(5) Ovarian failure, followed by Rokitansky syndrome and then physiologic delay, are the most frequently encountered etiologies. Other etiologies are diverse and numerically less frequent. The average age of presentation, patient's height, somatic anomalies, diagnostic errors, and subsequent reproductive potential of each diagnostic group are reported. Epidemiology study indicate the approximately 60% of all women will have amenorrhea throughout their lifetime³.

1.1.1 Classification:

Amenorrhea is abnormal except before puberty, during pregnancy, during early lactation and after menopause. Amenorrhea is traditionally categorized as primary amenorrhea and secondary Amenorrhea.

A. Primary Amenorrhea means menarche has not occurred by age 16.

B. Secondary Amenorrhea means menses has not occurred for >3 months in women who have had manses.

Primary Amenorrhea can be diagnosed with if a patent has normal sexual characteristics, but menarche by 16 year of age.

Secondary Amenorrhea is the absence of menses for three months in women with previously normal menstruation and for nine months in women with previous oligomenorrhea. Secondary amenorrhea is more commen than primary.

Amenorrhea is typically classified as Anovulatory and Ovulatory Amenorrhea.

(i) Anovulatory Amenorrhea – In this type of Amenorrhea both ovulation and meanses are absent, is the more common and results from functional rather than structural causes.

The hypothalamic pituitary axis is intact and ovaries are functional, but gonadotropin secretion is decreased resulting in mild estrogen secretion is decreased, resulting in mild estrogen deficiency⁴.

Anovulatory Amenorrhea causes are hypothalamic, pituitary ovarian or other endocrine dysfunction and some genetic disorders. Hypothalamic causes may be multifunctional and may include unknown factors.

Endocrine causes may involve in appropriate hormonal feedback and which can turned from altered level of free testosterone, other androgen or estrogen⁵. Due to lack of sex hormone binding globulin (eg. Chronic liver diseases) excessive extra glandular production of estrogens, excess of ovarian or adrenal androgen, or polycystic ovary syndrome⁶.

(ii) Ovulatory Amenorrhea – It is less common, ovulation occurs but there is an obstruction to outflow of menses it occurs due to anatomic genital abnormalities in women with normal hormonal function. Many congenital anatomic abnormalities physically obstruct menstrual flow through uterine outflow tract, causing Amenorrhea⁷.

Imperforate hymen and transverse vaginal septum are known causes of mucocolpos and hematocolpos. Hematocolpos (accumulation of menstrual blood in vagina), which causes vagina to bulge and hematometra (accumulation of blood in uterus) which can causes uterine distention or mass may also occur. Because ovarian function is normal the external genitals and other secondary sexual characteristics develop normally, however some congenital disorder (eg, that cause vaginal aplasia or vaginal spectrum) also cause urinary tract and skeletal abnormalities⁸.

1.1.2 Diagnosis:

· Girls are evaluated if no sign of puberty occurs by age 13 or if menarche has not occurred by age 16 year since the onset of puberty.

· Women of reproductive age should have pregnancy test after missing one menses, they are evaluated for amenorrhea if they are not pregnant and have missed menstrual cycle for >3 months, have < 9 menses a year, have a sudden change in menstrual pattern.

· There are different ways of physical examination which issued for diagnosis of Amenorrhea.

(a) Virilization (eg. Increased libido) reflects excess androgen effects, gonadal dysgenesis, polycystic ovarian syndrome.

(b) Absence or delayed development of secondary sexual characteristics (breast, pubic, genitals) suggest absent or decreased estrogen levels.

Amenorrhea is detected by different test include pregnancy test, a progesterone challenge and measurement of hormone levels. The progesterone challenge helps assess contribution of estrogen deficiency, structural endometrial lesions, uterine outflow obstruction to amenorrhea. Medroxy progesterone 5-10 mg once/day for 5 days or progesterone 5-10 mg IM once/day for 5-10 days is given. If bleeding occurs, amenorrhea is probably not caused by significant estrogen deficiency, an endormetrial lesion or obstruction to uterine outflow^9-12.

Estradiol follicle Stimulating hormone levels can be measured (when bleeding does not occur) to confirm primary or secondary estrogen deficiency and distinguish between them if results are normal, oral estrogen is given, if bleeding does not occur, amenorrhea is probably due to endometrial abnormalities. Serum level of follicle Stimulating hormone, prolactin and thyroid stimulating hormone are measured in all women with amenorrhea increased follicle Stimulating hormone level (>30 IU/L) suggest ovarian failure while increased level suggest (<7 IU/L) pituitary tumor. Prolactin is increased usually (> 20 mg/ml) in >30% of women with amenorrhea.

1.1.3 Treatment:

Ø Amenorrhea that may required to induce ovulation if pregnancy is desired.

Ø For hirsutism with elevated testosterone level physical approach (eg. Bleaching, electrolysis, waxing, laser) are encouraged.

Ø No systemic treatment are completely effective, initially oral contraceptive are used. They suppress sex hormone secretion and production of sex hormone binding globulin thus reducing biological active testosterone, initially results are delayed for some months but it is effective.

Ø If oral contraceptive are contraindicated. Oral progestin (25 mg once/day) can be used. Pregestin is used but it may cause pain, bloating, depression.

Ø Gonadotropin releasing hormone against (eg. Leuprolide 5-75 IM may also given to suppress gonadotropins and thus to inhibit hormone secretion.

1.2 Intra-vaginal Drug Delivery System:

For thousands of years, women have been administering a wide range of substances to the vagina, primarily for contraception or for the treatment of infection.

1.2.1Traditional concept:

Traditional drug delivery systems for vaginal and oral application have employed waxes, oils, natural macromolecules, and a relatively small number of water-soluble and -insoluble synthetic polymers as critical formulation material. Traditional vaginal dosage forms have been associated with disadvantages such as low residence time and discomfort and have been surpassed by newly designed drug delivery systems, particularly those based on bioadhesive polymers. In general, these delivery systems were constructed to achieve minimal local and systemic toxicity while simultaneously permitting predictable modulated drug delivery. These broad objectives have not changed in recent times and modern drug delivery systems¹³.

1.2.2 Vaginal Drug Delivery

Vaginal dosage forms have been studied in relation to many drugs as the vagina presents several advantages as a site for drug delivery, such as large surface area, rich blood supply, avoidance of the first-pass effect, relatively high permeability to several drugs, and self-insertion. The human vagina appears to be an under utilized route of drug delivery given its potential advantages.

Major advantages in vaginal delivery include:

v A non-invasive route of administration,

v A highly perused tissue,

v The ability to bypass first-pass liver metabolism,

v A reduction in the incidence and severity of gastrointestinal side effects, as observed during the vaginal delivery of bromocriptine.

v Intravaginal enzymatic activity is comparatively lower in the vagina than in the gastrointestinal tract.

v In addition, the vagina appears to be significantly permeable to many drugs. Especially large-molecular-weight protein and peptide drugs.

v Dose dumping concern to dosage forms.

Disadvantages to this route of drug delivery include:

v Gender specificity,

v The influence of sexual intercourse, and Personal hygiene concerns are the major.

1.2.3 Designing an Intravaginal Drug Delivery System: Key Considerations³:

A wide range of delivery systems are applicable to intravaginal drug delivery,very few of which are specifically designed for the vaginal route. General delivery platforms that may be used intravaginally include creams, foams, pessaries, gels, tablets, and particulate systems. Some of these incorporate the use of one or more mucoadhesive polymeric components. The best examples of specifically designed intravaginal delivery systems generally involve solid polymeric systems, usually either elastomers or hydrogels or in-situ gels ¹⁴.

The choice between local or systemic delivery may determine, for example, the use of a traditional dosage form, such as a semisolid cream or gel, or a system that promotes increased intravaginal residence, with an increased possibility of absorption across vaginal epithelium. Site-specific application may be preferable or it may be required that the drug is distributed rapidly throughout the vaginal space. The latter approach may be best suited to, for example, intravaginal administration of an antimicrobial or antifungal agent. Site-specific delivery will require the use of a self-locating system, typically a mucoadhesive formulation, although an intravaginal ring, owing to its elastomeric nature, will remain located high in the vaginal space. Conversely, for rapid distribution throughout the space, semisolid or fast-dissolving solid systems will be required. For semisolids, flow properties and viscoelastic character will be critical determinants of their ability to spread rapidly from their point of application^15-17.

Intravaginal drug release may be required to be immediate or modified (sustained or controlled release). Drug release by the intravaginal route is most commonly immediate but a viscoelastic semisolid can be designed to offer some increase in duration of delivery, as can solid hydrogels or intravaginal tablets. For controlled, zero-order sustained release over prolonged periods (days, extending to months), solid polymeric systems may be most suitable, provided they are compatible with the physicochemical nature of the drug to be delivered. Intravaginal applications of controlled release relate to systemic drug delivery applications, typically for potent drugs such as steroid sex hormones and, perhaps, peptides or peptidomimetic agents¹⁸.

The physicochemical and pharmacological nature of the penetrants are of paramount importance. The drug to be delivered should be considered in relation to its polarity and partition characteristics, molecular weight, and size, with respect to epithelial penetration, release into vaginal fluid, and performance in either water-based or more hydrophobic delivery systems.

Vaginal delivery may not be universally acceptable in all cultures, and within cultures the preference for systems that can be self-inserted and removed, or considerations relating to leakage, will vary considerably. From an industrial perspective, a cost-benefit analysis is an important factor in deciding upon the choice of delivery system. Capital costs, for example, are considerably higher for specifically designed intravaginal systems than for those capable of manufacture on generic equipment, such as semisolids and intravaginal tablets. These costs must be considered in relation to the commercial value of the active components and the likely benefits in relation to the disease state.

Molecules as large as immunoglobulins (IgG) and albumin are able to pass from the blood to the lumen of the vagina. Leukocytes are able to migrate from the lamina propria to the vaginal lumen by dilating the channels; they open desmosomes which remain connected with the cytoplasmic filaments which then reconnect when the leukocyte moves past the junction^19,20. It seems intuitive that these pores could also serve to allow diffusion of drug molecules from the lumen of the vagina into the bloodstream.

This suggests that estrogen has a direct effect on the formation of pores. Interchange between the blood vessels and the vaginal lumen occurs via these channels, and with channels in the epithelium itself ²¹.

1.2.4.3 Vaginal Fluid²⁰:

The vagina has no secretory glands apart from Bartholin's and Skene's glands, but it is broadly believed that these glands do contribute slight to the production of vaginal fluid. Vaginal fluid consists mainly of cervical secretions and transudation from the blood vessels through intercellular channels to the lumen of the vagina; thus, it is dependent on adequate blood flow. This fluid also contains secretions from the endometrium and fallopian tubes along with desquamated vaginal epithelial cells and leukocytes. Smaller contributions arise from follicular and peritoneal fluids and sometimes small amounts of urine. The chemical composition of the fluid includes carbohydrates, amino acids, aliphatic acids, proteins and immunoglobulins.

Table:1.1 Weights of vaginal discharge

Subjects	Weight of Discharge
Reproductive age including cervical secretions	3-4 g/4 h
Reproductive age without cervical secretions	2.7 g/24 h
Postmenopausal, no estrogen supplement	1.7 g/4 h
Hysterectomized, intact ovaries	1.89 ± 0.12 g/24 h
Hysterectomized, ovariectomized	1.56 ± 0.05 g/24 h
Hysterectomized, ovariectomized with estrogen supplement	1.97 ± 0.05 g/24 h

1.2.4.4 Vaginal Enzymes¹⁹

The outer cell layers and the basal cell layers of the vagina contain most of the enzyme activity. Outer layers have 3-glucuronidase, acid phosphatase, some α-naphthylesterase with small amounts of phosphoamidase and succinicdehydrogenase. Basal cell layers contain 3-glucuronidase, succinicdehydrogenase, small amounts of acid phosphatase, and α-naphthylesterase. The vaginal enzymes, especially proteases could potentially be an important barrier in the delivery of protein and peptide drugs.

1.2.4.5 Menopause

During menopause, the vagina changes and returns to a state similar to pre puberty. These changes are slow and can take 5-8 years to stabilize. There is also a decrease in vaginal size, loss of elasticity, loss of vascularity and a thinning of the mucosa. In a study of post-menopausal women, the average length of the vagina was reduced from approximately 8 to 6 cm and the width reduced from 2 to 1cm when compared to normally menstruating women. In addition, extensive leukocyte migration is often seen along with a thinning of the epithelial layer in post menopausal women. There is also a decrease in the amount of mitosis in the basal and parabasal layers, resulting in a thickness approximately the same as pre-puberty thickness. Some post-menopausal women show a loss of epithelium, exposing the sub epithelial connective tissue. Vaginal secretions lessen and become more watery after menopause and vaginal lubrication is less, taking more time to develop in post-menopausal women. The thinning of the mucosal and epithelial layer will lead to an increase in the permeability of vaginal tissue, which could be important for both local and systemic drug delivery in post-menopausal women. The vaginal epithelium can be restored to similar thicknesses seen in pre-menopausal women with estrogen replacement therapy (ERT).The thinning epithelial layer occurs with a corresponding loss of the outer intermediate and superficial cell layers. This loss is also reflected in a decrease in the amount of glycogen in the tissue, causing changes in the bacterial flora, along with a rise in pH from an average of 5 to about 7. In addition, menopause causes an increase in several enzymes such as 3-glucuronidase, acid phosphatase, and non-specific esterase’s. The increase in enzymatic levels could be useful for drug delivery to post-menopausal women using enzyme-degradable polymers.

1.2.4.6 Vaginal Absorption

Vaginally administered drugs are usually delivered by creams, foams, suppositories, gels, rings, or tablet formulations. The pathways for drug absorption through vaginal tissue are apparently no different from those found in other tissues, although the extensive pore system in vaginal tissue can be a significant pathway for some drugs. Drugs must be in solution prior to absorption and the moist layer on the vaginal surface helps dissolve drugs; however, cervical mucus secretions may also present a barrier to drug absorption and copious vaginal secretions may remove dosage forms from the site. Physicochemical properties of drugs such as molecular weight, lipophilicity, ionization, molecular size, chemical nature, and local action can influence drug absorption. Cyclic changes in the thickness and porosity of the vaginal epithelium can also affect absorption, as can pH, although conflicting results have been reported. As an example, the vaginal absorption of penicillin was reduced during the follicular phase of the menstrual cycle and correlated with a thickened vaginal epithelium.

Steroid hormones such as estrogen and progesterone are well absorbed vaginally. The vaginal absorption of steroids is affected by the thickness of the vaginal epithelium and has been reported to be higher in women with an atrophic epithelium. Vaginal absorption of estrogen in post-menopausal women showed a rapid rise in blood levels as compared to pre-menopausal women where levels did not significantly change. After long-term estrogen treatment, the absorption of steroids decreases as the epithelium thickens. The vaginal absorption of progesterone in estrogen-deficient women was enhanced when given estrogen even though the epithelial thickness increased. Such apparent contradiction were explained in that absorption because of the increased vascularity seen with estrogen treatment.

Proteins and peptides are also absorbed by the vagina. Bovine anti-luteinizing hormone-antibody (anti-LG-IG) was absorbed in baboons. Some large molecular-weight compounds such as peanut proteins were absorbed through the vagina, as well as sperm antigens, and bacterial antigenst, suggesting that the molecular weight cut-off for absorption may be higher for the vagina than for other mucosal surfaces.

Other compounds, however, are absorbed irregularly. Quinine and phenol red are absorbed slowly, while methylene blue is absorbed in minute quantities. Such irregularities may be due to self-association or binding to the proteins and cells of the tissue.

1.3 New approaches:

1.3.1 Modern tablet Device: A specially shaped tablet designed to increase its adherence to the genital tract. The tablet has a diameter of 20 mm, a flat bottom and a concave upper surface, aiming to better fit the uterine cervix. These devices are designed absolutely compatible with vaginal hydrodynamics and tablet shape and the relation with tablet residence time and erosion rate. Eventhough some women hesitate to use intravaginal rings out of fear of them getting lost, the intravaginal rings offer a novel approach and also have increasing acceptability among women ^22-24.

1.3.2 Hydrogels:

Hydrogels are hydrophilic polymers that have been cross-linked by means of covalent bonds. A 3% alginate gel off nonoxynol-9 has been investigated for intravaginal spermicide delivery. In the study, it was shown that spermicidal activity and diffusion of the agent changes with pH and osmolarity of the formulation. Recently, gelmicroemulsions have been proposed as a nontoxic vaginal formulation. A gel microemulsion based formulation of a spermicide with anti-HIV effect, phenyl phosphate derivative of zidovudine, has been developed. Multiple intravaginal application of this drug as microemulsion gel formulation did not cause any damage in the vaginal epithelium in a rabbit model. The vaginal gel has also been used for intravaginal vaccine delivery. Intravaginal delivery of cholera vaccine showed a greater mucosal response in the female genital tract compared to oral administration of the vaccine^25-27.

1.3.3 Self-emulsifying drug delivery systems (SEDDS):

It is self-emulsifying oil formulations which are defined as isotropic mixtures of natural or synthetic oils, solid or liquid surfactants, or alternatively, one or more hydrophilic solvents and co- olvents/surfactants. Upon mild agitation followed by dilution in aqueous media, such as GI fluids, these systems can form fine oil-in-water (o/w) emulsions or microemulsions (SMEDDS). Self-emulsifying formulations spread readily in the GI tract, and the digestive motility of the stomach and the intestine provide the agitation necessary for self-emulsification. SEDDS typically produce emulsions with a droplet size between 100 and 300 nm while SMEDDS form transparent microemulsions with a droplet size of less than 50 nm. When compared with emulsions, which are sensitive and metastable dispersed forms, SEDDS are physically stable formulations that are easy to manufacture. Thus, for lipophilic drug compounds that exhibit dissolution rate-limited absorption, these systems may offer an improvement in the rate and extent of absorption and result in more reproducible blood time profiles ²⁸.

In newer VagiSite technology a high-internal-phase ratio, water-in-oil emulsion is formed. As such, the phase of the emulsion acts as the carrier of the active drug. In this system drug is incorporated in internal dispersed phase globules serve a dual purpose for both the sequestering and the controlled release of the active substance. The high internal emulsion containing disperse phase globules develops a high affinity for surfaces, especially mucosal tissues. This tenacious, mucoadhesive film acts as a drug delivery platform providing a controlled release of the drug into the lumen of the vaginal canal²⁹.

1.3.4 Smart Dendrimeric Intravaginal Drug Delivery Approaches

In current scenario Intra-vaginal Drug Delivery move upwards with very recent advancement like dendrimer-based microbicide delivery system, albeit dendrimer are not used as a carrier but as an active ingredient also³⁰ 57. Dendrimeric carrier (SPL7013) are in the vein as emerged as most promising dendrimer, which binds and blocks HIV-1 thereby preventing STIs, including HIV and genital herpes, and has been formulated as a gel that is under phase-I clinical trail³¹ .

Simultaneously with the vigorous development of monoclonal human antibodies in medical field, many topical immunization hypothesis are also put forward as one of the major achievement in the form of microbicidal gel for protecting genital skin and epithelia against infection. This type of monoclonal synthetic antibodies know how to be directly applied to the genital skin and epithelia for protection from HIV and other STIs pathogens³² .

With the perfect rationality a non nucleoside reverse transcriptase inhibitor with potent activity against HIV-1, formulated as intravaginal gel (PHI-444 ) are designed as novel thiophen-thiourea formulation and found safe in animal studies. Furthermore in this vaginal delivery vicinity the molecular condom (A smart semen-triggered vaginal microbicide delivery vehicle, design to protect women and unborn or nursing child from HIV60) is also developed as anti-HIV vaginal gel, which release anti-HIV bioactives upon contract with the serum during sexual intercourse³³.

CONCLUSION:

There are often compelling reasons for administering drug via non-oral routes. During the last decade, intravaginal delivery has received increasing attention in the face of growing awareness, that drugs administered by conventional means are frequently excessively toxic and sometimes inactive as they are introduced into the body as pulses and produce large fluctuations of drug concentration in the blood stream and tissues and consequently elicit unfavorable patterns of efficacy and toxicity. In current scenario Intra-vaginal Drug Delivery move upwards with very recent advancement like vaginal hydrodynamics tablet, Hydrogels and gel microemulsion, highly effective tenacious mucoadhesive film and dendrimeric formulations contains anti-HIV and for genital herpes treatement. Fundamental studies carried out on intravaginal membrane, its structure and immunological properties to a great extent helped the formulator to overcome the exceptionally effective barrier properties of the mucosa.

REFERENCES:

1. Chumlea WE, Schubert CM, Roche AF, Kulin HE, Lee PA, Himes JH, . Age at menarche and racial comparisons in US girls. Pediatrics 2003;111:110–3.

2. National Center for Health Statistics. Age at menarche: United States. Rockville (MD): NCHS; 1973. Available at:http://www.cdc.gov/nchs/data/series/sr_11/sr11_133. pdf. Retrieved June 26, 2006.

3. Reindollar RH, Byrd JR, McDonough PG. Delayed sexual development: a study of 252 patients. Am J Obstet Gynecol 1981;140:371–80.

4. Cowan JT, Graham MG. Polycystic ovary syndrome: more than a reproductive disorder. Patient Care 2003;37: 23–33.

5. Warner PE, Critchley HO, Lumsden MA, Campbell-Brown M, Douglas A, Murray GD. Menorrhagia I: measured blood loss, clinical features, and outcome in women with heavy periods: a survey with follow-up data. Am J Obstet Gynecol 2004;190:1216–23.

6. Venturoli S, Porcu E, Fabbri R, Magrini O, Paradisi R, Pallotti G, et al. Postmenarchal evolution of endocrine pattern and ovarian aspects in adolescents with menstrual irregularities. Fertil Steril 1987;48:78–85.

7. Lunenfeld,B. and Insler, V., ClassificationOf Amenorrhoeic States and their Treatement by ovulationinduction. Clinical Endocrinology, 1974,3: 223–237.

8. Saeed Ahmed, L.L. Morris, E. Atkinson, Distal mucocolpos and proximal hematocolpos secondary to concurrent imperforate hymen and transverse viginal septum. J.Pedia. Sug.1999,34;10: 1555-1556.

9. Thomas F, Renaud F, Benefice E, de Meeus T, Guegan JF. International variability of ages at menarche and menopause: patterns and main determinants. Hum Biol 2001; 73:271–90.

10. Barnes-Josiah D, Augustin A. Secular trend in the age at menarche in Haiti. Am J Hum Biol 1997;7:357–62.

11. He Q, Karlberg J. BMI in childhood and its association with height gain, timing of puberty and final height. Pediatr Res 2001;49:244–51.

12. Wang Y. Is obesity associated with early sexual maturation. A comparison of the association in American boys versus girls. Pediatrics 2002;110:903–10.

13. Machado RM, Palmeira-de-Oliveira A, Martinez-De-Oliveira J, Palmeira-de-Oliveira R.Vaginal films for drug delivery. J Pharm Sci. 2013 Jul;102(7):2069-81.

14. Raghavendra S. Navath, Anupa R. Menjoge, Hui Dai, Roberto Romero, Sujatha Kannan and Rangaramanujam M. Kannan.Injectable PAMAM dendrimer-PEG hydrogels for the treatment of genital infections: formulation, in-vitro and in-vivo evaluation. Mol Pharm. 2011 August 1; 8(4): 1209–1223.

15. Vermani K, Garg S. The scope and potential of vaginal drug delivery. Pharm Sci Technolo Today, 3:359-364, 2000.

16. Richardson JL, Illum L. Routes of delivery: Case studies: The vaginal route of peptide and protein drug delivery. Adv Drug Deliv Rev, 8:341-366, 1992.

17. Robinson JR, Bologna WJ. Vaginal reproductive system treatments using a bioadhesive polymer. J Control Release, 28:87-94, 1994.

18. Valenta C. The use of mucoadhesive polymers in vaginal delivery. Adv Drug Deliv Rev, 57:1692-1712, 2005.

19. Voorspoels J, Casteels M, Remon JP, Temmerman M. Local treatment of bacterial vaginosis with a bioadhesive metronidazole tablet. Eur J Obstet Gynecol Reprod Biol, 105:64-66, 2002.

20. Burgos, M and Roig de Vargas-Linares, C.E. (1978) Ultrastructure of the vaginal mucosa. In:E.S.E. Hafez and T.N. Evans (Eds.), Human Reproductive Medicine: The Human Vagina, North- Holland Publishing Company, New York, Vol. 2, pp. 63-93.

21. Steger, R.W. and Hafez, E.S.E. (1978) Age-associated changes in the vagina. In: E.S.E. Hafez and T.N. Evans (Eds.), Human Reproductive Medicine: The Human Vagina, North-Holland Publishing Company, New York, Vol. 2, pp. 95 106.

22. Roig de Vargas-Linares, C.E. and Burgos, M.H. (1968) Migration of lymphocytes in the normal human vagina. Am. J. Obstet. Gynecol. 102, 1094~1101.

23. Brannon-Peppas L. Novel vaginal drug release applications. Adv Drug Deliv Rev, 11:169-177, 1993.

24. Alexander NJ, Baker E, Kaptein M, Karck U, Miller L, Zampaglione E. Why consider vaginal drug administration? Fertil Steril, 82:1-12, 2004.

25. Bouchemal K, Frelichowska J, Martin L, Lievin-Le Moal V, Le Grand R, Dereuddre-Bosquet N, Djabourov M, Aka-Any-Grah A, Koffi A, Ponchel G. Note on the formulation of thermosensitive and mucoadhesive vaginal hydrogels containing the miniCD4 M48U1 as anti-HIV-1 microbicide. Int J Pharm. 2013 Oct 1;454(2):649-52.

26. Kuklin N, Daheshia M, Karem K, Manickan E, Rouse BT, Induction of Mucosal Immunity Against Herpes Simplex Virus by Plasmid DNA Immunization, J. Virol, 71, 1997, 3138-3145.

27. Shetty A, Livingston I, Acharya S and Templeton A, Vaginal Prostaglandin E2 gel Versus Tablet in the Induction of Labour at Term—A Retrospective Analysis, J. Obstet. Gynaecol., 24, 2004, 243–246.

28. Kanika S, Yogesh P. Arbind K. Bansal. Self Emulsifying Drug Delivery system for Improved Bioavailability. Current. Res. and Inf. on Pharmaceutical Sci.2010;11;3, 42-49.

29. Levinson R.S., Thompson DJ. VagiSite Bioadhesive Technology. In: Rathborne M, Hadgraft J, Roberts MS (eds) 2003. Modified-release Drug Delivery Technology. Marcel Dekker, New York, pp801-806.

30. Smith M., TMC 120 Vaginal ring premising as microbicides carrier, XVI international conference, Toronto Canada, 2006.

31. Keller M.J., Tuyam A. and Carluc M.J., Topical microbicides for the prevention of genital herpes infection. J. Antimicrob. Chemother, 2005, 55(4): 420-23.

32. Boskey E.R., Cone R.A., Whaley K.J. and Moench T.R., Origin of vaginal acidity: high D/L lactate ratio is consistent with bacteria being the primary source, Hum. Reprod, 2001, 16(9): 1809-1813.

33. Stone A., MICROBICIDES: a new approach to preventing HIV and other sexually transmitted infections, Nature reviews, 2002,1(12) 977-985.

Received on 07.08.2013

Modified on 10.09.2013

Accepted on 20.10.2013

Research Journal of Pharmaceutical Dosage Forms and Technology. 5(6): November-December, 2013, 378-384