Contraceptive composition with reduced side effects

Abstract

The present invention relates to a combined oral contraceptive with a reduced risk of side effects (including a reduced risk of QT interval prolongation, a reduced risk of testosterone reduction, and a reduced risk of elevated C-reactive protein levels) when compared to other combined oral contraceptives. The estetrol / drospirenone combined oral contraceptive described herein exhibits favorable pharmacokinetics of the progestogen component. The use of a specific estrogen component in a combined oral contraceptive brings multiple beneficial effects compared to currently available combined oral contraceptives.

Description

Technical Field

[0001] The present invention relates to an oral contraceptive. In particular, the present invention relates to a combined oral contraceptive comprising estetrol and a progestogen component such as drospirenone, which exhibits favorable pharmacokinetic progestogen characteristics and reduced side effects. The present invention also relates to a contraceptive method and use thereof. Background Art

[0002] Over time, a variety of contraceptives have been developed and have given women increased freedom to bear children (Liao and Dollin, Half a century of the oral contraceptive pill, Can Fam Physician. 2012). A class of contraceptives that is particularly popular among women around the world is the combined oral contraceptive (COC) class. These COCs typically contain a combination of estrogen and progesterone, and are generally superior to oral contraceptives (pills) containing only progesterone, which are characterized by extremely strict daily dosing time and unpredictable bleeding patterns. Initially, COC contained high doses of estrogen (> 50 μg) and progestins such as norgestrel, linegestrol, norgestrel diacetate, norgestrel and norgestrel (i.e., the first generation of COCs), resulting in considerable side effects, including cardiovascular effects. Driven by ongoing research and post-marketing safety evaluation, recent COC preparations have been developed, including COCs (i.e., second-generation COCs) combining ethinylestradiol (typically <50 μg) with testosterone-derived progestins such as norgestrel and levonorgestrel, and COCs (i.e., third-generation COCs) combining ethinylestradiol with levonorgestrel-derived progestins (including desogestrel or gestodene). Recently, a fourth-generation COC combining drospirenone as a progesterone component with ethinylestradiol has been developed. This recently developed generation of progesterone binds more specifically to the progesterone receptor, thereby reducing androgen, estrogen, or glucocorticoid-related side effects, showing a more non-inclined effect on metabolic parameters (Bastianelli et al., Pharmacodynamics of combined estrogen-progestin oral contraceptives: 1. Effects on metabolism, Expert Rev Clin Pharmacol, 2017).

[0003] However, it is reported that when compared with the second generation COC, the use of the fourth generation COC can bring an increased risk of side effects, including venous thromboembolism events (Dinger et al., Risk of venous thromboembolism and the use of dienogest-and drospirenone-containing oral contraceptives: results from a German case-control study, J Fam Plann Reprod Health Care. 2010). In addition, it is reported that the fourth generation COC particularly contributes to the QT interval prolongation of the subject, which is caused by the QT prolongation effect of estrogen and the QT prolongation effect of drospirenone (Sedlak et al., Sex hormones and the QT interval: a review, J Womens Health, 2012). QT prolongation reflects delayed ventricular repolarization, and is associated with the development of arrhythmia, or even with the occurrence of cardiac arrest events. In addition, the overall anti-androgenic effect of COC is the reason for the reduction of free testosterone, and this phenomenon is mainly attributed to the effective estrogen contained in the preparation in the art. Low free testosterone levels are associated with female sexual dysfunction, including but not limited to lack of sexual desire (de Castro Coelho and Barros, The Potential of Hormonal Contraception to Influence Female Sexuality, Int J Reprod Med, 2019). Free testosterone has also been reported to have a general shortening effect on the QT interval (Sedlak et al., Sex hormones and the QT interval: a review, J Womens Health, 2012). Finally, an increase in C-reactive protein (inflammatory marker) was observed in subjects using COC. C-reactive protein is the most widely studied inflammatory biomarker in atherosclerotic cardiovascular disease (ASCVD). Multiple epidemiological studies have reached a consensus on the significant correlation between the increased serum or plasma concentrations of C-reactive protein and the prevalence of potential atherosclerosis, the increased risk of recurrent cardiovascular events in patients with established diseases, and the increased incidence of first cardiovascular events in individuals at risk of atherosclerosis (Crea and Morrow, C-reactive protein in cardiovascular disease, UpToDate, 2019).It remains unclear whether C-reactive protein is a nonspecific marker indicating an acute phase response to inflammatory stimuli or whether C-reactive protein is a direct player in the clinical imaging of atherosclerosis.

[0004] Estetrol is a natural estrogen produced during pregnancy (Holinka et al., Estetrol: a uniquesteroid in human pregnancy, J Steroid Biochem Mol Biol, 2008). The combination of estrol and the progestin drospirenone resulted in good ovulation inhibition, favorable vaginal bleeding characteristics, good tolerability, and high user satisfaction (Apter et al., Estetrol combined with drospirenone: an oral contraceptive with high acceptability, user satisfaction, well-being and favourable body weight control, Eur J Contracept Reprod Health Care, 2017).

[0005] In summary, although the development of the COC field has led to COCs with fewer side effects, there is still an unmet need in the art to address certain side effects associated with COCs (especially with fourth generation COCs). In particular, there is a need to address and avoid QT prolongation, avoid an increase in C-reactive protein levels, and avoid a decrease in free testosterone in a subject. Summary of the invention

[0006] The inventors unexpectedly observed that estetrol / drospirenone (E4 / DRSP) COCs having a composition as described herein exhibit a number of previously unknown beneficial effects when compared to currently available combined oral contraceptives, particularly when compared to fourth generation oral contraceptives (the latter generally considered in the art to be the most advanced generation of COCs). Thus, the E4 / DRSP COCs as described herein were developed in response to a clear unmet need in the art to provide a drospirenone-containing COC with minimal adverse side effects. Thus, the present invention provides the following aspects:

[0007] Aspect 1. A contraceptive kit comprising one or more packaging units, wherein each packaging unit comprises 21 to 28 daily active dosage units of a combined oral contraceptive (COC), and wherein each daily active dosage unit comprises:

[0008] (a) drospirenone (DRSP) as a progestogen component in an amount of 1 mg to 5 mg; and

[0009] (b) estratetrol (E4) as an estrogen component in an amount of 10 mg to 20 mg;

[0010] Wherein, when administered orally daily, the dosage unit provides the following pharmacokinetic characteristics of DRSP in plasma:

[0011] (i) Geometric mean AUC of DRSP 0-24 From about 150 ng.h / ml to about 1000 ng.h / ml; and / or

[0012] (ii) Geometric mean C of DRSP max From about 10 ng / ml to about 100 ng / ml.

[0013] More specifically, in such a kit, for a typical dose of about 3 mg (2.5 to 3.5 mg) of DRSP,

[0014] (i) Geometric mean AUC of DRSP 0-24 From about 200 ng.h / ml to about 600 ng.h / ml; and / or

[0015] (ii) Geometric mean C of DRSP max 20 ng / ml to about 50 ng / ml.

[0016] More particularly, the present invention provides estetrol in an amount of 10 mg to 20 mg as the estrogen component of the daily active dosage unit in a contraceptive kit comprising one or more packaging units, each packaging unit comprising 21 to 28 daily active dosage units of a combined oral contraceptive (COC), the combined oral contraceptive having drospirenone (DRSP) in an amount of 1 mg to 5 mg as the progestogen component,

[0017] It is intended to provide the following pharmacokinetic profile of drospirenone in plasma when administered daily:

[0018] (i) Geometric mean AUC of drospirenone 0-24 From about 150 to about 1000 ng.h / ml; and / or

[0019] (ii) Geometric mean C of drospirenone max From about 10 ng / ml to 100 ng / ml, preferably wherein one or more side effects of DRSP are reduced compared to a subject using a COC comprising an equivalent effective amount of DRSP and another estrogen.

[0020] More specifically, in the use described, for a typical dose of DRSP of about 3 mg (2.5 to 3.5 mg),

[0021] (i) Geometric mean AUC of DRSP 0-24 From about 200 ng.h / ml to about 600 ng.h / ml; and / or

[0022] (ii) Geometric mean C of DRSP max 20 ng / ml to about 50 ng / ml.

[0023] Aspect 2. The contraceptive kit according to aspect 1, or estetrol in an amount of 10 mg to 20 mg, for reducing the side effects of DRSP in a subject using a COC comprising an equivalent effective amount of DRSP and another estrogen, preferably a COC comprising an equivalent effective amount of DRSP and ethinyl estradiol (EE).

[0024] Aspect 3. The contraceptive kit according to Aspect 1 or 2, or an amount of estetrol of 10 mg to 20 mg, wherein the pharmacokinetic characteristics of DRSP in plasma are steady-state pharmacokinetic characteristics, preferably steady-state pharmacokinetic characteristics after 10 daily doses, more preferably after 14 daily doses.

[0025] Aspect 4. A contraceptive kit according to any one of Aspects 1 to 3, or an amount of estetrol of 10 mg to 20 mg, for use in reducing the decrease in free testosterone in serum associated with the use of a COC comprising an equivalent effective amount of DRSP and another estrogen, preferably a COC comprising an equivalent effective amount of DRSP and EE in a subject.

[0026] Aspect 5. A contraceptive kit according to aspect 4, or an amount of estetrol of 10 mg to 20 mg, wherein the reduction in the subject using the COC defined in aspect 1 is decreased by 10%, preferably 15%, more preferably 20% when compared to a subject using a COC comprising an equivalent effective amount of DRSP and another estrogen, preferably a COC comprising an equivalent effective amount of DRSP and EE.

[0027] Aspect 6. The contraceptive kit according to Aspect 4 or 5, or an amount of estetrol of 10 mg to 20 mg, wherein the free testosterone serum concentration level is at least 25%, preferably at least 40%, more preferably at least 50% of a baseline value, wherein the baseline value is the free testosterone serum expression level in the subject before using a COC comprising DRSP.

[0028] Aspect 7. The contraceptive kit according to any one of aspects 4 to 6, or estetrol in an amount of 10 mg to 20 mg, wherein when using a COC comprising DRSP and E4 as defined in aspect 1, the serum concentration of free testosterone in the subject is at least 0.09 ng / dL, preferably at least 0.20 ng / dL.

[0029] Aspect 8. A contraceptive kit according to any one of Aspects 1 to 3, or an amount of estetrol of 10 mg to 20 mg, for use in reducing the risk of QT interval prolongation associated with the use of a COC comprising DRSP in a subject, preferably by reducing the risk of prolongation of the mean and / or median QT interval by more than 5 ms.

[0030] Aspect 9. The contraceptive kit according to Aspect 8, or an amount of estetrol of 10 mg to 20 mg, wherein the risk of the subject experiencing QT interval prolongation in the subject using the COC is reduced by 10%, 25%, preferably 50%, more preferably 90%, or 100% when compared to subjects using a COC comprising EE as an estrogen component and an equivalent effective amount of DRSP.

[0031] Aspect 10. The contraceptive pill kit of Aspect 8 or 9, or an amount of estetrol of 10 mg to 20 mg, wherein the QT interval is considered prolonged when the time between the start of the Q wave and the end of the T wave in the subject's electrocardiogram is prolonged by at least 5 milliseconds when compared to the subject's QT interval before use of a COC comprising DRSP.

[0032] Aspect 11. A contraceptive kit according to any one of Aspects 8 to 10, or an amount of estetrol of 10 mg to 20 mg, wherein the mean QT interval prolongation in subjects using the COC is 20%, preferably 35%, more preferably 50% shorter than in subjects using a COC comprising equivalent effective amounts of DRSP as the progestogen component and EE as the estrogen component.

[0033] Aspect 12. The contraceptive kit according to any one of aspects 8 to 11, or an amount of estetrol from 10 mg to 20 mg, wherein E4 inhibits QT prolongation in a subject using the COC as defined in aspect 1 by counteracting DRSP-induced QT prolongation.

[0034] Aspect 13. The contraceptive kit according to any one of Aspects 8 to 12, or an amount of estetrol of 10 mg to 20 mg, wherein the COC has a reduced estrogen-related effect on the QT interval when compared to a subject using a COC comprising an equivalent effective amount of DRSP as a progestogen component and EE as an estrogen component.

[0035] Aspect 14. The contraceptive kit according to aspect 13, or an amount of estetrol of 10 mg to 20 mg, wherein the estrogen-related effect is QT interval prolongation, preferably through estrogen-mediated I Kr and / or Ks , and / or I K1The inhibition of channel current prolongs the QT interval.

[0036] Aspect 15. The contraceptive kit according to any one of aspects 1 to 3, or estetrol in an amount of 10 mg to 20 mg, for use in reducing or preventing elevated serum levels of C-reactive protein concentration associated with use of a COC comprising DRSP in a subject.

[0037] Aspect 16. The contraceptive kit according to Aspect 15, or an amount of estetrol of 10 mg to 20 mg, wherein the level is considered elevated when the C-reactive protein serum concentration level is 10%, preferably 20%, preferably 30% higher than a baseline value, wherein the baseline value is the C-reactive protein serum concentration level in the subject before using a COC comprising DRSP.

[0038] Aspect 17. The contraceptive kit according to aspect 15 or 16, or an amount of estetrol of 10 mg to 20 mg, wherein when using a COC comprising DRSP and E4 as defined in aspect 1, the C-reactive protein serum concentration level in the subject is below 2.00 mg / L, preferably below 1.75 mg / L, more preferably below 1.5 mg / L.

[0039] Aspect 18. A contraceptive kit according to any one of Aspects 1 to 17, or estetrol in an amount of 10 mg to 20 mg, wherein the COC comprising DRSP and E4 as defined in Aspect 1 is administered in a cyclical cycle, wherein optionally the dosing regimen comprises a 4 to 7 day dosing-free interval, or comprises administration of a placebo during the 4 to 7 days.

[0040] Aspect 19. A contraceptive kit according to any one of aspects 1 to 18, or estetrol in an amount of 10 mg to 20 mg, wherein E4 is present in the COC as defined in aspect 1 in an amount of 12 mg to 18 mg, preferably 14 to 16 mg, such as about 15 mg. In other embodiments and with respect to all aspects defined herein, E4 may be present in the E4 / DRSP COC described herein in an amount of 14.2 to 15.5 mg. In yet other embodiments, estetrol (E4) may be estetrol monohydrate present in the E4 / DRSP COC described herein in an amount of about 14.5 mg to about 15.5 mg, preferably about 15 mg. In other alternative embodiments, estetrol (E4) may be anhydrous (i.e., water-free) estetrol present in the E4 / DRSP COC described herein in an amount of about 14 to 15 mg, preferably about 14.2 mg.

[0041] Aspect 20. The contraceptive pill kit according to any one of aspects 1 to 19, or estetrol in an amount of 10 mg to 20 mg, wherein DRSP is present in the COC as defined in aspect 1 in an amount of 2.5 to 3.5 mg, more preferably in an amount of about 3 mg.

[0042] Aspect 21. The contraceptive kit according to any one of aspects 1 to 20, or estetrol in an amount of 10 mg to 20 mg, wherein a single dosage unit of the COC as defined in aspect 1 comprises about 2.5 to 3.5 mg of DRSP and about 14 to 16 mg of the E4 component.

[0043] Aspect 22. A composition comprising E4 for use in reducing the bioavailability of DRSP in a subject using a combined oral contraceptive comprising DRSP.

[0044] Aspect 23. The E4 composition for use according to aspect 22, wherein the E4 is used as the estrogen component of the combined oral contraceptive, and DRSP is used as the progestogen component.

[0045] Aspect 24. The E4 composition for use according to aspect 22 or 23, for reducing the side effects of DRSP in a subject who continuously uses a combined oral contraceptive comprising DRSP.

[0046] Aspect 25. An E4 composition for use according to any one of aspects 22 to 24, for reducing the risk of elevated serum levels of C-reactive protein (CRP) associated with continued use of a combined oral contraceptive comprising DRSP.

[0047] Aspect 26.E4, for reducing the steady state bioavailability of DRSP in a COC by at least 15%, preferably at least 20%, more preferably at least 25%, such as about 30% or more compared to a COC comprising equivalent amounts of DRSP and EE.

[0048] Aspect 27.E4, for use in reducing the peak plasma concentration of DRSP in a subject continuously using a COC comprising DRSP.

[0049] Aspect 28. A method for reducing the risk of side effects of DRSP in a subject on a continuous regimen of a COC comprising DRSP, comprising the step of providing a COC comprising DRSP as a progestogen component and E4 as an estrogen component.

[0050] Aspect 29. A COC comprising E4 and DRSP for use in reducing the side effects of DRSP associated with the continuous use of a combined oral contraceptive comprising DRSP. "Continuous use" means that the dosage regimen is applied for multiple periodic cycles. Typically, a periodic cycle comprises the administration of 21 to 28 daily dosage units of a COC comprising an active ingredient. The use may in some cases be interrupted for 4 to 7 days between different periodic cycles, optionally by providing a placebo dosage unit that does not contain the active ingredient of the COC, or simply by not taking any oral contraceptive on those 4 to 7 days. Typically, a regimen of 21-28 dosage units of the active COC ingredient is administered, with an interruption of 4 to 7 days of using a placebo dosage unit for compliance reasons.

[0051] Aspect 30.E4 Use for the manufacture of a medicament for preventing or treating side effects caused by the use of DRSP in COC.

[0052] Aspect 31.E4 Use for the manufacture of a composition (ie, a medicament or contraceptive) for preventing or treating QT interval prolongation in a subject using a COC comprising DRSP.

[0053] Aspect 32.E4 Use for the manufacture of a composition (ie, a medicament or contraceptive) for preventing or treating a decrease in serum levels of free testosterone in a subject using a COC comprising a DRSP.

[0054] Aspect 33.E4 Use for the manufacture of a composition (ie, a medicament or contraceptive) for preventing or treating increased levels of C-reactive protein in a subject using a COC comprising a DRSP.

[0055] In any of the aspects or embodiments listed herein above, the preferred amount of estetrol in the COC is equal to an amount of 14 to 16 mg estetrol and can be present in the form of estetrol monohydrate in the range of 14 to 16 mg, preferably in an amount of 15 mg estetrol monohydrate or its equivalent of 14.2 mg estetrol.

[0056] In any of the above listed aspects or embodiments, the preferred amount of drospirenone in the COC is equal to about 2 to 4 mg or about 2.5 to 3.5 mg drospirenone.

[0057] The above and other aspects and preferred embodiments of the present invention are described in the following sections and in the appended claims.The subject matter of the appended claims is hereby specifically incorporated into this description. BRIEF DESCRIPTION OF THE DRAWINGS

[0058] Figure 1.Subject stratification. 98 subjects were enrolled and received E4 / DRSP 15 / 3mg (n=38), EE / LNG 0.03 / 0.15mg (n=29), EE / DRSP 0.02 / 3mg (n=31) treatment. AE: adverse effect.

[0059] Figure 2 . Changes in QTcF interval on day 24 of treatment cycle 3. Treatment group: E4 / DRSP 15 / 3mg, reference group: EE / DRSP 0.02 / 3mg.

[0060] Figure 3 . Changes in QTcF interval on day 27 of treatment cycle 3. Treatment group: E4 / DRSP 15 / 3mg, reference group: EE / DRSP 0.02 / 3mg. DETAILED DESCRIPTION

[0061] As used herein, the singular form "a," "an," and "the" include both singular and plural referents unless the context clearly dictates otherwise.

[0062] As used herein, the terms "comprising," "comprises," and "comprised of" are synonymous with "including," "includes," or "containing," "contains," and are inclusive or open-ended and do not exclude additional unrecited members, elements, or method steps. The terms also encompass "consisting of" and "consisting essentially of," which have established meanings in patent terminology.

[0063] Numerical ranges recited by endpoints include all numbers and fractions contained in the corresponding ranges, as well as the recited endpoints. This applies to numerical ranges regardless of whether they are introduced by the expression "from ... to ..." or the expression "between ... and ..." or another expression.

[0064] As used herein, the term "about" or "approximately" when referring to a measurable value such as a parameter, amount, length of time, etc., is intended to encompass variations of and relative to the specified value, such as + / -10% or less, preferably + / -5% or less, more preferably + / -1% or less, and still more preferably + / -0.1% or less of the specified value, and such variations relative to the specified value, within which such variations are suitable for implementation in the disclosed invention. It should be understood that the value to which the modifier "about" or "approximately" refers itself is also specifically and preferably disclosed.

[0065] In view of the term "one or more" or "at least one", such as one or more members or at least one member of a group of members, it is clear by further examples that the term particularly covers reference to any one of the members, or to any two or more of the members, such as any ≥3, ≥4, ≥5, ≥6 or ≥7 of the members, and up to all of the members. For another example, "one or more" or "at least one" may refer to 1, 2, 3, 4, 5, 6, 7 or more.

[0066] The discussion of the background art herein is included to explain the context of the present invention. This should not be taken as an admission that any of the material referred to was published, known or part of the common general knowledge in any country as of the priority date of any claim.

[0067] Throughout this disclosure, various publications, patents and published patent specifications are cited by reference by identification. All documents cited in this specification are hereby incorporated by reference in their entirety. In particular, the teachings or portions of these documents specifically mentioned herein are incorporated by reference.

[0068] Unless otherwise defined, all terms used in disclosing the present invention, including technical and scientific terms, have the meanings commonly understood by those of ordinary skill in the art to which the present invention belongs. By way of further guidance, term definitions are included to better understand the teachings of the present invention. When a particular term is defined in conjunction with a particular aspect of the present invention or a particular embodiment of the present invention, such meaning or meaning is intended to apply throughout this specification, i.e., also in the context of other aspects or embodiments of the present invention, unless otherwise defined. For example, embodiments relating to products also apply to corresponding features of methods and uses.

[0069] In the following paragraphs, different aspects or embodiments of the present invention are defined in more detail. Each aspect or embodiment so defined can be combined with any other one or more aspects or one or more embodiments, unless clearly indicated to the contrary. Especially, any feature indicated as preferred or advantageous can be combined with any other one or more features indicated as preferred or advantageous.

[0070] References to "one embodiment", "embodiment" throughout this specification mean that a particular feature, structure or characteristic described in conjunction with the embodiment is included in at least one embodiment of the present invention. Therefore, the phrases "in one embodiment" or "in an embodiment" appearing throughout this specification do not necessarily all refer to the same embodiment. In addition, the particular features, structures or characteristics may be combined in one or more embodiments in any suitable manner, as will be apparent to those skilled in the art from this disclosure. In addition, although some embodiments described herein include some features and not other features included in other embodiments, the combination of features of different embodiments is intended to be within the scope of the present invention and to form different embodiments, as will be understood by those skilled in the art. For example, in the appended claims, alternative combinations of the claimed embodiments are covered, as will be understood by those skilled in the art.

[0071] As used herein, the term "subject" or "patient" refers to an animal, preferably a warm-blooded animal, more preferably a vertebrate, most preferably a mammal, such as a human and a non-human mammal. Particularly preferred are female human subjects, more preferably pre-menopausal and / or post-menopausal female subjects. The female subjects contemplated herein may be subjects who need, or are believed to need, a contraceptive as described herein, or a composition comprising estetrol as described herein, for contraceptive reasons, to improve bleeding patterns (i.e., to achieve less severe or less irregular bleeding patterns), to improve hormone-induced mental or physiological changes, or any combination thereof.

[0072] The skilled person knows that terms such as "quantity", "amount" and "level" are synonymous and have well-defined meanings in the art. As used herein, the term may particularly refer to the absolute quantification of a molecule such as a steroid in a subject (a sample taken), or the relative quantification of a molecule or analyte in a sample, i.e., relative to another value (such as relative to a reference value as taught herein), or a range of values ​​indicating a baseline for a certain parameter. These values ​​or ranges of values ​​may be obtained from a single subject or from a group of subjects (i.e., at least two subjects). In addition, when referring to parameters such as AUC or C maxWhen referring to the (absolute or relative) amount of testosterone, these amounts should be interpreted as the amount measured in the plasma (sample) of one or more subjects. Alternatively, when referring to the (absolute or relative) amount or concentration of parameters such as free testosterone and C-reactive protein, these amounts should be interpreted as the amount measured in the serum (sample) of one or more subjects. "Plasma" and "serum plasma" are both generally accepted terms in medical and clinical contexts, and there is no ambiguity in their interpretation for technicians (Matthew and Varacallo, Physiology, blood plasma, StatPearls, 2019).

[0073] "Estetrol" or "E4" for short is an estrogenic steroid produced by human fetal liver (PubChem CID: 27125). Estetrol can be described as a 3-hydroxy steroid corresponding to 17β-estradiol, in which the 15α and 16α positions are substituted by two additional hydroxyl groups. Estetrol is known to be an estrogen receptor agonist (Coelingh Bennink et al., Estetrol review: profile and potential clinical applications, Climacteric, 2008). Estetrol as indicated herein can be endogenous estetrol. Alternatively, estetrol can be chemically synthesized, synthesized by using (mutant) recombinant enzymes, or synthesized by any combination thereof. Estetrol can alternatively be referred to in the art by its molecular formula: C 18 H 24 O 4 , or indicated by structural formula (I):

[0074] Formula (I)

[0075]

[0076] It should be understood that when estetrol is mentioned in any part of the entire specification, any estetrol-containing component (i.e., compound) and / or estetrol derivative is also meant. Non-limiting examples include estetrol esters and estetrol hydrates. In a preferred embodiment, when present, the estetrol contained in the COC disclosed herein is estetrol monohydrate.

[0077] As used herein and in the art, the term "progestogen", "progestogen", "gestagen", or "gestagen" and its derived "progestogenic compounds" refer to any molecule that produces effects similar to those of the natural female sex hormone progesterone in a subject. Progestogens are considered agonists of the progesterone receptor, and their functions have been fully examined in the art (especially discussed in Kuhl, Pharmacology of estrogens and progestogens: influence of different routes of administration, Climateric, 2005). Progesterone is a subclass of progestogens that includes synthetic progestogens. Although the above terms can be used interchangeably in the art, it is generally understood that when referring to progesterone, it means a synthetic progestogen. "Drospirenone" (abbreviated as DRSP, PubChem CID: 68873) is an example of a progesterone and enjoys widespread use in COCs due to its anti-mineralocorticoid and anti-androgenic activities combined with generally low off-target activity. In general, COCs containing drospirenone are referred to as fourth generation COCs. A non-limiting example of a commercially available COC containing drospirenone is called "Yaz TM ” and Yasmin TM An illustrative example of a progestogen oral contraceptive containing only drospirenone is "Slynd TM ”, which is also commercially available. Drospirenone can alternatively be referred to in the art by its molecular formula C 24 H 30 O 3 Or indicated by structural formula (II):

[0078] Formula (II)

[0079]

[0080] It should be understood that when the term "drospirenone" is used herein, any drospirenone derivative is also envisaged. Furthermore, it is generally accepted that in COCs, a drospirenone dose of 2.5 to 3.5 mg / day, preferably about 3 mg / day, is required to achieve ovulation inhibition.

[0081] By way of example and not limitation, other progestins or progestins used in COCs include norgestrel, norethisterone, levonorgestrel (LNG), norgestrel, gestodene, desogestrel, norgestimate, cyproterone acetate, dienogest, and chlormadinone.

[0082] "Combined oral contraceptive" abbreviated herein as COC indicates any oral contraceptive containing both estrogen and progestogen molecules, and thus COC achieves clinical effect based on the combined activity of the estrogen and progestogen. COCs are typically classified based on the progestogen they contain. The 1st generation COC contains progestogens such as norgestrel, norgestrel, lynestol, norethisterol, or norgestrel. The 2nd generation COC contains progestogens such as levonorgestrel or norgestrel. The 3rd generation COC includes desogestrel, gestodene, or norgestodene. The 4th generation COC contains drospirenone as the progestogen component. Many COCs have been developed and made commercially available, such as Yaz TM . It will be apparent to the skilled person that throughout this specification, when reference is made in this specification to "(the) E4 / DRSP COC" or "(the) COC as described herein", unless expressly stated otherwise, the COC is intended to comprise estetrol as the estrogenic compound and drospirenone as the progestogenic compound. A comparison is made herein between a COC having estetrol as the estrogenic component and drospirenone as the progestogenic component and a COC having drospirenone or levonorgestrel (LNG) as the progestogenic component and ethinylestradiol (EE) as the estrogenic component. A non-limiting example is the COC sold under the trade name Yaz TM (0.02mg EE / 3mg DRSP), Yasmin TM (0.03mg EE / 3mg DRSP), or Melleva TM Most preferably, a COC as described herein (ie comprising both E4 and DRSP) is compared to a COC (EE / DRSP) comprising about 0.02 or about 0.03 mg ethinylestradiol and about 3 mg drospirenone.

[0083] "Contraceptive kit" refers to any package containing a contraceptive packaging unit (preferably a COC packaging unit in the context of the present invention). The skilled person knows that a contraceptive kit with a variable size, shape and the number of packaging units and / or dosage units contained therein can be designed. The contraceptive kit may include an information leaflet in the kit and / or instructions printed on the kit. "Active dosage unit" as used herein can be used interchangeably with the term "dosage form (dosage orms)" and refers to a pharmaceutical product having a specific mixture of active ingredients contained in a specific configuration (a specific amount of estrogen and progestin in the context of COC), non-limiting examples of which are capsules and tablets. Obviously, in the context of COC, the active dosage unit needs to be (considered) suitable for oral administration.

[0084] Since the COC disclosed herein is intended for oral administration, it is preferred to provide a configuration that is easy to administer orally. Therefore, the daily dosage unit as described herein can be a solid or semisolid dosage form. Also suitable non-limiting examples are tablets, (soft or hard) capsules, cachets, granules, pills, micropellets, cachets, buccal films, pastes, crystals, dissolving films, caplets, meltlets, etc. Obviously, some oral dosage forms such as capsules may contain aqueous or oily solutions containing estetrol and drospirenone. For each of these dosage formulations, suitable production methods have been disclosed in the art. Exemplary examples of tablet, caplet and meltlet production methods are wet granulation (i.e., steam granulation, moisture activated dry granulation, wet granulation, thermal adhesion granulation, melt granulation, frozen granulation, foam granulation, or reverse wet granulation), dry granulation such as pneumatic dry granulation, or compression (Shanmugam, Granulation techniques and technologies: recent progresses, Bioimpacts, 2015). Hard capsule shells can be prepared by dip molding or injection molding techniques, while an exemplary method of manufacturing soft capsules is to form a heat seal between two gelatin bands. Both hard and soft capsules have been fully evaluated and discussed in the art (e.g., in the reference book Augsburger and Hoag, Pharmaceutical dosage forms: Capsules, CRC press, 2017).

[0085] By the expressions "under use", "use" and similar expressions used throughout the specification, the expressions are used to designate one or more subjects who have used the COC or active ingredient referred to in the sentence or paragraph at least once. In preferred embodiments, under use can be interpreted as "under continuous use", or "uninterrupted continuous administration cycles". In certain embodiments referring to a subject who is using or has used a COC comprising drospirenone, the subject has used a COC comprising drospirenone for at least 1 administration cycle, preferably at least 2, at least 3, at least 4, at least 5, at least 6, or more than 6 administration cycles.

[0086] Several surprising and valuable discoveries are described herein, which are derived from several research results of the inventors. In essence, the inventors have found that several of the above-mentioned side effects of COCs with drospirenone as a progestogen component can be partially or completely mediated by using estetrol (E4) instead of ethinylestradiol (EE) as the estrogen component of the COC. Therefore, these discoveries have important value for the field of COCs. The advantages of the COCs described herein therefore include a reduced risk of side effects, which is reflected by the improvement of several molecular parameters indicating the side effects. Therefore, the immediate effect can be summarized as an improvement in the health status of subjects using COCs. The second effect of the reduced incidence of COC side effects is that improved user compliance will be achieved in subjects using COCs. Over time, these findings will mark a significant contribution to risk-free female reproductive autonomy. Since the inclusion of drospirenone in the fourth generation COC is ubiquitous, the industrial applicability of the uses, methods and compositions described herein is self-evident.

[0087] In the first discovery, the inventors observed that subjects using E4 / DRSP COC had significantly less reduction in serum free testosterone levels, which can be typically observed in subjects using COCs containing drospirenone, such as EE / DRSP COCs. More particularly, the typical reduction or "reduction" in serum free testosterone observed in subjects taking EE / DRSP COCs was significantly reduced in subjects taking E4 / DRSP COCs. It has been described in the art that drospirenone is the cause of the reduction in serum free testosterone, because drospirenone is a progesterone receptor agonist, and progesterone receptor activation leads to anti-gonadotropin and anti-estrogen effects (Kuhl et al., Pharmacology of estrogens and progestogens:influence of different routes of administration, Climacteric, 2005). One of the anti-gonadotropin effects of drospirenone is to suppress the production of gonadal sex hormones, including estradiol, progesterone and testosterone production. Therefore, the reduction in testosterone production is a direct result of drospirenone, as is also understood by the skilled person. However, surprisingly, when estrol was used to replace ethinylestradiol in EE / DRSP COC, the reduction of free testosterone in subjects using COC decreased significantly. This is the first observation: estrol is shown to have a beneficial (clinical) effect on the free testosterone concentration in subjects using COCs containing drospirenone, while still providing a satisfactory contraceptive effect. The improved testosterone levels contribute to the reduction of frequently reported side effects (such as lack of sexual desire, low libido, and lack of arousal) in the subjects. This effect of E4 / DRSP COC is not described in the art. In a related observation, the inventors observed that the use of E4 / DRSP COC does not increase or has a tendency to increase the QT interval of subjects using COCs containing drospirenone. The effects of known COCs on the prolonged QT interval of subjects have been debated in the art (see Salem et al. (2016) and Sedlak et al. (2012), both of which are cited in this article). The overall effect of sex hormones on the QT interval prolongation is the result of the complex interaction between testosterone, progesterone and estrogen, which is due to the opposite effects on the ion (potassium) channels in the muscle cells. Generally speaking, it is agreed in the art that both endogenous and exogenous sex hormones affect the QT interval. Because COC contains a large amount of progesterone and estraterol, significant changes in the QT interval can sometimes be observed. Generally speaking, testosterone and progesterone seem to shorten the action potential, and therefore have a beneficial effect on the QT interval prolongation. In contrast, estrogen seems to have a prolongation effect on the QT interval. In addition, it has been illustrated that during the menstrual cycle, progesterone is the main factor affecting female ventricular repolarization.However, drospirenone does not behave like a typical progestin, but appears to cause QT prolongation, thereby enhancing the effect of estrogen on QT interval prolongation rather than counteracting it (Salem et al., Association of Oral Contraceptives With Drug-Induced QT Interval Prolongation in Healthy Nonmenopausal Women, JAMA Cardiol, 2018). Therefore, the following summary of the effects of different contraceptives is acceptable in the art (derived from Sedlak et al. (2012)):

[0088]

[0089] Based on this, it can be inferred that the 4th generation COC (e.g., EE / DRSP COC) has an overall extension effect on the QT interval. Subsequently, the subject using the 4th generation COC has a considerable risk of QT extension. Generally speaking, when the QT interval increases by at least 5ms, it is considered that the QT interval is prolonged, which may be caused by any kind of intervention, such as the administration or use of active pharmaceutical ingredients, and in particular in the context of the present disclosure, the (continuous) use of the 4th generation COC. Unexpectedly, the inventor has observed that by replacing the ethinylestradiol component in the 4th generation COC with estrone, the risk of QT extension is alleviated. Without being bound by any theory, it is speculated that estrone contributes to this surprising effect by two molecular mechanisms. First, compared with ethinylestradiol, estrone seems to be a milder estrogen, and therefore may have a less significant estrogen-related effect on QT extension. It is reported that estrogen affects the QT interval at the molecular level by reducing potassium channel current (and / or expression), and it is possible that estrone has a less significant effect on these channels. Secondly, as indicated above, E4 / DRSP COC can reduce the degree of free testosterone reduction or the degree of free testosterone suppression. Because testosterone has a shortening effect on the QT interval---this may be attributed to the positive contribution to ion potassium channel current and / or expression, so the extension effect mediated by drospirenone may be invalid. Therefore, by this dual mechanism of action proposed above, estetrol can avoid the QT extension observed in EE / DRSP the 4th generation COC. This effect of estetrol and the result of E4 / DRSP COC are not reported in the art.

[0090] In the third unexpected observation, the inventors observed that the COC-induced elevated C-reactive protein serum levels of subjects using E4 / DRSP contraceptives tended to be less, or riskier, than subjects using common 4th generation COCs (such as EE / DRSP COCs). The increase in C-reactive protein (concentration) levels during and after COC use has been reported in the art (van Rooijen et al., Treatment with combined oral contraceptives induces arise in serum C-reactive protein in the absence of a general inflammatory response, J Thromb Haemost, 2006), and it is assumed that elevated C-reactive protein concentrations appear to be related to direct effects on hepatocyte C-reactive protein synthesis, and do not reflect IL-6-mediated inflammation, endothelial activation, or the induction of insulin resistance, although this is still controversial. There is a correlation between the elevated serum and / or plasma levels of C-reactive protein and atherosclerosis and atherosclerotic cardiovascular disease (ASCVD). While the exact contribution of C-reactive protein remains elusive, it is clear that any elevation of C-reactive protein should be avoided given the link to atherosclerosis. The reduced effect of E4 / DRSP COCs on elevation of C-reactive protein when compared to 4th generation COCs (e.g. EE / DRSP) has not been reported in the art.

[0091] Therefore, a first aspect of the present invention relates to a contraceptive kit comprising one or more packaging units, wherein each packaging unit comprises 21 to 28 daily active dosage units of a combined oral contraceptive (COC), and wherein each daily active dosage unit comprises: (a) drospirenone in an amount of 1 mg to 5 mg as a progestogen component; and (b) estetrol in an amount of 10 mg to 20 mg as an estrogen component; wherein when administered orally daily, the dosage unit provides the following pharmacokinetic profile of drospirenone in plasma:

[0092] (i) For DRSP, the geometric mean AUC of drospirenone for doses from 1 mg to 5 mg, respectively 0-24 From about 150 ng.h / ml to about 1000 ng.h / ml; and / or

[0093] (ii) The geometric mean C values ​​of drospirenone for doses from 1 mg to 5 mg, respectively max From about 10 ng / ml to about 100 ng / ml.

[0094] For a typical dose of about 3 mg (2.5 to 3.5 mg) of DRSP,

[0095] (i) Geometric mean AUC of drospirenone 0-24 From about 200 ng.h / ml to about 550 ng.h / ml; and / or

[0096] (ii) Geometric mean C of drospirenone max 20 ng / ml to about 50 ng / ml.

[0097] It should be understood that when the abbreviation "AUC" is used herein, this refers to "area under the curve" and should be interpreted as it has its common meaning in the art, i.e., the definite integral of the curve describing the change in drug concentration in plasma as a function of time. As used herein, AUC 0-24 represents the AUC from time "0" (i.e., the point at which the COC is administered to the subject) to the 24-hour time point. In the context used herein, "AUC" can be interpreted as bioavailability. Therefore, AUC inf Total AUC (time point "0" to infinity) is indicated.

[0098] As mentioned in this article, “C max ” is the maximum or peak plasma concentration achieved by a drug (e.g., drospirenone). Unless otherwise indicated, AUC and C max The values ​​can be measured by radioimmunoassay and / or HPLC and LC MS / MS, which are assays known to those skilled in the art (e.g., Jaffe, Methods of Hormone Radioimmunoassay, 2nd edition, Academic press, 1979, and Chen and Hsu, Development of a LC–MS / MS-based method for determining metolazone concentrations in human plasma: Application to a pharmacokinetic study, J of Food and Drug Anal, 2013).

[0099] In certain embodiments, each daily active dosage unit comprises the same or approximately the same amount of estetrol and drospirenone as defined elsewhere herein. In alternative embodiments, some daily active dosage units may comprise higher or lower doses of E4 and / or DRSP, as long as equivalent levels of E4 and / or DRSP are maintained during the periodic cycle. In an exemplary embodiment of this alternative, different daily dosage units may be configured for multiphasic administration (e.g., two-phase, three-phase, or four-phase administration), with each phase reaching slightly different concentrations of E4 and / or DRSP.

[0100] In certain embodiments, the pharmacokinetic profile of drospirenone after a single dose of a COC when administered at a daily dose of about 3 mg (e.g., 2.5 to 3.5 mg) is characterized by a geometric mean AUC of drospirenone of 0-24 Below 425 ng.h / ml, preferably below 400 ng.h / ml, preferably below 350 ng.h / ml, more preferably below 325 ng.h / ml, more preferably below 300 ng.h / ml, more preferably below 275 ng.h / ml, more preferably below 250 ng.h / ml, more preferably below 225 ng.h / ml. In certain embodiments, the pharmacokinetic profile of drospirenone after a single dose of a COC is characterized by a geometric mean AUC of drospirenone 0-24 450 ng.h / ml to 200 ng.h / ml, preferably 350 ng.h / ml to 150 ng.h / ml, more preferably 300 ng.h / ml to 200 ng.h / ml, most preferably 260 ng.h / ml to 220 ng.h / ml. In certain embodiments, the pharmacokinetic profile of drospirenone after a single dose of COC is characterized by a geometric mean C of drospirenone of max In some embodiments, the pharmacokinetic profile of drospirenone after a single dose of COC is characterized by a geometric mean C of drospirenone of less than about 45 ng / ml, preferably less than 40 ng / ml, preferably less than 35 ng / ml, preferably less than 30 ng / ml. max 20 ng / ml to 50 ng / ml, preferably 20 ng / ml to 45 ng / ml, preferably 24 ng / ml to 40 ng / ml, preferably 24 ng / ml to 35 ng / ml. In certain embodiments, the pharmacokinetic profile of drospirenone after a single dose of COC is characterized by a geometric mean AUC of drospirenone of inf Below 300 ng.h / ml, preferably below 275 ng.h / ml, preferably below 260 ng.h / ml, preferably below 250 ng.h / ml, preferably below 230 ng.h / ml. In certain embodiments, the pharmacokinetic profile of drospirenone after a single dose of a COC is characterized by a geometric mean AUC of drospirenone of inf From about 300 ng.h / ml to about 500 ng.h / ml, preferably from 350 ng.h / ml to about 450 ng.h / ml. In certain embodiments, the pharmacokinetic profile of drospirenone after a single dose of COC is characterized by a geometric mean AUC 0-24 Below 250 ng.h / ml, preferably about 224 ng.h / ml, and the geometric mean C maxBelow 45 ng / ml, preferably below 40 ng / ml, preferably below 35 ng / ml, and optionally the geometric mean AUC inf In certain embodiments, the pharmacokinetic profile of drospirenone after a single dose of a COC is characterized by a geometric mean AUC 0-24 is about 200 ng.h / ml to about 250 ng.h / ml, and C max From about 20 ng / ml to about 30 ng / ml, and optionally the geometric mean AUC inf 350ng.h / ml to 450ng.h / ml.

[0101] In certain embodiments, the pharmacokinetic profile of drospirenone is characterized by a geometric mean AUC of drospirenone after multiple daily doses of about 3 mg (e.g., 2.5 to 3.5 mg), preferably after 10, 12, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28 daily doses of a COC. 0-24 Below 650ng.h / ml, preferably below 600ng.h / ml, preferably below 550ng.h / ml, preferably below 625ng.h / ml, and optionally a geometric mean C max In certain embodiments, after multiple daily doses, preferably after 10, 12, 14, 21, or 21 to 28 daily doses of the COC, the pharmacokinetic profile of drospirenone is characterized by a geometric mean AUC of drospirenone of 0-24 400 ng.h / ml to 625 ng.h / ml, preferably 425 ng.h / ml to 550 ng.h / ml, preferably 425 ng.h / ml to 525 ng.h / ml, and optionally a geometric mean C max In certain embodiments, after 10 daily doses, the pharmacokinetic profile of drospirenone is characterized by a geometric mean AUC of drospirenone of 0-24 Below 450ng.h / ml, and C max Below 40ng / ml.

[0102] In certain embodiments, the pharmacokinetic profile of drospirenone after 14 daily doses is characterized by a geometric mean AUC of drospirenone of 0-24 Below 525ng.h / ml, and C maxLess than 50 ng / ml. It will be appreciated that the values ​​described herein are representative for subjects who are or are administered a COC as described herein at approximately regular intervals, preferably wherein the intervals between administrations are 18 to 28 hours, preferably about 24 hours. The parameters described herein can be observed after a single dose of a COC. These parameters were confirmed in a multiple dose trial at a time point of 14 days after the start of daily dosing. Obviously, the skilled person will appreciate that in the case of a multiple dose trial, other time points may be selected once a drospirenone steady state is reached. In a COC, the mean terminal elimination half-life (t 1 / 2 ) is about 20 to 30 hours. In this combination, the average t 1 / 2 The decline in plasma levels of E4 is biphasic, so part of the AUC is determined by the ratio of t 1 / 2 The steady state is determined by a faster decline, and the steady state is expected to be before 5 half-lives. The worst-case duration of reaching steady state is 5 times of 56 hours (280 hours or 11.6 days). Therefore, assuming linear dose kinetics, daily administration for 12 days should be sufficient to reach steady state. If the trough concentration is similar during the last few days of administration, steady state is reached. Therefore, the duration of 14 days of multiple administration is sufficient to achieve the steady state of estetrol and / or drospirenone in the blood. In the results of the multiple dose test explained in the examples, when using E4 / DRSP COC as described herein, the steady state of estetrol is reached after about 5 daily doses, and the steady state of drospirenone is reached after about 10 daily doses. Therefore, in one aspect of the invention, the pharmacokinetic characteristics as disclosed herein are steady-state pharmacokinetic characteristics. In certain embodiments, the steady-state pharmacokinetic characteristics are pharmacokinetic characteristics measured after administration of 10 daily doses. In other embodiments, the steady-state pharmacokinetic profile is the pharmacokinetic profile following administration of 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, or more daily doses.

[0103] In certain embodiments, the contraceptive kit comprises a packaging unit. In alternative embodiments, the contraceptive kit comprises at least two packaging units, preferably at least three, preferably more than three packaging units. In certain embodiments, the packaging unit is a blister or a strip. The packaging unit of the contraceptive kit disclosed herein can be a "compliance package". As known in the art, a "compliance package" is a packaging unit of variable size and form, which, in addition to providing a suitable storage device for one or more drugs (COC in this context), is also intended to provide help and / or guidance to the subject to comply with the expected regular administration of the COC (Peck Gossel, Packaging the Pill, Manifesting Medicine: Bodies and Machines, New York: Taylor & Francis, 1999). As a non-limiting example, a packaging unit may be provided with digital indications and / or symbols so that the subject can keep tracking the menstrual cycle of the subject. In alternative non-limiting examples, a packaging unit may include a device that sends an electronic signal to the subject when the scheduled administration time (i.e., a certain day) is reached and the COC is still contained in the packaging unit at this time point. In those instances, the electronic signal can be sent to a data storage device and / or to a user-defined electronic device, smart phone, and smart wearable to initiate the exemplary instance. In certain embodiments, different portions of one or more packaging units provide different sensory triggers to the subject, non-limiting examples being different colors or roughness.

[0104] In certain embodiments, each packaging unit comprises 21,22,23,24,25,26,27 or 28 COC daily dosage units.In other embodiments, each packaging unit comprises 21 to 24 COC daily dosage units and one or more placebo dosage units, preferably 4 to 7 placebo units.Placebo units are provided for increasing patient compliance, because it is easier to maintain with a specific interval than taking pills every day.In certain embodiments, the order of COC and placebo daily dosage units is arranged in groups (that is, the first 21 to 24 daily dosage units are COC, followed by 4 to 7 placebo units, or vice versa).In other embodiments, the packaging unit does not provide the instruction of the information of which daily dosage units are COC dosage units and which daily dosage units are placebo dosage units to the experimenter.In certain embodiments, the placebo dosage unit comprises lactose, magnesium stearate and starch.In other embodiments, the placebo dosage unit comprises lactose monohydrate, magnesium stearate and corn starch.

[0105] In certain embodiments, the contraceptive kit as described herein is administered in a cyclical cycle, wherein the cycle comprises a 7-day free dose interval. In other embodiments, the cycle comprises a 4-day free dose interval. So-called "free dose interval" means a 7 or 4-day time span during which COC is not administered to a subject. Therefore, in the free dose interval, estetrol or progestogen is not administered to the subject. In certain embodiments, during the free dose interval, a placebo preparation may be administered, which optionally has a visually indistinguishable appearance relative to the active dosage unit.

[0106] Placebo formulations as contemplated herein do not contain estrogen such as estetrol or progesterone such as drospirenone. The free dose interval may be considered in the art as a hormone-free interval. During the free dose interval, withdrawal bleeding may occur, which may last for about 3, 4, 5, 6, or 7 days. In certain embodiments, the placebo formulation comprises iron supplements and / or folic acid.

[0107] In certain embodiments, estetrol is present in the E4 / DRSP COC described herein in an amount of 12 to 18 mg. In certain embodiments, estetrol is present in the E4 / DRSP COC described herein in an amount of 14 to 16 mg. In other embodiments, estetrol is present in the E4 / DRSP COC described herein in an amount of 14.2 to 15.5 mg. In still other embodiments, estetrol is estetrol monohydrate present in the E4 / DRSP COC described herein in an amount of about 14 mg to about 16 mg, or about 14.5 mg to about 15.5 mg, preferably about 15 mg. In other alternative embodiments, estetrol is anhydrous (i.e., water-free) estetrol present in the E4 / DRSP COC described herein in an amount of about 13.5 to about 15.5 mg, or about 14 to about 15 mg, preferably about 14.2 mg. In certain embodiments, drospirenone is present in the E4 / DRSPCOC described herein in an amount of 2 to 4 mg. In other embodiments, drospirenone is present in an E4 / DRSP COC described herein in an amount of 2.5 to 3.5 mg. In yet other embodiments, drospirenone is present in an E4 / DRSP COC described herein in an amount of 2.75 to 3.25 mg. In yet other embodiments, drospirenone is present in an amount of about 3 mg. In certain embodiments of the E4 / DRSP COC described herein, a single dosage unit of the COC comprises about 3 mg drospirenone and about 15 mg estetrol.

[0108] In certain embodiments, the pharmacokinetic profile of drospirenone following a single dose of a COC comprising about 3 mg drospirenone and about 15 mg estetrol is characterized by a geometric mean AUC 0-24Below 250 ng.h / ml, preferably below 230 ng.h / ml, and the geometric mean C max Below 45 ng / ml, preferably below 40 ng / ml, preferably below 35 ng / ml, and optionally the geometric mean AUC inf Below about 600 ng.h / ml or below about 550 ng.h / ml.

[0109] In certain embodiments, the contraceptive kit as described herein is intended for use in subjects using a reference COC comprising drospirenone and another estrogen other than estetrol to reduce the side effects of drospirenone. In certain embodiments, the reference COC comprising drospirenone is a COC comprising ethinyl estradiol and drospirenone, preferably a reference COC comprising about 0.02 or about 0.03 mg ethinyl estradiol and about 3 mg drospirenone.

[0110] The side effects described herein can be clinical manifestations, i.e., undesirable or pathogenic symptoms, but can also include changes in molecular parameters, such as a decrease or increase in a certain molecule such as a hormone or enzyme, or even a transmembrane channel. The technician knows that many changes at the molecular level may not lead to clinical manifestations, but they can still indicate clinical events occurring at a later time point or contribute to the risk of clinical events occurring at a later time point. It should be understood that different changes at the molecular level can lead to a single clinical event, effect, or manifestation. In certain embodiments, the reduction of the side effects of drospirenone in a subject using a COC comprising estetrol and drospirenone is compared with one or more subjects using a COC comprising drospirenone and an estrogen that is not estetrol. In other embodiments, the estrogen that is not estetrol is an equivalent amount of ethinyl estradiol (EE). "Ethinyl estradiol" is a well-defined molecule in the art and can be represented by the molecular formula C 20 H 24 O 2 (PubChem CID: 5991). The skilled artisan will appreciate that the observations, assumptions, and conclusions described herein are readily applicable to alternative estrogens (including but not limited to estradiol (E2) (Formula C 18 H 24 O 2 , PubChem CID:5757)).

[0111] In certain embodiments, the percentage of subjects who observed or reported a reduction in one or more drospirenone-related side effects was at least 20%, preferably at least 40%, at least 50%, at least 75%, at least 100%. In certain embodiments, one or more drospirenone-related side effects are independently selected from: QT interval prolongation of at least 5 milliseconds (ms), free testosterone reduction or free testosterone suppression, C-reactive protein increase, libido loss, headache, nausea, vomiting, abdominal distension, cramps, breast pain, breast tenderness, breast swelling, fatigue, hair loss, increased potassium levels, etc.

[0112] On the other hand, it is envisioned that the COC comprising estetrol and drospirenone is used to reduce the side effects of drospirenone associated with the continuous use of the combined oral contraceptive comprising drospirenone. "Continuous use" means the administration of a dosage regimen during multiple periodic cycles, such as experiencing 2, 3, 4, 5, 6 or more periodic cycles. In certain embodiments, a periodic cycle comprises administering 21 to 28 daily dosage units of E4 / DRSP COC as described herein, followed by 4 to 7 days wherein the subject does not use COC and optionally uses a placebo product for compliance reasons, i.e., to provide a daily pill for each day of the cycle, so that the subject does not have to calculate the number of days without COC in the dosage regimen. In certain embodiments, by using a drospirenone-containing COC that does not comprise estetrol, the drospirenone side effect is triggered in the subject. In certain embodiments, the subject is a first COC user. So-called "first COC" users mean subjects who have not used COCs comprising estrogen and progestogen in the early stage during the life span of the subject. In other embodiments, the subject is a first-time COC user participant in a family (i.e., a biological family, in which family members are genetically related) in which cardiovascular problems have been reported. In other alternative embodiments, the subject is a first-time COC user participant in a family in which female sexual dysfunction has been reported.

[0113] In certain embodiments, the COC comprising estetrol and drospirenone further comprises one or more excipients. As used herein, the term "excipient" may indicate any solvent, diluent, buffer (e.g., neutral buffered saline, phosphate buffered saline, Tris-HCl, acetate, phosphate buffer), solubilizer (e.g., Tween 80, polysorbate 80), colloid, dispersion medium, vehicle (e.g., petrolatum, dimethyl sulfoxide, mineral oil), filler, anti-adherent (e.g., magnesium stearate, talc), chelating agent (e.g., EDTA, glutathione), amino acid (e.g., glycine, (L-) glutamic acid, (L-) arginine, (L-) histidine), protein, disintegrant (e.g., corn starch, sodium starch glycolate (Type A)), binder (e.g., gelatin, synthetic polymer, The invention also includes polyvinylpyrrolidone (PVP, povidone) and polyethylene glycol, sugars such as sucrose, lactose, (corn) starch, cellulose, hydroxypropylcellulose, xylitol, sorbitol, mannitol), lubricants, wetting agents, stabilizers, emulsifiers, sweeteners (e.g., sugars), colorants, flavoring agents (natural flavoring agents such as fruit extracts or artificial flavoring agents are contemplated), flavor enhancers, thickeners, agents for achieving a depot effect, coating agents, antifungal agents, preservatives (e.g., thimerosal TM , benzyl alcohol), antioxidants (ascorbic acid, sodium metabisulfite, butylated hydroxyanisole and / or toluene), tonicity control agents, absorption delaying agents, adjuvants, bulking agents (e.g., lactose, mannitol), etc. "Excipient" may be indicated in the art by synonyms, including but not limited to "carrier". In addition, it is obvious to the skilled person that certain excipients may fulfill multiple functions. Alternatively, certain excipients may be used during the manufacturing process of the COC, but are no longer detectable in the final product, such as (purified) water.

[0114] A representative typical (single) tablet composition of the composition contemplated herein may comprise estetrol monohydrate, drospirenone, lactose monohydrate, sodium starch glycolate type 1, maize or corn starch, povidone K30 and magnesium stearate, optionally coated with AquaPolish Pink 044.08MS. For coating, a suspension may be prepared first and then applied to the tablet by any suitable coating process. Coating processes have been discussed in detail in the art and are therefore known to the skilled person (e.g. Ankit et al., Tablet Coating techniques: Concepts and recent trends, IRJP, 2012). More specifically, a typical (single) tablet composition may comprise about 10 mg to 20 mg, preferably about 12 mg to 18 mg, more preferably 14 mg to 16 mg of estetrol monohydrate; about 1 mg to 5 mg, preferably about 2 mg to 4 mg of drospirenone; about 25 to 50 mg, preferably about 30 to 45 mg of lactose monohydrate; about 1 mg to 10 mg, preferably about 2 to 8 mg of sodium starch glycolate type A; about 5 mg to 20 mg, preferably about 10 mg to 20 mg of maize or corn starch; about 0.5 mg to 5 mg of povidone K30; and about 0.1 mg to about 5 mg, preferably about 0.2 mg to about 3 mg of magnesium stearate. The optional coating suspension may add about 1 mg to 10 mg, preferably about 1 mg to 5 mg, to the tablet weight when dried. In certain embodiments, the preparation may include pharmaceutically acceptable auxiliary substances such as pH adjusters and buffers, preservatives, complexing agents, tension regulators, wetting agents, etc. as required to approximate physiological conditions, non-limiting examples of which include sodium acetate, sodium lactate, sodium phosphate, sodium hydroxide, hydrogen chloride 20, benzyl alcohol, parabens, EDTA, sodium oleate, sodium chloride, potassium chloride, calcium chloride, sorbitan monolaurate, and triethanolamine oleate. The use of such media and agents for preparing pharmaceutical compositions is well known in the art (see, e.g., Kalasz and Antal, Drug excipients, Curr Med Chem, 2006). In addition, methods and information on the preparation and administration of pharmaceutical compositions have been disclosed in the art (e.g., reference books: Remington: The Science and Practice of Pharmacy, regularly revised).

[0115] Also contemplated herein is a method for reducing (or alleviating) the risk of adverse (side) effects of drospirenone in a subject under a continuous regimen of a COC comprising drospirenone, the method comprising providing a subject with a COC comprising drospirenone as a progestogen component and estetrol as an estrogen component. In certain embodiments, the subject is diagnosed with or suspected of having a side effect caused by the use of a COC comprising drospirenone. In certain embodiments, the subject has experienced side effects caused by the previous use of a COC comprising drospirenone. In certain embodiments, the side effect is selected from: a decrease in free testosterone serum concentration of at least 0.25 ng / dL or more than 50%, preferably more than 60% or more than 70% relative to the baseline concentration; a prolongation of the QT interval of at least 5 ms; an increase in the serum concentration of C-reactive protein, resulting in a value equal to or higher than 1.5, such as equal to or higher than 2 mg / L serum. In certain embodiments, COC is provided to the subject by daily oral administration, preferably daily oral administration during a period of at least 21 days, or up to 28 days. In certain embodiments, the subject is a first-time COC user. In alternative embodiments, the subject is a subject who has previously used a COC comprising drospirenone, a subject who has changed COC type, or a subject who has discontinued COC use for more than 4 weeks.

[0116] In a non-limiting sense, "predicted" or "prediction" generally refers to a statement, declaration, indication or forecast of a disease or condition in a subject that (yet) does not show any or limited clinical manifestations of the disease, condition or (bad) side effect. The prediction of a disease, condition or adverse effect in a subject can indicate, for example, a possibility, chance or risk that the subject will develop the disease, condition or (bad) side effect within a certain period of time, a certain age, a certain time range of taking a certain medicine (or a contraceptive in the context of the present invention). The possibility, chance or risk can be indicated as any suitable qualitative or quantitative representation, wherein the non-limiting examples of quantitative representation include absolute values, ranges or statistical values. Alternatively, the possibility, chance or risk can be indicated relative to a suitable control subject or control subject group (i.e., a control subject population (such as relative to a general, normal or healthy subject or subject population)). Therefore, any possibility, chance or risk that a subject will develop a disease, disorder, or (bad) side effect can be advantageously indicated as an increase or decrease, up-regulated or down-regulated, multiple increase or multiple reduction relative to a suitable control subject or subject population, or relative to a baseline value, a textbook reference value that can be derived from a control subject (population). Obviously, when a subject population is used to define a baseline value, the baseline value will be the central size of one or more values ​​(parameters) of the population, such as the mean or median of the value. The term "prediction" of a disorder, disease, or (bad) side effect as described herein can also specifically mean that a subject has a "positive" prediction of this condition, that is, the subject is at risk of having this condition (e.g., relative to a control subject or control or a general subject population, the risk is significantly increased).

[0117] "Diagnosed with", "diagnosed" and diagnostics indicate the process of confirming, determining, or concluding a disease, disorder, or (adverse) side effect in a subject based on symptoms and signs and / or from the results of various diagnostic procedures (e.g., from the presence, absence, and / or amount of one or more biomarkers or clinical symptoms characteristic of a known diagnosed disease or disorder). "Diagnosis" of a disease, disorder, or (adverse) side effect as taught herein in a subject may particularly mean that the subject suffers from such a disease or disorder. A subject may be diagnosed as not suffering from such a disease or disorder despite showing one or more conventional symptoms or signs of such a disease or disorder.

[0118] The skilled person understands that monitoring a disease, disorder, or (adverse) side effect may allow prediction of the occurrence of the disease, disorder, or (adverse) side effect, or monitoring the progression, aggravation, remission or recurrence of a disease, disorder, or (adverse) side effect, or the response to treatment or other external or internal factors, conditions or stressors, etc. In addition, monitoring may be applied during the medical treatment of a subject. Such monitoring may include, for example, making a decision as to whether a patient may be discharged from a controlled clinical or health practice setting, requires a change in treatment or therapy, or requires (further) hospitalization.

[0119] In certain embodiments, the contraceptive kit as described herein is intended to be used for reducing the reduction of serum free testosterone concentration associated with the use of a COC comprising drospirenone in a subject. In other embodiments, the contraceptive kit and COC use at least 6 cycles. As used in this context, "free testosterone concentration reduction" refers to the reduction of free testosterone serum concentration levels, or the median reduction of free testosterone serum concentration levels when considering multiple subjects. In other embodiments, when compared with a subject using a COC comprising ethinylestradiol as an estrogen component and drospirenone of equivalent effective amount, the free testosterone serum concentration in the subject using E4 / DRSP COC as described herein is reduced by 10%. In other embodiments, when compared with a subject using the same amount of COC cycles comprising ethinylestradiol as an estrogen component and drospirenone of equivalent effective amount, in the subject using E4 / DRSP COC as described herein for at least 6 cycles, the free testosterone serum concentration is reduced by 12%, preferably 14%, preferably 15%, preferably 16%, preferably 18%, preferably 20%.

[0120] In certain embodiments, for subjects with a free testosterone serum concentration of 0.20 ng / dL to 0.80 ng / dL before using the COC, the free testosterone serum concentration of subjects using a COC comprising at least 6 cycles of ethinyl estradiol as the estrogen component and an equivalent effective amount of drospirenone is about 0.09 ng / dL to 0.20 ng / dL. In certain embodiments, for subjects with a free testosterone concentration of 0.100 ng / dL to 1.0 ng / dL before using the COC, the free testosterone serum concentration of subjects using the E4 / DRSP COC as described herein for at least 6 cycles is reduced by about 0.09 ng / dL to 0.60 ng / dL. In certain embodiments, the median free testosterone serum concentration in subjects using the COC with the estrogen component ethinyl estradiol for at least 6 cycles is about 0.086 ng / dL, and the median free testosterone serum concentration in subjects using the COC as described herein for at least 6 cycles is about 0.20 ng / dL.

[0121] In certain embodiments, the free testosterone concentration is at least 25% of the baseline value, preferably at least 30%, preferably at least 35%, preferably at least 40%, more preferably at least 50%, wherein the baseline value is the free testosterone serum expression level in the subject before using the COC comprising drospirenone. In certain embodiments, the free testosterone serum concentration of the subject using the COC comprising ethinylestradiol as the estrogen component and an equivalent effective amount of drospirenone for at least 6 cycles is reduced to 89% to 50% of the baseline value. In other embodiments considering multiple subjects, the free testosterone serum concentration of the COC comprising ethinylestradiol as the estrogen component and an equivalent effective amount of drospirenone is reduced to a median of 71% of the baseline value. In certain embodiments, the free testosterone serum concentration of the subject using the E4 / DRSP COC as described herein for at least 6 cycles is reduced to 80% to 0% of the baseline value. In other embodiments considering multiple subjects, the free testosterone serum concentration of the E4 / DRSP COC as described herein is reduced to a median of 50% of the baseline value. In certain embodiments, the baseline value is the median free testosterone concentration before using any COC, and it is obvious to the technician that the baseline value will change due to inter-subject variability. By means of guidance and not limitation, a suitable testosterone serum concentration baseline value can be any value from about 0.10 ng / dL to about 1.20 ng / dL, such as about 0.10 ng / dL, about 0.20 ng / dL, about 0.35 ng / dL, 0.50 ng / dL, 0.80 ng / dL, 1.00 ng / dL. In certain embodiments, when using E4 / DRSP COC as described herein, the free testosterone serum concentration in the subject is at least 0.09 ng / dL, preferably at least 0.20 ng / dL. In certain embodiments, when using E4 / DRSP COC as described herein for at least 6 cycles, the free testosterone serum concentration in the subject is at least 0.09 ng / dL, preferably at least 0.20 ng / dL.

[0122] As used herein, "free testosterone" or "free T" refers to testosterone that is not bound to proteins including albumin and sex hormone binding globulin (SHBG). Free testosterone is transported to the cytoplasm of target tissue cells, where it can bind to androgen receptors, or can be reduced to 5α-dihydrotestosterone (DHT) by cytoplasmic enzyme 5α-reductase (Goldman et al., A Reappraisal of Testosterone's Binding in Circulation: Physiological and Clinical Implications, Endocrine Reviews, 2017). COC has been disclosed in the art to reduce androgen, particularly testosterone (free testosterone and total testosterone) levels. It has been clarified that in female subjects, about 65% to 70% of circulating testosterone is bound and inactivated by SHBG, about 30% to 35% is bound to albumin, and thus free testosterone is present at about 0.5% to 3%. Many methods suitable for measuring free testosterone in a subject (sample) have been described in the art, and include but are not limited to liquid chromatography-tandem mass spectrometry (LC-MS / MS), equilibrium dialysis, immunoassay. Alternatively, the level of free testosterone in a female subject (sample) can be obtained by total testosterone, SHBG and albumin concentrations.

[0123] The term "baseline value" used herein should be interpreted as the meaning generally accepted in the art. The baseline value in the medical field represents the value before the experiment or study starts in the subject (sample), or can even be a reference value known in the art for a subject population. The use of baseline values ​​enables technicians to express the changes over time caused by one or more interventions, which affect the parameters (Chiolero et al., Assessing the Relationship between the Baseline Value of a Continuous Variable and Subsequent Change Over Time, Front Public Health, 2013) of establishing baseline values. In the context of this specification, unless otherwise noted, intervention is the administration of COC.

[0124] In certain embodiments, it is envisioned that a contraceptive kit as described herein is used to reduce the risk of QT interval prolongation associated with the use of a COC comprising drospirenone in a subject, preferably by reducing the risk of the prolongation of the mean and / or median QT interval exceeding 5ms. In other embodiments, the contraceptive kit and COC are used for at least 6 cycles. In the context of the present disclosure, "the risk of QT interval prolongation" is considered to be the chance of observing (mean or median) QT interval prolongation in a subject by using a COC. In certain embodiments, when compared to a subject using a COC comprising ethinylestradiol as an estrogen component and an equivalent effective amount of drospirenone, in the subject using the E4 / DRSP COC described herein, the subject experiences a 10% decrease in the risk of QT interval prolongation, preferably 25%, preferably 30%, preferably 40%, preferably 50%, preferably 60%, preferably 75%, preferably 90%, more preferably 100%. In certain embodiments, the average QT interval of subjects using COCs comprising ethinylestradiol as an estrogen component and an equivalent effective amount of drospirenone for at least 6 cycles is prolonged by 5ms to 15ms, preferably an average and / or median interval of 5ms to 10ms, while the average and / or median interval of subjects using E4 / DRSP COCs as described herein for at least 6 cycles is prolonged by 0ms to 5ms. In certain embodiments, when compared to the QT interval of the subject before using a COC comprising drospirenone, the (average and / or median) time between the start of the Q wave and the end of the T wave in the subject's electrocardiogram is prolonged by at least 5 milliseconds, the QT interval is considered to be prolonged. In other embodiments, when compared to the QT interval of the subject before using a COC, the time between the start of the Q wave and the end of the T wave in the subject's electrocardiogram is prolonged by at least 6, preferably at least 7, preferably at least 8 milliseconds, the QT interval is considered to be prolonged.

[0125] In certain embodiments, the difference between the baseline QT interval and the mean QT interval prolongation after at least 6 cycles of using an E4 / DRSP COC as described herein is 4 to 10 units shorter than the difference between the baseline QT interval and the mean QT interval prolongation after at least 6 cycles of using a COC comprising ethinyl estradiol as an estrogen component and an equivalent effective amount of drospirenone, preferably 5 to 10 units shorter, preferably 5.5 to 10 units shorter. In certain embodiments, the difference between the baseline QT interval and the median QT interval prolongation after at least 6 cycles of using an E4 / DRSP COC as described herein is 8 to 15 units shorter than the difference between the baseline QT interval and the mean QT interval prolongation after at least 6 cycles of using a COC comprising ethinyl estradiol as an estrogen component and an equivalent effective amount of drospirenone, preferably 8 to 12 units shorter, preferably 7 to 10 units shorter.

[0126] As used herein, "QT interval" refers to a parameter that can be obtained from an electrocardiogram, and describes the time from the beginning of the Q wave to the end of the T wave. The QT interval (approximately) indicates the time taken by the subject's heart to transition from the beginning of ventricular contraction to the end of the diastolic period of the ventricle. Alternatively, the phrase QT interval is equal to the time taken from the beginning of ventricular contraction to the end of ventricular diastole. The length of the QT interval can be manually measured in the electrocardiogram complex wave by different methods, including the tangent method and the threshold method. In the tangent method, the end of the T wave is determined by defining the intersection (i.e., convergence) point of the isoelectric baseline of the T wave and the electrocardiogram. In the threshold method, the end of the T wave is determined by the intersection of the tangent extrapolated from the T wave at the maximum downslope point with the isoelectric baseline (Panicker et al., Intra-and interreader variability in QT interval measurement by tangent andthreshold methods in a central electrocardiogram laboratory, J Electrocardiol, 2009).

[0127] Since the length of the QT interval is negatively correlated with heart rate (i.e., a faster heart rate is reflected by a shorter QT interval), different correction formulas (such as, but not limited to, the Bazett formula, the Friderica formula, the Sagie formula, and the Framingham formula) can be used to correct for heart rate differences in the QT interval. In general, a longer QT interval corresponds to an increased chance of a subject experiencing sudden cardiac death (Algra et al., QTc prolongation measured by standard 12-lead electrocardiography is an independent risk factor for sudden death due to cardiac arrest, Circulation, 1991). In certain embodiments, the average Friderica QT interval (hereinafter indicated by QTcF interval) of subjects using COCs comprising ethinylestradiol as an estrogen component and an equivalent effective amount of drospirenone for at least 6 cycles is prolonged by 3ms to 10ms, preferably 3ms to 8ms, preferably an average and / or median interval of about 4ms, while the QTcF interval of subjects using E4 / DRSP COCs as described herein for at least 6 cycles is prolonged by 0ms to 3ms, preferably 0ms to 2.5ms. The average and / or median interval. In certain embodiments, the difference between the baseline QTcF interval and the average QTcF interval extension after at least 6 cycles of using E4 / DRSP COCs as described herein is 2 to 5 units shorter than the difference between the baseline QTcF interval and the average QTcF interval extension after at least 6 cycles of using COCs comprising ethinylestradiol as an estrogen component and an equivalent effective amount of drospirenone, preferably 2.5 to 4 units shorter, preferably about 2.8 units shorter. In certain embodiments, the difference from baseline QTcF interval to median QTcF interval prolongation after at least 6 cycles of use of an E4 / DRSP COC as described herein is 1 to 4 units shorter, preferably 1 to 3 units shorter, preferably 1.5 to 2.5 units shorter than the difference from baseline QTcF interval to median QTcF interval prolongation after at least 6 cycles of use of a COC comprising ethinyl estradiol as an estrogen and an equivalent effective amount of drospirenone.

[0128] In certain embodiments, the mean and / or median QT interval prolongation in subjects using an E4 / DRSP COC as described herein is 20% shorter, preferably 25% shorter, preferably 30% shorter, preferably 35% shorter, preferably 40% shorter, more preferably 45% shorter, and most preferably 50% shorter than the corresponding mean and / or median QT interval prolongation in subjects using a COC comprising an equivalent effective amount of drospirenone as a progestogen component and ethinyl estradiol as an estrogen component. In certain embodiments, the median and / or median QtcF interval prolongation in subjects using an E4 / DRSP COC as described herein is 20% shorter, preferably 25% shorter, preferably 30% shorter, preferably 35% shorter, preferably 40% shorter, more preferably 45% shorter, and most preferably 50% shorter than the corresponding mean and / or median QtcF interval prolongation in subjects using a COC comprising an equivalent effective amount of drospirenone as a progestogen component and ethinyl estradiol as an estrogen component.

[0129] In certain embodiments, estetrol suppresses the QT interval extension in the subject using E4 / DRSP COC as described herein by counteracting the QT interval extension induced by drospirenone. Although the technician knows that progestogens generally reduce the length of the QT interval in the subject, drospirenone particularly exerts an opposite effect on the length of the QT interval (i.e., drospirenone induces QT interval extension, as discussed in Salem et al., Association of Oral Contraceptives With Drug-Induced QT Interval Prolongation in Healthy Nonmenopausal Women, JAMA Cardiology, 2018). In certain embodiments, estetrol suppresses the QT interval extension in the subject by invalidating the QT interval extension induced by drospirenone. In other embodiments where estetrol in E4 / DRSP COC as described herein invalidates the QT extension effect induced by drospirenone, the estrogenic activity of estetrol is the only factor that works on the QT extension obtained in the subject using the COC. In alternative embodiments where estrol in an E4 / DRSP COC as described herein nullifies the QT prolongation effect induced by drospirenone, the anti-androgenicity of estrol is the only contributing factor to the QT prolongation obtained in subjects using the COC. "Anti-androgenicity" indicates the ability of a molecule to prevent androgens such as testosterone, dihydrotestosterone, etc. from achieving a biological effect in a subject. Anti-androgens can act by inhibiting binding to androgen receptors and / or suppressing the production of one or more such androgens. Anti-androgens are generally considered to be functional antagonists of androgen receptor agonists. In general, anti-androgenicity may be associated with estrogenic activity.

[0130] In certain embodiments, when compared to subjects using COCs containing an equivalent effective amount of drospirenone as a progestin component and ethinyl estradiol as an estrogen component, the E4 / DRSP COC as described herein has a reduced estrogen-related effect on the QT interval. It is disclosed in the art that estrogen is often the cause of QT prolongation in subjects using COCs (Salem et al., Influence of steroid hormones on ventricular polarization, Pharmacology & Therapeutics, 2016). In other embodiments, the estrogen-related effect is a QT prolongation, preferably through estrogen-mediated I Kr and / or Ks The inhibition of channel current prolongs the QT interval. The skilled person understands that cardiac repolarization is achieved by rapid (I Kr ) and slow (I Ks ) is controlled by the activation of delayed rectifier potassium channels, and a decrease in any of these channels can lead to QT prolongation and optionally the development of long QT syndrome (a heart disorder characterized by a high risk of cardiac arrest) (Chiamvimonvat et al., Potassium currents in the heart: functional roles in repolarization, arrhythmia and therapeutics, J Physiol, 2017). In certain embodiments, estrogen-mediated I Kr and / or Ks The inhibition of the channel current is 25% lower, preferably 50% lower, preferably 75% lower than the estrogen-mediated inhibition of an estrogen selected from the group consisting of ethinyl estradiol, estradiol and estrogen. In other embodiments, the estrogen to which the effect of estetrol is compared is ethinyl estradiol. In other embodiments, the estrogen-related effect is a prolongation of the QT interval, preferably through estrogen-mediated I Kr ,I Ks and inwardly rectifying channels (I K1 The inhibition of QT channel current prolongs the QT interval. K1 The role of channels in shaping the QT interval (Dhamoon and Jalife, The inwardrectifier current (I K1 )controls cardiac excitability and is involved in arrhythmogenesis, Heart Rhythm, 2005).

[0131] In certain embodiments, the contraceptive kit as described herein is intended to be used to reduce the increase in the C-reactive protein serum concentration level associated with the use of a COC containing drospirenone and ethinylestradiol or to prevent the elevated C-reactive protein serum concentration level in a subject. As contemplated herein, when the C-reactive protein serum concentration level is 10% higher than the baseline value, preferably 15% higher, preferably 20% higher, preferably 25% higher, preferably 30% higher, the level is considered elevated, wherein the baseline value is the C-reactive protein serum concentration level in the subject before using the COC. The technician understands that the baseline value C-reactive protein concentration level is attributed to an individual subject, or is based on one or more textbook reference values. By way of guidance and not limitation, a suitable baseline value for CRP is 0.100 mg / dL (1,00 mg / L). In certain embodiments, a 0% median increase in serum concentration of C-reactive protein based on baseline values ​​was observed in subjects using E4 / DRSP COC as described herein for at least 6 cycles, while a 30% median increase in serum concentration of C-reactive protein was observed in subjects using COCs containing ethinylestradiol as an estrogen component and an equivalent effective amount of drospirenone for at least 6 cycles. In certain embodiments, the serum concentration of C-reactive protein in subjects using E4 / DRSP COC as described herein for at least 6 cycles is increased by 1.5 times less than the baseline value, and the serum concentration of C-reactive protein in subjects using COCs containing ethinylestradiol as an estrogen component and an equivalent effective amount of drospirenone for at least 6 cycles. In certain embodiments, when using E4 / DRSP COC as described herein, the serum concentration level of C-reactive protein in the subject is less than 1.75 mg / L. In certain embodiments, the serum concentration level of C-reactive protein in subjects using E4 / DRSP COC as described herein for at least 6 cycles is less than 2,00 mg / L. In other embodiments, the serum concentration of C-reactive protein in the subject is less than 1.75 mg / L, preferably less than 1.5 mg / L, when using an E4 / DRSP COC as described herein, preferably for at least 6 cycles. The use of the COC of the present invention reduces the risk of increased CRP levels associated with long-term and continuous use of COCs containing DRSP and another estrogen in addition to E4. Typically, CRP levels in healthy subjects who are not experiencing an inflammatory phase are less than 2 mg / L serum, and continued use of the COC of the present invention does not result in a significant increase in CRP levels in the healthy subjects who are not experiencing an inflammatory phase above this threshold.

[0132] C-reactive protein has been described in detail in the art and is a pentamer protein present in serum. It is known that the circulating concentration of C-reactive protein increases (i.e., rises) in response to inflammation. Increased C-reactive protein levels are associated with atherosclerotic cardiovascular disease (ASCVD). However, whether C-reactive protein is a nonspecific marker indicating an acute phase response to inflammatory stimuli, or whether C-reactive protein is a direct participant in the clinical imaging of ASCVD, no conclusion has been drawn. As generally accepted in the art (see 2019ACC / AHA Guideline on the Primary Prevention ofCardiovascular Disease:Report of the American College of Cardiology / AmericanHeart Association Task Force on Clinical Practice Guidelines), in view of cardiac risk stratification, C-reactive protein serum concentration levels can be divided into different categories: low-risk category (<2mg / L), moderate to high risk (≥2mg / L). Therefore, in a preferred embodiment, the C-reactive protein serum concentration observed in a subject using E4 / DRSP COC as described herein corresponds to a low-risk category concentration level. Conventional assays for measuring C-reactive protein levels in subjects (samples) are available, and include, but are not limited to, immunoassays, such as enzyme-linked immunosorbent assays (ELISA) and turbidimetry. Obviously, the changes in C-reactive protein concentrations as disclosed herein are minor after a single dose or even a limited amount of daily doses. However, over a long period of time, the increase in C-reactive protein when using E4 / DRSP COC will be significantly lower than the increase in C-reactive protein when using COCs containing ethinylestradiol and drospirenone, which is compared throughout this specification. Therefore, the decline in the increase in C-reactive protein in subjects using E4 / DRSP COC is more significant as the daily dosage units administered to the subject increase. Its long-term effect is that subjects using E4 / DRSP COC as described herein are classified in a lower cardiovascular risk group. For example, when compared with the same subjects using EE / DRSP COC, subjects who initially showed low risk characteristics (<2mg / L) will keep the changes unchanged in the same risk group to a higher degree after (long-term) use of E4 / DRSP COC as described herein. In the EE / DRSP regimen, subjects were more likely to experience an increase in C-reactive protein concentration resulting in a change in risk category from low to moderate or high risk (≥2 mg / L).

[0133] Also contemplated are compositions comprising estetrol for reducing the bioavailability of drospirenone in subjects using a COC comprising drospirenone. In certain embodiments, the composition comprising estetrol is contained in the same contraceptive kit as the COC, optionally in the same packaging unit. In certain embodiments, the composition comprising estetrol is provided as a separate active dosage unit to a subject using a COC comprising drospirenone and an estrogen that is not estetrol. In certain embodiments, due to the presence of estetrol, the bioavailability of drospirenone is reduced by at least 5%, preferably at least 10%, preferably at least 15%, preferably at least 25%, preferably at least 50%. In other embodiments, the estetrol is used as the estrogen component of the combined oral contraceptive, and drospirenone is used as the progestogen component. In other alternative embodiments, the estetrol is used as the main estrogen component of the combined oral contraceptive, and drospirenone is used as the main progestogen component. Therefore, the description as described herein does not exclude embodiments in which estetrol in the amounts disclosed herein is combined with a different estrogen in the E4 / DRSPCOC described herein, and / or does not exclude embodiments in which drospirenone in the amounts disclosed herein is combined with a different progestin or progestin in the E4 / DRSP COC described herein.

[0134] "Bioavailability" as used herein and with the generally accepted abbreviations "BA" and "F" should be interpreted as having its generally accepted meaning in the art, and therefore refers to the expression of the rate and degree at which a drug is able to achieve systemic circulation and thus exert its envisioned function, preferably quantitatively. Alternatively, the wording bioavailability is a subclass of absorption and is the fraction of the administered drug that reaches the systemic circulation, usually expressed as a percentage (%). It is generally accepted that when administered intravenously, bioavailability is considered to be 100%, and when other modes of administration are used, lower bioavailability is typically obtained, mainly due to the first-pass effect or first-pass metabolism and absorption metabolism of the subject (Herman and Santos, First pass effect, StatPearls, 2019). Bioavailability is typically calculated or derived by comparing the area under the (plasma drug concentration) curve (AUC) of an extravascular preparation with an intravascular preparation. AUC is a preferred way to obtain the bioavailability of a drug (or a contraceptive in the context of the present invention) because AUC is proportional to the dose present in the systemic circulation.

[0135] In certain embodiments, the estratetol composition as described herein is intended to be used to reduce the side effects of drospirenone in subjects using a combined oral contraceptive containing drospirenone. In other embodiments, the estratetol composition is administered to the subject in an oral administration manner. In certain embodiments, the estratetol composition is administered simultaneously with a combined oral contraceptive containing drospirenone. In alternative embodiments, the estratetol composition as described herein is intended to be used to reduce the side effects of drospirenone in subjects using an oral contraceptive containing a progestogen (such as but not including drospirenone) and lacking an estrogen component. In certain embodiments, it is a progesterone oral contraceptive (i.e., "oral contraceptive containing only progesterone", which is generally abbreviated as "POP" in the art). In certain embodiments, it is envisioned that the estratetol composition is used to reduce the risk of elevated C-reactive protein (CRP) serum concentration levels associated with the use of a combined oral contraceptive containing drospirenone. In other embodiments, elevated C-reactive protein serum concentrations were not observed in subjects using E4 / DRSP COC.

[0136] Another aspect of the invention relates to estetrol, which is used to reduce the steady-state bioavailability of drospirenone in a COC by at least 15% compared to a COC containing ethinylestradiol or estradiol. Thus, the E4 / DRSP COC as described herein is intended to achieve a lower relative steady-state bioavailability of DRSP when compared to a subject using a COC having drospirenone as a progestogen component and an estrogen other than estetrol as an estrogen component. In certain embodiments, the steady-state bioavailability of drospirenone is reduced by at least 20%, preferably at least 25%, at least 30%, at least 35%, at least 40%, at least 45%, at least 50%. In certain embodiments, the bioavailability of drospirenone when using a COC comprising estetrol and drospirenone is compared to the steady-state bioavailability of a COC comprising an equivalent amount of drospirenone and comprising ethinylestradiol in an amount of about 0.015 mg to about 0.05 mg, preferably about 0.02 mg to about 0.03 mg, more preferably wherein the amount of ethinylestradiol is about 0.02 mg, about 0.025 mg, or about 0.03 mg. In yet other embodiments, the equivalent amount of drospirenone is 3 mg. In certain embodiments, the steady-state bioavailability of drospirenone is the total bioavailability.

[0137] Another aspect of the invention relates to estetrol for reducing the peak plasma concentration of drospirenone in a subject using a COC comprising drospirenone. In certain embodiments, the COC comprising drospirenone comprises drospirenone in an amount of about 3 mg. In certain embodiments, the COC comprising drospirenone comprises an estrogen component that is not estetrol. In other embodiments, the estrogen component is ethinyl estradiol or estradiol. In certain embodiments, the peak plasma concentration of drospirenone in a subject using a COC comprising about 3 mg of drospirenone decreases by at least 5%, preferably at least 10%, at least 15%, at least 20%, at least 25%, at least 30%, at least 35%, at least 40%, at least 45%, at least 50%, when compared to the subject in which estetrol is not used to reduce bioavailability. In certain embodiments, the peak plasma concentration of drospirenone in subjects using a COC comprising about 3 mg of drospirenone is decreased by at least 5%, preferably at least 10%, at least 15%, at least 20%, at least 25%, at least 30%, at least 35%, at least 40%, at least 45%, at least 50% when compared to said subjects in which estetrol is not used to reduce bioavailability.

[0138] Another aspect of the invention relates to the use of estetrol for the manufacture of a composition (i.e., a drug or contraceptive) for preventing or treating side effects caused by the use of drospirenone in a COC. In another embodiment, estetrol is expected to be used for the manufacture of a composition (i.e., a drug or contraceptive) for preventing or treating a prolonged QT interval in a subject using a COC containing drospirenone. In other alternative embodiments, estetrol is expected to be used for the manufacture of a composition (i.e., a drug or contraceptive) for preventing or treating a decrease in free testosterone serum levels in a subject using a COC containing drospirenone. In yet other alternative embodiments, estetrol is expected to be used for the manufacture of a composition (i.e., a drug or contraceptive) for preventing or treating an increase in C-reactive protein levels in a subject using a COC containing drospirenone.

[0139] The term "treatment" or "treat" should be interpreted as therapeutic treatment of a disease or condition that has already developed, resulting in clinical manifestations, such as treatment of already developed prolonged QT syndrome, sexual dysfunction (e.g., hyposexuality), as well as prophylactic or preventative measures, where the goal of treatment is to prevent, reduce, or reduce the chance of the incidence of undesirable suffering, such as preventing the occurrence, development and progression of clinical conditions or diseases. Beneficial or desired clinical results may include, but are not limited to, relief of one or more symptoms, improvement of one or more biomarkers, reduction of disease extent, stabilization (i.e., not worsening) of the disease state, delay or slowing of disease progression, improvement or alleviation of the disease state, etc. "Treatment" may also mean prolonged survival, or reduced risk of death compared to expected survival if not receiving treatment.

[0140] As used herein, the term "therapeutic treatment" or "therapy" and the like refers to treatment wherein the goal is to change the subject's body or a part of the subject's body from an undesirable physiological state, disease or disorder (such as one or more adverse side effects induced by the use of a COC comprising drospirenone) to a desired state (such as a less severe state (e.g., improvement or alleviation)) or even back to its normal healthy state (e.g., restoration of the subject's health, physical integrity and physical health) to maintain (e.g., stabilize) the undesirable physiological state (i.e., not worsen), or to slow the progression to a state that is more severe or worse than the undesirable physiological change or disorder. Measurable reduction includes any statistically significant decrease in a measurable marker or symptom. As used herein, statistically significant means a p-value below 0.05, which is a generally accepted cutoff score in statistical analysis as understood by the skilled person. "Treatment" encompasses both curative treatment and treatment involving reduction of symptoms and / or slowing of progression and / or stabilization of the disease. The skilled person is aware that in order to achieve effective therapeutic treatment, a therapeutically effective dose needs to be administered to the subject.

[0141] As used in the context of the present invention, "Prevention" or "prevent" refers to the prevention of the manifestation of disease imaging in a subject, that is, the establishment of preventive measures or preventive measures. Preventive treatment refers to such treatment, wherein the purpose is to avoid the subject's body or its elements to show undesirable physiological changes or clinical symptoms of the disorder. The skilled person knows that in order to achieve an effective therapeutic treatment, it is necessary to administer a preventively effective dose to the subject. In the context of the present invention, E4 / DRSP COC can be administered to a subject to prevent the manifestation of a medical condition, disease, or (adverse) side effect that will or may occur in the subject when the subject uses a COC comprising drospirenone as a progestogen component and an estrogen other than estetrol.

[0142] As used herein, the term "therapeutically effective dose" or "therapeutically effective amount" refers to an amount of a therapeutic protein or therapeutic peptide as taught herein, which, when administered, elicits a positive therapeutic response in treating a subject suffering from a disease (e.g., a patient who has been selected (e.g., diagnosed) with a certain disease). The term "prophylactically effective dose" or "prophylactically effective amount" refers to an amount of a gene product that inhibits or delays the onset of a disorder in a subject, as sought by a researcher, veterinarian, medical doctor or other clinician.

[0143] Although the present invention has been described in conjunction with specific embodiments thereof, it is apparent that many substitutions, modifications and variations will be apparent to those skilled in the art from the foregoing description. Therefore, within the spirit and broad scope of the appended claims, it is intended to encompass all such substitutions, modifications and variations as follows. The various aspects and embodiments of the present invention disclosed herein are further supported by the following non-limiting examples.

[0144] Example

[0145] Example 1. Containing DRSP (3 mg), EE / DRSP (0.02 mg / 3 mg), E4 / DRSP (15 mg / 3 mg) and DRSP Comparison of pharmacokinetic characteristics of oral contraceptives (4 mg).

[0146] Clinical studies were performed to evaluate the different pharmacokinetic characteristics after multiple dose studies of different COCs. The pharmacokinetic parameters after single (Table 1) or repeated (Table 2) oral administration of DRSP alone or different COCs are shown below. From the single dose results, it can be inferred that the E4 / DRSP combination showed lower DRSP AUC values ​​(AUC 1.0) when compared to COCs containing ethinyl estradiol (EE / DRSP COCs). 0-24 :224vs 268-288ng.h / mL; AUC inf :358-444vs 458ng.h / ml), while achieving similar C max For the multiple-dose regimen, even more significant differences were found between E4 / DRSP and EE / DRSP (AUC 0-24 : 442-519 vs 763-827 ng.h / ml). The AUC values ​​are sufficient to achieve a contraceptive effect, but the relatively lower AUC may contribute to the improvement in (adverse) side effects observed when compared to EE / DRSP COCs (discussed further in Examples 2 and 3).

[0147] Table 1. Pharmacokinetic parameters of DRSP alone or in combination with estrogens (EE and E4) after a single oral dose. AUC: Area under the plasma concentration versus time curve, AUC 0-24 : AUC from time zero to 24 hours after administration, AUC 0-inf : AUC from zero to infinite time, C max : Maximum plasma concentration, 1Geometric mean (% coefficient of variation [CV]), DRSP: drospirenone, E4: estetradiol, EE: ethinylestradiol, ND: not determined. For comparison purposes, only data from Caucasian subjects are reported in this table. *Blode et al., Pharmacokinetics of drospirenone and ethinylestradiol in Caucasian and Japanese women, Eur J Contracept Reprod Health Care, Table 2, Study 1 / 3. **MIT-Es0001-C103 / C101 / C109 / C110: clinical trial conducted by the inventors.

[0148]

[0149]

[0150] Table 2. Pharmacokinetic parameters of DRSP alone or in combination with estrogens (EE and E4) after repeated oral administration. AUC = area under the plasma concentration vs. time curve, AUC 0-24 = AUC from time zero to 24 hours after administration, AUC 0-inf = AUC from zero to infinite time, C max= maximum plasma concentration, GM CV = coefficient of variation of the geometric mean, DRSP = drospirenone, E4 = estetrol, EE = ethinyl estradiol, GM = geometric mean, ND = not determined. For the purpose of comparison with data generated by the sponsor, only data from Caucasian subjects are reported in this table. *Richter et al., Comparative pharmacokinetic estimates of drospirenone alone and in combination with ethinyl estradiol after single and repeated oral administration in healthy females, Contraception, 2020) **Blode et al., Pharmacokinetics of drospirenone andethinylestradiol in Caucasian and Japanese women, Eur J Contracept Reprod Health Care, 2012, Table 2, Study 3. ***Wiesinger et al., Pharmacokinetic interaction between the CYP3A4 inhibitor ketoconazole and the hormone drospirenone incombination with ethinylestradiol or estradiol, Br J Clin Pharmacol, 2015, Table 4. **MIT-Es0001-C103 / 106: clinical trial conducted by the inventors.

[0151]

[0152]

[0153] Example 2. A combined oral contraceptive (COC) containing 15 mg of estetrol (E4) and 3 mg of drospirenone (DRSP) and a combination oral contraceptive (COC) containing Comparative bioavailability study between COCs with ethinyl estradiol (EE) 0.02 mg and DRSP 3 mg (single-dose study).

[0154] 2.1. Research concept and objectives

[0155] In healthy female volunteers, the difference between a combined oral contraceptive (COC) containing estetrol (E4) 15 mg and drospirenone (DRSP) 3 mg (i.e., treatment A) and a COC containing ethinylestradiol (EE) 0.02 mg and DRSP 3 mg (i.e., treatment A) was not statistically significant. TM or Yasmin TM, i.e., an open-label, single-dose, randomized, two-period, double-treatment, two-factor crossover comparative bioavailability study between treatment B).

[0156] The primary objective of this study was to compare the rate and extent of absorption of DRSP following administration of a single oral dose of the E4 / DRSP 15 / 3 mg combination (test product) and the ethinyl estradiol (EE) / DRSP 0.02 / 3 mg combination (reference product) under fasting conditions. A secondary objective of this study was to evaluate the general safety of a single oral dose of the E4 / DRSP 15 / 3 mg combination and the EE / DRSP 0.02 / 3 mg combination in healthy female volunteers. Subjects were selected from a group of volunteers recruited by Quotient Sciences and screened for inclusion in the study up to 28 days prior to dosing. Please refer to the publicly available clinical study report for study MIT-Es001-C112 (QSC203723) for detailed inclusion and exclusion criteria.

[0157] The two-phase, two-factor crossover design is most suitable for comparing the PK of two different treatments because it allows intra-subject comparisons and reduces the impact of potential period effects. The design of this study is in accordance with the US Food and Drug Administration (FDA) recommendations for conducting bioavailability studies (USDepartment of Health and Human Services Food and Drug Administration Center for Drug Evaluation and Research, Guidance for Industry; Bioavailability and Bioequivalence Studies Submitted in NDAs or INDs–General Considerations, March 2014). Subjects are allowed to withdraw their consent at any time for any reason. In the event of an effect that makes the risk / effectiveness ratio unacceptable, in the event of poor compliance, or in the event of a violation of the protocol, the investigator may interrupt the subject. For this PK study, if there are difficulties in blood collection, the subject may also be interrupted.

[0158] Subjects received the first treatment (Treatment A or B, depending on randomization) on Day 1 of Cycle 1. After a period of at least 14 days (washout), subjects received the second treatment (Treatment B or A) on Day 1 of Cycle 2. Subjects had blood samples collected on a regular basis for up to 5 days after each dose for PK measurements.

[0159] It is emphasized that the research described in this section (Section 2) is a single-dose study. Obviously, some parameters will draw more statistically relevant results in multiple-dose studies, as summarized in Section 3. However, even after analyzing the pharmacokinetic characteristics of single-dose administration, some trends such as lower DRSP AUC values ​​achieved herein are also obvious. Therefore, the results of Example 2 do not affect the validity of the multiple-dose studies described in Examples 1, 3 and 4.

[0160] Pharmacokinetic measurements

[0161] 2.2.1. Sample collection - DRSP bioanalysis

[0162] Venous blood samples were collected into 4.0 mL sodium heparin tubes. The tubes were gently inverted 8 to 10 times to mix with the anticoagulant. The tubes were immediately stored in an ice bath after mixing and centrifuged at 1500 g for 10 minutes at <4°C within 60 minutes of collection. Aliquots of separated plasma were transferred to storage cryovials immediately after centrifugation. For Treatment A, three aliquots of plasma were produced, each containing approximately 0.5 mL. For Treatment B, two aliquots of plasma were produced, one approximately 0.5 mL and the other approximately 1.0 mL. The tubes were immediately capped and stored in a vertical position in a freezer at -20°C (±5°C) within 90 minutes of sample collection until transport.

[0163] Analytical methods

[0164] The accurate time of blood sampling is recorded in the source workbook, and the actual collection time is used for PK analysis. According to the good laboratory practice (GLP) requirement (OECD is about the principle of good laboratory practice; ENV / MC / CHEM (98) 17.1998.) of this type of research determined in the Organization for Economic Co-operation and Development (Organization for Economic Co-operation and Development, OECD) principle applicable to GLP, the mensuration of DRSP in blood plasma is performed using validated liquid chromatography-tandem mass spectrometry (LC-MS / MS) method.

[0165] 2.3. Pharmacokinetic results and statistical evaluation

[0166] The resulting statistical analysis is shown in Table 3.

[0167] Table 3. Statistical evaluation of pharmacokinetic values. Statistical analysis of pharmacokinetic values ​​in healthy female subjects following a single oral dose of DRSP with E4E4 (E4 / DRSP 15 / 3 mg test formulation) and EE (EE / DRSP 0.02 / 3 mg [Yaz TM] Reference formulation) after the combination of geometric mean (geometric CV%) DRSP plasma pharmacokinetic parameters. Tlag: time before the first measurable concentration. T max T: Time of maximum observed concentration. 最后 : The time when the concentration can be measured last. C max : Maximum observed concentration. AUC 0-24 : AUC from 0 to 24 hours after administration. AUC 0-t最后 : AUC from time 0 to the time of the last measurable concentration. AUC 0-inf : AUC extrapolated from time 0 to infinity.

[0168] Table 3: Statistical evaluation of pharmacokinetic values

[0169]

[0170]

[0171] For statistical evaluation of pharmacokinetic values, the relative bioavailability (Frel) can be calculated from Table 3.1. according to formula (III):

[0172] Formula (III)

[0173]

[0174] Table 4. Evaluation of relative bioavailability: PK analysis set. Bioavailability of DRSP in healthy female subjects after a single oral dose of E4 (E4 / DRSP 15 / 3 mg test formulation) and EE (EE / DRSP 0.02 / 3 mg [Yaz TM ] reference formulation). (1) Adjusted geometric mean (Adj. geo mean) = adjusted geometric mean from model, (2) ratio of adjusted geometric means, where comparisons are presented as test / reference, (3) CI = confidence interval of the ratio of adjusted geometric means, (4) P value for two-sided test (null hypothesis of no difference), (5) CVw = within-subject variability.

[0175] Table 4. Assessment of relative bioavailability: PK analysis set.

[0176]

[0177] The results indicated that for the E4 / DRSP 15 / 3 mg test formulation, as measured by AUC 0-t最后 The average total exposure level of DRSP measured was EE / DRSP 0.02 / 3mg (Yaz TM) of the reference formulation. The lower and upper limits of the 90% CI indicate that the true measure of relative bioavailability is unlikely to be less than 88.68% or more than 95.68%. AUC 0-t最后 The difference between treatments was statistically significant (p=0.001). The cycle effect (i.e., slightly higher exposure levels in cycle 2 compared to cycle 1) was statistically significant at the 10% level (p=0.037), while the sequence effect was not (p=0.46). There was no evidence of any carryover from cycle 1 to cycle 2, i.e., all pre-dose concentrations in cycle 2 were not quantifiable.

[0178] For AUC 0-inf , and obtained the same 0-t最后 Similar results were observed for the E4 / DRSP 15 / 3 mg test formulation, as shown by AUC 0-inf The average total exposure level of DRSP measured was EE / DRSP 0.02 / 3mg (Yaz TM ) of the reference formulation. The lower and upper limits of the 90% CI indicate that the true measure of relative bioavailability is unlikely to be less than 87.89% or more than 95.56%. AUC 0-inf The difference between the treatments was statistically significant (p=0.002). The cycle effect (i.e., slightly higher exposure levels in cycle 2 compared to cycle 1) was statistically significant at the 10% level (p=0.010), but the sequence effect was not (p=0.40).

[0179] 2.4. Pharmacokinetic and statistical discussion

[0180] In EE / DRSP 0.02 / 3mg (Yaz TM ) After a single oral administration of DRSP, the reference preparation showed rapid absorption of DRSP, with a median t max Appears at 1.50 hours. The geometric mean terminal of DRSP t1 / 2 The duration of the combined oral contraceptive (COC) containing estetrol (E4) 15 mg and drospirenone (DRSP) 3 mg was compared with that of the COC containing ethinylestradiol (EE) 0.02 mg and DRSP 3 mg in healthy female volunteers. Estetra SPRL. Clinical Study Protocol: An open-label, singledose, randomized, two-period, two-treatment, two-way crossover, comparative bioavailability study between a combined oral contraceptive (COC) containing estetrol (E4) 15 mg and drospirenone (DRSP) 3 mg and a COC containing ethinylestradiol (EE) 0.02 mg and DRSP 3 mg in healthy femalevolunteers.Version 1.1.18December 2019)).

[0181] With EE / DRSP 0.02 / 3mg(Yaz TM ) Compared with the reference formulation, the E4 / DRSP 15 / 3 mg test formulation showed no change in DRSP absorption, with a median t max The clearance of DRSP did not change in the E4 / DRSP 15 / 3 mg test formulation, with a geometric mean terminal t 1 / 2 It is 38.20 hours.

[0182] The variability associated with exposure was similar between treatments, with C max The geometric mean CV% ranged from 22.4% to 25.0%, and the AUC ranged from 20.5% to 28.0%.

[0183] After administration of the E4 / DRSP 15 / 3mg test formulation, based on C max The peak plasma exposure of DRSP was similar to that of EE / DRSP 0.02 / 3 mg The reference formulation was comparable, with the resulting relative bioavailability (90% CI) being 97.26% (88.63%, 106.72%), demonstrating the absence of statistically significant differences.

[0184] After administration of the E4 / DRSP 15 / 3 mg test formulation, based on AUC 0-t最后 and AUC 0-inf The overall exposure is lower than EE / DRSP 0.02 / 3mg (YazTM ) reference preparation, the difference in values ​​was statistically significant, with ratios (90% CI) of 92.11% (88.68%, 95.68%) and 91.65% (87.89%, 95.56%), respectively. Note that the intra-subject variability associated with the results of the formal statistical analysis was very low, which resulted in relatively small differences in treatment and cycle being declared statistically significant. The cycle effect is not considered to affect the overall interpretation of the results or conclusions.

[0185] Example 3. A combined oral contraceptive (COC) containing 15 mg of estetrol (E4) and 3 mg of drospirenone (DRSP) and a combination oral contraceptive (COC) containing Comparative bioavailability studies (single and multiple dose studies) between COCs with ethinyl estradiol (EE) 0.03 mg and DRSP 3 mg.

[0186] 3.1. Research concept and objectives

[0187] In healthy female volunteers, the difference between a combined oral contraceptive (COC) containing estratetol monohydrate (E4) 15 mg and drospirenone (DRSP) 3 mg and a COC containing ethinylestradiol (EE) 0.03 mg and DRSP 3 mg (Yasmin TM ) were conducted as an open-label, single-dose and multiple-dose, randomized, two-period, double-treatment, two-factor crossover comparative bioavailability study.

[0188] The primary objective is to compare the rate and extent of absorption of DRSP following single and 14-day multiple doses of the E4 / DRSP 15 / 3 mg combination (test product) and the EE / DRSP 0.03 / 3 mg combination (reference product) under fasting conditions. For multiple doses, only the last dose (before pharmacokinetic [PK] measurements) will be performed under fasting conditions. The secondary objectives are to evaluate the general safety of single and 14-day multiple doses of the E4 / DRSP 15 / 3 mg combination and the EE / DRSP 0.03 / 3 mg combination in healthy female volunteers.

[0189] The study includes a screening period of up to 28 days, two treatment periods, each of 24 days, and a follow-up visit on the last day of the second treatment period. Subjects will receive two treatments: E4 / DRSP 15 / 3mg (treatment A) and EE / DRSP 0.03 / 3mg (treatment B). Treatment will be given in order starting with A (AB) or B (BA). Subjects will be randomly assigned to receive treatment order AB or BA in the morning of the first day of the first cycle. Subjects will receive a single dose of treatment A or treatment B orally on the first day of the first treatment period, and then receive the same treatment on days 6 to 19 for 14 days after a 4-day period without treatment (days 2 to 5). After a washout period of at least 14 days, subjects will receive a single dose of another treatment (treatment B or treatment A) orally on day 1 of the second treatment period, and then receive the same treatment on days 6 to 19 for 14 days after a 4-day period without treatment (days 2 to 5).

[0190] Half of the subjects were randomized to receive the sequence AB (treatment A followed by treatment B), and half of the subjects were randomized to receive the sequence BA (treatment B followed by treatment A).

[0191] Both test formulations (as indicated above) will be administered orally: Single dose: after an overnight fast of at least 10 hours. Multiple doses: 14 days, administered once daily, at the same time each day; the last dose must be taken after an overnight fast of at least 10 hours.

[0192] 3.2. Study endpoints (pharmacokinetics)

[0193] Primary PK endpoint

[0194] For DRSP after treatment with E4 / DRSP 15 / 3 mg and after treatment with EE / DRSP 0.03 / 3 mg, the following non-compartmental PK parameters were calculated:

[0195] Single dose

[0196] Maximum plasma concentration (C max );

[0197] The area under the plasma concentration versus time curve (AUC) from time 0 until the last observed quantifiable concentration (AUC 0-t最后 );

[0198] AUC from time 0 to infinity (AUC 0-inf ).

[0199] Multiple doses (after last dose)

[0200] ·C max ;

[0201] AUC from time 0 to 24 hours (AUC 0-24 ).

[0202] Secondary PK endpoints

[0203] For DRSP after treatment with E4 / DRSP 15 / 3 mg and after treatment with EE / DRSP 0.03 / 3 mg, the following non-compartmental PK parameters were calculated:

[0204] Single and multiple doses (after last dose)

[0205] ·Achieve C max The time (t max );

[0206] Apparent terminal elimination half-life (t 1 / 2 );

[0207] The AUC was extrapolated from the time of the last measurable plasma concentration to infinity and was given as the AUC 0-inf Percentage of (AUC%ext);

[0208] Apparent terminal clearance rate constant (λz);

[0209] Apparent total body clearance (CL / F);

[0210] ·Apparent volume of distribution (Vz / F).

[0211] Single dose

[0212] AUC after single dose administration 0-24 .

[0213] Multiple doses (after last dose)

[0214] AUC 0-t最后 ;

[0215] AUC 0-inf ;

[0216] The average concentration at steady state (C av );

[0217] The lowest concentration (C min );

[0218] Peak-to-trough fluctuation (PTF%) in steady state.

[0219] In addition, the accumulation rate (RAUC) will be calculated as (AUC 0-24 ) steady-state and single-dose ratios.

[0220] 3.2.3. Safety endpoints:

[0221] Safety will be assessed by monitoring treatment-emergent adverse events (TEAEs), physical examinations, vital signs, clinical laboratory tests, and electrocardiogram (ECG) results.

[0222] Twelve-lead ECGs will be recorded at Screening, on Days 19 and 21 of Treatment Period 1, and on Days -1, 19, and 21 of Treatment Period 2. If ET occurs before or on Day 20, it will also be recorded at ET. Measurements will be performed after a rest period of at least 10 minutes (supine position). ECG recordings will include heart rhythm, ventricular rate, PR, QRS, QT, and QTcF intervals.

[0223] PD endpoints:

[0224] PD effects were assessed by measuring plasma aldosterone concentrations, plasma renin (direct renin concentration [DRC] and plasma renin activity [PRA]), angiotensinogen, angiotensin (I and II), free testosterone, and CRP at baseline and after the last dose of 14-day MD (original concentrations and changes from baseline). PD assessments included assessments of aldosterone, plasma renin (DRC and PRA), angiotensinogen, angiotensin (I and II), free testosterone, and CRP. Blood samples were collected before dosing on Days -1 and 19 of each treatment period for PD assessment.

[0225] Statistical methods

[0226] Continuous variables were summarized using the following descriptive statistics: arithmetic mean, standard deviation (SD), minimum, median, maximum, coefficient of variation (CV%), and number of subjects. In addition, DRSP plasma concentrations and PK parameters (t max The geometric means and CV% of the geometric means were calculated (except for

[0227] Frequency distributions of all categorical variables were presented using counts and percentages. The software generated the data tabulations, descriptive statistics, statistical analyses, summary tables, and figures for this study.

[0228] Descriptive statistics were used to summarize DRSP concentrations by treatment and time point. Pharmacokinetic PK parameters based on DRSP concentrations were summarized by treatment. Graphical displays were also provided for individual and mean DRSP concentration data.

[0229] To compare the bioavailability of DRSP between E4 / DRSP and EE / DRSP, analysis of variance (ANOVA) was used to evaluate the natural log-transformed parameters. The model was applied to the C max , AUC 0-t最后 and AUC 0-inf , and C after the last multiple dose on day 19 max and AUC 0-24 The model for each PK parameter will include sequence, subject within sequence (random effect), period and treatment. The mean difference between treatments along with its associated 90% confidence interval (CI) will be estimated for the log-transformed values ​​of each parameter. The CI will be estimated based on the adjusted mean of the mean square error using the ANOVA model. The differences and CIs calculated on a logarithmic scale will be back-transformed to obtain the geometric mean test-to-reference ratio and 90% CI for each parameter on the original scale.

[0230] Example 4. Comparative study with multiple COCs to evaluate the effects on free testosterone and C-reactive protein.

[0231] Materials and methods

[0232] Study design

[0233] This was a single-center, randomized, open-label, controlled, three-arm study in healthy women conducted at Dinox BV (Groningen, the Netherlands) from September 2016 to October 2017 (EudraCT 2016-001316-37, Clinicaltrials.gov NCT02957630). The study was approved by an independent ethics committee, and written informed consent was obtained from all participants before study entry. This study was conducted in accordance with the Declaration of Helsinki and the ICH Good Clinical Practice guidelines.

[0234] The study consisted of a pretreatment period (baseline), followed by six 28-day treatment periods, and five visits: screening visit, pretreatment / randomization visit, two treatment visits (periods 3 and 6), and end-of-study visit.

[0235] 4.1.2. Study population

[0236] Body mass index (BMI) for those aged 18-50 years is 18.0 to 30.0 kg / m 2 Healthy women with a natural menstrual cycle of 35 days or less were eligible for inclusion. Women with contraindications to oral contraceptives, dyslipoproteinemia, or use of antilipidemic drugs were excluded from participation. Hormonal contraceptives and concomitant medications that interact with COCs were not allowed during the two cycles before the start of treatment and during study treatment.

[0237] Study treatment

[0238] Eligible subjects were stratified according to duration since previous use of hormonal contraception (no use of hormonal contraception for 2 cycles or more before starting study treatment) and age (≤35 years or >35 years) to ensure uniform distribution in treatment groups. Subjects were assigned to receive one of the following treatments: 15 mg E4 (as monohydrate, equivalent to 14.2 mg anhydrate) in combination with 3 mg DRSP (E4 / DRSP), 30 mcg EE in combination with 150 mcg LNG (EE / LNG), or 20 mcg EE in combination with 3 mg DRSP (EE / DRSP). Subjects took one tablet daily for six consecutive 28-day cycles. E4 / DRSP and EE / DRSP treatments were provided as a 24-day active substance / 4-day placebo regimen, and EE / LNG was provided as a 21-day active substance / 7-day placebo regimen. E4 / DRSP is manufactured by Haupt Pharma (Münster, Germany) and supplied by Estetra SPRL (Liège, Belgium). EE / LNG (Melleva TM 150 / 30, Leon Farma, Spain) and EE / DRSP (Yaz TM , Bayer Healthcare, Germany) were obtained from a local pharmacy. Study treatment started on the first day of menstruation after the pre-treatment period. Treatment compliance was verified by using a diary and by inspecting returned packaging.

[0239] 4.1.4. Study evaluation and outcome parameters

[0240] The following outcome parameters were studied:

[0241] - Endocrine function: prolactin, follicle-stimulating hormone (FSH), luteinizing hormone (LH), estradiol (E2), progesterone (P), thyroid-stimulating hormone (TSH), free thyroxine (fT3) / free triiodothyronine (fT4), dihydroepiandrostenedione (DHEAS), androstenedione, total testosterone (T), free T, dihydrotestosterone (DHT), total cortisol and aldosterone;

[0242] - Liver proteins: C-reactive protein (CRP), cortisol-binding globulin (CBG), sex hormone-binding globulin (SHBG), thyroxine-binding globulin (TBG), and angiotensinogen;

[0243] Blood samples were collected between days 18 and 21 at baseline and during cycles 3 and 6 for measurement of these parameters. Plasma, serum, and whole blood samples were shipped to a central laboratory (BARC laboratories, Gent, Belgium) for analysis. Serum samples for E2 assessment were shipped to ABL in Assen, the Netherlands. Details of the analytical methods, including reference ranges, are provided in Table 5.

[0244] Table 5. Details and reference ranges of analytical methods used

[0245]

[0246] *All measurements were performed in serum, except angiotensinogen, which was measured in plasma.

[0247] Statistical analysis

[0248] All randomized subjects who received at least one dose of study drug, had at least one post-treatment endocrine assessment, and did not have any major protocol deviations affecting these assessments were included in the analysis of endocrine parameters (per the protocol data set). Parameters were summarized using descriptive statistics (n, mean, standard deviation [SD], minimum, median, maximum, and coefficient of variation [CV]), and no formal statistical analysis was planned.

[0249] Additional exploratory nonparametric analyses were performed on the absolute changes from baseline in endocrine parameters and liver proteins. Only data from cycle 6 were included in this analysis because this time point was most relevant for evaluating long-term treatment effects. To explore the differences between cycle 6 and baseline, a signed rank test was used. To explore the differences in treatment changes from baseline in cycle 6, a Kruskal-Wallis test was used. In cases where this analysis indicated a possible difference, paired comparisons of treatments were performed using the Dwass-Steel-Critchlow-Fligner procedure. The alpha level was set at 0.05. Only data obtained at baseline and cycle 6 are reported herein.

[0250] Results

[0251] 4.2.1. Study population

[0252] A total of 101 subjects were randomized, 98 received study treatment, and 88 subjects completed the study ( Figure 1 ). The demographic characteristics are summarized in Table 6. There were no significant between-group differences at baseline.

[0253] Table 6. Mean demographic data at study entry. BMI: body mass index.

[0254]

[0255] 4.2.2. Endocrine parameters

[0256] The androgen parameters measured during the study include androstenedione, dehydroepiandrosterone sulfate, dihydrotestosterone, testosterone, free testosterone and SHBG. The treatment of E4 / DRSP, EE / LNG and EE / DRSP is associated with reduced androgen concentration. In all treatment groups, androstenedione (from -31.0% of E4 / DRSP to -49.0% of EE / DRSP) and free T (from -50.0% of E4 / DRSP to -71.0% of EE / DRSP) levels are reduced, but the reduction of EE / DRSP treatment is higher. In parallel, it is observed that the median concentration of SHBG in the group treated with E4 / DRSP, EE / LNG and EE / DRSP respectively increases by 55%, 74% and 251%. Decreases in median concentrations of dehydroepiandrosterone (-10.5%, -16.0%, -27.0%) and dihydrotestosterone (-13.0%, -25.0%, -3.5%) were also observed in the E4 / DRSP, EE / LNG, and EE / DRSP groups. Cortisol increased by more than 100% during treatment with EE / LNG (109.0%) and EE / DRSP (107.0%), while only a slight increase of 26.0% was observed with E4 / DRSP. Aldosterone levels increased with E4 / DRSP (103.0%) and EE / DRSP (179.5%), while a decrease was observed with EE / LNG (-40.0%).

[0257] In the table, changes from baseline in the above-mentioned endocrine parameters that achieved statistical significance (p<0.05) are indicated in bold.

[0258] Table 7. Endocrine parameters. Median values ​​(min, max) at baseline and cycle 6 and changes from baseline at cycle 6. Bold values ​​represent statistically significant changes from baseline in additional exploratory analyses (p<0.05). CFB = change from baseline, DHEAS = dihydroepiandrosterone, DHT = dihydrotestosterone, E2 = estradiol, FSH = follicle stimulating hormone, free T = free testosterone, fT3 = free triiodothyronine, fT4 = free thyroxine, LH = luteinizing hormone, TSH = thyroid stimulating hormone. # No statistical analysis was performed on the change in E2 from baseline.

[0259]

[0260]

[0261] 4.2.3. Liver protein

[0262] CRP values ​​increased in the EE / DRSP group, but not in the E4 / DRSP group (Table 8). At cycle 6, angiotensinogen levels increased by 170.0% and 206.5% with EE / LNG and EE / DRSP, respectively, while the increase with E4 / DRSP was less pronounced (75.0%). A similar pattern was seen for CBG, which increased by 152.0% and 140.0% with EE / LNG and EE / DRSP, respectively, and by 40.0% with E4 / DRSP. The highest increase in SHBG was found with EE / DRSP (251.0%); treatment with EE / LNG and E4 / DRSP increased SHBG levels by 74.0% and 55.0%, respectively. TBG levels increased by 70.0% in the EE / DRSP group, with smaller changes observed in the EE / LNG (37.0%) and E4 / DRSP (17.0%) groups. The change in CRP in the case of E4 / DRSP (0% vs +30%) was less significant compared to EE / DRSP. All parameters changed much more with EE / DRSP compared to E4 / DRSP.

[0263] Table 8. Liver proteins. Median values ​​(min, max) at baseline and cycle 6 and change from baseline at cycle 6. Bold values ​​represent statistically significant changes (p<0.05) in exploratory analysis. CBG = cortisol binding globulin, CFB = change from baseline, CRP = C-reactive protein, SHBG = sex hormone binding globulin, TBG = thyroxine binding globulin.

[0264]

[0265] 4.3. Discussion and conclusion

[0266] The results of this study using 15mg E4 / 3mg DRSP combination and 6 cycles of duration show that E4 / DRSP has limited effects on endocrine parameters (such as free testosterone) and liver proteins (such as C-reactive protein). Compared with two reference treatments, i.e., the 2nd generation EE-based COC (EE / LNG) and the 4th generation EE-based COC (EE / DRSP), the E4 / DRSP combination shows favorable characteristics to endocrine and liver parameters. As expected, all treatments show that E2 and progesterone levels decrease, indicating the contraceptive activity of these combinations. Interestingly, compared with EE / LNG and EE / DRSP, treatment with E4 / DRSP causes a smaller increase in cortisol and aldosterone levels and a smaller suppression of LH and FSH, indicating that the overall pseudo-estrogen activity of the E4 / DRSP combination is lower. Although compared with E4 / DRSP, EE / LNG and EE / DRSP are significantly higher in the degree of response to angiotensinogen, CRP, CBG and TBG, all 3 COCs show an increase in liver protein levels. SHBG increased after EE / DRSP treatment, while only limited effects were seen after treatment with EE / LNG and E4 / DRSP. This confirms previous observations that E4 has a small effect on SHBG and indicates a lower overall estrogenic activity of the E4 / DRSP combination (Kluft et al., Reduced haemostatic effects with drospirenone-based oral contraceptives containing estetrol versusethinyl estradiol, Contraception, 2017; and Hammond et al., Estetrol does not bind sexhormone binding globulin or increase its production by human HepG2 cells, Climacteric, 2008).

[0267] These results confirm previous observations that treatment with E4 / DRSP had limited effects on liver proteins (such as C-reactive protein) and endocrine function. The effects on other endocrine parameters (including suppression of ovarian steroids) were comparable to the comparative preparations. Thus, the E4 / DRSP combination has a favorable profile when compared to 2nd generation (EE / LNG) and 4th generation (EE / DRSP) EE-containing COCs.

[0268] Example 5. E4 / DRSP and EE / DRSP Effects of COCs on the QT interval

[0269] QT values ​​were measured at screening and at the end of cycle 3 (day 24 or 27). QT values ​​were corrected according to the Fridericia formula to account for changes in heart rate (QTcf). Changes in QTcf were calculated as the difference between QTcf at the end of cycle 3 - screening QTcf (positive values ​​indicate an increase in QTcf). Patients were measured on day 24 or 27. On day 24, they were receiving treatment, and on day 27, treatment had been terminated.

[0270] As shown in Table 9, the mean change at the end of treatment was greater in the reference group when compared to the treatment group. The results show that E4 / DRSP COC is less prone to cause QT prolongation when compared to the reference group (EE / DRSP COC users). The results of the QTcF analysis after 24 days and after 27 days are additionally shown in Figure 2 and 3 At day 27 or when all data were considered, the change in QTcf was numerically higher in the reference group.

[0271] The change in the reference group was above 5 ms (the threshold considered significant for a possible effect on arrhythmias) on Day 27. This change from baseline was statistically significant.

[0272] Table 9. 12-lead ECG; Change from Baseline at Cycle 3 - Overall and by Day. N = number of subjects. STD = standard deviation. [1] Exploratory p-values ​​to indicate whether there is a possible difference between Cycle 3 and Baseline for each treatment using a signed rank test.

[0273]

[0274] The efficacy of the treatment for preventing pregnancy was evaluated by assessing the suppression of ovarian function. As shown by the distribution of Hoogland scores presented in Table 10, most subjects showed a Hoogland score of 1 (inactive). No Hoogland scores above 4 were observed in the E4 / DRSP15 / 3 mg group, and therefore no ovulation. In two treatment cycles, one subject who received EE / DRSP had a score of 6 (ovulation).

[0275] Table 10. Summary of Hoogland scores. FLS: follicle-like structure. LUF: luteinized unruptured follicle. N: total number of subjects treated. n: number of subjects in the category. (A) Ovulation was reported for one (same) subject in two treatment cycles. (B) Overall ovarian suppression was indicated by a Hoogland score ≤4. (C) In cycle 3, some subjects dropped out and Hoogland scores were not available.

[0276] Table 10. Summary of Hoogland scores.

[0277]

[0278]

[0279] As can be deduced from the Hoogland score, the majority of subjects were characterized by a Hoogland score of 1 (inactive). No Hoogland score above 4 was observed in the E4 / DRSP 15 / 3 mg group, and thus no ovulation. Strikingly, one subject receiving EE / DRSP had a score of 6 (ovulation) in both treatment cycles. Despite lower DRSP exposure than seen with EE / DRSP, E4 / DRSP was able to show complete ovulation inhibition.

Claims

1. Use of 10 mg to 20 mg of estetrol and 1 mg to 5 mg of drospirenone (DRSP) in the preparation of a combined oral contraceptive (COC) for reducing one or more DRSP-related side effects in a subject, wherein the DRSP-related side effects occur when the subject uses a combined oral contraceptive comprising drospirenone and an estrogen other than estetrol, wherein the one or more DRSP-related side effects are selected from: - QT interval prolongation of at least 5 milliseconds, - Decreased free testosterone plasma concentrations, and - Increased plasma concentration of C-reactive protein, wherein the 10 mg to 20 mg of estetrol is used as the estrogen component of the daily active dosage unit in the combined oral contraceptive (COC), and the 1 mg to 5 mg of drospirenone (DRSP) is used as the progestogen component of the daily active dosage unit in the combined oral contraceptive (COC), wherein when orally administered, the daily active dosage unit provides the following pharmacokinetic characteristics of drospirenone in plasma: (i) Geometric mean AUC of drospirenone 0-24 150 to 1000 ng.h / ml; and / or (ii) Geometric mean C of drospirenone max 10ng / ml to 100ng / ml.

2. The use according to claim 1, wherein the daily active dosage unit is provided in a contraceptive kit comprising one or more packaging units, each of which contains 21 to 28 daily active dosage units of the combined oral contraceptive (COC).

3. The use according to claim 1, wherein the COC is used continuously in a cycle of 21 to 28 daily active dosage units of the COC.

4. The use according to claim 1, wherein one or more side effects of DRSP are reduced compared to a subject using a COC comprising an equivalent effective amount of DRSP and another estrogen.

5. The use according to claim 4, wherein the COC comprising equieffective amounts of DRSP and another estrogen is a COC comprising equieffective amounts of DRSP and ethinylestradiol (EE).

6. The use according to claim 2, wherein the one or more side effects of DRSP comprise or consist of: Reduction in free testosterone in plasma associated with the use of COCs containing equipotent effective amounts of DRSP and another estrogen in subjects.

7. The use according to claim 6, wherein the reduction in free testosterone in the subject using the COC is decreased by 10% when compared to a subject using a COC comprising an equivalent effective amount of DRSP and another estrogen.

8. The use according to claim 6, wherein the free testosterone plasma concentration level is at least 25% of a baseline value, wherein the baseline value is the free plasma testosterone expression level in the subject before use of a COC comprising drospirenone.

9. The use according to claim 6, wherein the free testosterone concentration in the subject is at least 0.09 ng / dL when the COC is used.

10. The use according to claim 2, wherein the one or more side effects of DRSP comprise or consist of: Risk of QT prolongation associated with use of drospirenone-containing COCs in subjects.

11. The use according to claim 10, wherein the risk of the subject experiencing QT interval prolongation is decreased by 10% in the subject using the COC when compared to a subject using a COC comprising ethinyl estradiol as the estrogen component and an equivalent effective amount of drospirenone.

12. The use according to claim 10, wherein the mean QT interval prolongation in subjects using the COC is 20% shorter than in subjects using a COC comprising an equivalent effective amount of DRSP and another estrogen.

13. The use according to claim 10, wherein the COC has a reduced estrogen-related effect on the QT interval when compared to a subject using a COC comprising an equivalent effective amount of DRSP and another estrogen.

14. The use according to claim 2, wherein the one or more side effects of DRSP comprise or consist of: Elevated C-reactive protein plasma concentration levels associated with the use of drospirenone-containing COCs in subjects.

15. The use according to claim 14, wherein the C-reactive protein plasma concentration level is considered elevated when the level is 10% higher than a baseline value, wherein the baseline value is the C-reactive protein plasma concentration level in the subject before use of a COC comprising drospirenone.

16. The use according to claim 14, wherein the C-reactive protein plasma concentration level in the subject is below 2.00 mg / L when using a COC comprising drospirenone.

17. The use according to claim 1, wherein the COC is administered in a cyclical cycle, wherein the cycle comprises a 7-day dosing-free interval.

18. Use according to any one of claims 1 to 17, wherein a single dosage unit of the COC comprises 15 mg of the estetrol component and 3 mg of drospirenone.

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