Visit 5 (Day +14): Assessments, replacement of study agent patch A with 
patch B (Condition 2) 
- Removal of study patch and end of pills on day +21 
- Study Followup Visit 6 (Day +22): Assessments 
 
Condition 3 (Follow-Up Visits 7-9):  
 
- Ovulation Testing  
- Positive Ovulation Test #2= Day 0 
- Study Followup Visits 4-6 Scheduled for days +7, +14, +22 
- Study Followup Visit 4 (Day +7): Assessments, pregnancy test, drug test, vitals, administration 
of study agent patch A and dispensation of pills (Condition 3) 
- Study Followup Visit 5 (Day +14): Assessments, replacement of study agent patch A with 
patch B (Condition 3) 
- Removal of study patch and end of pills on day +21 
- Study Followup Visit 9 (Day +22): Assessments, Schedule Debriefing 
 
 
7.3.4 FINAL STUDY VISIT 
 
Debriefing visits will be scheduled within 15 days of study completion. In this final visit, a final 
risk assessment will be conducted and the participant will be referred as appropriate for 
additional clinical care. This final risk evaluation visit is included in order to reduce the likelihood 
of emergent risk following withdrawal from exogenous hormones in participants who had the 
placebo-experimental condition order. Participants will not be provided with individualized study 
results.  
 
 
 
7.3.5 EARLY TERMINATION VISIT 
 
Should early termination be deemed necessary (following procedures detailed above), and the 
situation does not involve a need for immediate hospitalization of the participant, then the 
participant will be invited to an early termination visit in which the full typical debriefing interview 
(i.e., risk assessment and referral as appropriate) will be conducted.  
 
7.3.6 UNSCHEDULED VISIT 
 
There will be no unscheduled visits. Should a participant present at the laboratory at the wrong 
time, a member of the study staff will reschedule the visit if needed or refer her to her mental 
health provider as appropriate. 
 


 
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7.3.7 SCHEDULE OF EVENTS TABLE 
 
Procedures 
Screening 
Enrollment/Baseline 
IDS RANDOMIZATION 
Follow-Up (Condition 1, Visit 1) 
Follow-Up (Condition 1, Visit 2) 
Follow-Up (Condition 1, Visit 3) 
Follow-Up (Condition 2, Visit 4)* 
Follow-Up (Condition 2, Visit 5)* 
Follow-Up (Condition 2, Visit 6)* 
Final Visit/ Debriefing Visit 
Informed Consent 
Verbal 
x 
Written 
x 
 
 
 
 
 
 
 
 
Demographics 
x 
x 
 
 
 
 
 
 
 
 
Medical History/Inclusion/Exclusion Criteria 
x 
x 
 
 
 
 
 
 
 
 
SCID – Diagnostic Interview 
 
x 
 
 
 
 
 
 
 
 
SITBI – Suicidality Interview 
 
x 
x 
x 
x 
x 
x 
x 
x 
x 
Randomization 
 
 
x 
 
 
 
 
 
 
 
Administer Study Agent E2 (or placebo) Patch 
 
 
 
x 
x 
 
x 
x 
 
 
Dispense Study Agent P4 (or placebo) Pills 
 
 
 
x 
x 
 
x 
x 
 
 
Height/Weight  
 
 
 
x 
 
 
x 
 
 
 
Pregnancy and Drug Tests 
 
 
 
x 
 
 
x 
 
 
 
E2/P4/ALLO/Inflammatory Gene Expression Blood Measure 
 
 
 
x 
x 
x 
x 
x 
x 
 
CESD - Depression Self-Report 
 
 
 
x 
x 
x 
x 
x 
x 
 
BHI – Hopelessness Self-Report 
 
 
 
x 
x 
x 
x 
x 
x 
 
STAI – Anxiety/Threat Sensitivity Self-Report 
 
 
 
x 
x 
x 
x 
x 
x 
 
SSES – Negative Social Appraisals Self-Report 
 
 
 
x 
x 
x 
x 
x 
x 
 
UPPS-P – Impulsivity/Inhibitory Control Self-Report 
 
 
 
x 
x 
x 
x 
x 
x 
 
FT-IRAP – Hopelessness Task 
 
 
 
x 
x 
x 
x 
x 
x 
 
SAR-IAT – Negative Social Appraisal Task 
 
 
 
x 
x 
x 
x 
x 
x 
 
SST – Inhibitory Control Task 
 
 
 
x 
x 
x 
x 
x 
x 
 
DPT – Threat Sensitivity Task 
 
 
 
x 
x 
x 
x 
x 
x 
 
Adverse Event/Side Effect Evaluation 
 
 
 
x 
x 
x 
x 
x 
x 
 
Parasympathetic Activity – Respiratory Sinus Arrythmia 
 
 
 
x 
x 
x 
x 
x 
x 
 
 
*Condition 3, Visits 7-9 are identical to Condition 2, Visits 4-6. 
 
 
7.4 
JUSTIFICATION FOR SENSITIVE PROCEDURES 
 
Placebo control is required to demonstrate unique effects (vs. expectancy effects) of hormones 
on indices of suicidality.  
 
Ongoing Assessment of Suicidality 
 
The PI (Dr. Eisenlohr-Moul) is a clinical psychologist with nine years of experience in risk 
assessment and empirically supported treatment of chronic suicidality (e.g., Dialectical Behavior 
Therapy); Dr. Wagner, whose office is adjacent to Dr. Eisenlohr-Moul’s, is an experienced 
clinical psychiatrist with clear expertise in suicide risk assessment and management. These 
clinical qualifications will allow the PI and Dr. Wagner, the prescribing physician for the study, to 
carefully assess and manage any emergent changes in imminent suicide risk. 
 


 
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The available literature3 indicates that participants in research studies do not generally 
become acutely upset in response to the psychological assessments conducted in the 
present study. If participants do become upset during an assessment, they will be reminded of 
their right to discontinue participation, and mood changes or suicidality will be assessed and 
managed using the University of Washington Risk Assessment and Management Procedure 
(UWRAP), the suicide risk management protocol recommended by NIH in the context of RCTs 
for mood disorders.  
 
7.5 
CONCOMITANT MEDICATIONS, TREATMENTS, AND PROCEDURES  
 
 
All concomitant prescription medications taken during study participation will be recorded. For 
this protocol, a prescription medication is defined as a medication that can be prescribed only by 
a properly authorized/licensed clinician. Medications to be reported are concomitant prescription 
medications, over-the-counter medications and non-prescription medications. 
 
 
7.5.1 PRECAUTIONARY MEDICATIONS, TREATMENTS, AND PROCEDURES 
 
There are no medications that are prohibited for concomitant use with the study agents, with the 
exception of any hormonal preparations (that are exclusionary). 
 
7.6 
PROHIBITED MEDICATIONS, TREATMENTS, AND PROCEDURES  
 
There are no prohibited medications or procedures except hormonal preparations, which are 
exclusionary. However, inclusion/exclusion criteria exclude those reporting ongoing treatment 
for a chronic (non-psychiatric) medical condition, as well as excluding those with a positive 
enrollment drug screen for opioids, methamphetamines, or cocaine, since recreational use of 
these drugs may indicate heightened risk of a suicide attempt.  
 
7.7 
PROPHYLACTIC MEDICATIONS, TREATMENTS, AND PROCEDURES  
 
Not applicable. 
 
7.8 
RESCUE MEDICATIONS, TREATMENTS, AND PROCEDURES  
 
Not Applicable.  
 
Hospitalization will serve as a “rescue treatment” should imminent suicidal risk emerge. 
 
7.9 
PARTICIPANT ACCESS TO STUDY AGENT AT STUDY CLOSURE  
 
Participants will not be provided access to study medications following the termination of this 
study; as noted above, this is a mechanistic experimental study and not a treatment study. 
 


 
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8 
ASSESSMENT OF SAFETY 
 
The safety of the study and its participants (as described in 2.3.1) will be monitored via (1) 
Supervising physician Melissa Wagner, M.D./Ph.D. (hormone-related AEs) and Tory Eisenlohr-
Moul, Ph.D. (mood and suicide-related AEs) as well as (2) a Data and Safety Monitoring Board 
(DSMB).  
 
AEs will be assessed daily during the telephone contacts in the two administration conditions, 
and will be assessed weekly at laboratory visits. All AEs will be reported immediately to the PI 
and Dr. Wagner, who will determine severity and next steps. 
 
A DSMB of three experts outside the PI’s department will evaluate AEs that are submitted 
during scheduled reviews (every 6 months). The DSMB will be composed of MDs and PhDs 
from relevant disciplines, including clinical psychology, gynecology, and endocrinology.  
 
Although not expected given the doses and duration of hormone exposure, the DSMB will, 
during scheduled reviews, specifically evaluate the frequency of AEs related to the hormonal 
RCT. The DSMB will specify the tables and data it wishes to have presented to it at all 
meetings, including but not limited to, moderate to severe side effects and all serious adverse 
events. DSMB review of this study will occur every six months. At these meetings the 
DSMB will also review data from participants who have been discontinued by study staff or who 
have withdrawn or dropped out of the study, and the reasons for discontinuation. 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. The DSMB will evaluate issues of 
participant safety as well as the adequacy and integrity of accumulating data, review of 
enrollment data, and making recommendations regarding safety. 
 
8.1 
SPECIFICATION OF SAFETY PARAMETERS 
 
8.1.1 DEFINITION OF ADVERSE EVENTS (AE) 
 
Adverse event means any untoward medical occurrence associated with the use of an 
intervention inhumans, whether or not considered intervention-related (21 CFR 312.32 (a)). 
 
8.1.2 DEFINITION OF SERIOUS ADVERSE EVENTS (SAE) 
 
Serious adverse event or serious suspected adverse reaction. An 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, or a persistent or significant incapacity. 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 patient or subject and may require medical intervention to prevent one of the outcomes 
listed in this definition.  
 
*Notable examples of serious adverse events in the present study include development 
of a venous thromboembolism or suicide attempt.  
 
8.1.3 DEFINITION OF UNANTICIPATED PROBLEMS (UP) 


 
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OHRP considers unanticipated problems involving risks to participants or others to include, in 
general, any incident, experience, or outcome that meets all of 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 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.  
 
This study will use the OHRP definition of UP. 
 
8.2 
CLASSIFICATION OF AN ADVERSE EVENT 
 
8.2.1 SEVERITY OF EVENT 
 
For AEs not included in the protocol defined grading system, the following guidelines will be 
used to describe severity. 
 
• 
Mild – Events require minimal or no treatment and do not interfere with the participant’s 
daily activities.  
• 
Moderate – Events result in a low level of inconvenience or concern with the therapeutic 
measures. Moderate events may cause some interference with functioning.  
• 
Severe – Events interrupt a participant’s usual daily activity and may require systemic 
drug therapy or other treatment. Severe events are usually potentially life-threatening or 
incapacitating. 
 
 
8.2.2 RELATIONSHIP TO STUDY AGENT 
 
For all AEs, Dr. Eisenlohr-Moul will urgently collaborate with Dr. Wagner to determine the 
AE’s causality based on temporal relationship and clinical judgment. The degree of certainty 
about causality will be graded using the categories below.  
Definitely Related – There is clear evidence to suggest a causal relationship, and other 
possible contributing factors can be ruled out. The clinical event occurs in a plausible time 
relationship to drug administration and cannot be explained by concurrent disease or other 
drugs or chemicals. The response to withdrawal of the drug (dechallenge) should be clinically 
plausible. The event must be pharmacologically or phenomenologically definitive, with use of a 
satisfactory rechallenge procedure if necessary.  
Probably Related – There is evidence to suggest a causal relationship, and the influence of 
other factors is unlikely. The clinical event occurs within a reasonable time after administration 
of the drug, is unlikely to be attributed to concurrent disease or other drugs or chemicals, and 


 
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follows a clinically reasonable response on withdrawal (dechallenge). Rechallenge information 
is not required to fulfill this definition.  
 
Possibly Related – There is some evidence to suggest a causal relationship (e.g., the event 
occurred within a reasonable time after administration of the trial medication). However, other 
factors may have contributed to the event (e.g., the participant’s clinical condition, other 
concomitant events). Although an AE may rate only as “possibly related” soon after discovery, it 
can be flagged as requiring more information and later be upgraded to “probably related” 
or“definitely related,” as appropriate. 
 
Unlikely to be related – A clinical event whose temporal relationship to drug administration 
makes a causal relationship improbable (e.g., theevent did not occur within a reasonable time 
after administration of the trial medication) and inwhich other drugs or chemicals or underlying 
disease provides plausible explanations (e.g., theparticipant’s clinical condition, other 
concomitant treatments). 
 
Not Related – The AE is completely independent of study drug administration, and/or 
evidenceexists that the event is definitely related to another etiology. There must be an 
alternative, definitive etiology documented by Dr. Wagner or Dr. Eisenlohr-Moul. 
 
 
8.2.3 EXPECTEDNESS  
 
Dr. Eisenlohr-Moul will collaborate with Dr. Wagner to make determinations about whether an 
AE is expected or unexpected. An AE will be considered unexpected if the nature, severity, or 
frequency of the event is not consistent with the risk information previously described for the 
study agent. 
 
8.3 
TIME PERIOD AND FREQUENCY FOR EVENT ASSESSMENT AND 
FOLLOW-UP 
 
The occurrence of an AE or SAE may come to the attention of study personnel during study 
visits and interviews of a study participant. All AEs including local and systemic reactions not 
meeting the criteria for SAEs will be captured on the appropriate documentation. Information 
to be collected includes event description, time of onset, clinician’s assessment of severity, 
relationship to study product (assessed only by those with the training and authority to make 
a diagnosis), and time of resolution/stabilization of the event. All AEs occurring while on 
study must be documented appropriately regardless of relationship. All AEs will be followed 
to adequate resolution.  
 
Pre-existing medical conditions are exclusionary for participation in the trial, with the 
exception of psychiatric conditions. Any psychiatric condition or symptom that is present at 
the time that the participant is screened, including mood symptoms and suicidal ideation, will 
be considered as baseline and not reported as an AE. However, if the study participant’s 
condition or symptom deteriorates significantly with regard to the severity or impact of the 
symptom on the participants functioning or safety (as determined by Drs. Eisenlohr-Moul and 
Wagner) at any time during the study, it will be recorded as an AE. UPs will be recorded in the 
data collection system throughout the study.  


 
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Changes in the severity of an AE will be documented to allow an assessment of the duration of 
the event at each level of severity to be performed. AEs characterized as intermittent require 
documentation of onset and duration of each episode.  
The PI will record all reportable events with start dates occurring any time after informed 
consent is obtained until 7 (for non-serious AEs) or 30 days (for SAEs) after the last day of 
study participation. At each phone call and study visit, study staff will inquire about the 
occurrence of AE/SAEs since the last visit. All AEs will be immediately reported to the PI, who 
will respond (psychiatric AEs) or consult with Dr. Wagner as soon as possible (for medical AEs). 
Events will be followed for outcome information until resolution or stabilization. 
 
8.4 
REPORTING PROCEDURES 
 
8.4.1 ADVERSE EVENT REPORTING  
 
Study staff will screen for all AEs at each telephone call and study visit. Dr. Eisenlohr-
Moul will be on call for all visits and telephone calls to ensure that emergent mood 
deterioration or suicide risk can be immediately handled by a licensed clinical 
psychologist with experience in suicide risk assessment (Eisenlohr-Moul) using the 
LRAP/UWRAP protocol (the tool recommended by NIH for clinical trials with suicidal 
subjects). Medical/physical AEs will be discussed as soon as possible with Dr. Wagner.  
 
The PI Dr. Eisenlohr-Moul (in consultation with Dr. Wagner) will review all protocol data 
at monthly meetings, including enrollment and retention statistics and aggregate reports 
of side effects/AEs. As the contact PI, Dr. Eisenlohr-Moul will be the one responsible for 
reporting any 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 Serious AEs will 
be 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. 
 
 
8.4.2 SERIOUS ADVERSE EVENT REPORTING  
 
The PI (Dr. Eisenlohr-Moul) will complete a SAE Form within the following timelines:  
• 
All deaths and immediately life-threatening events, whether related or unrelated, will be 
recorded on the SAE Form and submitted to the DCC/study sponsor within 24 hours of 
site awareness. See Section 1, Key Roles for contact information.  
 
All SAEs will be followed until satisfactory resolution or until the PI deems the event to be 
chronic or the adherence to be stable. Other supporting documentation of the event may be 
requested by the DSMB or study sponsor and will be provided as soon as possible. The study 
sponsor will be responsible for notifying FDA of any unexpected fatal or life-threatening 
suspected adverse reaction as soon as possible but in no case later than 7 calendar days after 
the sponsor's initial receipt of the information. 


 
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8.4.3 UNANTICIPATED PROBLEM REPORTING  
 
Incidents or events that meet the OHRP criteria for UPs require the creation and completion 
of an UP report form. It is the site investigator’s responsibility to report UPs to their IRB and 
to the study sponsor. The UP report will include the following information:  
• 
Protocol identifying information: protocol title and number, PI’s name, and the IRB 
projectnumber; 
• 
A detailed description of the event, incident, experience, or outcome; 
• 
An explanation of the basis for determining that the event, incident, experience, or 
outcomerepresents 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:  
• 
All UPs will be reported to the IRB, the DSMB, and to the study sponsor within 1 week of 
the investigator becoming aware of the event. 
 
8.4.4 EVENTS OF SPECIAL INTEREST  
 
Not applicable. 
 
8.4.5 REPORTING OF PREGNANCY  
 
Pregnancy will result in immediate withdrawal from the study and a breaking of the blind 
to Dr. Wagner; Dr. Wagner will oversee appropriate clinical care, including supervised 
hormonal discontinuation.  
 
 
8.5 
STUDY HALTING RULES  
 
Administration of study agent will be halted when three serious AEs* determined to be 
“probably related” (i.e., with new onset during study patches/pills) are observed. The PI 
will immediately notify the DSMB when this occurs. The DSMB will notify the study sponsor and 
investigators immediately when the third severe event is reported and enrollment screens will 
stop accepting new study participants. The DSMB will request the statistical analyses and 
tables that they wish to review, and these will be prepared by an unblinded biostatistician 
associated with the study. All requested documentation will be provided to the DSMB. The 
DSMB will convene an ad hoc meeting by teleconference or in writing as soon as possible. The 
DSMB will provide recommendations for proceeding with the study to the PI and the NIH. The 
study sponsor will inform all appropriate regulatory agencies of the temporary halt and the 
disposition of the study. 
 
*Statistically, the most likely examples of serious adverse events in the present study 
include development of a venous thromboembolism or a suicide attempt during an 
experimental phase of the study.  


 
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8.6 
SAFETY OVERSIGHT 
 
Safety oversight will be under the direction of a DSMB composed of individuals with the 
appropriate expertise as determined by their regulatory guidelines. The DSMB will meet every 6 
months to assess safety and efficacy data in each condition of the study. The DMSB will 
operate under the rules of an approved charter that will be written and reviewed at the 
organizational meeting of the DSMB. At this time, each data element that the DSMB needs to 
assess will be clearly defined. The DSMB will provide its input as required to NIMH. 
 
9 
CLINICAL MONITORING 
Clinical site monitoring is conducted to ensure that the rights and well-being of human subjects 
are protected, that the reported trial data are accurate, complete, and verifiable, and that the 
conduct of the trial is in compliance with the currently approved protocol/amendment(s), with 
GCP, and with applicable regulatory requirement(s).  
• 
Madeline Divine, the project manager, will be responsible for the adequate clinical 
documentation of all events as described in the current protocol, including data 
verification and backup.  
• 
Evaluation of the safety of the study will take place via the DSMB every six months and 
as needed when AEs emerge (see sections above).  
 
10 
STATISTICAL CONSIDERATIONS  
 
10.1 STATISTICAL AND ANALYTICAL PLANS 
 
There will be no formal SAP. The PI will conduct all analyses at the end of the trial.  
 
10.2 STATISTICAL HYPOTHESES 
 
Hypotheses. For suicidal desire and suicidal action capacity—our primary endpoints)—we 
predict that perimenstrual increases in suicidal desire and action capacity (Lab 2 – Lab 1 within 
each condition) will be larger in the placebo (natural E2 + P4 withdrawal) condition and 
experimental E2 stabilization (P4 withdrawal) condition than in the experimental P4 stabilization 
(E2 withdrawal) condition. The associated null hypothesis is that there will be no difference in the 
perimenstrual increase in suicidality across conditions. For our secondary endpoints, including 
hopelessness, negative social appraisals, reduced inhibitory control, and threat sensitivity, we 
predict the same pattern of results.   
 
There are no “efficacy” endpoints in the present trial since it is mechanistic and not a treatment 
study. 
 
10.3 ANALYSIS DATASETS 
 
An intent-to-treat dataset will be utilized. The study statistician will use a carry-forward approach 
to evaluate the within-person condition effect using this intent-to-treat sample.  


 
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10.4 DESCRIPTION OF STATISTICAL METHODS 
 
10.4.1 GENERAL APPROACH 
 
The design of this study is a three-period crossover design, where each of three study 
periods is a perimenstrual frame of the menstrual cycle (days +7 to +22 following 
ovulation where positive ovulation test day=0). Each participant will complete all three 
conditions in a randomized order.  
 
Primary hypothesis tests will be evaluated using a alpha level of .05, with a two-tailed 
test. 
 
All outcomes will be checked for normality; given the low likelihood that suicidality will 
follow a normal distribution even in this clinical sample, we expect that we will need to 
utilize nonparametric procedures.  
 
10.4.2 ANALYSIS OF THE PRIMARY EFFICACY ENDPOINT(S) 
 
Primary and secondary endpoints are operationalized above (i.e., mean within-person 
differences between conditions) for the daily SITB suicidal ideation and planning 
subscales (primary endpoints) as well as the daily UPPS-P impulsivity, PROMIS 
anxiety, CESD depression, BHI hopelessness, and SSES rejection sensitivity subscales 
(secondary endpoints).  
 
Analyses will proceed identically for all outcomes listed above. First, we will 
calculate each subject’s mean daily rating (via phone) on the outcome measure during 
each condition. 
 
Second, we will utilize repeated measures ANCOVA to examine the within-person 
condition effects. Covariates (medicines, BMI, age) will be examined and included. 
These analyses will be conducted on the intent-to-treat dataset. 
 
If necessary due to violations of model assumptions, we will utilize similar 
nonparametric tests. 
 
10.4.3 ANALYSIS OF THE SECONDARY ENDPOINT(S) 
 
See above.  
 
10.4.4 SAFETY ANALYSES 
 
All adverse events will be measured daily and recorded at the end of each condition for 
each subject, calculated dichotomously based on its emergence during the treatment 
timeframe. These outcomes will be presented in tables for review by the DSMB, and 
such outcomes will be accompanied by descriptive and inferential statistics (both mean 


 
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levels and change from baseline in each condition) to determine whether AEs and 
changes in AEs are more likely to occur in the experimental conditions.  
 
Below, we list the adverse events that are most likely to occur in the course of the study 
and will therefore be monitored most closely (at every daily and weekly participant 
contact during administration of study agents). However, participants will have the 
opportunity to report any other adverse event in addition to those listed below. 
 
GENERAL ADVERSE EVENTS 
 
• 
Significant deterioration in mood  
• 
Significant deterioration in suicidality 
• 
Any adverse event related to venipuncture 
• 
Any adverse event related to emotional or behavioral reactions to interviews, 
questionnaires, or tasks 
 
ESTRADIOL PHYSICAL SIDE EFFECT ADVERSE EVENTS 
 
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) 
- 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) 
 
Rare side effects (<1%) include: 
- jaundice (yellowing of skin) 
- increased blood pressure 
- worsening of migraines or asthma 
- enlargement of uterine fibroids 
- intolerance to contact lenses 
- dizziness 
- changes in appetite and weight 
 
PROGESTERONE PHYSICAL SIDE EFFECT ADVERSE EVENTS 
 
The most common side effects associated with progesterone 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 


 
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patients) 
- drowsiness (occurs in 9% of patients) 
 
Rare (<1%) side effects include: 
- vaginal discharge 
- chest pain 
- abdominal bloating 
 
10.4.5 ADHERENCE AND RETENTION ANALYSES 
 
Adherence to hormone administration protocols will be characterized following the close 
of the study using serum assays for E2 and P4 during the active conditions relative to 
hormonal profiles during the placebo condition; it will not be monitored in real time.  
 
Participants will be monitored in their compliance daily during each study condition via a 
phone call with study staff. Any deterioration in adherence will be immediately remedied 
via increased reminders and phone calls. 
 
10.4.6  
BASELINE DESCRIPTIVE STATISTICS 
 
Groups (counterbalanced orders) will be compared on demographic factors such as 
age, severity of perimenstrual mood change in the placebo condition, and general 
suicidality. However, inferential statistics are not necessary as our primary outcome 
modeling procedures will control for any baseline differences that exist.  
 
10.4.7 PLANNED INTERIM ANALYSES  
 
10.4.7.1 
SAFETY REVIEW 
 
Administration of study agent will be halted when three serious AEs* determined to be 
“probably related” (i.e., with new onset during study patches/pills) are observed. The PI 
will immediately notify the DSMB when this occurs. The DSMB will notify the study sponsor and 
investigators immediately when the third severe event is reported and enrollment screens will 
stop accepting new study participants. The DSMB will request the statistical analyses and 
tables that they wish to review, and these will be prepared by an unblinded biostatistician 
associated with the study. All requested documentation will be provided to the DSMB. The 
DSMB will convene an ad hoc meeting by teleconference or in writing as soon as possible. The 
DSMB will provide recommendations for proceeding with or terminating the study to the PI and 
the NIH. The study sponsor will inform all appropriate regulatory agencies of the temporary halt 
and the disposition of the study (i.e., terminate, continue). 
 
*Statistically, the most likely examples of serious adverse events in the present study 
include development of a venous thromboembolism or a suicide attempt during an 
experimental phase of the study.  
 
10.4.7.2 
EFFICACY REVIEW 
 


 
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There are no efficacy endpoints in the present study because this is not a treatment 
study and the intervention used is not expected to be an effective treatment for any 
condition. 
 
10.4.8 ADDITIONAL SUB-GROUP ANALYSES 
 
The study is not powered to conduct sub-group analyses, and therefore they will not be 
performed. 
 
10.4.9 MULTIPLE COMPARISON/MULTIPLICITY 
 
N/A 
 
10.4.10 
TABULATION OF INDIVIDUAL RESPONSE DATA 
 
Individual response data will be tabulated only if requested by the DSMB.  
 
10.4.11 
EXPLORATORY ANALYSES 
 
Not applicable. 
 
10.5 SAMPLE SIZE 
 
An unlimited number of potential participants will be screened. 60 females will be 
enrolled in the study, with the goal of 40 participants completing the study.  
 
Power analyses are described below; alpha is set at .05, power at 80%. The null 
hypothesis is no link between the study experimental condition and risk for suicidal 
ideation, intent, and planning; the alternate hypothesis is that hormone stabilization in 
the experimental condition will prevent flux in these suicide-related outcomes. Because 
no previous studies have examined the impact of experimental hormones on suicidality, 
we have conducted power analyses using existing effect sizes on related constructs 
(e.g., BPD features).  
 
Power Analysis. For primary hypothesis tests, 80% power to detect a conventionally medium-
sized effect of condition (f = .25) is achieved with 24 participants117. To allow for attrition and 
improve generalizability and power, we propose to include 40 participants in the final sample.  
 
10.6 MEASURES TO MINIMIZE BIAS 
 
10.6.1 ENROLLMENT/ RANDOMIZATION/ MASKING PROCEDURES 
 
Individuals will be enrolled following phone screen and an enrollment visit as described above. 
Individuals will be randomized by IDS to one of six condition orders (permutations of A-B-C) 
following enrollment visit if they meet study criteria and give informed consent. Masking and 
blinding will be handled by IDS according to standard procedures for double blinding, and will be 


 
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fully double-blind. Randomization codes will be kept by IDS until the completion of the study, 
and will be shared only as needed for unblinding as needed for safety monitoring (described 
above).  
Blinding and Compliance: Pills are dispensed in a double-blind manner. Patches will be placed 
by CTSA staff at UIC. All study staff will remain blinded. Preliminary analyses from the preceding 
similar experiment revealed that the blinding was successful; participants were not more likely to 
report believing they were on active treatment in the active condition relative to the placebo 
condition (p = .58). Participants will: 1) be educated on the importance of compliance; 2) be asked 
about compliance on each daily call; and 3) have steroid levels measured to confirm compliance. 
 
 
 
10.6.2 EVALUATION OF SUCCESS OF BLINDING  
 
At the conclusion of the study, each participant will be asked to guess which condition 
order they had. Blinding will be evaluated by determining whether the accuracy of these 
reports is greater than 50% (chance).  
 
10.6.3 BREAKING THE STUDY BLIND/PARTICIPANT CODE 
 
Breaking of blind will occur to Dr. Eisenlohr-Moul and Dr. Wagner in the case of severe 
physical AEs (e.g., VTE) or psychiatric AEs (hospitalization/suicide attempt). 
 
11 
SOURCE DOCUMENTS AND ACCESS TO SOURCE DATA/DOCUMENTS 
 
All data collected in this study will be maintained on the UIC protected servers and in 
clinical binders kept under lock and key in Dr. Eisenlohr-Moul’s locked laboratory.  
 
12 
QUALITY ASSURANCE AND 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; this will be carried out by study project 
manager Madeline Divine. Any missing data or data anomalies will be communicated to the PI 
for clarification/resolution.  
Following written SOPs, the monitors will verify that the clinical trial is conducted and 
data are generated, documented (recorded), and reported in compliance with the 
protocol, GCP, and the applicable regulatory requirements (e.g., Good Laboratory 
Practices (GLP), Good Manufacturing Practices (GMP)).  
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. 
 
13 
ETHICS/PROTECTION OF HUMAN SUBJECTS  


 
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13.1 ETHICAL STANDARD  
 
The investigator will ensure that this study is conducted in full conformity with Regulations for 
the Protection of Human Subjects of Research codified in 45 CFR Part 46, 21 CFR Part 50, 21 
CFR Part 56, and/or the ICH E6. 
 
13.2 INSTITUTIONAL REVIEW BOARD  
 
The protocol, informed consent form(s), recruitment materials, and all participant materials will 
be submitted to the 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. All 
changes to the consent form will be IRB approved; a determination will be made regarding 
whether previously consented participants need to be re-consented. 
 
13.3 INFORMED CONSENT PROCESS  
 
13.3.1 CONSENT/ASSENT AND OTHER INFORMATIONAL DOCUMENTS 
PROVIDED TO PARTICIPANTS 
 
Consent forms describing in detail the study agent, study procedures, and risks are given to the 
participant and written documentation of informed consent is required prior to starting 
intervention/administering study product. The following consent materials are submitted with this 
protocol including the adult informed consent and the consent for storage of specimens. 
 
13.3.2 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. Extensive discussion of 
risks and possible benefits of participation will be provided to the participants and their families. 
Consent forms will be 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. All participants will receive a verbal explanation in terms suited to their 
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 will have the opportunity to 
discuss the study with family or health care providers and 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. The participants may withdraw consent at any time 
throughout the course of the trial. A copy of the informed consent document will be given to the 
participants for their records. 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. 
 
13.4 PARTICIPANT AND DATA CONFIDENTIALITY  
 


 
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Participant confidentiality is strictly held in trust by the participating investigators, their staff, and 
the sponsor(s) and their agents. This confidentiality is extended to cover testing of biological 
samples 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. 
 
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 local IRB and Institutional regulations.  
Study participant research data, which is for purposes of statistical analysis and scientific 
reporting, will be transmitted to and stored on protected servers at UIC. Identifying information 
will be linked to ID number only in one password-protected file. Individual participants and their 
research data will otherwise be identified by a unique study identification number. The study 
data entry and study management systems used by study staff will be secured and password 
protected. At the end of the study, all study databases will be de-identified (linking files 
destroyed) and archived on UIC servers. 
 
Certificate of Confidentiality 
To further protect the privacy of study participants, a Certificate of Confidentiality will be 
obtained from the 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. 
 
13.4.1 RESEARCH USE OF STORED HUMAN SAMPLES,SPECIMENS OR DATA 
 
Study data include blood samples from laboratory visits and all psychosocial data from 
study participation.  
 
• 
Intended Use: Samples and data collected under this protocol may be used to study the 
role of E2, P4, ALLO, and inflammatory gene expression in suicidality and psychiatric 
symptoms.  
 
• 
Storage: Access to stored samples will be limited using locked access areas. Samples 
and data will be stored using codes assigned by the investigators. Data will be kept in 
password-protected computers. Only investigators will have access to the samples and 
data.  
 
• 
Tracking: Data will be tracked using password-protected files on the UIC server. 
Disposition at the completion of the study: All serum samples will be kept under locked 
access areas at UIC. Study participants who request destruction of samples will be 
notified of compliance with such request and all supporting details will be maintained for 
tracking. 


 
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13.5 FUTURE USE OF STORED SPECIMENS  
 
Data collected for this study will be analyzed at UIC within 2 years of the time they are 
collected. The data and samples collected in this study will not be stored for future use, and 
will not be shared with other investigators. 
14 
DATA HANDLING AND RECORD KEEPING  
 
14.1 DATA COLLECTION AND MANAGEMENT RESPONSIBILITIES  
 
Data collection is the responsibility of the staff at the site under the supervision of the PI. 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. Black ink is required to ensure clarity of reproduced copies. When making 
changes or corrections, cross out the original entry with a single line, and initial and date the 
change. DO NOT ERASE, OVERWRITE, OR USE CORRECTION FLUID OR TAPE ON THE 
ORIGINAL.  
 
Copies of the electronic data will be provided for use as source documents and maintained for 
recording data for each participant enrolled in the study. Data reported in the electronic data file 
derived from source documents should be consistent with the source documents or the 
discrepancies should be explained and captured in a progress note and maintained in the 
participant’s official electronic study record.  
 
Clinical data (including AEs, concomitant medications, and expected adverse reactions data) 
and laboratory data will be entered into a local database on UIC servers. 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. 
 
14.2 STUDY RECORDS RETENTION  
 
Study documents including identifying information (e.g., names, phone numbers, addresses, 
and other identifying information collected as part of data collection from the participant) will be 
retained until the end of data collection and cleaning (maximum 1 year following the completion 
of the study), after which all identifying information on study documents will be be destroyed or 
deleted.  Deidentified study documents (documents without identifying information, redacted if 
necessary) will be retained indefinitely. 
 
14.3 PROTOCOL DEVIATIONS  
 


 
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A protocol deviation is any noncompliance with the clinical trial protocol, GCP, or 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 E6:  
• 
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 to use continuous vigilance to identify and report deviations 
within 7 working days of identification of the protocol deviation. All significant deviations must be 
addressed in study source documents, reported to NIMH Program Official and DSMB. Protocol 
deviations must be sent to the local IRB per their guidelines. The PI/study staff is responsible for 
knowing and adhering to their IRB requirements.  
 
14.4 PUBLICATION AND DATA SHARING POLICY 
 
This study will comply with the 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.  
The International Committee of Medical Journal Editors (ICMJE) member journals have adopted 
a clinical trials registration policy as a condition for publication. The ICMJE defines a clinical trial 
as any research project that prospectively assigns human subjects to intervention or concurrent 
comparison or control groups to study the cause-and-effect relationship between a medical 
intervention and a health outcome. Medical interventions include drugs, surgical procedures, 
devices, behavioral treatments, process-of-care changes, and the like. Health outcomes include 
any biomedical or health-related measures obtained in patients or participants, including 
pharmacokinetic measures and adverse events. The ICMJE policy, and the Section 801 of the 
Food and Drug Administration Amendments Act of 2007, requires that all clinical trials be 
registered in a public trials registry, which is sponsored by the National Library of Medicine. 
Other biomedical journals are considering adopting similar policies. For interventional clinical 
trials performed under NIH IC grants and cooperative agreements, it is the grantee’s 
responsibility to register the trial in an acceptable registry, so the research results may be 
considered for publication in ICMJE member journals. The ICMJE does not review specific 
studies to determine whether registration is necessary; instead, the committee  
recommends that researchers who have questions about the need to register err on the side of 
registration or consult the editorial office of the journal in which they wish to publish.  
FDAAA mandates that a "responsible party" (i.e., the sponsor or designated principal 
investigator) register and report results of certain "applicable clinical trials":  
• 
Trials of Drugs and Biologics: Controlled, clinical investigations, other than Phase I 
investigations, of a product subject to FDA regulation; 
 
The PI will ensure compliance with NIH implementation of FDAAA. 
 
15 
STUDY ADMINISTRATION 


 
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15.1 STUDY LEADERSHIP 
 
The PI (Eisenlohr-Moul) and Dr. Melissa Wagner will govern the conduct of the study, along with 
NIMH program officer Mark Chavez. The PI will continue to consult as needed with key mentors 
as described in the NIMH R00 award on which this protocol is based. 
 
16 
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 trial. The 
study leadership in conjunction with the NIMH has established policies and procedures for all 
study group members to disclose all conflicts of interest and will establish a mechanism for the 
management of all reported dualities of interest. 
 
17  
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APPENDIX 
 
Version 
Date 
Significant Revisions