North American Menopause Society Presidential Plenary Symposium:

1. North American Menopause Society Presidential Plenary Symposium: New Findings from the Kronos Early Estrogen Prevention Study (KEEPS) Randomized Trial • Overview: KEEPS Rationale, Design, and Study Population • JoAnn E. Manson, MD, DrPH Brigham and Women’s Hospital Harvard Medical School • KEEPS Biomarker and Vascular Imaging Findings • S. Mitchell Harman, MD, PhD Kronos Longevity Research Institute Phoenix VA Health Care System • KEEPS Cognitive Function and Mood/Affective Outcomes • Sanjay Asthana, MD, FACP, FCRP University of Wisconsin NIA/NIH Wisconsin Alzheimer’s Dis. Research Ctr

2. Support • The core KEEPS was funded by the Phoenix-based Kronos Longevity Research Institute, which is supported by the not-for-profit Aurora Foundation, and was conducted at 9 U.S. academic medical centers. • The KEEPS Cognitive Ancillary Study was supported by a grant from the National Institute on Aging, NIH.

3. Kronos Early Estrogen Prevention Study (KEEPS) Principal Investigators S. Mitchell Harman (KEEPS Director, KLRI) Frederick Naftolin (KEEPS Co-Director, NYU) Eliot A. Brinton/Paul Hopkins (U. of Utah) Marcelle I. Cedars (UCSF) Rogerio A. Lobo (Columbia) JoAnn E. Manson (Harvard) George R. Merriam (VA Puget Sound/U. of Washington) Virginia M. Miller (Mayo Clinic) Nanette Santoro (U. of Colorado)/Genevieve Neal-Perry (Einstein) Hugh S. Taylor (Yale) Core Investigators and Ancillary Study Centers Sanjay Asthana (Cognitive Study PI, U. of Wisconsin) Dennis M. Black (Biostatistical Center, UCSF) Matthew J. Budoff (CAC Reading Center, UCLA) Howard N. Hodis (CIMT Reading Center, USC)

4. KEEPS Study Design • N = 727 women aged 42-59 (mean age, 52.7, within 3 yrs of FMP) • Trial Duration = 48 months • Multi-center double-blinded placebo-controlled RCT • Treatment Arms: • Oral conjugated equine estrogens (o-CEE) given as Premarin®, 0.45 mg/d (lower dose than WHI) • Transdermal Estradiol (t-E2) given by Climara® patch, 50 µg/d • Placebo (active arms received cyclical micronized progesterone [Prometrium®], 200 mg/d x 12 days/month; placebo arm received placebo Prometrium)

5. KEEPS: Specific Aims • To compare effects of oral vs transdermal estrogen vs placebo on: • Atherosclerosis progression as assessed by Carotid IMT • Development/progression of coronary artery calcium (CAC) • Other • CVD risk factors/biomarkers (BP, lipids, HOMA-IR) • Cognition and mood/depression (Ancillary Study) • Vasomotor symptoms, sexual function, QOL • Bone mineral density • Mammographic breast density/breast outcomes (Ancillary Study)

6. Inclusion Criteria • 42-59 years of age at randomization • Final menses <3 years earlier • Good general health • Plasma FSH ≥ 35 mIU/ml and/or E2 levels <40 pg/ml • Normal mammogram within one year before randomization

7. KEEPS Baseline Characteristics* • MeanSD • Age 52.7 2.6 • Yrs since menopause 1.43 0.7 • BMI (kg/m2) 26.2 4.3 • Systolic BP (mm Hg) 119 15 • Diastolic BP (mm Hg) 75.0 9.2 • Total cholesterol (mg/dl) 208 34 • LDL cholesterol (mg/dl) 111 28 • HDL cholesterol (mg/dl)† 72.0 15(p <0.05) * Unless otherwise noted, there were no differences between treatment groups at baseline. †p=0.0497

8. Race/Ethnicity White 77% African-American 7% Hispanic 7% Asian 3% Other 6% Education No college degree 28% Bachelor’s degree 40% >4 years college 32% Prior Hormone Use Never 79% Current/Past 21% Smoking Never 76% Current/Past 24% KEEPS Baseline Characteristics* * Unless otherwise noted, there were no differences between treatment groups at baseline.

9. Changes in Risk Factors, Blood Pressure p=NS p=NS

10. Changes in Risk Factors, LDL Cholesterol & Triglycerides

11. Changes in Risk Factors, HDL Cholesterol Month Levels * * * * *

12. Changes in Risk Factors, Fasting Blood Sugar & Insulin Resistance

13. Changes in Risk Factors, CRP & IL-6 p=NS

14. Summary: Direction of Changes in Risk Factors* * Relationship of some factors to CVD risk equivocal or subsidiary to related factors

15. Ultrasound Measurement of CIMT Distal Far Wall CCA Hodis HN, et al. Arterial Lumen Thickness of the common carotid artery intima-media layers measured by ultrasound (CIMT). Gray’s Anatomy, 1918, fig. 507

16. Changes in Imaging Endpoints, CIMT p=NS

17. Coronary Artery Calcium (CAC) by CAT Scan Linear calcification in the left coronary artery in a KEEPS participant, Mayo Clinic

18. CAC Agatston Scores at Baseline p=NS O- T- o-CEE t-E2 Placebo

19. Percent of Subjects with Increases in CAC Score ≥ 5 Agatston Units p=NS p=NS p=NS o-CEE t-E2 Placebo o-CEE t-E2 Placebo o-CEE t-E2 Placebo

20. Serious Adverse Events Probably or Possibly Related to HT *Calculated by Chi Square (with Yates’ correction) for both estrogen groups pooled vs. placebo (2 x 2 table)

21. Results: Cognition and Cardiovascular Risk Profile Significant o-CEE by Risk interaction for the Verbal Learning and Memory Factor Women at “low” CVD risk receiving the o-CEE drug therapy were significantly more likely than the Placebo group to improve on Verbal learning and memory ability across time.

22. Results: Tests of Mood and Affect Profile of Mood States (POMS) • Total Score • Depression-Dejection • Tension-Anxiety

23. Change from Baseline on Total POMS Better *p < 0.05

24. Change from Baseline on POMS Depression-Dejection Better *p < 0.05

25. Change from Baseline on POMS Tension-Anxiety Better *p < 0.05 18 36 48

26. Overall Summary and Conclusions • Both o-CEE and t-E2 had favorable effects on vasomotor sx, sexual function, QOL, bone density (presented elsewhere). • Both had neutral effects on BP (adverse effect in WHI). • Both had generally favorable or neutral effects on CVD biomarkers (but differences related to first-pass liver metabolism). • Both had neutral effects on CIMT and CAC (but ns trend for latter). • Both had neutral effects on cognition (adverse effect in WHI, age >65). • Differences: o-CEE improved mood, t-E2 improved HOMA-IR and some advantages for sexual function. • KEEPS highlights the need for individualized decision making about HT, given different treatment priorities and risk factor status of women. • Additional research on HT in newly menopausal women, including different formulations/doses/routes of delivery, is needed.