Treatment of female sexual dysfunction

TECHNICAL FIELD
This invention relates generally to methods and pharmaceutical formulations for treating female sexual dysfunction, and more particularly relates to vaginal and/or vulvar administration of a vasodilating agent, such as a prostaglandin, in such treatment. The invention further relates to additional methods of using the present pharmaceutical formulations, including, but not limited to, the prevention of yeast infections and the improvement of vaginal muscle tone.
BACKGROUND
Sexual response in women is generally classified into four stages: excitement, plateau, orgasm, and resolution. Masters and Johnson, Human Sexual Response (Boston, Mass.: Little, Brown & Co., 1966). With sexual arousal and excitement, vasocongestion and muscular tension increase progressively, primarily in the genitals, and is manifested by increased blood flow, elevated luminal oxygen tension, and vaginal surface lubrication as a result of plasma transudation that saturates the fluid reabsorptive capacity of the vaginal epithelium. Vasoactive intestinal polypeptide ("VIP") release may induce the physiological changes of sexual arousal and excitement, and may be the major neurotransmitter which participates in the innervation of the vaginal blood supply. Peptide histidine methionine has been co-located with VIP within nerve fibers that innervate small blood vessels, smooth muscle and epithelial cells in the vaginal tract.
Sexual excitement is initiated by any of a number of psychogenic or somatogenic stimuli and must be reinforced to result in orgasm. With continued stimulation, excitement progresses in intensity into a plateau stage, from which the individual can shift into orgasm. The orgasmic stage is characterized by a rapid release from vasocongestion and muscular tension.
During the various stages of sexual response, characteristic genital and extragenital responses occur. Estrogens magnify the sexual responses; however, sexual responses may also occur in estrogen-deficient individuals. Sexual dysfunction may be due to organic or functional disturbances. For example, a variety of diseases affecting neurologic function, including diabetes mellitus and multiple sclerosis, may interrupt sexual arousal. More commonly, local pelvic disorders, such as endometriosis and vaginitis, both of which cause dyspareunia (difficult or painful coitus) may also affect a woman's sexual response. In addition, estrogen deficiency, causing vaginal atrophy and dyspareunia, is a common cause of sexual dysfunction. For a discussion of other causes of female sexual dysfunction, see, e.g., Kaplan, The Evaluation of Sexual Disorders: Psychological and Medical Aspects (New York: Brunner-Mazel, 1983), and Kolodny et al., Textbook of Sexual Medicine (Boston, Mass.: Little, Brown & Co., 1979).
Excitement stage dysfunction generally involves touch sensation impairment, loss of clitoral sensation, vaginal dryness and urinary incontinence. Such excitement phase dysfunction generally results in dyspareunia. Dyspareunia is thought to affect approximately 40% of women, due in large part to inadequate lubrication. It has been estimated that over 40 million women will suffer dyspareunia at some time in their lives. On the order of twenty-five million will experience dyspareunia in the peri- and postmenopausal period (see Kelly, S. (1992) Clinical Practice and Sexuality 8(8):2 and Sato et al. (1992) Clinical Practices in Sexuality 8(5):1). Contemporary symptomatic treatments generally involve the use of physiologically safe lubricants such as egg white, K-Y surgical lubrication jelly (hydroxyethylcellulose), Astroglide.RTM., and Replens.RTM.. See: Semmens (1974) Medical Aspects of Human Sex 8:85-86; and Frishmen et al. (1992) Fertility and Sterility 58(3):630. When symptomatic treatment fails, pharmacological treatment may be indicated.
Estrogen therapy is commonly used in the pharmacological treatment of sexual dysfunction in women. Estrogen-based therapies are generally used to increase mucous production, provide vasodilatory effects, or to increase the general health of the vagina. Nadelson et al., eds., Treatment Interventions in Human Sexuality (New York: Plenum Press, 1983). In such treatments, estrogen is administered orally, parenterally (e.g., by injection), or topically. With oral administration, the estrogen concentration encountered by the liver is generally four- to five-fold greater than estrogen levels in peripheral blood (the "first pass effect"). This effect may lead to an undesirable increase in the production of certain coagulation factors and renin substrates by the liver. Parenterally administered estrogen avoids the first pass effect in the liver. However, all estrogen-based therapies are known to increase the risk of endometrial hyperplasia endometrial cancer and breast cancer in treated individuals.
Because of the increased risk of endometrial hyperplasia and endometrial cancer encountered with unopposed estrogen therapies, estrogen/progestogen combinations have been employed. However, progestogens are known to have some androgenic activity. Further, common side effects from such therapies include uterine bleeding and the continuation of menstrual periods. Accordingly, there remains a need in the art to provide safer and more effective treatments of female sexual dysfunction.
The present invention is directed to the aforementioned need in the art, and provides a new, highly effective method of treating sexual dysfunction. The method involves vaginal and/or vulvar administration of a pharmaceutical formulation containing one or more vasodilating agents, e.g., a prostaglandin or the like.
Drug therapy for treating female sexual dysfunction has been described. For example, U.S. Pat. No. 4,507,323 to Stern describes the use of the anxiolytic m-chloro-.alpha.-t-butylamino-propiophenone in the treatment of sexual dysfunction in male and female individuals. Pharmaceutical compositions containing the agent are described, which are presented in discrete units, e.g., cachets, tablets, capsules, ampules and suppositories for oral or anal delivery of the agent.
Additionally, U.S. Pat. No. 4,521,421 to Foreman describes the treatment of sexual dysfunction in male and female individuals using the stereoisomers of octahydropyrimido�4,5-g!quinoline agents, centrally acting dopamine agonists.
U.S. Pat. No. 5,190,967 to Riley describes the treatment of sexual disorders in male and female individuals using heterocyclic benzodioxinopyrrole compounds, which, like the drugs described in the aforementioned patents, are centrally acting agents.
A number of references describe various methods and devices suitable for vaginal or uterine drug administration, and may accordingly be of some interest with respect to the present invention. The following are representative of such references:
U.S. Pat. No. 3,967,618 to Zaffaroni describes an intrauterine device adapted for drug delivery. A number of drugs are mentioned as being suitable for use in conjunction with the device. However, the Zaffaroni patent does not mention treatment of sexual dysfunction, nor is application of a drug-containing composition to the clitoris or vulvar area disclosed or suggested. U.S. Pat. No. 3,948,254 to Zaffaroni is a related patent which describes an intrauterine device for continuous administration of a contraceptive agent.
U.S. Pat. No. 4,014,987 to Heller et al. describes a tampon-like device for delivery of a drug to the uterus or vagina. Heller et al. mention that delivery of prostaglandins is a preferred use of the invention; however, there is no disclosure concerning treatment of sexual dysfunction or delivery to the clitoris.
U.S. Pat. No. 4,564,362 to Burnhill describes a vaginal sponge for controlled release of a contraceptive agent.
U.S. Pat. No. 3,800,038 to Rudel describes a method and composition for uterine administration of steroid hormones. Prostaglandins such as PGE.sub.1 are mentioned as useful in conjunction with the invention. However, there is no disclosure concerning vaginal drug delivery, application of a drug-containing formulation to the clitoris or surrounding vulvar area, or treatment of sexual dysfunction.
U.S. Pat. No. 4,961,931 to Wong describes a vaginal drug administration device adapted to deliver contraceptive hormones, including progestational and estrogenic hormones;.
U.S. Pat. No. 4,112,942 to Scaife generally describes vaginal administration of medicinal foams.
The vaginal delivery of prostaglandins in connection with contraceptives, labor and delivery has also been described. U.S. Pat. No. 4,976,692 to Atad describes the uterine administration of a composition containing PGE.sub.2 and triacetin gel in priming the cervix before induction of labor.
Vaginal PGE.sub.2 suppositories ("Prostin E2.RTM.") and a cervical gel containing PGE.sub.2 ("Prepidil".RTM. gel), both manufactured by Upjohn (Kalamazoo, Mich.), are commercially available. See, e.g., Physicians' Desk Reference.RTM., 51st Edition (Montvale, N.J.: Medical Economics Data Production Company, 1997). The suppositories are primarily indicated for evacuation of uterine contents, while the gel is used in connection with induction of labor.
U.S. Pat. Nos. 4,818,517 to Kwee et al., 4,680,312 to Johnson, 4,454,339 to Skaballa et al. and 4,128,577 to Nelson each relate to vaginal administration of prostaglandins. However, the documents generally describe the use of prostaglandins in contraceptives, labor and delivery, and thus fail to disclose or suggest the use of these compounds in the treatment of sexual dysfunction.
U.S. Pat. No. 4,254,145 to Birnbaum is also of interest, and relates to the use of prostaglandins, including natural and synthetic analogues of prostaglandin types PGE, PGA and PGE.sub..beta., in the treatment of arteriospastic and occlusive peripheral vascular disorders as well as in the treatment of impotency. The described methods of treatment involve topical administration or localized injection of pharmaceutical compositions containing the exemplified prostaglandins to increase peripheral circulation. The compositions are also described for use in lowering systemic blood pressure. Although a number of therapeutic applications are described, Birnbaum fails to disclose the treatment of female sexual disorders using vaginal, vulvar or clitoral delivery of prostaglandins.
There are, accordingly, a number of background references relating to treatment of female sexual dysfunction as well as cervical or uterine administration of prostaglandins. However, the present method for treating female sexual dysfunction, by way of vaginal and/or vulvar delivery of a vasodilating agent such as a prostaglandin, is completely novel and unsuggested by the art.
SUMMARY OF THE INVENTION
Accordingly, it is a primary object of the invention to provide a method for treating sexual dysfunction in a female individual by administering a pharmaceutical formulation containing a selected vasodilating agent to the vagina and/or vulvar area of the individual undergoing treatment.
It is still another object of the invention to provide methods for preventing the occurrence of yeast infections, for improving vaginal muscle tone and tissue health, for enhancing vaginal lubrication, and for minimizing collagen misdeposition resulting from hypoxia, each of such methods involving vaginal administration of a pharmaceutical formulation containing a selected vasodilating agent, in combination with a pharmaceutically acceptable vehicle.
It is a further object of the invention to provide pharmaceutical formulations useful in conjunction with the aforementioned methods.
It is still a further object of the invention to provide a drug delivery device for administering a pharmaceutical formulation directly to the clitoral area.
Additional objects, advantages and novel features of the invention will be set forth in part in the description which follows, and in part will become apparent to those skilled in the art upon examination of the following, or may be learned by practice of the invention.
In one aspect of the invention, then, a method is provided for treating sexual dysfunction in a female individual comprising vaginally administering a pharmaceutical formulation containing a selected vasodilating agent. The vasodilating agent is selected from the group consisting of naturally occurring prostaglandins, synthetic prostaglandin derivatives, endothelial-derived relaxation factors, vasoactive intestinal polypeptide agonists, smooth muscle relaxants, leukotriene inhibitors, pharmaceutically acceptable salts, esters and inclusion complexes of any of the foregoing, and mixtures thereof. Any number of drug delivery platforms may be used, e.g., ointments, creams, gels, and the like, which will be described in detail below. Additionally, one or more additional types of drugs, i.e., pharmacologically active agents other than vasodilators, may be incorporated into the pharmaceutical formulations.
In a related aspect of the invention, the aforementioned method of treating sexual dysfunction is carried out by applying the pharmaceutical composition to the vulvar area of the individual undergoing treatment, as an alternative to or in combination with vaginal drug administration.
In other aspects of the invention, vaginal administration of a vasodilating agent as just described is used to prevent the occurrence of yeast infections, to improve vaginal muscle tone and tissue health, to enhance vaginal lubrication, or to minimize collagen misdeposition resulting from hypoxia as well as the associated lack of elasticity resulting from the collagen misdeposition.
In still another aspect of the invention, pharmaceutical formulations are provided for carrying out the aforementioned methods. The formulations contain a vasodilating agent as described above, a pharmaceutically acceptable vehicle, and, optionally, one or more additional pharmacologically active agents.
In another aspect of the invention, a drug delivery device is provided for administering a pharmaceutical formulation directly to the clitoral area. The device is a patch that includes a drug reservoir and a clitoral applicator.

BRIEF DESCRIPTION OF THE DRAWINGS
FIG. 1 is a pictorial representation of a clitoral drug application device which can be used as a carrier and dispenser for pharmaceutical compositions.

DETAILED DESCRIPTION OF THE INVENTION
Definitions:
Before describing the present invention in detail, it is to be understood that this invention is not limited to delivery of specific drugs, carriers or use of particular drug delivery systems, as such may vary. It is also to be understood that the terminology used herein is for the purpose of describing particular embodiments only, and is not intended to be limiting.
It must be noted that, as used in this specification and the appended claims, the singular forms "a," "an" and "the" include plural referents unless the context clearly dictates otherwise. Thus, for example, reference to "a vasodilating agent" includes a mixture of two or more vasodilating agents, reference to "a pharmaceutically acceptable excipient" includes mixtures of such excipients, and the like.
In describing and claiming the present invention, the following terminology will be used in accordance with the definitions set out below.
The terms "active agent," "drug" and "pharmacologically active agent" are used interchangeably herein to refer to a chemical material or compound which, when administered to an organism (human or animal) induces a desired pharmacologic and/or physiologic effect by local and/or systemic action. Preferred pharmacologically active agents used in conjunction with the present invention are vasodilating agents.
The term "vaginal delivery" is used herein to mean direct administration of a pharmaceutical composition to the vagina of the individual undergoing treatment. Generally, "vaginal delivery" of a pharmaceutical composition involves administration to the distal several centimeters of the vagina.
The term "vulvar delivery" or "vulvar administration" is used herein to refer to application of a pharmaceutical formulation to the vulvar area of an individual undergoing treatment. The term is intended to encompass application to the clitoris as well as the surrounding vulvar area. The terms "vulvar delivery" and "clitoral delivery" are used interchangeably herein and are both intended to refer to administration to the vulvar area of the individual undergoing treatment.
"Carriers" or "vehicles" as used herein refer to carrier materials suitable for vaginal and/or vulvar drug administration, and include any such materials known in the art, e.g., an liquid, gel, solvent, liquid diluent, solubilizer, or the like, which is nontoxic and which does not interact with other components present in the pharmaceutical formulation or drug delivery system in a deleterious manner.
By an "effective" amount of a drug or pharmacologically active agent is meant a nontoxic but sufficient amount of the drug or agent to provide the desired effect. For example, in treating sexual dysfunction in women, an "effective" amount of drug would be an amount which is at least sufficient to provide the desired degree of treatment. Similarly, in preventing yeast infections, an "effective" amount of drug would be an amount which is at least sufficient to prevent a vaginal yeast infection in a female individual.
The term "synthetic prostaglandin derivatives" is intended to encompass known or unknown compounds related to the naturally occurring prostaglandins PGE.sub.0, PGE.sub.1, PGA.sub.1, PGB.sub.1, PGE.sub.1.alpha., 19-hydroxy-PGA.sub.1, 19-hydroxy-PGB.sub.1, PGE.sub.2, PGA.sub.2, PGB.sub.2, 19-hydroxy-PGA.sub.2, 19-hydroxy-PGB.sub.2, PGE.sub.3, PGF.sub.3.alpha., and PGI.sub.2, and which are chemically synthesized using starting materials other than one of the naturally occurring prostaglandins. The term "semi-synthetic prostaglandin derivatives" refers to known or unknown compounds related to the aforementioned naturally occurring prostaglandins which are synthesized therefrom. The synthetic and semisynthetic prostaglandin derivatives useful in conjunction with the present invention will typically although not necessarily have the structure of Formula (I) ##STR1## wherein:
R.sup.1 and R.sup.2 may be the same or different and are selected from the group consisting of ##STR2## in which R.sup.3 and R.sup.4 are independently selected from the group consisting of hydrogen, lower alkyl and OR.sup.5 in which R.sup.5 is selected from the group consisting of hydrogen, tetrahydropyranyl, tetrahydrofaranyl, triloweralkylsilyl, 1-methyl-1-methoxyethyl, 1-methyl-1-ethoxyethyl and --(CO)--R.sup.6, wherein R.sup.6 is hydrogen, lower alkyl, or halogen-substituted lower alkyl;
A is selected from the group consisting of ##STR3## wherein R.sup.5 is as defined above;
r.sup.1 and r.sup.2 represent optional double bonds; and
R.sup.7 is R.sup.5, lower alkyl or lower alkenyl.
In a first embodiment, the invention relates to a method for treating sexual dysfunction in a female individual and involves vaginal administration of a pharmaceutical formulation containing a vasodilating agent selected from the group consisting of naturally occurring prostaglandins, synthetic prostaglandin derivatives, endothelial-derived relaxation factors, vasoactive intestinal polypeptide agonists, smooth muscle relaxants, leukotriene inhibitors, pharmaceutically acceptable salts, esters and inclusion complexes of any of the foregoing, and mixtures thereof, in combination with a pharmaceutically acceptable vehicle.
In an alternative embodiment, the invention involves a method for treating sexual dysfunction in a female individual by administering such a pharmaceutical formulation to the vulvar area of the individual, as an alternative to or in combination with vaginal administration.
Preferred vasodilating agents are naturally occurring prostaglandins or hydrolyzable lower alkyl esters of a naturally occurring prostaglandin, as well as synthetic or semisynthetic prostaglandins.
The "naturally occurring" prostaglandins useful in conjunction with the present invention are PGE.sub.0, PGE.sub.1, PGA.sub.1, PGB.sub.1, PGF.sub.1.alpha., 19-hydroxy-PGA.sub.1, 19-hydroxy-PGB.sub.1, PGE.sub.2, PGA.sub.2, PGB.sub.2, 19-hydroxy-PGA.sub.2, 19-hydroxy-PGB.sub.2, PGE.sub.3, PGF.sub.3.alpha., and PGI.sub.2, with PGE.sub.0, PGE.sub.1 and PGE.sub.2 particularly preferred.
Synthetic prostaglandins or semisynthetic prostaglandins (i.e., compounds derived from naturally occurring prostaglandins) having the above Formula (I) include, but are not limited to, carboprost tromethamine, dinoprost tromethamine, lipoprost, gemeprost, metenoprost, sulprostone and tiaprost.
Additional vasodilating agents useful in conjunction with the present invention include endothelial-derived relaxation factors ("EDRFs") such as nitric oxide releasing agents, e.g., nitroglycerin, sodium nitroprusside and "NONOates." NONOates include, but are not limited to, (Z)-1-{N-methyl-N-�6-(N-methyl-ammoniohexyl)amino!}diazen-1-ium-1,2-diolate ("MAHMA/NO"), (Z)-1-�N-(3-ammoniopropyl)-N-(n-propyl)amino!diazen-1-ium-1,2-diolate ("PAPA/NO"), (Z)-1-{N-�3-aminopropyl!-N-�4-(3-aminopropylammonio)butyl!-amino}diazen-1-ium-1,2-diolate (spermine NONOate or "SPER/NO") and sodium (Z)-1-(N,N-diethylamino)diazenium-1,2-diolate (diethylamine NONOate or "DEA/NO") and derivatives thereof). Other nitric oxide releasing agents include molsidomine, linsidomine ("SIN-1") and S-nitrosothiols, with the latter group represented by compounds such as S-nitroso-N-acetyl-D,L-penicillamine ("SNAP"), S-nitroso-N-cysteine and S-nitroso-N-glutathione ("SNO-GLU"). Still other vasodilating agents include vasoactive intestinal polypeptide agonists and derivatives thereof (particularly derivatives in the form of hydrolyzable lower alkyl esters), smooth muscle relaxants, leukotriene inhibitors, calcium channel blockers, .alpha.1-adrenergic antagonists, .beta.2-adrenergic agonists, phosphodiesterase inhibitors, and antihypertensive agents such as angiotensin-converting enzyme ("ACE") inhibitors and angiotensin II receptor antagonists.
The pharmaceutical formulations of the invention will include one or more vasodilating agents as just described, or a pharmaceutically acceptable salt, ester, or inclusion complex thereof. "Pharmaceutically acceptable salts, esters, or inclusion complexes" refer to those salts, esters and inclusion complexes which retain the biological effectiveness and properties of the base compounds and which are not biologically or otherwise undesirable.
Salts, esters and inclusion complexes of the active agents may be prepared using standard procedures known to those skilled in the art of synthetic organic chemistry and described, for example, by J. March, Advanced Organic Chemistry: Reactions, Mechanisms and Structure, 4th Ed. (New York: Wiley-Interscience, 1992). For example, acid addition salts are prepared from the free base (typically wherein the neutral form of the drug has a neutral --NH.sub.2 group) using conventional means, involving reaction with a suitable acid. Generally, the base form of the drug is dissolved in a polar organic solvent such as methanol or ethanol and the acid is added thereto. The resulting salt either precipitates or may be brought out of solution by addition of a less polar solvent. Suitable acids for preparing acid addition salts include both organic acids, e.g., acetic acid, propionic acid, glycolic acid, pyruvic acid, oxalic acid, malic acid, malonic acid, succinic acid, maleic acid, fumaric acid, tartaric acid, citric acid, benzoic acid, cinnamic acid, mandelic acid, methanesulfonic acid, ethanesulfonic acid, p-toluenesulfonic acid, salicylic acid, and the like, as well as inorganic acids, e.g., hydrochloric acid, hydrobromic acid, sulfuric acid, nitric acid, phosphoric acid, and the like. An acid addition salt may be reconverted to the free base by treatment with a suitable base. Conversely, preparation of basic salts of acid moieties which may be present on a drug are prepared in a similar manner using a pharmaceutically acceptable base such as sodium hydroxide, potassium hydroxide, ammonium hydroxide, calcium hydroxide, trimethylamine, or the like. For example, basic salts may be prepared from prostaglandins existing in acid form, i.e., prostaglandins retaining the prostanoic acid functionality, Preparation of esters involves functionalization of hydroxyl and/or carboxyl groups which may be present within the molecular structure of the drug. The esters are typically acyl-substituted derivatives of free alcohol groups, i.e., moieties which are derived from carboxylic acids of the formula RCOOH where R is allyl, and preferably is lower alkyl. Esters can be reconverted to the free acids, if desired, by using conventional hydrogenolysis or hydrolysis procedures. Inclusion complexes may also be prepared using methods known in the art, typically by admixing a macrocyclic compound such as a cyclodextrin with the active agent, under conditions which result in the incorporation of the active agent into the intramolecular cavity of the host molecule.
The pharmaceutical formulations used in the methods of the present invention may also include one or more pharmacologically active agents other than the vasodilator. For example, the formulations may contain a steroid, a steroid agonist, partial agonist, or antagonist. Steroids will generally be selected from the group consisting of progestogens, estrogens, pharmaceutically acceptable salts and esters of any of the foregoing, and mixtures thereof. Specifically, such steroids include estradiol, estradiol benzoate, estradiol cypionate, estradiol dipropionate, estriol, estrone, estrone benzoate, ethynyl estradiol, and mestranol, in the estrogen family, and acetoxypregnenolone, ethisterone, fluorogestone acetate, hydroxymethylprogesterone, hydroxymethylprogesterone acetate, hydroxyprogesterone, hydroxyprogesterone acetate, hydroxyprogesterone caproate, norethindrone, norethindrone acetate, norethynodrel, pregnenolone and progesterone, in the progestogen family. Additionally, with pharmaceutical formulations adapted for vulvar administration, it may be desirable to include an androgenic agent such as testosterone, dihydrotestosterone, testosterone analogues such as dehydroepiandrosterone ("DHEA") and DHEA sulfate, or the like. Examples of preferred antagonists or partial agonists are tamoxifen, cenchroman, clomiphene, droloxifene, raloxifene and pharmaceutically acceptable salts thereof, particularly tamoxifen or clomiphene citrate.
It may in some cases be desirable or necessary to include a detergent in the formulation, in an amount effective to increase solubility of the vasodilating agent in the vehicle and bioavailability of the agent following administration. The detergent will typically be a nonionic, anionic, cationic or amphoteric surfactant. In the practice of the invention, the surfactant is selected such that local irritation at the site of administration is avoided. Examples of suitable surfactants include Tergitol.RTM. and Triton.RTM. surfactants (Union Carbide Chemicals and Plastics, Danbury, Conn.), polyoxyethylenesorbitans, e.g., TWEEN.RTM. surfactants (Atlas Chemical Industries, Wilmington, Del.), and pharmaceutically acceptable fatty acid esters such as lauryl sulfate and the like.
The formulations may also include one or more components to enhance permeation of the vasodilating agent, i.e., "permeation enhancers." Suitable permeation enhancers include those generally useful in conjunction with topical, transdermal or transmucosal drug delivery. Examples of suitable permeation enhancers include dimethylsulfoxide ("DMSO"), dimethyl formamide ("DMF"), N,N-dimethylacetamide ("DMA"), decylmethylsulfoxide ("C.sub.10 MSO"), polyethylene glycol monolaurate ("PEGML"), glycerol monolaurate, lecithin, the 1-substituted azacycloheptan-2-ones, particularly 1-n-dodecylcyclazacycloheptan-2-one (available under the trademark Azone.RTM. from Nelson Research & Development Co., Irvine, Calif.), lower alkanols (e.g., ethanol), SEPA.RTM. (available from Macrochem Co., Lexington, Mass.), and surfactants as discussed above, including, for example, Tergitol.RTM., Nonoxynol-9.RTM. and TWEEN-80.RTM..
The pharmaceutical formulations used herein will typically contain one or more pharmaceutically acceptable carriers (also termed "excipients" or "vehicles") suited to the particular type of formulation, i.e., gel, ointment, suppository, or the like. The vehicles are comprised of materials of naturally occurring or synthetic origin that do not adversely affect the vasodilating agent or other components of the formulation. Suitable carriers for use herein include water, silicone, waxes, petroleum jelly, polyethylene glycol, propylene glycol, liposomes, sugars such as mannitol and lactose, and a variety of other materials, depending, again, on the specific type of formulation used.
In some cases, the formulations used in the present methods will include one or more compounds effective to inhibit enzymes present in the vaginal or vulvar areas which could degrade or metabolize the pharmacologically active agent. For example, with a prostaglandin as the vasodilating agent, it may be preferred to include an effective inhibiting amount of a compound effective to inhibit prostaglandin-degrading enzymes. Such compounds will include, for example, fatty acids, fatty acid esters, and NAD inhibitors. These formulations are believed to be novel.
The compositions used herein may be in the form of an ointment, cream, emulsion, lotion, gel, solid, solution, suspension, foam or liposomal composition; such formulations may be used for clitoral, vulvar or vaginal delivery. Alternatively, the compositions may be contained within a vaginal ring, tampon, suppository, sponge, pillow, puff, or osmotic pump system; these platforms are useful solely for vaginal delivery. Preferred formulations are long-acting or pulsatile release solid phase systems, as well as ointments, gels and suppositories. Methods for preparing various dosage forms are known, or will be apparent, to those skilled in this art; for example, see Remington's Pharmaceutical Sciences, 18th Ed. (Easton, Pa.: Mack Publishing Company, 1990).
Ointments are semisolid preparations that are typically based on petrolatum or other petroleum derivatives. The specific ointment base to be used, as will be appreciated by those skilled in the art, is one that will provide for optimum drug delivery. As with other carriers or vehicles, an ointment base should be inert, stable, nonirritating and nonsensitizing. As explained in Remington: The Science and Practice of Pharmacy, supra, at pages 1399-1404, ointment bases may be grouped in four classes: oleaginous bases; emulsifiable bases; emulsion bases; and water-soluble bases. Oleaginous ointment bases include, for example, vegetable oils, fats obtained from animals, and semisolid hydrocarbons obtained from petroleum. Emulsifiable ointment bases, also known as absorbent ointment bases, contain little or no welter and include, for example, hydroxystearin sulfate, anhydrous lanolin and hydrophilic petrolatum. Emulsion ointment bases are either water-in-oil (W/O) emulsions or oil-in-water (O/W) emulsions, and include, for example, cetyl alcohol, glyceryl monostearate, lanolin and stearic acid. Preferred water-soluble ointment bases are prepared from polyethylene glycols of varying molecular weight; again, reference may be had to Remington: The Science and Practice of Pharmacy for further information.
Lotions are preparations that may be applied without friction, and are typically liquid or semiliquid preparations in which solid particles, including the active agent, are present in a water or alcohol base. Lotions are usually suspensions of solids, and preferably, for the present purpose, comprise a liquid oily emulsion of the oil-in-water type. It is generally necessary that the insoluble matter in a lotion be finely divided. Lotions will typically contain suspending agents to produce better dispersions as well as compounds useful for localizing the active agent in contact with the skin, e.g., methylcellulose, sodium carboxymethyl-cellulose, or the like.
Pharmaceutical emulsion formulations are generally formed from a dispersed phase (e.g., a pharmacologically active agent), a dispersion medium and an emulsifing agent. If desired, emulsion stabilizers can be included in the formulation as well. A number of pharmaceutically useful emulsions are known in the art, including oil-in-water (o/w) formulations, water-in-oil (w/o) formulations and multiple emulsions such as w/o/w or o/w/o formulations. Emulsifying agents suitable for use in such formulations include, but are not limited to, TWEEN 60.RTM., Span 80.RTM., cetostearyl alcohol, myristyl alcohol, glyceryl monostearate and sodium lauryl sulfate.
Pharmaceutical creams, are, as known in the art, viscous liquid or semisolid emulsions, either oil-in-water or water-in-oil. Cream bases are water-washable, and contain an oil phase, an emulsifier and an aqueous phase. The oil phase, also sometimes called the "internal" phase, is generally comprised of petrolatum and a fatty alcohol such as cetyl or stearyl alcohol; the aqueous phase usually, although not necessarily, exceeds the oil phase in volume, and generally contains a humectant. The emulsifier in a cream formulation is generally a nonionic, anionic, cationic or amphoteric surfactant.
The above pharmaceutical formulations are formed by dispersing finely divided or dissolved vasodilating agent uniformly throughout the vehicle or base using conventional techniques, typically by a levigating the agent with a small quantity of the base to form a concentrate which is then diluted geometrically with further base. Alternatively, a mechanical mixer may be used. Creams, lotions and emulsions are formed by way of a two-phase heat system, wherein oil-phase ingredients are combined under heat to provide a liquified, uniform system. The aqueous-phase ingredients are separately combined using heat. The oil and aqueous phases are then added together with constant agitation and allowed to cool. At this point, concentrated agents may be added as a slurry. Volatile or aromatic materials can be added after the emulsion has sufficiently cooled. Preparation of such pharmaceutical compositions is within the general skill of the art. See, e.g., Remington's Pharmaceutical Sciences, 18th Ed. (Easton, Pa.: Mack Publishing Company, 1990).
The vasodilating agents can also be incorporated into gel formulations using known techniques. Two-phase gel systems generally comprise a suspension or network of small, discrete particles interpenetrated by a liquid to provide a dispersed phase and a liquid phase. Single-phase gel systems are formed by distributing organic macromolecules uniformly throughout a liquid such that there are no apparent boundaries between the dispersed and liquid phases. Suitable gelling agents for use herein include synthetic macromolecules (e.g., Carbomers.RTM., polyvinyl alcohols and polyoxyethylene-polyoxypropylene copolymers), gums such as tragacanth, as well as sodium alginate, gelatin, methylcellulose, sodium carboxymethylcellulose, methylhydroxyethyl cellulose and hydroxyethyl cellulose. In order to) prepare a uniform gel, dispersing agents such as alcohol or glycerin can be added, or the gelling agent can be dispersed by trituration, mechanical mixing or stirring, or combinations thereof.
Inclusion complexes are complexes formed by interaction of macrocyclic compounds containing an intramolecular cavity of molecular dimensions with the smaller, pharmacologically active agent. Preferred inclusion complexes are formed from .alpha.-, .beta.- and .gamma.-cyclodextrins, or from clathrates, in which the "host" molecules form a crystal lattice containing spaces in which "guest" molecules (i.e., in this case, the vasodilating agent) will fit. See, e.g., Hagan, Clathrate Inclusion Compounds (New York: Reinhold, 1962).
Liposomes are microscopic vesicles having a lipid wall comprising a lipid bilayer, and can be used as drug delivery systems as well. Generally, liposome formulations are preferred for poorly soluble or insoluble pharmaceutical agents. Liposomal preparations for use in the instant invention include cationic (positively charged), anionic (negatively charged) and neutral preparations. Cationic liposomes are readily available. For example, N�1-2,3-dioleyloxy)propyl!-N,N,N-triethylammonium ("DOTMA") liposomes are available under the tradename Lipofectin.RTM. (GIBCO BRL, Grand Island, N.Y.). Similarly, anionic and neutral liposomes are readily available as well, e.g., from Avanti Polar Lipids (Birmingham, Ala.), or can be easily prepared using readily available materials. Such materials include phosphatidyl choline, cholesterol, phosphatidyl ethanolamine, dioleoylphosphatidyl choline ("DOPC"), dioleoylphosphatidyl glycerol ("DOPG"), dioleoylphoshatidyl ethanolamine ("DOPE"), among others. These materials can also be mixed with DOTMA in appropriate ratios. Methods for making liposomes using these materials are well known in the art. See Remington's Pharmaceutical Sciences, supra.
The pharmaceutical formulations of the invention are typically contained within drug delivery systems selected to provide a predetermined agent release profile, e.g., pulsatile, continuous, cyclical or diurnal. Such systems can include, for example, osmotic pumps which are capable of delivering variable amounts of the agent in a pulsatile manner. Osmotic pump systems typically involve incorporation of the pharmaceutical agent within a hard coating shell which is usually semi-permeable, e.g., a microporous cellulose acetate latex coating; the shell further contains a bore hole drilled into the outer layer. After delivery, water from the surrounding moist environment is osmotically pulled into shell through the bore hole, dissolving the agent and creating a high integral pressure sufficient to effect release of the agent from the shell. In this manner, the active agent is automatically "pulsed" out of the delivery system. A number of suitable osmotic pumps have been described in the art. See, for example, Appel et al. (1992) Pharm. Res. 9:1664-1667 and Kleinbloesem et al. (1984) Clin. Phann. Therapeut. 36:396-401.
Other drug delivery platforms capable of providing a pulsatile, continuous, cyclical or diurnal agent release profile include those formed from bio-erodible polymers, wherein the vasoactive agent is dispersed within a polymer matrix. Such polymers are selected such that they bioerode in the presence of moisture, and provide for sustained agent release at readily predictable rates.
More particularly, release of the vasodilating agent can be controlled by dissolution (bioerosion) of a polymer using either encapsulated dissolution control or matrix dissolution control. In encapsulated dissolution control, the vasodilating agent is coated with a membrane of slowly dissolving polymeric or wax materials. When the encapsulating membrane has dissolved, the agent core is available for immediate release and adsorption across the epithelial or mucosal surfaces of the vagina or vulvar area. Bioerodible coating materials may be selected from a variety of natural and synthetic polymers, depending on the agent to be coated and the desired release characteristics. Exemplary coating materials include gelatins, carnauba wax, shellacs, ethylcellulose, cellulose acetate phthalate or cellulose acetate butyrate. Release of the agent is controlled by adjusting the thickness and dissolution rate of the polymeric membrane. A uniform sustained release can be attained by compressing a population of particles of the agent with varying membrane thickness (e.g., varying erosion times) into a tablet form for a single administration.
In matrix dissolution control, the vasodilating agent is dissolved or dispersed within a matrix of, for example, an erodible wax. The agent is released for adsorption across the epithelial or mucosal surfaces of the vagina or vulvar area as the matrix bioerodes. The rate of agent availability is generally controlled by the rate of penetration of the dissolution media (i.e., vaginal fluids) into the matrix, wherein the rate of penetration is dependent on the porosity of the matrix material. Bioerodible matrix dissolution delivery systems can be prepared by compressing the vasodilating agent with a slowly soluble polymer carrier into a tablet or suppository form. There are several methods of preparing drug/wax particles including congealing and aqueous dispersion techniques. In congealing methods, the vasodilating agent is combined with a wax material and either spray-congealed, or congealed and then screened. For an aqueous dispersion, the vasodilating agent/wax combination is sprayed or placed in water and the resulting particles collected. Matrix dosage formulations can be formed by compaction or compression of a mixture of vasodilating agent, polymer and excipients.
In an alternative embodiment, the pharmaceutical formulation is administered in the form of biodegradable adhesive film or sheet which adheres to the vulvar area. Such drug delivery systems are generally composed of a biodegradable adhesive polymer based on a polyurethane, a poly(lactic acid), a poly(glycolic acid), a poly(ortho ester), a polyanhydride, a polyphosphazene, or a mixture or copolymer thereof. Preferred biodegradable adhesive polymers include polyurethanes and block copolyurethanes containing peptide linkages, simple mixtures of polyurethanes and polylactides, and copolymers of acrylates and mono- or disaccharide residues.
If desired, a clitoral application device may be used to facilitate application of a pharmaceutical formulation containing one or more vasodilating agents directly to the clitoral area. Referring to FIG. 1, an embodiment of a clitoral application device is generally indicated at 2. The device 2 is configured in the shape of an elongate patch having a top surface 4. The patch can be formed from any suitably flexible material such as polymers or fibrous materials. The patch is dimensioned to be generally co-extensive with the external female genitalia. The top surface 4 of the patch has an upper region 6 and a lower region 8 which correspond to the upper and lower portions of the female genitalia. A clitoral applicator, generally shown at 10, is provided on the top surface 4 of the patch at the upper region 6 thereof. The clitoral applicator 10 generally comprises an extended finger or protuberance 12 which is disposed over a reservoir 14 containing the pharmaceutical formulation. The reservoir 14 can be formed by disposing the pharmaceutical between the top surface 4 of the patch and a permeable membrane 16 which encircles the base of the protuberance 12. An optional suction tip 18 can be provided at the distal end of the protuberance 12 to facilitate positioning of the device.
The membrane 16 contains micropores through which the pharmaceutical agent can diffusively migrate to contact the clitoral wall. A number of suitable porous materials are known, such as water insoluble natural gums, cellulose, cellulose diacetate, microporous polyurethanes, polyarylenes, polycarbonates, polysulfones and polyamides, or microporous copolymers of polyvinylchloride and acrylonitrile. The release rate of the vasodilating agent can be readily controlled by adjusting the pore size in the membrane, the physical attributes of the pharmaceutical formulation (e.g., providing colloidal pharmaceutical solutions, suspensions or sols and/or adjusting the ratio of the size of the pores to the molecular size of the pharmaceutical agent), or by adjusting the thickness of the membrane. In addition, controlled or sustained release pharmaceutical formulations can be used in the application device 2 to provide a desired release effect.
In use, the device 2 is positioned by inserting the protuberance 12 to extend into the clitoral hood. The device can then be left in place for a suitable time to administer the vasodilating agent with the lower region 8 extending over the remainder of the genitalia. If desired, an opening 20 can be provided to allow for urethral voiding during drug administration. If the device includes a suction tip 18, a vacuum can be formed against the surface of the clitoral glans by pressing the protuberance firmly into place within the clitoris.
For treatment of sexual dysfunction, the pharmaceutical formulation is administered either vaginally, or to the vulvar area, or both. The amount of active agent administered is at least the minimum necessary to treat the dysfunction, e.g., excitement stage dysfunctions such as touch sensation impairment, loss of clitoral sensation, vaginal dryness, urinary incontinence and concomitant dyspareunia. In the treatment of dyspareunia, prostaglandin E1, E2 and analogues thereof can be administered at a level sufficient to exceed naturally occurring levels at the point of administration, for example in an amount ranging from 50 to 500 .mu.g/kg.
In addition to treatment of sexual dysfunction, the formulations of the invention have other uses as well. They may be administered vaginally to prevent the occurrence of yeast infections, to improve vaginal muscle tone and tissue health, to enhance vaginal lubrication, and to minimize collagen misdeposition associated with hypoxia.
It is to be understood that while the invention has been described in conjunction with the preferred specific embodiments thereof, that the foregoing description as well as the examples which follow are intended to illustrate and not limit the scope of the invention. Other aspects, advantages and modifications within the scope of the invention will be apparent to those skilled in the art to which the invention pertains.
Experimental: Topical vasodilating cream and ointment formulations are prepared. The formulations contain a selected vasodilating agent as described earlier herein, for example a synthetic or semisynthetic prostaglandin derivatives having the general structure of Formula (I) ##STR4## wherein the various substituents are as defined earlier herein.
EXAMPLE 1
A cream formulation is prepared using a synthetic or semisynthetic prostaglandin having a structure encompassed by the general structure of Formula (I). The cream includes the following components:
______________________________________Prostaglandin 0.25 gmBeeswax 2.7 gmCarbopol .RTM. 934 q.s. 100.0 gm______________________________________
Mixing is conducted with tile and spatula until a homogeneous cream mixture is obtained having the prostaglandin uniformly dispersed throughout the composition.
EXAMPLE 2
The procedure of Example 1 is repeated except that the following components are used:
______________________________________Prostaglandin 0.25 gmPolyethylene glycol 400 37.5 gm1,2,6-hexanetriol 20.0 gmPolyethylene glycol 4000 q.s. 100.0 gm______________________________________
A homogenous cream mixture is obtained.
EXAMPLE 3
The procedure of Example 1 is repeated except that the following components are used:
______________________________________Prostaglandin 0.25 gmPolyethylene glycol 400 37.0 gmPolyethylene glycol 400 monostearate 26.0 gmPolyethylene glycol 4000 q.s. 100.0 gm______________________________________
A homogenous cream mixture is obtained.
EXAMPLE 4
The procedure of Example 1 is repeated except that the following components are used:
______________________________________Prostaglandin 0.25 gmPolyethylene glycol 400 47.5 gmCetyl Alcohol 5.0 gmPolyethylene glycol 4000 q.s. 100.0 gm______________________________________
A homogenous cream mixture is obtained.
EXAMPLE 5
An ointment formulation is prepared using a synthetic or semisynthetic prostaglandin having a structure encompassed by the general structure of Formula (I). The ointment includes the following components:
______________________________________Prostaglandin 0.25 gmAnhydrous lanolin 20.0 gmMineral oil 25.0 gmWhite Petrolatum q.s. 100.0 gm______________________________________
Mixing is conducted with tile and spatula until a homogeneous ointment mixture is obtained having the prostaglandin uniformly dispersed throughout the composition.
EXAMPLE 6
The procedure of Example 5 is repeated except that the following components are used:
______________________________________Prostaglandin 0.25 gmDiisopropyl Adipate 19.95 gmWhite Petrolatum, USP q.s. 100.0 gm______________________________________
A homogenous ointment mixture is obtained.
In the cream and ointment formulations described in Examples 1-6, optional ingredients can include materials such as antioxidants, viscosity modifiers (e.g., paraffin wax or lanolin wax), and topical absorption rate modifiers. The formulations may be administered using the clitoral application device of FIG. 1.
EXAMPLE 7
Individuals are assessed and pre-screened to assemble an experimental group of subjects suffering from sexual dysfunction. The formulations prepared in Examples 1-6 are each assessed in the experimental subjects for their ability to increase uterine or vaginal epithelial blood flow. The formulations are topically applied, and changes in blood flow or vaginal fluid production after application of the vasodilating formulations are determined using known methods. Increase in vaginal epithelial blood flow is determined using indirect methods such as photoplethysmography (Levin (1980) Clinics in Obstet. Gynaecol. 7:213-252), heated oxygen electrode (Wagner et al. (1978), "Vaginal Fluid" in The Human Vagina, Evans et al. (eds.), Amsterdam: Elsevier/North Holland Biomedical Press, pp. 121-137), and direct clearance of radioactive Xenon (Wagner et al. (1980) Obstet. Gynaecol. 56:621-624). Changes in vulvar blood flow are monitored using laser Doppler velocimetry (Sarrel, P. M. (1990) Obstet. Gynaecol. 75:26S-32S).
Decreased vaginal dryness and/or dyspareunia are negatively correlated with vaginal blood flow rates, wherein increased blood flow to the vagina correlates with increased lubrication and decreased frequency and severity of dyspareunia (Sarrel, P. M. (1990) Obstet. Gynaecol. 75:26S-32S). Accordingly, vulvar blood flow after treatment is assessed using laser Doppler velocimetry and compared to baseline levels. Increased vaginal lubrication as a result of treatment with the vasodilating formulations can also be assessed using the methods of Semmens et al. (1982) J. Am. Med. Assoc. 248:445-448.

Number	Name	Date
3800038	Rudel	Mar 1974
3948254	Zaffaroni	Apr 1976
3967618	Zaffaroni	Jul 1976
4014987	Heller et al.	Mar 1977
4112942	Scaife	Sep 1978
4128577	Nelson	Dec 1978
4254145	Birnbaum	Mar 1981
4454339	Skuballa	Jun 1984
4507323	Stern	Mar 1985
4521421	Foreman	Jun 1985
4564362	Burnhill	Jan 1986
4680312	Johnson	Jul 1987
4818517	Kwee et al.	Apr 1989
4961931	Wong	Oct 1990
4976692	Atad	Dec 1990
5190967	Riley	Mar 1993
5565466	Gioco et al.	Oct 1996
5731339	Lowrey	Mar 1998
5773457	Nahoum	Jun 1998

Treatment of female sexual dysfunction

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Frishman et al. (1992), "Evaluation of Astroglide, a New Vaginal Lubricant: Effects of Length of Exposure and Concentration on Sperm Motility," Fertility and Sterility 58(3):630.
Levin (1991), "VIP, Vagina, Clitoral and Periurethral Glans--An Update on Human Female Genital Arousal," Exp. Clin. Endocrinol. 98(2):61-69.
Semmens, Medical Aspects of Human Sexuality 8:85-86 (1974).