Application of estetrol in liver injury patients

Abstract

The present invention relates to a composition comprising an estetrol component for use in alleviating estrogen deficiency symptoms, including menopausal related symptoms, in a subject characterized by a degree of liver injury. The compositions described herein exhibit advantageous pharmacokinetic properties when compared to existing estrogen-based compositions intended to alleviate symptoms of estrogen deficiency. Uses related to the above and corresponding methods of treatment are also described herein.

Description

Technical Field

[0001] The present invention generally relates to the field of medicine, and more specifically to hormone therapy for postmenopausal female subjects characterized by liver injury. Specifically, the present invention relates to a composition comprising an estetrol component for treating subjects with liver injury in a safe manner, wherein the composition is effective against estrogen deficiency symptoms in the subjects. Background Art

[0002] The liver is the main organ of the phase I and phase II drug metabolism processes, and it participates in the clearance of many drugs through multiple oxidative and conjugation metabolic pathways and / or through the biliary excretion of the parent drug or its metabolites (Almazroo et al., Clin Liver Dis, 2017).

[0003] Numerous reports in the biomedical literature have confirmed that due to these altered excretion and metabolic activities, liver diseases can alter the absorption and distribution (PK, pharmacokinetics) of drugs, as well as their efficacy and safety (PD, pharmacodynamics). Such liver injury can lead to the accumulation of drugs and their metabolites and / or the failure to form active metabolites, resulting in different sensitivities to the pharmacological effects of the administered drugs, including the expected efficacy and adverse reactions (Verbeeck, Eur J Clin Pharmacol, 2008; FDA report on pharmacokinetics in patients with impaired hepatic function, Clinical Pharmacology, 2003). These reports are based on studies of patients with common liver diseases such as alcoholic liver disease, chronic infection with hepatitis B virus and hepatitis C virus, and rarer diseases such as acute hepatitis D or acute hepatitis E, primary biliary cirrhosis, primary sclerosing cholangitis, and α1-antitrypsin deficiency. The specific impact of any disease on liver function is usually poorly characterized and highly variable, especially with respect to the PK and PD of drugs.

[0004] In the general aging population, the use of drugs aimed at alleviating one or more symptoms of estrogen deficiency (such as menopause-related symptoms) is very common. Menopause has been described in detail and can be regarded as a progressive process involving changes in different hormones over a period of usually several years, leading to the permanent cessation of ovarian follicle activity and the menstrual cycle. In short, the early stage of menopause includes an increase in follicle-stimulating hormone levels and a decrease in inhibin B expression compared to the estrogen levels typically observed in premenopausal women, although estrogen levels are generally still maintained. Over time, estrogen levels will eventually decline with the occurrence of the permanent cessation of menstruation (Djahanbakhch et al., J Pathol, 2007). The menopause process can cause a variety of adverse effects on (peri)menopausal women, including but not limited to vasomotor symptoms (VMS) (such as night sweats, hot flashes, and flushing) (Utian et al., Menopause, 2005), as well as thinning of the epithelial layers of the vagina and urethra, leading to genitourinary syndrome of menopause (GSM), which includes a wide range of symptoms such as vulvovaginal atrophy (VVA), urinary discomfort, vaginal dryness, itching, dyspareunia, dysuria, increased frequency of urination, and an increased risk of recurrent urinary tract infections (Portman et al., Menopause, 2014). In addition, menopause may have a profound impact on an individual's mental state, resulting in, for example, depression, irritability, mood changes, insomnia, sleep disorders, anxiety, and nervousness. These psychological aspects of menopause can occur independently of the physiological symptoms but can also be the consequence of the physiological symptoms. Despite significant inter-individual differences, the potential impact of menopause on an individual's overall health should not be underestimated or trivialized.

[0005] To date, estrogen therapy (i.e., hormone replacement therapy) remains the gold standard for alleviating menopausal symptoms, especially VMS. Estrogen therapy is the most consistently effective treatment used in the United States and Europe for treating VMS caused by menopause. With the reporting of safety issues in the first Women's Health Initiative publications (Anderson et al., JAMA, 2004) and the ongoing treatment needs of subjects, clinicians face challenges in determining the lowest effective dose of estrogen required to alleviate menopausal symptoms, especially for subjects with underlying medical conditions (Simon et al., Expert Opin Investig Drugs, 2007). In addition, developing safer estrogen treatment regimens compared to currently used therapies remains a prevalent challenge.

[0006] As with any drug in general, it is not possible to predict how estrogen is metabolized in subjects with liver injury, and thus the efficacy, safety, and tolerability profiles of these drugs are unknown. Typically, drugs containing estrogen are generally explicitly contraindicated in subjects with liver injury because of altered exposure to one or more of their pharmaceutically active ingredients or their metabolites. As an illustrative example, reference is made to or wherein said contraindications are explicitly recorded in the patient package insert approved by the U.S. Food and Drug Administration (FDA). In fact, estrogen may be metabolized less well in women with impaired liver function. Therefore, it is not clear whether the use of the corresponding drugs in these patients is safe or whether adjustment is needed.

[0007] Accordingly, there is a high level of interest among patients and healthcare professionals in providing any estrogen-based drug that is designed to relieve estrogen deficiency symptoms and is safe for use in subjects with liver injury, and this is also an unmet need to date.

[0008] As a prerequisite, good pharmacokinetic parameters need to be obtained in the presence of liver injury in said subjects. SUMMARY OF THE INVENTION

[0009] The inventors have observed that estetrol exhibits good tolerability in subjects with liver injury and thus provides a safer means for treating estrogen deficiency symptoms (such as menopausal-related symptoms) in said subjects compared to currently available products (see the Background section). More particularly, an estetrol dose of about 15 mg to 25 mg, more particularly an estetrol component in the range of about 15 mg to about 20 mg, was well tolerated in all subjects, and no significant treatment-related adverse events (TEAEs) were observed. All subjects maintained optimal vital signs, and laboratory values are further shown in the Examples section.

[0010] In fact, the hormone replacement therapy of the present invention (designed to relieve menopausal-related symptoms and, more generally, estrogen deficiency symptoms) has been shown to be significantly beneficial and has an extremely limited impact on a large number of liver parameters, hemostasis parameters, endocrine parameters, and metabolic parameters in subjects with liver injury. Surprisingly and extremely advantageously, in contrast, the treatment of the present invention was found to cause no change or only minimal change in most parameters.

[0011] More particularly, compared to currently known formulations for relieving estrogen deficiency symptoms such as hormone replacement therapy, the pharmacokinetic properties of a pharmaceutical composition containing estetrol as an estrogen component for relieving estrogen deficiency symptoms are generally favorable for subjects with different degrees of liver injury. The parameters covered by the favorable pharmacokinetic properties include the maximum observed plasma concentration (C of the estetrol component max) The area under the concentration-time curve (AUC) from time 0 to infinity of the estriol component (AUC inf ), the AUC of E4-3-glucuronide inf , and the half-life of the estriol component and its metabolites.

[0012] Based on the above pharmacokinetic results, it was surprisingly found that estrogen deficiency symptoms in patients with different severities of liver injury can be treated with the same dose of estriol as used in patients with normal liver function, with no significant differences in terms of safety and efficacy. The same effect on the endometrium was observed in patients with liver injury and those without liver injury: with a dose of 15 mg or higher of estriol, the number of biopsies required in both groups was lower than that in the low-dose group of 10 mg. Based on these findings, patients with liver injury can now be treated for estrogen deficiency symptoms, especially menopausal symptoms, with estrogen alone, i.e., estriol, without the need to use a progestogen such as drospirenone to counteract the effect on the endometrium. In addition, hysterectomized patients with liver function impairment also benefit from the corresponding therapy, with the advantage that the patient does not have to bear unnecessary progestogens. This therapy, i.e., a treatment regimen applicable to both hysterectomized and non-hysterectomized patients with liver injury, has not been reported to date. Accordingly, the present invention provides the following aspects:

[0013] Aspect 1. A composition for relieving estrogen deficiency symptoms in a subject with liver injury, wherein the composition comprises an estriol component, and wherein the composition is administered in a single daily dose equivalent to about 15 mg to about 25 mg of estriol.

[0014] Aspect 2. Use of a composition for the preparation of a medicament for relieving estrogen deficiency symptoms in a subject with liver injury, wherein the composition comprises an estriol component, and wherein the composition is administered in a single daily dose equivalent to about 15 mg to about 25 mg of estriol.

[0015] Aspect 3. Use of a composition comprising an estriol component for relieving estrogen deficiency symptoms in a subject with liver injury, wherein the composition is administered in a single daily dose equivalent to about 15 mg to about 25 mg of estriol.

[0016] Aspect 4. A method for relieving (i.e., treating) estrogen deficiency symptoms in a subject with liver injury, wherein the method comprises the step of administering a composition comprising an estriol component in a single daily dose equivalent to about 15 mg to about 25 mg of estriol.

[0017] Aspect 5. A method for improving the safety of a therapy for estrogen deficiency symptoms in a subject with liver injury, wherein the method comprises administering a composition comprising an estriol component in a single daily dose equivalent to about 15 mg to about 25 mg of estriol.

[0018] Aspect 6. The composition used according to Aspect 1, the use according to Aspect 2 or 3, the method according to Aspect 4 or 5, wherein the liver injury subject is characterized by a Child-Pugh score of at least 5 (corresponding to liver injury of Child-Pugh class A).

[0019] Aspect 7. The composition, use or method used according to any one of the preceding aspects, wherein the liver injury subject is characterized by a Child-Pugh score of 5 to 15 (corresponding to liver injury of Child-Pugh class A, B or C according to the Child-Pugh score).

[0020] Aspect 8. The composition, use or method used according to any one of the preceding aspects, wherein the liver injury subject is characterized by being classified as mild liver injury (Child-Pugh score of 5 or 6, or designated as "class A"), moderate liver injury (Child-Pugh score of 7 to 9, or designated as "class B") or severe liver injury (Child-Pugh score of 10 to 15, or designated as "class C") according to the Child-Pugh scoring system.

[0021] Aspect 9. The composition, use or method used according to any one of the preceding aspects, wherein the liver injury subject is characterized by being classified as mild liver injury (class A) or moderate liver injury (class B) according to the Child-Pugh scoring system.

[0022] Aspect 10. The composition, use or method used according to any one of the preceding aspects, wherein the estrogen deficiency symptoms are menopause-related symptoms.

[0023] Aspect 11. The composition, use or method used according to any one of the preceding aspects, wherein the estrogen deficiency symptoms are psychological aspects of the menopausal transition.

[0024] Aspect 12. The composition, use or method used according to Aspect 11, wherein the psychological aspects of the menopausal transition are selected from: depression, irritability, mood changes, insomnia, sleep disorders, anxiety, nervousness and any combination thereof.

[0025] Aspect 13. The composition, use or method used according to any one of the preceding aspects, wherein the estrogen deficiency symptoms are physical aspects of the menopausal transition.

[0026] Aspect 14. The composition, use or method used according to Aspect 13, wherein the physical aspects of the menopausal transition are selected from: joint pain, decreased bone density, urinary tract infection, urinary incontinence, vaginal dryness, uterine prolapse, skin tissue changes, weight gain, dyspareunia, cardiovascular disease, diabetes and any combination thereof.

[0027] Aspect 15. The composition, use or method as used according to any one of the foregoing aspects, which is used for reducing the frequency of VMS, the severity of VMS, the weekly weighted score of hot flashes, vaginal dryness, dyspareunia or any combination thereof, or for improving the quality of life according to the Menopause Rating Scale (MRS) and / or the Menopause-Specific Quality of Life (MENQOL) questionnaire.

[0028] Aspect 16. The composition, use or method as used according to any one of the foregoing aspects, wherein the composition is formulated as an oral, sublingual, buccal or sublabial dosage unit, preferably, wherein the composition is formulated as an oral dosage unit.

[0029] Aspect 17. The composition, use or method as used according to aspect 16, wherein a single administration of the oral dosage unit provides pharmacokinetic characteristics for subjects with liver injury, which are characterized by the geometric mean (GM) C of estetrol (E4) max less than 2 times the corresponding GM Cmax in subjects with normal liver function, preferably, wherein the GM C max is about 1.7 times or lower than the corresponding GM Cmax in subjects with normal liver function.

[0030] Aspect 18. The composition, use, or method as used according to aspect 16 or 17, wherein a single administration of the oral dosage unit provides pharmacokinetic characteristics for subjects with liver injury, which are characterized by the GM AUC of E4 inf less than about 2 times the corresponding GM AUC in subjects with normal liver function inf and preferably, wherein the GM AUC of E4 inf is about 1.1 times or lower than the corresponding GM AUC in subjects with normal liver function inf and preferably, wherein the GM AUC of E4

[0031] Aspect 19. The composition, use or method as used according to any one of aspects 16 to 18, wherein a single administration of the oral dosage unit provides pharmacokinetic characteristics for subjects with liver injury, which are characterized by the GMAUC of E4-3-glucuronide inf and there is no significant difference from the corresponding GM AUC of E4-3-glucuronide in subjects with normal liver function inf and preferably, wherein the GM AUC of E4-3-glucuronide

[0032] Aspect 20. The composition, use or method as used according to any one of aspects 16 to 19, wherein a single administration of the oral dosage unit provides pharmacokinetic characteristics for subjects with liver injury, which are characterized by the GM T of E4 1 / 2 and the corresponding GM T in subjects with normal liver function1 / 2 Similar.

[0033] Aspect 21. The composition, use or method used according to any one of the foregoing aspects, wherein the number, frequency and / or severity of adverse reactions do not differ between the group of subjects with liver injury and the group of subjects with normal liver function.

[0034] Aspect 22. The composition, use or method used according to any one of the foregoing aspects, wherein the subject is a female in menopause, perimenopause or postmenopause.

[0035] Aspect 23. The composition, use or method used according to any one of the foregoing aspects, wherein the composition comprises from about 15 mg to about 25 mg of an estetrol component.

[0036] Aspect 24. The composition, use or method used according to any one of the foregoing aspects, wherein the composition comprises from about 15 mg to about 20 mg of an estetrol component.

[0037] Aspect 25. The composition, use or method used according to any one of the foregoing aspects, wherein the composition comprises about 15 mg of an estetrol component.

[0038] Aspect 26. The composition, use or method used according to any one of Aspects 1 to 24, wherein the composition comprises about 20 mg of an estetrol component.

[0039] Aspect 27. The composition, use or method used according to any one of the foregoing aspects, wherein the estetrol component is estetrol or an ester thereof.

[0040] Aspect 28. The composition, use or method used according to any one of Aspects 1 to 26, wherein the estetrol component is estetrol monohydrate.

[0041] Aspect 29. The composition, use or method used according to any one of the foregoing aspects, wherein the composition further comprises a progestogen component.

[0042] Aspect 30. The composition, use or method as used according to aspect 29, wherein the progestogen component is selected from: progesterone, drospirenone, norethisterone, norethisterone acetate (NETA), dydrogesterone, levonorgestrel (LNG), etonogestrel, norgestrel, nomegestrol, nomegestrol acetate (NOMAC), trimegestone, nestorone, dydrogesterone, gestodene, desogestrel, norgestimate, cyproterone acetate, dienogest, and chlormadinone.

[0043] Aspect 31. The composition, use or method as used according to aspect 29 or 30, wherein the progestogen component is selected from drospirenone, progesterone or dydrogesterone.

[0044] Aspect 32. The composition, use or method as used according to any one of aspects 29 to 31, wherein the progestogen component is drospirenone, preferably about 0.25 mg to about 10 mg of drospirenone, more preferably about 1 mg to about 4 mg of drospirenone, even more preferably about 3 mg of drospirenone, or wherein the progestogen component is administered in an amount equivalent to about 0.25 mg to about 10 mg of drospirenone, preferably equivalent to about 1 mg to about 4 mg of drospirenone, more preferably equivalent to about 3 mg of drospirenone.

[0045] Aspect 33. The composition, use or method as used according to any one of aspects 29 to 32, wherein the progestogen component is progesterone, preferably about 25 mg to about 300 mg of progesterone, more preferably about 100 mg to about 200 mg of progesterone, or wherein the progestogen component is administered in an amount equivalent to about 0.25 mg to about 10 mg of drospirenone, preferably equivalent to about 1 mg to about 4 mg of drospirenone, more preferably equivalent to about 3 mg of drospirenone.

[0046] Aspect 34. The composition, use or method as used according to any one of Aspects 29 to 33, wherein the progestogen component is dydrogesterone, preferably about 1 mg to about 20 mg of dydrogesterone, more preferably about 5 mg to about 10 mg of dydrogesterone, or wherein the progestogen component is administered in an amount equivalent to about 1 mg to about 20 mg of dydrogesterone, preferably in an amount equivalent to about 5 mg to about 10 mg of dydrogesterone.

[0047] Aspect 35. The composition, use or method as used according to any one of Aspects 1 to 28, wherein the composition further comprises bazedoxifene.

[0048] Aspect 36. The composition, use or method as used according to any one of Aspects 1 to 28, wherein the estetrol component is the single (i.e., the only) pharmaceutically active ingredient in the composition.

[0049] Aspect 37. The composition, use or method as used according to any one of the preceding aspects, wherein the composition is formulated to correspond to a single-day dosage unit.

[0050] Aspect 38. The composition, use or method as used according to any one of the preceding aspects, wherein the composition is used in a multi-dose regimen once a day.

[0051] In any aspect defined by the present invention, the dosage unit may exist in the form of a kit-of-parts, the kit comprising a packaging unit, such as a blister pack, the packaging unit comprising a single-day oral dosage unit containing the estetrol component. Those skilled in the art will understand that within the scope of the present invention, each packaging unit, such as a blister pack, may be numbered or otherwise marked.

[0052] Within the scope of the present invention, each such packaging unit may be a sealed blister pack with a cardboard, cardstock, foil plastic backing and encapsulated in a suitable protective outer shell.

[0053] Such packaging units for any aspect contemplated by the present invention are also bottles. The material of the bottle is not particularly limited. In a preferred embodiment, the bottle is a glass bottle, characterized in that its color can reduce or prevent, for example, the degradation of the contents of the bottle caused by ultraviolet (UV) light, while maintaining a certain transparency for visual inspection of the contents of the bottle. Suitable colors include, but are not limited to, amber, cobalt or vintage green.

[0054] Aspect 40. In a specific embodiment of the kit according to Aspect 39, the packaging unit comprises 28 containers or an integer multiple of 28 containers, such as 2 to 12 times 28 containers.

[0055] The above and other aspects and preferred embodiments of the present invention will be described in detail in the following sections and the appended claims. The subject matter of the appended claims is hereby expressly incorporated into this specification. BRIEF DESCRIPTION OF THE DRAWINGS

[0056] Figure 1 . Curve of the arithmetic mean (+ standard deviation, SD) plasma concentration of E4 versus time (linear scale) within up to 24 hours after dosing (pharmacokinetic data set). SD = standard deviation; LLOQ = lower limit of quantification. Note: LLOQ = 0.025 ng / mL. X-axis: time after dosing (hours); Y-axis: plasma concentration (ng / ml). Circles: normal liver function group; solid circles: mild liver injury group; triangles: moderate liver injury group; solid triangles: severe liver injury group.

[0057] Figure 2 . Curve of the geometric mean plasma concentration of E4 versus time (semi-logarithmic scale) (pharmacokinetic data set). LLOQ = lower limit of quantification. Note: LLOQ = 0.025 ng / mL. X-axis: time after dosing (hours); Y-axis: plasma concentration (ng / ml). Circles: normal liver function group; solid circles: mild liver injury group; triangles: moderate liver injury group; solid triangles: severe liver injury group.

[0058] Figure 3 . Curve of the arithmetic mean (± standard deviation) plasma concentration of E4-3-glucuronide versus time (linear scale) within up to 24 hours after dosing (pharmacokinetic data set). SD = standard deviation; LLOQ = lower limit of quantification. Note: LLOQ = 0.250 ng / ml. X-axis: time after dosing (hours); Y-axis: plasma concentration (ng / ml). Circles: normal liver function group; solid circles: mild liver injury group; triangles: moderate liver injury group; solid triangles: severe liver injury group.

[0059] Figure 4 . Curve of the geometric mean plasma concentration of E4-3-glucuronide versus time (semi-logarithmic scale) (pharmacokinetic data set). LLOQ = lower limit of quantification. Note: LLOQ = 0.250 ng / ml. X-axis: time after dosing (hours); Y-axis: plasma concentration (ng / ml). Circles: normal liver function group; solid circles: mild liver injury group; triangles: moderate liver injury group; solid triangles: severe liver injury group.

[0060] Figure 5Arithmetic mean (+SD) plasma concentration-time curve (linear scale) of E4-16-glucuronide within up to 24 hours after dosing (pharmacokinetic data set). SD = standard deviation; LLOQ = lower limit of quantification. Note: LLOQ = 0.500 ng / ml. X-axis: time after dosing (hours); Y-axis: plasma concentration (ng / ml). Circles: normal liver function group; solid circles: mild liver injury group; triangles: moderate liver injury group; solid triangles: severe liver injury group.

[0061] Figure 6 Relationship between geometric mean plasma concentration of E4-16-glucuronide and time (semi-logarithmic scale) (pharmacokinetic data set). LLOQ = lower limit of quantification. Note: LLOQ = 0.500 ng / ml. X-axis: time after dosing (hours); Y-axis: plasma concentration (ng / ml). Circles: normal liver function group; solid circles: mild liver injury group; triangles: moderate liver injury group; solid triangles: severe liver injury group.

[0062] Figure 7 Main pharmacokinetic parameters of E4 and Child-Pugh score (pharmacokinetic data set). AUC inf = area under the concentration-time curve from time 0 to infinity; C max = maximum observed plasma concentration. White circles: normal liver function group; solid circles: mild liver injury group; squares: moderate liver injury group; triangles: severe liver injury group; X-axis: Child-Pugh score; Y-axis: C max (ng / mL); AUC inf (ng / mL).

[0063] Figure 8 Geometric least squares mean ratio of C max of E4. X-axis: geometric least squares mean ratio (Cmax (ng / ml) and 90% confidence interval); Y-axis: comparison group (test vs. control vs. reference). Top comparison group: mild vs. normal. Middle comparison group: moderate vs. normal. Bottom comparison group: severe vs. normal.

[0064] Figure 9 Geometric least squares mean ratio of AUC inf of E4. X-axis: geometric least squares mean ratio (AUC inf (h*ng / mL)) and 90% confidence interval; Y-axis: comparison group (test vs. control vs. reference). Top comparison group: mild vs. normal. Middle comparison group: moderate vs. normal. Bottom comparison group: severe vs. normal.

[0065] Figure 10. The frequencies of vasomotor symptoms (VMS) (measured as the number of hot flashes per week) in the 0.15 mg estetrol monohydrate, 20 mg estetrol monohydrate, and placebo treatment groups. The changes in the weekly frequency of moderate to severe VMS from baseline to week 4 and week 12 were statistically analyzed based on the MMRM model; intention-to-treat (ITT) population; p-values (least-squares mean differences) for the change from baseline in the E4 treatment groups compared to the placebo group.

[0066] Figure 11 . The proportion of subjects with a ≥50% or ≥75% reduction in the weekly frequency of moderate to severe VMS from baseline over time; efficacy study section - intention-to-treat (ITT) population; *: p-value < 0.05; **: p-value < 0.01; ***: p-value < 0.001; ****: p-value < 0.0001.

[0067] Figure 12 . The severity of VMS in the 0.15 mg estetrol monohydrate group, 20 mg estetrol monohydrate group, and placebo treatment group. Based on the FDA method, the changes in the weekly severity of moderate to severe VMS from baseline to week 4 and week 12 were statistically analyzed using the MMRM model; intention-to-treat (ITT) population; p-values (least-squares mean differences) for the change from baseline in the E4 treatment groups compared to the placebo group.

[0068] Figure 13 . After 12 weeks of treatment with 0.15 mg and 20 mg estetrol monohydrate, the glycated hemoglobin A1C levels in the subjects decreased. (A) Levels of glycated hemoglobin A1C. Left condition = baseline value, right condition = week 12; (B) Change from baseline. *: p-value < 0.05; **: p-value < 0.01; ***: p-value < 0.001; ****: p-value < 0.0001.

[0069] Figure 14 . After 12 weeks of treatment with 0.15 mg and 20 mg estetrol monohydrate, the fasting blood glucose levels in the subjects decreased. (A) Fasting blood glucose levels. Left condition = baseline value, right condition = week 12; (B) Change from baseline. *: p-value < 0.05; **: p-value < 0.01; ***: p-value < 0.001; ****: p-value < 0.0001. Detailed implementation

[0070] As used herein, the singular forms "a / an" and "the" include singular and plural referents unless the context clearly dictates otherwise.

[0071] As used herein, the terms "comprising", "comprises" and "comprised of" are synonymous with "including" or "contains" as used herein, 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 the meanings recognized in patent terminology.

[0072] The description of a numerical range by endpoints includes all the values and fractions contained within the respective ranges, as well as the recited endpoints. This applies to numerical ranges, whether they are introduced by recitation "from... to...", or "between... and...", or other expressions.

[0073] As used herein, the terms "about" or "substantially" when referring to a measurable value (such as a parameter, amount, period, etc.) are intended to cover variations of and from the recited value, such as variations of + / −10% or less, preferably + / −5% or less, more preferably + / −1% or less, still more preferably + / −0.1% or less of the recited value, and variations from the recited value of + / −10% or less, preferably + / −5% or less, more preferably + / −1% or less, still more preferably + / −0.1% or less, insofar as such variations are suitable for carrying out the invention disclosed. It is to be understood that the values themselves recited by the modifier "about" or "substantially" are also specifically and preferably disclosed.

[0074] The terms "one or more" or "at least one", such as one or more members or at least one member of a group of members, are clear in themselves. By way of further illustration, the term specifically encompasses any one of the recited members, or any two or more of the recited members, such as, for example, any ≥3, ≥4,

[0075] ≥5, ≥6 or ≥7, etc., and up to all of the recited members. In another example, "one or more" or "at least one" can mean 1, 2, 3, 4, 5, 6, 7 or more.

[0076] The discussion of the background of the invention is included herein to explain the background of the invention. This should not be construed as an admission that any of the materials recited is part of the prior art, known or part of the common general knowledge in any country as of the priority date of any claim.

[0077] Throughout this disclosure, various publications, patents, and published patent specifications are referred to by their identifying citation. All documents cited in this specification are hereby incorporated by reference in their entirety. In particular, the teachings of these documents or portions thereof herein are specifically incorporated by reference.

[0078] Unless otherwise specified, 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 pertains. By way of further explanation, term definitions are included to better understand the teachings of the present invention. When a particular term is defined for a specific aspect or particular embodiment of the present invention, unless otherwise stated, the specific meaning or interpretation of that term shall apply throughout the entire specification, i.e., also to other aspects or other embodiments of the present invention. For example, an embodiment for a product shall equally apply to the corresponding features in a method and use.

[0079] In the following paragraphs, different aspects or embodiments of the present invention are defined in more detail. Each aspect or embodiment so defined may be combined with any other aspect or embodiment, unless clearly indicated to the contrary. In particular, any feature indicated as being preferred or advantageous may be combined with any one or more other features indicated as being preferred or advantageous.

[0080] Throughout this specification, reference to "an embodiment" or "embodiments" means that a particular feature, structure, or characteristic described in connection with the embodiment is included in at least one embodiment of the present invention. Thus, the appearances of the phrases "in an embodiment" or "in embodiments" in various places throughout this specification are not necessarily all referring to the same embodiment, but may not be the same embodiment. Furthermore, in one or more embodiments, the particular features, structures, or characteristics may be combined in any suitable manner, as will be apparent to those skilled in the art from this disclosure. Additionally, although some embodiments described herein include some but not other features included in other embodiments, combinations of features of different embodiments are intended to be included 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, any of the claimed embodiments may be used in any combination, as will be understood by those skilled in the art.

[0081] Unless otherwise indicated, all methods, steps, techniques, and operations not specifically described in detail may be carried out in the manner known per se and have been carried out in the manner known per se, which will be clear to those skilled in the art. For example, reference may again be made to standard manuals, the prior art background cited herein, and other references cited therein.

[0082] As used throughout this document, the term "estetrol component" includes substances selected from the following: estetrol; estetrol esters; estetrol esters in which a hydrogen atom of at least one hydroxyl group is substituted by an acyl group of a hydrocarbon carboxylic acid, sulfonic acid or sulfamic acid having 1-25 carbon atoms; estetrol hydrates, such as estetrol monohydrate; and combinations thereof. When estetrol is mentioned in any part of this specification, it should be understood to simultaneously consider estetrol-containing components (i.e., compounds) and / or estetrol derivatives (e.g., estetrol esters). More preferably, in the context of the present disclosure, the particularly preferred estetrol component applicable to the dosage units, pharmaceutical uses and treatment methods described herein is estetrol (including estetrol hydrates). Most preferably, the estetrol component is estetrol monohydrate.

[0083] As used herein, the term "estetrol" refers to 1,3,5(10)-estratriene-3,15α,16α,17β-tetrol or 15α-hydroxyestriol and hydrates of estetrol, such as estetrol monohydrate. "Estetrol" or simply "E4" is an estrogen steroid produced by the human fetal liver (PubChem CID: 27125). Estetrol can be described as a 3-hydroxy steroid whose structure corresponds to 17β-estradiol, where 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., Climacteric, 2008). Estetrol can be synthesized by chemical synthesis, synthesis using (mutant) recombinant enzymes, or any combination of the above methods. Thus, it is obvious that the terms "estetrol" and "estetrol component" also cover estetrol further chemically modified. Estetrol can be represented in the art by its molecular formula: C 18 H 24 O4 or structural formula (I).

[0084] Formula (I)

[0085]

[0086] In a preferred embodiment, the estetrol component is estetrol or its ester. In a further embodiment, the estetrol component is estetrol monohydrate. Those skilled in the art should understand that estetrol monohydrate corresponds to estetrol containing one water molecule, and the core structural formula of estetrol is not different from formula (I). By way of illustration and not limitation, the structural formula of estetrol monohydrate is represented by formula (II):

[0087] Formula (II)

[0088]

[0089] As used herein, the term "subject" or "patient" refers to a female human subject, preferably a perimenopausal and / or postmenopausal female subject. The female subjects contemplated herein can be treatment subjects in need of, or determined to be in need of, alleviation of symptoms of estrogen deficiency (such as menopausal-related symptoms), or subjects who are expected to need such treatment at a foreseeable future time point due to, for example, entering the perimenopausal stage of life.

[0090] Those skilled in the art will appreciate that terms such as "quantity", "amount", and "level" are synonyms and have well-defined meanings in the art. The terms used herein can specifically refer to the absolute quantification of a molecule, such as a steroid, in a subject (a sample taken from the subject); to the relative quantification of a molecule or analyte in a sample, i.e., relative to another value such as a reference value as taught herein; or to a numerical range representing the baseline value of a certain parameter. These values or ranges of values can be obtained from a single subject or a group of subjects (i.e., at least two subjects). Additionally, when referring to the (absolute or relative) amount of a parameter such as AUC or C max , these amounts should be interpreted as the amounts measured in the plasma (samples) of one or more subjects. "Plasma" and "serum plasma" are both commonly accepted terms in the medical and clinical context, and there is no ambiguity in their interpretation for those skilled in the art (Matthew and Varacallo, Physiology, Blood plasma, StatPearls, 2019).

[0091] "Dosage unit" and "dosage form" are used interchangeably herein and in the art to denote a physical formulation suitable for administration to a subject without the need to adjust the pharmaceutical product prior to administration, i.e., the final effective formulation. Thus, a dosage unit represents a ready-to-use composition. The term does not define any other specific details of the treatment, such as the frequency of administration and / or any characteristics of the dosage unit (taste, appearance, specifications, etc.). In the context of the present invention, each dosage unit preferably contains an estetrol component in an amount equivalent to about 15 mg to about 25 mg of estetrol as a pharmaceutically acceptable ingredient. The presence of the estetrol component as a pharmaceutically acceptable ingredient does not exclude the presence of one or more additional pharmaceutical ingredients and / or pharmaceutically acceptable ingredients in the dosage unit. The term "pharmaceutically acceptable" as used herein is consistent with the art and means compatible with the other components of the pharmaceutical composition and not harmful to its recipient. Non-limiting suitable excipients are described throughout the present disclosure.

[0092] Those skilled in the art should be aware of the meanings of the following abbreviations used throughout this disclosure, and each abbreviation should be interpreted in accordance with its generally accepted meaning:

[0093] Cmax : Maximum observed plasma concentration;

[0094] AUC inf : Area under the concentration-time curve from time 0 to infinity (AUC);

[0095] AUC 0-24h : AUC within 0 to 24 hours after dosing;

[0096] AUC last : AUC up to the last time point with concentration higher than the lower limit of quantification;

[0097] t max : Time to reach C max Required time;

[0098] t 1 / 2 : Terminal elimination half-life;

[0099] C L / F : Apparent clearance (only applicable to E4);

[0100] λz: Terminal elimination phase rate constant;

[0101] Vz / F: Apparent volume of distribution at the terminal stage (only applicable to E4).

[0102] Through extensive research, the inventors have observed that when used to treat estrogen deficiency symptoms, such as but not limited to menopausal-related symptoms, in subjects with liver injury, estetrol unexpectedly exhibits excellent safety characteristics. This is contrary to existing commercially available products such as (containing 1 mg of estradiol and 0.5 mg of drospirenone), which even clearly state that liver injury is an explicit contraindication for using the product. It is worth noting that while maintaining satisfactory efficacy, this improved safety can still be achieved. The degree of liver injury of the subjects is not particularly limited for the present invention, and favorable pharmacokinetic characteristics can be found to a certain extent in any group classified according to the Child-Pugh classification, although these unexpected characteristics are most significant in subjects with mild or moderate liver injury. Particularly favorable parameters include the maximum observed plasma concentration (C max ) of the estetrol component, the area under the concentration-time curve from time 0 to infinity (AUC) (AUC inf ) of the estetrol component, the AUC of E4-3-glucuronide inf , and the half-lives of the estetrol component and its metabolites obtained after dosing estetrol to subjects with liver injury.

[0103] Accordingly, in a first aspect, the present invention relates to a composition for alleviating estrogen deficiency symptoms in a subject with liver injury (which symptoms may optionally occur during menopause), wherein the composition comprises an estetrol component, and wherein the composition is administered in a single daily dose equivalent to about 15 mg to about 25 mg of estetrol.

[0104] Those skilled in the art should understand that the expression "administered in a single daily dose equivalent to about x mg to about y mg of estetrol" means that in the context of the present invention, a certain substance (estetrol component) is administered to achieve the same physiological and / or psychological effects as when the subject is administered x mg to y mg of estetrol. Additionally, the term "single daily" means that the stated dose is the cumulative amount administered to the subject per day. Those skilled in the art should understand that when the estetrol component is administered only once a day (i.e., single daily), the amount of estrogen administered in that single dose is the single daily dose. Alternatively, those skilled in the art should understand that if the estetrol component is administered more than once a day (e.g., 2 or 3 times), the single daily dose corresponds to the sum of the estetrol components administered in each dosing event within a 24-hour total time window. In embodiments where the composition comprises different estetrol components (e.g., estetrol monohydrate and estetrol esters), those skilled in the art are capable of verifying the amount of estetrol corresponding to each estetrol component. Preferred embodiments in the context of the present invention include administering a single estetrol component, such as but not limited to estetrol monohydrate.

[0105] Furthermore, the present invention contemplates the use of a composition comprising an estetrol component in the manufacture of a medicament for alleviating estrogen deficiency symptoms, such as menopause-related symptoms, in a subject with liver injury, wherein the medicament is formulated to be administered such that the single daily dose of the estetrol component is equivalent to about 15 mg to about 25 mg of estetrol.

[0106] Furthermore, the use of a composition comprising an estetrol component in alleviating estrogen deficiency symptoms, such as menopause-related symptoms, in a subject with liver injury is contemplated, wherein the composition is used such that the estetrol component is administered to the subject in a single daily dose equivalent to about 15 mg to about 25 mg of estetrol.

[0107] Additionally, a method for alleviating (i.e., treating) estrogen deficiency symptoms, such as menopause-related symptoms, in a subject with liver injury is contemplated. The method comprises the step of administering to the subject a composition comprising an estetrol component in a single daily dose equivalent to about 15 mg to about 25 mg of estetrol.

[0108] "Estrogen deficiency symptoms" have been described in the art and include any symptoms that a subject may experience due to estrogen deficiency (i.e., "estrogen insufficiency" or "estrogen deficiency syndrome"). In a preferred embodiment of the present invention, estrogen deficiency symptoms occur in the context of menopause, and thus such symptoms may be referred to as menopause-related symptoms. The expression "alleviating menopause-related symptoms" used throughout this specification has a recognized meaning in the art and refers to the treatment of any adverse physical or psychological manifestations that accompany or occur at the onset of menopause. Accordingly, the compositions disclosed herein are generally used for the (therapeutic) treatment of menopause-related symptoms, i.e., as compositions administered to a subject during the course of treatment. The use of the compositions described herein for preventing the occurrence of estrogen deficiency symptoms, or more specifically menopause-related symptoms, is also contemplated.

[0109] Furthermore, those skilled in the art should understand that the expression "alleviating menopause-related symptoms" in combination with the characteristics of the compositions comprising an estetrol component means that the uses and methods described herein additionally cover the medical indications of hormone replacement therapy. It is generally accepted in the fields of pharmacy and medicine that hormone replacement therapy (abbreviated as "HRT") involves the use of one or more drugs (i.e., one or more compositions) that are intended to increase or supplement the hormone levels in women with insufficient hormone production. HRT can alleviate and prevent symptoms caused by a reduction in circulating estrogen (and progesterone hormones), regardless of whether the subject is in the premenopausal, perimenopausal, menopausal or postmenopausal stage. Hormone replacement therapy (HRT) is used to describe unopposed estrogen application (for female subjects who have had a hysterectomy) or combined estrogen-progesterone therapy (for female patients who still have a uterus). More specific disease states have been documented for each stage of the menopausal process.

[0110] The term "treatment / treat" shall be interpreted as therapeutic treatment of symptoms, diseases or disorders that have developed and led to (clinical) manifestations, as well as preventive or prophylactic measures aimed at preventing, alleviating or reducing the likelihood of the occurrence of an unwanted ailment, such as preventing menopausal-related symptoms, the appearance, development and progression of (clinical) disorders. Beneficial or desired clinical outcomes may include, but are not limited to, alleviating one or more symptoms, improving one or more biomarkers, reducing the degree of menopausal-related symptoms (i.e., reduced severity), stabilizing menopausal symptoms (i.e., not worsening), delaying or slowing the onset of menopausal-related symptoms, etc. As used in the context of the present invention, "prevention" (or "prevent") means avoiding the appearance of a certain disorder or disease manifestation in a subject, i.e., establishing preventive or prophylactic measures. Preventive treatment means treatment aimed at preventing the worsening of symptoms of unwanted physiological or psychological changes caused by menopause in the body of the subject or its components. As used herein, terms such as "therapeutic treatment" or "therapy" mean treatment aimed at transforming the body of the subject or a part of the subject's body from an unwanted physiological state, disease or disorder caused by aging into a desired state, such as a less severe state (e.g., improvement, or even restoration to a normal healthy state (such as restoring the health, physiological integrity and well-being of the subject), maintaining (i.e., not worsening) the unwanted physiological state (e.g., stabilizing), or delaying the progression to a more severe or worsening state compared to the unwanted physiological changes or disorders). Measurable alleviation includes any statistically significant decrease in measurable markers or symptoms. Statistically significant as used herein means a p-value below 0.05, which is a critical value in statistical analysis generally accepted by those skilled in the art. "Treatment" includes curative treatment and treatment aimed at alleviating estrogen deficiency symptoms and / or delaying their progression and / or stabilizing estrogen deficiency symptoms.

[0111] The subjects preferably contemplated by the present invention are female subjects (diagnosed, identified or predicted (i.e., foreshadowed)) characterized by liver injury and who are suffering from or predicted (i.e., foreshadowed) to suffer from one or more estrogen deficiency symptoms, which may optionally be regarded as one or more menopausal-related symptoms.

[0112] In the embodiment in which the subject has suffered from one or more menopausal symptoms, the subject can be a subject with hormone imbalance. In the context of the present invention, imbalance is determined or established by comparing the hormone levels of the subject with the representative values of adult, healthy female subjects. The cause of hormone imbalance is particularly limited for this disclosure and can be natural causes (such as menopausal hormone changes), but can also be caused by pathological conditions or lack thereof. In certain embodiments, hormone imbalance is estrogen imbalance, such as 17β-estradiol imbalance. In such embodiments, the value of 17β-estradiol and the representative 17β-estradiol of adult female subjects differs by at least 15%, preferably at least 25%, more preferably at least 50%. In the case where the endogenous estrogen generation of a female subject reduces, the subject can be considered as a subject suffering from estrogen deficiency syndrome.

[0113] The term "17β-estradiol" refers to (17β)-estradiol-1,3,5(10)-triene-3,17-diol, which may be interchangeably referred to as "estradiol" or "E2," and is an estrogen produced endogenously by the human body. More specifically, estradiol is the primary estrogen produced by the human ovary during the first half of the menstrual cycle (i.e., the follicular phase). Estradiol has also been implicated in maintaining bone density, reducing vasomotor symptoms, and maintaining the normal structure of the female reproductive organs in menopausal subjects.

[0114] The present invention contemplates embodiments involving subjects characterized by estrogen depletion (i.e., too little estrogen or estrogen deficiency syndrome). Although the present invention is primarily directed to alleviating menopausal-related symptoms, it will be appreciated by those skilled in the art that many of these symptoms themselves may also occur in female subjects suffering from medical conditions that are not menopausal but still cause one or more menopausal-related symptoms. Therefore, the present invention is equally applicable to alleviating estrogen deficiency symptoms that may occur in people who are not experiencing menopause and / or who are not predicted to be about to enter menopause. The cause of too little estrogen is not particularly limited and can therefore be caused by non-limiting causes of menopause, hypogonadism, castration, primary ovarian failure, and aromatase inhibitors or gonadotropin-releasing hormone analogs for breast cancer treatment.

[0115] In certain embodiments, the subject is a postmenopausal, perimenopausal or menopausal female subject. In certain embodiments, the subject is a postmenopausal, perimenopausal or menopausal subject with a 17β-estradiol level of less than 100 pg / ml, preferably less than 50 pg / ml, preferably less than 30 pg / ml, more preferably less than 20 pg / ml, more preferably less than 20 pg / ml, and most preferably less than 10 pg / ml. In alternative embodiments, the subject is a postmenopausal, perimenopausal or menopausal subject characterized by a follicle-stimulating hormone concentration of at least 20 milli-international units per milliliter (mIU / ml), preferably at least 25 mIU / ml, more preferably at least 30 mIU / ml, further preferably at least 35 mIU / ml, and most preferably at least 40 mIU / ml.

[0116] "Menopausal subject" is used interchangeably in the art with "postmenopausal subject" or "menopause subject" and refers to a female subject who has had no menstrual bleeding for one year and is accompanied by a decrease or cessation of hormones produced by the ovaries, such as 17β-estradiol.

[0117] According to the US Food and Drug Administration (US FDA), the criteria for determining the postmenopausal state are:

[0118] · At least 12 months of spontaneous amenorrhea; or

[0119] · At least 6 months of spontaneous amenorrhea and a serum follicle-stimulating hormone (FSH) level > 40 mIU / mL; or

[0120] · At least 6 weeks after bilateral oophorectomy, with or without hysterectomy.

[0121] In other words, "menopause" can be described as a biological state characterized by primary impairment or termination of ovarian function. Menopause may be accompanied by a variety of clinical symptoms of varying severity, such as but not limited to vasomotor dysfunction, vaginal dryness, mood swings, sleep disorders, urinary incontinence, cognitive changes, somatic discomfort, and sexual dysfunction. Methods for diagnosing menopause have been described in the art and are thus known to those skilled in the art (Nelson, Menopause, Lancet, 2008).

[0122] "Perimenopause" refers to the life stage that begins approximately three to four years before menopause and ends one year after the last menstrual period, characterized by irregular menstrual cycles, dramatic hormonal fluctuations, frequent anovulation, and the onset of vasomotor symptoms (Harlow et al., Executive summary of the Stages of Reproductive Aging Workshop +10: addressing the unfinished agenda of staging reproductive aging, Menopause, 2012). The term "postmenopausal" or "post-menopausal" denotes a female subject characterized by the permanent cessation of the menstrual cycle. This permanent cessation is retrospectively determined after observing 12 months of amenorrhea without any other obvious pathological or physiological cause. The term "postmenopausal" also includes menopause due to premature ovarian failure, surgery (e.g., oophorectomy), chemotherapy or radiotherapy for cancer, and certain diseases (e.g., infections or hypothyroidism).

[0123] Thus, in the context of the present invention, a female subject is a menopausal, perimenopausal, or postmenopausal subject.

[0124] Preferably, the subject is an adult female subject. More preferably, the subject is a middle-aged or elderly female subject. Even more preferably, the subject is a female subject who is at least 40 years old, preferably at least 50 years old, preferably at least 55 years old, more preferably at least 60 years old, more preferably at least 65 years old. Alternatively, the subject can be a female subject who is 40 to 90 years old, preferably 45 to 85 years old, preferably 50 to 80 years old, more preferably 55 to 75 years old, more preferably 60 to 70 years old or 65 to 75 years old. In certain embodiments, the female subject is not more than 90 years old, preferably not more than 85 years old, more preferably not more than 80 years old, more preferably not more than 75 years old, more preferably not more than 70 years old, more preferably not more than 65 years old, more preferably not more than 60 years old. "Diagnosed with", "diagnosing" and "diagnosis" are processes of identifying, determining or confirming a disease, disorder or (adverse reaction) in a subject based on the results of symptoms and signs and / or various diagnostic procedures (such as by detecting the presence, absence and / or quantity of one or more biomarkers, or the clinical symptom characteristics of the diagnosed disease or disorder). The "diagnosis" of one or more estrogen deficiency symptoms may specifically refer to the determination by a professional medical practitioner that the subject has at least one estrogen deficiency symptom. Although the subject exhibits one or more typical symptoms or signs indicating such symptoms, a lack of symptoms may ultimately still be diagnosed. The "diagnosis" of one or more estrogen deficiency symptoms in an individual herein may specifically refer to the subject having at least one physiological estrogen deficiency symptom and / or at least one psychological estrogen deficiency symptom. "Predict" in the context of the present invention means predicting the progression and recovery prospects (such as probability, duration and / or degree) of one or more estrogen deficiency symptoms in a subject and / or the severity or improvement of the suffering of said one or more estrogen deficiency symptoms. The term may include a prediction, preferably within a specific time period, that the symptoms will not further deteriorate or worsen. The "poor prognosis" of a disease or disorder generally includes an expected substandard recovery and / or an unsatisfactory slow recovery, or no recovery at all, or a further deterioration of one or more estrogen deficiency symptoms, said one or more estrogen deficiency symptoms including physiological estrogen deficiency symptoms, psychological estrogen deficiency symptoms or a combination thereof.

[0125] In relation to the foregoing, "predicting" (or "prediction") generally refers to the statement, declaration, indication, or prediction of a disease or disorder in a subject who has not yet shown any or only limited clinical manifestations of one or more estrogen deficiency symptoms. The prediction of one or more estrogen deficiency symptoms in a subject can indicate the likelihood, chance, or risk that the subject will develop the clinical manifestation, disorder, or (adverse) side effect, for example, within a certain period of time after the diagnosis of one or more estrogen deficiency symptoms. The likelihood, chance, or risk can be expressed as any suitable qualitative or quantitative expression, non-limiting examples of quantitative expressions including absolute values, ranges, or statistics. Alternatively, the likelihood, chance, or risk can be expressed relative to a suitable control subject or group of control subjects (i.e., a control subject population (e.g., relative to an average, normal, or healthy subject or subject population)). Thus, any likelihood, chance, or risk can be advantageously expressed as an increase / decrease, upregulation / downregulation, such as a fold increase / fold decrease, relative to a suitable control subject or subject population, or relative to a baseline value, where the baseline value can be derived from a control subject (population) or a textbook reference value. It is evident that when a subject population is used to define the baseline value, the baseline value should be the central magnitude of one or more numerical values (parameters) of the population, such as the mean or median of the numerical values. Those skilled in the art should also understand that monitoring can be implemented during the medical process of the subject. Such monitoring can include, for example, determining whether a patient can be discharged from a controlled clinical or healthcare environment, whether the treatment regimen needs to be adjusted, or whether hospitalization is required.

[0126] In each embodiment disclosed herein, the composition is intended to alleviate estrogen deficiency symptoms, such as menopause-related symptoms, by providing an estetrol component in an amount equivalent to about 15 mg to about 25 mg of estetrol. This means that the estetrol component in the composition is present in a pharmaceutically effective amount, including in embodiments where a single-day equivalent dose is obtained by administering the composition multiple times. A "pharmaceutically effective amount" means the amount necessary to achieve a physiological effect, which can be expressed as a therapeutically effective amount and / or a prophylactically effective amount. The physiological effect can be achieved by a single administration or multiple administrations. A "therapeutically effective amount" or "therapeutically effective dose" means the amount of the estetrol component that, when administered to a subject suffering from estrogen deficiency symptoms, is capable of producing a clinically positive response upon administration. Similarly, a "prophylactically effective amount" or "prophylactically effective dose" is the amount of the estetrol component that an investigator, veterinarian, physician, or other clinician desires to inhibit or delay the onset of the clinical manifestation of a disorder. Those skilled in the art will appreciate that terms such as "quantity," "amount," and "level" are synonyms and have well-defined meanings in the art, and in particular, recognize that these terms can refer to the absolute quantitative value of the estetrol component, i.e., the effective amount for use as described herein, or to the relative quantitative value of the estetrol component. Suitable numerical values or ranges of values can be obtained from a single subject or a group of subjects (i.e., at least two subjects).

[0127] Another aspect of the invention relates to a method of improving the safety of a treatment for alleviating estrogen deficiency symptoms (including but not limited to menopause-related symptoms) in a subject with liver injury, the method comprising administering a composition comprising an estetrol component in a single-day amount equivalent to about 15 mg to about 25 mg. As shown in the examples included herein, it has been demonstrated that, compared to existing alternative therapies that rely on administering estrogens other than the estetrol component described herein, administering the estetrol component can improve the safety of the treatment of estrogen deficiency symptoms by reducing the liver burden on the subject. Accordingly, the invention also relates to a method of improving the pharmacokinetic profile of a drug for treating estrogen deficiency symptoms, and a method of improving the safety of a treatment for alleviating estrogen deficiency symptoms based on the improvement of the pharmacokinetic profile in a subject with liver injury.

[0128] The subjects described in this article are subjects with liver injury. Unless otherwise specifically stated, the degree of liver injury is not particularly restricted in the context of the present invention. In this specification, liver injury can be represented by the Child-Pugh score. Alternative names for this scoring system have been used in the art, including but not limited to "Child-Turcotte-Pugh score" or "Child criteria". The Child-Pugh score is widely used throughout the field (Tsoris and Marlar, Updated 2022 Mar 18, StatPearls), and its liver injury grading criteria are as follows, as known to those skilled in the art.

[0129] Liver function classification - Child-Pugh score

[0130]

[0131] *The assessment of encephalopathy is mainly based on the clinical signs and symptoms described in detail below; electroencephalogram examination is not necessary for encephalopathy grading;

[0132] Grade 0: Normal state of consciousness, personality, neurological examination, electroencephalogram

[0133] Grade 1: Restlessness, sleep disorder, irritability / agitation, tremor, dysgraphia, 5 Hz brain waves

[0134] Grade 2: Somnolence, disorientation to time, inappropriate behavior, asterixis, ataxia, slow triphasic waves

[0135] Grade 3: Drowsiness, stupor, disorientation to place, hyperreflexia, rigidity, slower waves

[0136] Grade 4: Unarousable coma, no personality / behavior, decerebration, slow delta wave activity of 2 - 3 Hz

[0137] The liver function groupings are defined as follows:

[0138] · Group 1: Normal liver function

[0139] · Group 2: Mild liver function injury (Child-Pugh score 5 - 6 points)

[0140] · Group 3: Moderate liver injury (Child-Pugh score 7 - 9 points)

[0141] · Group 4: Severe liver injury (Child-Pugh score 10 - 14 points)

[0142] Preferred subjects in the context of the present invention are subjects with an encephalopathy grade of 2 or less, preferably subjects with an encephalopathy grade of 1 or less, and more preferably subjects with an encephalopathy grade of 0.

[0143] Optionally, the subject is a female postmenopausal, perimenopausal or postmenopausal subject, characterized in that the liver injury corresponds to a Child-Pugh score of at least 5. In a preferred embodiment, the subject is a female postmenopausal, perimenopausal or postmenopausal subject, characterized in that the Child-Pugh score corresponding to the liver injury is at least 6, preferably at least 7, preferably at least 8, preferably at least 9, preferably at least 10, preferably at least 11, preferably at least 12, preferably at least 13, preferably at least 14. Thus, the subject can be a female postmenopausal, perimenopausal or postmenopausal subject, characterized in that the liver injury corresponds to Child-Pugh class A, B or C. In certain embodiments, the subject is a female postmenopausal, perimenopausal or postmenopausal subject, characterized in that the Child-Pugh score corresponding to the liver injury is from 5 to 15, preferably from 5 to 14, preferably from 5 to 13, preferably from 5 to 12, preferably from 5 to 11, preferably from 5 to 9, preferably from 5 to 8, preferably from 5 to 7, preferably from 5 to 6.

[0144] In an alternative embodiment, the subject is a female postmenopausal, perimenopausal or postmenopausal subject, characterized in that the Child-Pugh score corresponding to the liver injury is from 5 to 15, preferably from 6 to 15, preferably from 7 to 15, preferably from 8 to 15, preferably from 9 to 15, preferably from 10 to 15, preferably from 11 to 15, preferably from 12 to 15, preferably from 13 to 15, preferably from 14 to 15.

[0145] In certain embodiments, the subject is a female postmenopausal, perimenopausal or postmenopausal subject characterized by mild liver injury (i.e., Child-Pugh score corresponding to "class A"). In an alternative embodiment, the subject is a female postmenopausal, perimenopausal or postmenopausal subject characterized by moderate liver injury (i.e., Child-Pugh score corresponding to "class B"). In an alternative embodiment, the subject is a female postmenopausal, perimenopausal or postmenopausal subject characterized by severe liver injury (i.e., Child-Pugh score corresponding to "class C"). In a preferred embodiment, the subject is a female postmenopausal, perimenopausal or postmenopausal subject characterized by mild to moderate liver injury (i.e., Child-Pugh score corresponding to "class A" or "class B").

[0146] It is obvious that both the expressions "symptoms of estrogen deficiency" and "symptoms related to menopause" include psychological symptoms, physiological symptoms and any combination thereof.

[0147] Psychological estrogen deficiency symptoms and menopausal-related symptoms include, by way of example and without limitation, depression, irritability, mood changes, insomnia, sleep disorders, anxiety, nervousness, and any combination thereof. It is understood that the term "psychological menopausal-related symptoms" also includes any form or degree of emotional distress resulting from one or more physical menopausal-related symptoms that occur in the subject.

[0148] Physiological estrogen deficiency symptoms and menopausal-related symptoms include, by way of example and without limitation, joint pain, decreased bone density, urinary tract infections, urinary incontinence, vaginal dryness, uterine prolapse, skin tissue changes, weight gain, dyspareunia, cardiovascular disease, diabetes, and any combination thereof. Optionally, the diabetes is type 2 diabetes (e.g., as described in Mauvais-Jarvis et al., Endocr Rev, 2017).

[0149] Preferably, the compositions, uses, and methods described herein are used to reduce the frequency of VMS, alleviate the severity of VMS, improve the weekly weighted score of hot flashes, relieve vaginal dryness, relieve dyspareunia, or any combination thereof, or to improve the quality of life according to the Menopause Rating Scale (MRS) and / or the Menopause-Specific Quality of Life (MENQOL) questionnaire.

[0150] As used herein, the term "VMS" (or in its non-abbreviated form, "vasomotor symptoms") corresponds to the thermoregulatory disorder characteristics of menopause. The term "VMS" includes symptoms such as hot flashes (which can be used interchangeably with the term "hot flushes"), sweating episodes such as night sweats, chills, increased sweating, and palpitations. VMS is an episode of profuse heat accompanied by sweating and flushing, mainly occurring in the head, neck, chest, and upper back. VMS is classified into mild, moderate, and severe categories. In certain embodiments, VMS is selected from: hot flashes, night sweats, sleep disorders, mood swings, and any combination thereof.

[0151] In the art, a severity scoring system is commonly used to define the different severity categories of VMS:

[0152] · Mild (1 point), for the presence of only a sense of heat without sweating;

[0153] · Moderate (2 points), for a sense of heat accompanied by sweating / the subject can continue daily activities; and

[0154] · Severe (3 points), for a sense of heat accompanied by sweating / resulting in the cessation of activities.

[0155] In addition, for patients who experienced 100% VMS relief within a specific week, the severity score was zero. Based on these score records, the baseline VMS severity was typically calculated by only considering moderate and severe VMS. Multiply the total number of moderate VMS within 7 days of the baseline week by 2, and then add the total number of severe VMS within 7 days of that baseline week multiplied by 3. Then divide that sum by the total number of moderate and severe VMS within that baseline week.

[0156] For each of these weeks, the severity scores for week 4 and week 12 were calculated according to the following formula:

[0157] · Multiply the number of mild VMS within 7 days by 1;

[0158] · Multiply the number of moderate VMS within 7 days by 2;

[0159] · Multiply the number of severe VMS within 7 days by 3;

[0160] And after adding the 3 numerical values, then divide that sum by the total number of mild, moderate, and severe VMS within 7 days of that week.

[0161] The VMS severity was evaluated as follows: The severity at baseline was also calculated by only considering moderate and severe VMS, such that the total number of moderate VMS within 7 days of the baseline week was multiplied by 2, and added to the total number of severe VMS within 7 days of that baseline week multiplied by 3. Then divide that sum by the total number of moderate and severe VMS within that baseline week.

[0162] However, for each of these weeks, the severity scores for week 4 and week 12 were calculated according to the following formula:

[0163] · Multiply the number of moderate VMS within 7 days by 2;

[0164] · Multiply the number of severe VMS within 7 days by 3.

[0165] And add the 2 resulting numerical values, then divide that sum by the total number of mild, moderate, and severe VMS within 7 days of that week.

[0166] In another embodiment, the severity score can be calculated according to the method described in Archer et al. (Menopause, 2014). According to this method, the single-day severity score for each day during a 7-day period was calculated using the following formula:

[0167] · Multiply the number of moderate VMS within 1 day by 2;

[0168] · Multiply the number of severe VMS within 1 day by 3;

[0169] · Add the 2 resulting numerical values;

[0170] · Then divide the sum result by the total number of VMSs (moderate and severe) on the same day.

[0171] Apply the same formula over a consecutive 7-day period, add the 7 resulting values and divide by 7 to calculate the “weekly average single-day severity” score for moderate to severe VMS.

[0172] In addition, the term “weekly weighted score for hot flushes” as used herein corresponds to a score that takes into account frequency and severity, which is calculated by using the severity score (calculated as above): over 7 days, [(1 x number of mild VMSs)+(2 x number of moderate VMSs)+(3 x number of severe VMSs)].

[0173] Notelovitz et al. (Obstetrics and Gynaecology, 2000) used this weighted score.

[0174] In an alternative embodiment, any combination of the above evaluation methods can be employed to evaluate the weekly severity and / or frequency of VMS.

[0175] As used herein, the term "quality of life" (abbreviated "QoL") refers to a parameter, for example, that can be evaluated by using a questionnaire, such as a questionnaire that includes, but is not limited to, the "Menopause Rating Scale" questionnaire (Heinemann et al., 2003, "International versions of the Menopause Rating Scale (MRS)" Health Qual Life Outcomes 1:28; Heinemann et al., 2004, "The Menopause Rating Scale (MRS) scale: A methodological review". Health Qual Life Outcomes 2:45; Heinemann et al., 2004, "The Menopause Rating Scale (MRS) as outcome measure for hormone treatment? A validation study". Health Qual Life Outcomes 2:67; as further detailed below in Example 1 Section C.) or the MENQOL questionnaire (The Menopause-specific Quality of Life (MENQOL) questionnaire, Hilditch et al.; Maturitas 1996; A menopause-specific quality of life questionnaire: development and psychometric properties; 24(3); p. 161-175).

[0176] In a specific embodiment, it is advantageous to administer the compositions described herein to take advantage of the fact that the smoking status of the subject has no effect on the treatment of the present invention. In fact, it has long been shown that smoking significantly reduces serum estrogen concentration, as reported in the clinical study analysis published by Bjarnason et al. (Bjarnason et al.; Climacteric 2012; Acute and long-term estradiol kinetics in smoking postmenopausal women; 15:5; p. 449-454), which found that in the estrogen group, smoking led to a significant decrease in serum estrone and serum estradiol levels at all post-randomization time points, while there was no difference between smokers and non-smokers in the placebo group. Bjarnason et al. concluded that in postmenopausal women receiving estrogen therapy, smoking simultaneously reduces the trough and 2-hour post-dose serum estrogen concentrations; the effect of smoking on estrogen concentration is fully manifested in women who smoke no more than 10 cigarettes per day; and the effect of smoking on estrogen therapy metabolism is persistent, with no dose response for standard smoking intensities.

[0177] In this specific embodiment, based on the surprising finding that the therapy of the present invention is not affected by the smoking status of the subject, the composition is optionally administered to patient populations who smoke 5 or more cigarettes per day, 10 or more cigarettes per day, or 15 or more cigarettes per day.

[0178] In yet another specific embodiment of the present invention, it is advantageous to administer the compositions described herein to take advantage of the fact that the BMI of the subject has no effect on the treatment of the present invention. In fact, it has been surprisingly found that, contrary to the hormone replacement therapies described in the art, the efficacy of the therapy of the present invention is not affected by the BMI value of the subject. In this specific embodiment, the hormone therapy of the present invention is preferably administered to subjects with a BMI of 25 or higher, 28 or higher, 30 or higher, 33 or higher, or 40 or higher. In this specific embodiment, the hormone therapy of the present invention is preferably administered to overweight or obese subjects. As used herein, "BMI" (or its non-abbreviated form "Body Mass Index") refers to an index related to the weight and height of a subject, which is calculated by dividing the weight of the subject in kilograms by the square of the height of the subject in meters. A BMI of 27.3 or higher classifies female subjects as "overweight", while a BMI of 30 or higher classifies subjects as "obese".

[0179] It is obvious that any composition and dosage unit may suitably contain one or more pharmaceutically acceptable excipients. As used herein, the term "pharmaceutically acceptable" is consistent with the art and means compatible with the other ingredients of the pharmaceutical composition and not harmful to its recipient.

[0180] The composition subject matter of the present invention is particularly suitable for formulation as an oral dosage unit, as demonstrated by the examples included herein, which show good pharmacokinetic properties in subjects with liver injury. Preferably, the oral dosage unit used according to the present invention is swallowed. More preferably, the oral dosage unit used according to the present invention is swallowed whole. However, dosage units formulated for alternative modes of administration are also contemplated, such as, but not limited to, sublingual, buccal, or sublabial dosage units.

[0181] "Oral dosage unit" includes any dosage unit designed for and / or suitable for administration to a subject by the oral route. Swallowing the dosage unit (immediately or nearly immediately) is contemplated but not a limitation of the oral dosage unit of the present invention, as detailed below.

[0182] The oral dosage units described herein may be solid or semi-solid dosage units, such as tablets, capsules, cachets, pellets, pills, powders, or granules, or any combination thereof. For example, the oral dosage unit of the subject matter of the present invention may be a tablet containing particles comprising an estetrol component or a capsule containing particles comprising an estetrol component. The term "solid or semi-solid dosage unit" also includes capsules containing a liquid such as an oil, in which the estetrol component and / or optional progestin component of the present invention is dissolved or dispersed.

[0183] Tablets and equivalent solid and semi-solid dosage units may suitably contain materials such as binders (e.g., hydroxypropyl methylcellulose, polyvinylpyrrolidone (povidone, PVP), other cellulose materials, and starches), diluents (e.g., lactose (monohydrate) and other sugars, starches (e.g., corn starch), dicalcium phosphate, and cellulose materials), disintegrants (e.g., starch polymers and cellulose materials (such as sodium starch glycolate)), and lubricants (e.g., stearates (magnesium) and talc). These tablets and equivalent solid dosage units may be prepared by any suitable method known in the art, which has been described in detail in the prior art (e.g., Kaur, Int Res J Pharm, 2012). Non-limiting examples of processing the estetrol component in preparing the dosage unit include wet granulation, such as using an aqueous or organic solution, direct compression, 3D printing, or coating the estetrol component onto carrier particles using an organic or inorganic solvent.

[0184] As described above, the compositions, and thus the resulting (oral) dosage units, can include one or more suitable excipients. The term "excipient", which is used interchangeably with "carrier" herein and in the art, can denote any solvent, diluent, buffer (including but not limited to neutral buffered saline, phosphate buffered saline or optionally Tris-HCl, acetate or phosphate buffer), solubilizer (including but not limited to Tween 80 or polysorbate 80), colloid, dispersion medium, vehicle, filler, chelating agent (including but not limited to EDTA or glutathione), amino acid, protein, disintegrant, binder, lubricant, wetting agent, stabilizer, emulsifier, sweetener, colorant, flavoring agent, fragrance, thickening agent, any reagent capable of achieving storage effects, coating agent, antifungal agent, any preservative (including but not limited to TM (Thimerosal TM ), benzalkonium chloride or benzyl alcohol), antioxidant (including but not limited to ascorbic acid, sodium metabisulfite), tonicity modifier, absorption delaying agent, adjuvant, bulking agent (including but not limited to lactose, mannitol) and any other ingredient that can affect any parameter or characteristic of the oral dosage unit subject matter of the present invention. Those skilled in the art should understand that one or more excipients can be used in the oral dosage unit, provided that the excipients used are compatible with one or more pharmaceutically active ingredients (i.e., at least the estetrol component in the present invention) and a pharmaceutically acceptable formulation can be obtained.

[0185] In certain embodiments, the excipient can be an active pharmaceutical ingredient excipient, binder excipient, carrier excipient, co-processed excipient, coating system excipient, controlled release excipient, diluent excipient, disintegrant excipient, dry powder inhalation excipient, effervescent system excipient, emulsifier excipient, lipid excipient, lubricant excipient, modified release excipient, penetration enhancer excipient, permeation enhancer excipient, pH modifier excipient, plasticizer excipient, preservative excipient, solubilizer excipient, solvent excipient, sustained release excipient, sweetener excipient, flavoring agent excipient, thickening agent excipient, viscosity modifier excipient, filler excipient, tableting excipient, dry granulation excipient, hot melt extrusion excipient, wet granulation excipient, immediate release excipient, bioavailability enhancer excipient, dispersant excipient, solubility enhancer excipient, stabilizer excipient, capsule filling excipient or any combination thereof. Those skilled in the art should know that the use of these media and reagents for pharmaceutically active substances is routine practice, and thus the incorporation of these excipients is well known in the art. It is obvious that the concentration of all ingredients used should be non-toxic in the final pharmaceutical composition and should not negatively interfere with the activity of one or more pharmaceutically active ingredients, which is at least the estetrol component herein.

[0186] Optionally, the composition is included in a tablet and contains excipients that perform the functions of a first or additional filler, superdisintegrant, binder, disintegrant, and lubricant in addition to estetrol. An excipient can perform several of these functions. Thus, a binder can also act as a disintegrant. The tablet can also contain two or more excipients with the same function, such as two different binders. In a preferred embodiment, the composition is included in a tablet that contains estetrol, lactose, sodium starch glycolate, corn starch, povidone, and magnesium stearate. Preferably, the composition is included in a tablet that contains estetrol monohydrate, lactose monohydrate, sodium starch glycolate type A, corn starch, povidone K30, and magnesium stearate. Optionally, the tablet is coated with a coating agent. In a further optional embodiment, the coating agent contains hypromellose, hydroxypropyl cellulose, titanium dioxide, iron oxide red, hydrogenated cottonseed oil, and talc. By way of illustration and not limitation, suitable coating agents are AquaPolish Orange034.23 MS, AquaPolish P Blue064.65 MS, AquaPolish Yellow024.15 MS, or AquaPolish Pine044.08 MS. Those skilled in the art know that such coatings can be used in combination with an appropriate amount of purified water. Those skilled in the art should also understand that excipients contained in any dosage form, such as an oral dosage unit, should comply with the quality standards of the pharmaceutical grade industry, such as the European Pharmacopoeia (Ph.Eur.) and the United States National Formulary (USP-NF).

[0187] The oral dosage unit can be suitable for, or specifically prepared for, sublingual administration, buccal administration, and / or sublabial administration. In such embodiments, the solid dosage unit is capable of rapidly releasing the estetrol component upon contact with an aqueous solvent such as saliva. Thus, in these embodiments, the solid dosage unit is an orally dispersible dosage unit that releases at least about 50%, preferably at least about 60%, more preferably at least about 70%, still more preferably at least about 80%, and most preferably more than about 80% of the estetrol component within about 5 minutes, preferably within about 3 minutes, more preferably within about 2.5 minutes, more preferably within about 90 seconds, and most preferably within about 90 seconds. The oral dosage unit can be an orally dispersible dosage unit. In such an embodiment, when the dosage unit comes into contact with saliva, it rapidly disintegrates in the mouth and disperses the estetrol component into the saliva so that it can be absorbed through the mucosal lining of the mouth. Those skilled in the art should know the methods for determining the release rate of the estetrol component from the dosage unit. Non-limiting standard tests generally recognized in the art include the disintegration test according to Section 2.9.1 of the Ph.Eur. ("Disintegration of Tablets and Capsules") and the United States Pharmacopeia (USP) <701> ("Disintegration"), for example, using water as the disintegration medium.

[0188] As used herein, the term "sublingual" refers to the pharmacological route of administration by which the estriol component diffuses through the sublingual tissues into the bloodstream.

[0189] As used herein, the term "buccal" refers to the pharmacological route of administration by which the estriol component diffuses into the bloodstream through the vestibule of the mouth, i.e., the intraoral area between the lining of the cheek (oral mucosa) and the teeth / gums.

[0190] As used herein, the term "sublabial" refers to the pharmacological route of administration in which the estriol component is placed between the lip and the gum.

[0191] In certain embodiments, the estriol component is included in an immediate-release dosage unit or composition.

[0192] In certain embodiments, the estriol component is formulated into a solid dosage unit, including but not limited to hard capsules, soft capsules, tablets, coated tablets such as lacquered-coated tablets or sugar-coated tablets, granules, aqueous or oily solutions, syrups, emulsions, suspensions, ointments, pastes, lotions, gels, inhalants, or suppositories. In embodiments where an effective dose of the estriol component is administered by an oral route of administration, the oral dosage unit according to the present invention is preferably a solid or semi-solid dosage unit, such as tablets, capsules, cachets, pellets, pills, powders, and granules. The term "solid or semi-solid dosage unit" also includes capsules containing a liquid such as an oil, in which the estriol component of the present invention and / or an optional progestin component is dissolved or dispersed. Tablets and equivalent solid and semi-solid dosage units may suitably contain materials such as binders (e.g., hypromellose, polyvinylpyrrolidone, other cellulosic materials, and starches), diluents (e.g., lactose and other sugars, starches, dicalcium phosphate, and cellulosic materials), disintegrants (e.g., starch polymers and cellulosic materials), and lubricants (e.g., stearates and talc). These tablets and equivalent solid dosage units can be prepared by any suitable method known in the art, which has been described in detail in the prior art (e.g., Kaur, Int Res J Pharm, 2012). Non-limiting examples of processing the estriol component in the preparation of dosage units include wet granulation, e.g., using an aqueous or organic solution, direct compression, 3D printing, or coating the estriol component on carrier particles using an organic or inorganic solvent.

[0193] By way of illustration and not limitation, oral dosage units containing the composition subject matter of the present disclosure can be prepared by a process involving wet granulation. Those skilled in the art will understand that the wet granulation process can suitably include the following sequential steps: dispensing or sieving the active ingredient and excipients, mixing the sieved materials in a processor, granulating, screening of the granules (i.e., further sieving), and one or more mixing steps of the sieved granules with one or more additional excipients. Then, if desired for the final dosage unit, the granules can be compressed into, for example, tablets, optionally including a tablet coating step.

[0194] As described above, the compositions described herein unexpectedly provide favorable pharmacokinetic profiles in female subjects with liver injury. The compositions are particularly suitable for relieving estrogen deficiency symptoms (such as but not limited to menopause-related symptoms) in this subject population by oral administration. Favorable pharmacokinetic profiles include multiple parameters, including but not limited to the geometric mean (GM) plasma concentration of estetrol, C max , AUC inf and GM T 1 / 2 . In addition, the metabolites of estetrol also exhibit favorable pharmacokinetic properties, such as demonstrated by the AUC inf of E4-3-glucuronide. "E4-3-glucuronide", which can be used interchangeably with the full name "estetrol-3-glucuronide", is a known and well-documented metabolite of estetrol.

[0195] Those skilled in the art should know the generally accepted meaning of the term "geometric mean", and thus understand that the geometric mean represents the typical value of a set of numbers by using the product of the values of the set of numbers (i.e., ).

[0196] It should be understood that when the abbreviation "AUC" is used herein, it refers to "area under the curve" and should be interpreted in its common meaning in the art, i.e., the definite integral of the curve describing the change in drug concentration in plasma over time. The AUC 0-24 used herein represents the AUC from the time point "0" to the time point of 24 hours, where the time point "0" is the time point of administering the COC to the subject. In the context used herein, "AUC" can be interpreted as bioavailability. Accordingly, AUC inf represents the total AUC (from time point "0" to infinity). The "C max " referred to herein is the maximum or peak plasma concentration reached by a drug such as drospirenone. Unless otherwise specified, AUC and C maxValues can be measured by radioimmunoassay and / or HPLC and LC MS / MS, which are detection methods 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). As used herein, "T1 / 2" refers to the amount of time required for the concentration of a drug in the measured plasma (or other biological matrix) to decrease to half of its initial concentration or amount.

[0197] In the following embodiments, some parameters defining specific pharmacokinetic characteristics are discussed. It should be understood that these parameters are defined in a relative manner and are expressed as relative values and / or ranges relative to a subject with normal liver function. Obviously, in the context of the present invention, a "subject with normal liver function" refers to a subject who generally corresponds to a subject with liver injury (e.g., age, menopausal status, race, BMI, etc.) and is substantially different from the subject with liver injury only in that they do not have liver function impairment. A medical practitioner classifies a subject as having normal liver function or having liver injury within their ability by using any means or methods they deem necessary, such as but not limited to one or more biomarkers. Optionally, in the context of the present invention, a subject with normal liver function can be defined as a subject with a Child-Pugh score of less than 5, preferably less than 4, more preferably less than 3, still more preferably less than 2, and most preferably a Child-Pugh score of 1. Optionally, in the context of the present invention, a subject with normal liver function can be defined as a subject with a Child-Pugh score of 1 to up to and including 4, preferably a subject with a Child-Pugh score of 1 to up to and including 3, and more preferably a subject with a Child-Pugh score of 1 to up to and including 2.

[0198] Thus, in certain embodiments, the composition formulated as an oral dosage unit exhibits pharmacokinetic characteristics in subjects with liver injury after a single dose, characterized in that the geometric mean C of estetrol max is less than 3 times the corresponding GM C of a subject with normal liver function max Preferably, the GM C of estetrol provided in subjects with liver injury maxFor subjects with normal liver function, the GM C max is 2.5-fold or less, more preferably 3-fold or less, and even more preferably 1.7-fold or less. Optionally, a subject with liver injury refers to a subject with mild liver injury, moderate liver injury, or severe liver injury as defined by the Child-Pugh scoring criteria. In a further embodiment, the composition formulated as an oral dosage unit exhibits pharmacokinetic characteristics in subjects with mild hepatitis injury after a single dose, characterized in that the GM C max of estriol is about 1.5-fold to about 2.0-fold, preferably about 1.7-fold, of the corresponding GM C max in subjects with normal liver function. In a further alternative embodiment, the composition formulated as an oral dosage unit exhibits pharmacokinetic characteristics in subjects with moderate liver injury after a single dose, characterized in that the GM C max of estriol is max about 1.8-fold to about 2.5-fold, preferably about 1.9-fold, of the corresponding GM C max in subjects with normal liver function. In other alternative embodiments, the composition formulated as an oral dosage unit exhibits pharmacokinetic characteristics in subjects with severe liver injury after a single dose, characterized in that the GM C max of estriol is about 5-fold to about 6-fold, preferably about 4.5-fold, of the corresponding GM C

[0199] After a single dose of the composition formulated as an oral dosage unit to a subject with liver injury, another favorable pharmacokinetic parameter is that there is no difference or substantially no difference in the peak exposure level of the estriol metabolite E4-3-glucuronide. Thus, optionally, the composition is characterized in that the peak exposure level of E4-3-glucuronide is not significantly different from the peak exposure level of E4-3-glucuronide after a single dose of the composition formulated as an oral dosage unit to a subject with normal liver function. In a further embodiment, the peak exposure level of E4-3-glucuronide in subjects with liver injury is about 90% to about 110% of the peak exposure level of E4-3-glucuronide in subjects with normal liver function. Preferably, the peak exposure level of E4-3-glucuronide in subjects with liver injury is about 95% to about 105% of the peak exposure level of E4-3-glucuronide in subjects with normal liver function, preferably about 97% to about 102.5%.

[0200] After a single dose of the composition formulated as an oral dosage unit to a subject with liver injury, another favorable pharmacokinetic parameter is the GM AUC of estriol and / or E4-3-glucuronide infThe geometric mean AUC of estetrol and / or E4-3-glucuronide after single administration of the composition formulated into oral dose units to subjects with normal liver function inf showed no significant difference (i.e., was similar) compared to inf the geometric mean AUC of estetrol and / or E4-3-glucuronide in subjects with normal liver function inf was from about 90% to about 110% of that in subjects with normal liver function inf The geometric mean AUC of estetrol and / or E4-3-glucuronide in subjects with mild or moderate liver injury inf was preferably 1.1 times or less of that in subjects with normal liver function inf The geometric mean AUC of estetrol and / or E4-3-glucuronide in subjects with severe liver injury inf was preferably 2 times or less of that in subjects with normal liver function.

[0201] Another favorable pharmacokinetic parameter after single administration of the composition formulated into oral dose units to subjects with liver injury is that the geometric mean T1 / 2 of estetrol and / or metabolites such as E4-3-glucuronide is similar to the corresponding geometric mean T1 / 2 after single administration of the composition formulated into oral dose units to subjects with normal liver function. Preferably, the geometric mean T1 / 2 of estetrol and / or its metabolites such as E4-3-glucuronide in subjects with mild liver injury is similar to the corresponding geometric mean T1 / 2 after single administration of the composition formulated into oral dose units to subjects with normal liver function.

[0202] In combination with one or more favorable pharmacokinetic characteristic parameters described herein, there is no difference in the number, frequency, and / or severity of adverse events (AEs) between the population of subjects with liver injury and the population of subjects with normal liver function. In a further embodiment, there is no difference in the number, frequency, and / or severity of treatment-emergent adverse events (TEAEs) between the population of patients with liver injury and the population of patients with normal liver function. It should be understood that treatment-emergent adverse events are any adverse events that occur from the time point of the first administration of the study until the last visit or any pre-existing event whose severity or frequency deteriorates after exposure to the treatment. Thus, TEAEs include both newly emerging adverse events due to treatment and the exacerbation of pre-existing adverse events due to the use of the compositions described herein. Treatment-related adverse events are not particularly limited in the context of the present invention and include, but are not limited to, abdominal distension, breast tenderness, breast swelling, swelling in other parts of the body, general discomfort, leg cramps, headache, indigestion, diarrhea, and vaginal bleeding.

[0203] Notably, when using the compositions described in the present invention, there is no difference in the number, frequency, and / or severity of adverse events between the population of subjects with liver injury and the population of subjects with normal liver function. Thus, the compositions described herein exhibit good safety and tolerability in subjects with normal liver function, mild liver injury, moderate liver injury, and severe liver injury. Optionally, there is no difference between the population of subjects with liver injury and the population of subjects with normal liver function in terms of the risk of experiencing one or more treatment-emergent adverse events. Optionally, the subjects are subjects with liver injury who do not have severe liver injury (i.e., subjects with mild or moderate liver injury).

[0204] As detailed above, the estetrol component comprised in the compositions described in the present invention is equivalent to a single-day dose of from about 15 mg to about 25 mg of estetrol. Obviously, this includes embodiments in which the composition comprises from about 15 mg to about 25 mg of the estetrol component (which those skilled in the art will understand encompasses the definition of "equivalent to from about 15 mg to about 25 mg of estetrol"). In a further embodiment, the composition comprises from about 15 mg to about 20 mg of the estetrol component, preferably, wherein the estetrol component is estetrol, estetrol monohydrate, or an ester of estetrol. Preferably, the composition comprises from about 15 mg to about 25 mg of estetrol monohydrate, more preferably from about 15 mg to about 20 mg of estetrol monohydrate. In an alternative embodiment, the composition comprises from about 15 mg to about 25 mg of estetrol or its ester, preferably from about 15 mg to about 20 mg of estetrol or its ester.

[0205] Optionally, the composition comprises about 17 mg of an estetrol component, or an amount of an estetrol component equivalent to a single - day dose of about 17 mg of an estetrol component. In a further embodiment, the composition comprises about 17 mg of estetrol monohydrate, or an amount of an estetrol component equivalent to a single - day dose of about 17 mg of estetrol monohydrate. In a further alternative embodiment, the composition comprises about 17 mg of estetrol or its ester, or an amount of an estetrol component equivalent to a single - day dose of about 17 mg of estetrol or an estetrol ester.

[0206] In an alternative embodiment, the composition comprises from about 12 mg to about 28 mg of an estetrol component, or an amount of an estetrol component equivalent to a single - day dose of from about 12 mg to about 28 mg of estetrol. In a preferred alternative embodiment, the composition comprises from about 12 mg to about 28 mg of estetrol monohydrate, or an amount of an estetrol component equivalent to a single - day dose of from about 12 mg to about 28 mg of estetrol monohydrate. In an alternative embodiment, the composition comprises from about 12 mg to about 28 mg of estetrol or its ester, or an amount of an estetrol component equivalent to a single - day dose of from about 12 mg to about 28 mg of estetrol or its ester.

[0207] Optionally, the composition comprises about 15 mg of an estetrol component, or an amount equivalent to about 15 mg of estetrol. Optionally, the composition may comprise about 15 mg of estetrol. In a further optional embodiment, the composition comprises about 15 mg of estetrol monohydrate.

[0208] Alternatively, the composition comprises about 20 mg of an estetrol component, or an amount equivalent to about 20 mg of estetrol. Optionally, the composition may comprise about 20 mg of estetrol. In a further optional embodiment, the composition comprises about 20 mg of estetrol monohydrate.

[0209] The estriol component can be included in the composition as a large number of particles. The particle size of the estriol component is not particularly limited. By way of illustration and not limitation, suitable particle sizes can be represented by particle size distribution values such as, for example but not limited to, D(10), D(50), and D(90). Those skilled in the art should be fully aware of how to interpret these parameters. "Particle size distribution", commonly abbreviated as "PSD", is a numerical value representing the relative content of particles based on size, where the relative content of the particles is preferably expressed in mass. For example, the D10 or Dv(10) value represents the point value in the particle size distribution containing 10% of the total volume of the sample (i.e., the collection of particles), up to and including that point value. For example, a D10 value of 10 μm means that 10% of the sample has a maximum size of 10 μm. The D10, D50, and D90 values are conventionally used in the art to calculate the span of the sample, and the span represents the width of the particle size distribution. The span is calculated according to the following formula: (D90 - D10) / D50. Those skilled in the art should understand that representative particle size distribution values can only be obtained from representative samples.

[0210] Optionally, the estriol particles have a D(10) of from about 0.5 μm to about 10 μm, preferably from about 1 μm to about 5 μm, more preferably from about 1.5 μm to about 2.5 μm. Optionally, the estriol particles have a D(50) of less than 20 μm, preferably less than 12 μm, more preferably from about 5 μm to about 15 μm, preferably from about 6 μm to about 12 μm, more preferably from about 7 μm to about 11 μm, and most preferably from about 8 μm to about 12 μm. Optionally, the estriol particles have a D(90) of from about 15 μm to about 50 μm, preferably from about 20 μm to about 30 μm, more preferably from about 22 μm to about 28 μm.

[0211] A variety of measurement techniques can be used to determine the particle size distribution values, including sieve analysis, air elutriation analysis, image analysis, optical counting, electrical resistance counting, sedimentation, laser diffraction, laser obscuration, transit time, acoustic spectroscopy, ultrasonic attenuation microscopy, cascade impactor method, or any combination thereof. Unless otherwise explicitly stated, the particle size distribution values of the present disclosure are obtained by laser diffraction analysis. Laser diffraction analysis, which can be interchangeably labeled as laser diffraction spectroscopy in the art, is a particle measurement technique based on the analysis of the laser diffraction pattern generated after passing through an object. Laser diffraction can measure the geometric size of particles. Laser diffraction schemes have been described in detail in the art on many occasions (e.g., as reviewed in detail in Eshel et al., Soil Science Society of America Journal, 2004).

[0212] Optionally, the estriol granules are further granulated into larger granules. In certain embodiments, the estriol component is present in the composition as a plurality of larger granules having a volume median diameter of from about 100 μm to about 4000 μm, preferably from about 200 μm to about 1000 μm, more preferably from about 200 μm to about 600 μm.

[0213] In certain embodiments, the estriol component is the only (i.e., single, sole) pharmaceutically active ingredient in the composition. The term "pharmaceutically active ingredient", which is used interchangeably with "pharmaceutically active agent" in the present disclosure, shall be interpreted in accordance with the definition of the World Health Organization: "a substance used in a finished pharmaceutical product (FPP) which is intended to exert a pharmacological activity or have a direct effect in the diagnosis, cure, mitigation, treatment or prevention of disease, or to have a direct effect in restoring, correcting or modifying physiological functions in the human body". More particularly, in certain embodiments, the estriol component is not co-administered with any progestogen component (neither in the same composition or oral dosage unit, nor in other compositions or dosage units administered concomitantly). In embodiments directed to subjects with liver impairment who have undergone hysterectomy, it is preferred to administer the estriol component as the sole pharmaceutically active ingredient.

[0214] In alternative embodiments, the composition comprises at least one additional pharmaceutically active ingredient in addition to the estriol component.

[0215] Optionally, the oral dosage form comprises a progestogen component as an additional pharmaceutically active ingredient, or the method of treatment comprises the step of co-administering a progestogen component to the subject. While embodiments in which the progestogen component and the estriol component are included in the same composition are preferred, embodiments in which the progestogen component is administered by a separate composition or dosage unit are also contemplated.

[0216] The term "progestogen / gestagen / gestogen" and its derivative "progestogen component" as used herein and in the art refers to any molecule that produces an effect in a subject similar to that of the natural female hormone progestogen. Progestogens are considered agonists of the progesterone receptor, the function of which has been well studied in the art (discussed in particular in Kuhl, Climacteric, 2005). Progestins are a subclass of progestogens and consist of synthetic progestogens. While the above terms may be used interchangeably in the art, it is generally understood that when referring to progestins, synthetic progestogens are meant.

[0217] Examples of progestogen components contemplated by the present invention include, but are not limited to: levonorgestrel, norgestimate, norethisterone, dydrogesterone, drospirenone, 3-β-hydroxy desogestrel, 3-keto desogestrel, 17-deacetyl norgestimate, 19-norprogesterone, acetoxy pregnenolone, allylestrenol, amadinone, chlormadinone, cyproterone, demegestone, desogestrel, dienogest, dihydrogesterone, dimethisterone, ethisterone, ethynodiol diacetate, flurogestone acetate, gestodene, gestrinone, hydroxymegestone, hydroxyprogesterone, lynestrenol, megestrol acetate, medroxyprogesterone acetate, megestrol acetate, melengestrol acetate, nomegestrol acetate, norethisterone, noretynodrel, norgestrel (including D-norgestrel and DL-norgestrel), norgestrienone, methandrostenolone, chlormadinone acetate, (17α)-17-hydroxy-11-methylene-19-norpregna-4,15-dien-20-yn-3-one, tibolone, trimegestone, progesterone benzoate, norgestomet acetate, promegestone, 17-hydroxyprogesterone caproate, 19-nor-17-hydroxyprogesterone, 17α-ethynyl testosterone, 17α-ethynyl-19-nortestosterone, D-17β-acetoxy-13β-ethyl-17α-ethynyl pregn-4-ene-3-one oxime, 6β,7β; 15β,16β-dimethylene-3-oxo-17-pregn-4,9(11)-diene-21,17β-carbolactone or tanaproget and precursors of said components capable of releasing these progestogens in vivo.

[0218] The progestogen component may be selected from: progesterone, drospirenone, norethisterone, norethisterone acetate (NETA), dydrogesterone, levonorgestrel (LNG), etonogestrel, norgestrel, nomegestrol acetate, nomegestomet acetate, trimegestone, norgestomet acetate, dydrogesterone, dienogest, desogestrel, norgestimate, cyproterone acetate, dienogest and chlormadinone acetate. Progestogens that are particularly preferred in the context of the present invention include, but are not limited to, drospirenone, progesterone and dydrogesterone.

[0219] In certain embodiments, the progestogen is a naturally occurring progestogen. In alternative embodiments, the progestogen is progesterone.

[0220] Drospirenone (abbreviated as DRSP, PubChem CID: 68873) is an example of a progestogen component and is widely used in combined oral contraceptives (commonly abbreviated as COCs) due to its antimineralocorticoid and antiandrogenic activities and generally low off-target activity. Generally speaking, COCs containing drospirenone are referred to as fourth-generation COCs. Non-limiting examples of currently commercially available COCs containing drospirenone include and An illustrative example of a drospirenone-only progestogen contraceptive is It is also commercially available. In addition, hormone replacement therapy compositions comprising estrogens such as estradiol and drospirenone are available, such as Drospirenone is also known in the art by its molecular formula C 24 C 30 C3, or is represented by structural formula (III):

[0221] Formula (III)

[0222]

[0223] It should be understood that when the term "drospirenone" is used herein, any drospirenone derivative may also be contemplated.

[0224] The methods described herein may include administering drospirenone to a subject receiving an estetrol component. In certain embodiments, the composition may comprise from about 0.25 mg to about 10 mg of drospirenone, or a progestogen component in an amount equivalent to a single daily dose of from about 0.25 mg to about 10 mg of drospirenone. Preferably, the composition may comprise from about 1 mg to about 4 mg of drospirenone, or a progestogen component in an amount equivalent to a single daily dose of from about 1 mg to about 4 mg of drospirenone. More preferably, the composition may comprise from about 1 mg to about 3 mg of drospirenone, or a progestogen component in an amount equivalent to a single daily dose of from about 1 mg to about 3 mg of drospirenone. Even more preferably, the composition may comprise from about 2.5 mg to about 3.5 mg of drospirenone, or a progestogen component in an amount equivalent to from about 2.5 to about 3.5 mg of drospirenone.

[0225] Optionally, the composition comprises an estetrol component in an amount of from about 15 mg to about 25 mg, preferably estetrol monohydrate, and an amount of from about 0.25 mg to about 10 mg of drospirenone. In a further alternative embodiment, the composition comprises an estetrol component of from about 15 mg to about 20 mg, preferably estetrol monohydrate, and from about 1 mg to about 4 mg of drospirenone. In yet a further alternative embodiment, the composition comprises an estetrol component of about 15 mg or about 20 mg, preferably estetrol monohydrate, and about 3 mg of drospirenone.

[0226] "Progesterone" (commonly abbreviated as "P4"; PubChem CID 5994) is an endogenous steroid and progestogenic sex hormone that is involved in the female menstrual cycle, pregnancy, and embryogenesis and constitutes the major progestogen in the body. Progesterone is a well-documented substance in the literature and has been used in the art in indications including but not limited to contraception, female hormone replacement therapy, and feminizing hormone therapy. Progesterone is known in the art by reference to its structural formula C 21 H 30 O2 or is represented by structural formula (IV):

[0227] Formula (IV)

[0228]

[0229] It should be understood that when the term "progesterone" is used herein, any progesterone derivative may also be considered.

[0230] In certain embodiments, the composition may comprise from about 10 mg to about 500 mg, preferably from about 25 mg to about 300 mg of progesterone, or a progestogenic component, in an amount equivalent to a single daily dose of from about 10 mg to about 500 mg, preferably from about 25 mg to about 300 mg of progesterone. Preferably, the composition may comprise from about 100 mg to about 200 mg of progesterone, or a progestogenic component, in an amount equivalent to a single daily dose of from about 100 mg to about 200 mg of progesterone.

[0231] Optionally, the composition comprises an amount of estetrol component from about 15 mg to about 25 mg, preferably estetrol monohydrate, and an amount of progesterone from about 25 mg to about 300 mg. In a further optional embodiment, the composition comprises an amount of estetrol component from about 15 mg to about 20 mg, preferably estetrol monohydrate, and an amount of progesterone from about 100 mg to about 200 mg. In yet a further optional embodiment, the composition comprises an amount of estetrol component of about 15 mg or about 20 mg, preferably estetrol monohydrate, and an amount of progesterone from about 100 mg to about 200 mg. In another embodiment, when progesterone is used continuously, progesterone is used at a single daily dose of 100 mg to 200 mg, for example, progesterone is administered during about 14 days per month. In yet another embodiment, when progesterone is used continuously, progesterone is used at a single daily dose of 100 mg to 200 mg, for example, when it is administered during about 14 days after the estetrol component has been orally administered once daily at a dose of 15 or 20 mg for at least 12 weeks and not more than 13 weeks. Preferably, after treatment with the estetrol component is completed, progesterone is used once daily for 14 days.

[0232] The progesterone "dydrogesterone" (PubChem CID9051), which can be interchangeably represented in the art, has been used in many medical indications, including dysfunctional uterine bleeding, infertility, dysmenorrhea, endometriosis, and menopausal hormone therapy. Dydrogesterone can be referred to in the art by reference to its structural formula C 21 C 28 C2 or is represented by its structural formula (V):

[0233] Formula (Ⅴ)

[0234]

[0235] It should be understood that when the term "dydrogesterone" is used herein, any dydrogesterone derivatives are also contemplated.

[0236] In certain embodiments, the composition can comprise from about 1 mg to about 20 mg of dydrogesterone, or a progestogen component in an amount equivalent to a single daily dose of from about 5 mg to about 10 mg of dydrogesterone. Preferably, the composition can comprise from about 1 mg to about 20 mg of dydrogesterone, or a progestogen component in an amount equivalent to a single daily dose of from about 5 mg to about 10 mg of dydrogesterone.

[0237] Optionally, the composition comprises an estetrol component in an amount from about 15 mg to about 25 mg, preferably estetrol monohydrate, and from about 1 mg to about 20 mg of dydrogesterone. In a further alternative embodiment, the composition comprises from about 15 mg to about 20 mg of the estetrol component, preferably estetrol monohydrate, and from about 5 mg to about 10 mg of dydrogesterone. In yet a further alternative embodiment, the composition comprises about 15 mg or about 20 mg of the estetrol component, preferably estetrol monohydrate, and from about 5 mg to about 10 mg of dydrogesterone.

[0238] In the context of the present invention, other compounds (i.e., components, reagents) can be used in combination with the estetrol component for administration to females with a uterus. Selective estrogen receptor modulators (SERMs), as a class of such compounds, are considered a beneficial addition to the estetrol component in the methods of the present invention. The preferred SERM used in the context of the present invention is bazedoxifene. In the methods and compositions further described herein, it must be understood that when reference is made to a "progestogen component", such reference includes SERMs, particularly bazedoxifene. Preferably, bazedoxifene is administered at a single daily dose of from about 10 mg to 50 mg. More preferably, bazedoxifene is administered at a single daily dose of from about 15 to about 25 mg. Most preferably, bazedoxifene is administered at a single daily dose of about 20 mg.

[0239] The composition can be formulated into dosage units and administered to a subject at any time interval considered appropriate by a person skilled in the art. In the context of the present invention, the preferred dosing regimen is a single daily dosing regimen (i.e., administered once every about 24 hours). In such embodiments, the compositions described herein thus represent single daily compositions, single daily dosage units. In alternative embodiments, the composition is formulated for a multiple daily dosing regimen, by accumulation to achieve a dose in accordance with the present invention, such as 15 to 25 mg of the estetrol component.

[0240] Optionally, the dosage units are administered to a subject by continuous administration. As used herein, the terms "continuous" and "continuously" mean that the dosage units are administered at relatively regular intervals without (therapeutically) significant interruption. Naturally, minor interruptions that do not affect the overall effectiveness of the method may occur, and indeed such deviations are actually included within the scope of the present invention. In a preferred embodiment, more arithmetically, if the longest interval between two consecutive administrations does not exceed 3.5 times the average interval, the dosing regimen is considered continuous. Even more preferably, the longest interval does not exceed 2.5 times the average interval, and most preferably, does not exceed 1.5 times. By way of illustration and not limitation, the therapeutic strategies and methods described herein preferably employ continuous administration of the estetrol component over a period of at least 10 days, preferably at least 20 days.

[0241] Alternatively, the dosage units are administered to a subject by sequential administration. It should be understood that the term "sequential" means administration, for example, during days 10 to 14 of each month or on day 14 of every three months. The sequential administration mode is particularly contemplated, wherein the progestogen component is part of the composition or treatment described herein.

[0242] Another aspect of the present invention relates to a packaging unit comprising the dosage units described herein. The packaging unit may comprise at least 14, preferably at least 21, and even more preferably at least 28 containers for containing individually packaged and separately removable dosage units, wherein each container contains at least one dosage unit comprising from about 15 to about 25 mg of the estetrol component. Preferably, the individually packaged and separately removable dosage units are oral dosage units. More preferably, each individually packaged and separately removable dosage unit contains about 15 mg or about 20 mg of the estetrol component, preferably about 15 mg or 20 mg of estetrol monohydrate.

[0243] Optionally, the packaging unit further comprises at least 10, preferably 12, and more preferably 14 additional containers for containing individually packaged and separately removable dosage units, wherein each additional container contains at least one dosage unit comprising a progestogen component. Optionally, when the two dosage units must be administered on the same day, each additional container for containing the dosage unit comprising the progestogen component is visually arranged separately next to the container for containing the dosage unit comprising the estetrol component. Optionally, the packaging unit further comprises an equal number of additional containers for containing individually packaged and separately removable oral dosage forms, wherein each additional container contains at least one single-day, preferably solid, oral dosage form comprising a progestogen, preferably wherein the progestogen is selected from drospirenone, progesterone, and dydrogesterone.

[0244] Those skilled in the art should understand that the above-described embodiments for the packaging unit can equivalently be presented in the form of a kit, which comprises: a first packaging unit (e.g., blister packaging) containing a single-day oral dose unit of the estetrol component; and a separate second packaging unit (e.g., a separate second blister packaging) containing a single-day oral dose unit of the progestogen.

[0245] Those skilled in the art should understand that within the scope of the present invention, each packaging unit, such as a blister packaging, can be numbered or otherwise marked.

[0246] The packaging unit can adopt any suitable packaging form known in the art, and non-limiting examples include lozenges, sealed sachets, pouch containers, bottles, films, sprays, microcapsules, implants, rods, or blister packagings.

[0247] By way of illustration and not limitation, each packaging unit can be a sealed blister packaging with a cardboard, cardstock, foil plastic backing and encapsulated in a suitable protective outer shell. Packaging units such as bottles are also contemplated in any of the aspects defined herein. The material in the form of a bottle is not particularly limited. In a preferred embodiment, the bottle is a glass bottle, characterized in that the color can reduce or prevent the contents of the bottle from being degraded by, for example, UV light while maintaining the transparency allowing visual inspection of the contents of the bottle. Suitable colors include, but are not limited to, amber, cobalt, or vintage green.

[0248] In a specific embodiment of the present invention, the packaging unit comprises 28 containers or a multiple of 28 containers, such as 2 to 12 times 28 containers.

[0249] Although the present invention has been described in connection with specific embodiments thereof, it will be apparent that, in light of the foregoing description, various alternatives, modifications, and variations will be apparent to those skilled in the art. Accordingly, all such alternatives, modifications, and variations are intended to be included within the spirit and broad scope of the appended claims. The aspects and embodiments of the present invention disclosed are further supported by the following non-limiting examples. The following specific experimental examples are provided to corroborate the claimed invention but should not be construed as limiting the scope of the present invention.

[0250] Examples

[0251] Example 1: Clinical Study Report (CSR) in Subjects with Liver Injury

[0252] 1. Research Objectives

[0253] 1.1 Main

[0254] · Evaluate the PK of E4 in subjects with different classes of liver injury and subjects with normal liver function.

[0255] 1.2 Secondary

[0256] · Evaluate the PK of E4 metabolites in subjects with different categories of liver injury and subjects with normal liver function.

[0257] · Evaluate the safety of E4 in subjects with different categories of liver injury and subjects with normal liver function.

[0258] 2. Research Protocol

[0259] 2.1 Overall study design and protocol

[0260] In the following sections, the study design and protocol are summarized. See also the summaries of clinical procedures and evaluations in Tables 2 and 3 in Section 2.5.1.

[0261] 2.1.1 Study type

[0262] This is a Phase 1, multicenter, open-label PK and safety study of a single oral dose of 20 mg E4 monohydrate in female subjects with normal liver function (Group 1), mild liver injury (Group 2), moderate liver injury (Group 3), and severe liver injury (Group 4) defined by the Child-Pugh classification at screening.

[0263] The study consists of an eligibility screening period (within 28 days before study drug administration), an evaluation period including an inpatient stay and outpatient visits (including a single oral dose of 20 mg E4 on Day 1), and a follow-up. All subjects are required to be hospitalized at the study center from Day -1 (the day before dosing) to Day 4 and to return to the study center daily from Day 5 to Day 9 for evaluation. Alternatively, with the investigator's consent, subjects may extend their inpatient stay. The follow-up is conducted on Day 14 (±2 days).

[0264] 2.1.2 Screening period

[0265] All subjects are screened within 28 days before study drug administration.

[0266] Before any study-specific screening procedures were conducted, the subjects signed a study-specific informed consent form (ICF). Written informed consent was obtained regardless of whether the subject met the study enrollment criteria; the signed ICF was filed and archived by the CRO, and a copy was provided to the subject. The liver function of subjects with liver injury was evaluated according to the Child-Pugh classification criteria during the screening period. The results of the evaluation were used to classify the subjects into mild, moderate, and severe liver injury groups (see Section 2.3). Subjects with liver injury were assigned to these groups based on the results that had to be obtained within 15 days before dosing. If screening was conducted within 15 days before dosing, the evaluation used for the Child-Pugh classification had to be repeated, and the corresponding subject was classified into the corresponding liver injury group using the most recent results. If this evaluation was conducted on Day -2, the subject could choose whether to start the confinement period from that time or enter the ward on an outpatient basis.

[0267] After signing the ICF, eligibility screening consisted of the evaluations shown in Table 2.

[0268] 2.1.3 Evaluation Period

[0269] All subjects arrived at the study site on the morning of Day -1 in a fasting state (no food for at least 8 hours, water was allowed) for scheduled evaluations to confirm eligibility as outlined in the inclusion and exclusion criteria (Sections 2.3.1 and 2.3.2, respectively). On the morning of Day 1 after an overnight fast, the subjects received an oral dose of 20 mg of E4 monohydrate and were observed at the study center. Study-related evaluations were conducted at the time points shown in the evaluation schedule in Table 2.

[0270] According to the pharmacokinetic sampling schedule shown in Table 3, continuous blood oxygen collection for PK evaluation was conducted from Day 1 until Day 9.

[0271] [[ID=IS]]On Day 4, the subjects could leave the study site and return for outpatient visits from Day 5 to Day 9. Alternatively, at the discretion of the investigator, the subjects could extend their hospitalization until Day 9.

[0272] For a detailed overview of the evaluations, see Section 2.5.1 and the evaluation schedule (Table 2).

[0273] 2.1.4 Follow-up

[0274] A follow-up medical examination was conducted on Day 14 (±2 days). For a detailed overview of the evaluations, see Section 2.5.1 and the evaluation schedule (Table 2).

[0275] 2.2 Discussion of Study Design

[0276] In accordance with the recommendations of the US Food and Drug Administration (FDA) and the European Medicines Agency (EMA), this study followed the guidelines for research in subjects with liver injury.

[0277] For the purpose, a parallel design was used to study the potential differences in PK characteristics between subjects with liver injury at different stages and subjects with normal liver function. Liver function was scored according to the Child-Pugh classification recommended in the FDA and EMA guidelines (FDA Guidance for Industry, Pharmacokinetics in Patients with Impaired Hepatic Function, 2003; EMA Guideline on the Evaluation of the Pharmacokinetics of Medicinal Products in Patients with Impaired Hepatic Function, 2005).

[0278] Initially, 2 subjects were recruited into the liver injury groups (groups 2, 3, and 4). Once these 2 subjects in a specific group completed day 5, a safety laboratory data review was conducted for that group. If the results of this data review were satisfactory (see section 2.8), the remaining subjects in that group could then be recruited thereafter.

[0279] The study was open-label because all subjects received the same treatment and needed to be assigned to the appropriate liver function groups.

[0280] 2.3 Selection of the study population

[0281] Approximately 32 female subjects were recruited into this study: 24 subjects with liver injury (8 subjects in each severity group: mild, moderate, and severe) and 8 subjects with normal liver function as the control group. Subjects could be replaced, or additional subjects could be recruited to ensure a minimum of 6 evaluable subjects per group and a sufficient number of subjects for matching.

[0282] The liver function of subjects with liver injury (cirrhosis) was evaluated using the Child-Pugh scoring system (Table 1) and laboratory results at the time of screening.

[0283] Table 1. Liver function classification - Child-Pugh score

[0284]

[0285] * The assessment of encephalopathy was mainly based on the clinical signs and symptoms detailed below; electroencephalogram is not a mandatory examination for encephalopathy grading.

[0286] Grade 0: Consciousness, personality, neurological examination, and electroencephalogram are all normal; Grade 1: Restlessness, sleep disorder, irritability / excitement, tremor, dysgraphia, 5 Hz brain waves; Grade 2: Somnolence, time disorientation, inappropriate behavior, asterixis, ataxia, slow triphasic waves; Grade 3: Somnolence, stupor, place disorientation, hyperreflexia, rigidity, even slower waves; Grade 4: Unarousable coma, no personality / behavior, decerebration, 2 - 3 Hz slow delta wave activity

[0287] The liver function groups are defined as follows:

[0288] · Group 1: Normal liver function

[0289] · Group 2: Mild liver injury (Child - Pugh score 5–6 points)

[0290] · Group 3: Moderate liver injury (Child - Pugh score 7–9 points)

[0291] · Group 4: Severe liver injury (Child - Pugh score 10–14 points)

[0292] ** Subjects with > Grade 2 encephalopathy are not recruited.

[0293] The control group (Group 1) is matched with the liver injury population in terms of age, body mass index (BMI), and smoking habit. After at least 50% of the liver injury subjects in each group receive the drug administration, subjects with normal liver function are recruited, and the median, minimum, and maximum values of age and BMI in Groups 2 - 4 are determined. The enrollment of subjects with normal liver function occurs within the calculated range of age and BMI (covering the extreme values as much as possible, with approximately 50% of the subjects on each side of the median). Roughly similar proportions of smokers / non - smokers are recruited.

[0294] 2.3.1 Inclusion Criteria

[0295] Subjects must meet the following inclusion criteria to participate in this study.

[0296] 2.3.2.1 All Subjects

[0297] 1. Able to understand and voluntarily sign the ICF and be able to comply with the study restrictions.

[0298] 2. At the time of informed consent, adult female subjects are 18 to 75 years old (inclusive).

[0299] 3. BMI is 18.0 - 35.0 kg / m 2 (inclusive), where BMI (kg / m 2 ) = body weight (kg) / height 2 (m 2)。

[0300] 4. Subjects may be enrolled if they meet the following criteria:

[0301] a. Documented surgical sterilization or postmenopausal (amenorrhea > 1 year and FSH ≥ 30 mU / mL), or

[0302] b. Serum pregnancy test negative at screening, urine pregnancy test negative on Day - 1, and willing to use non - hormonal contraception (i.e., non - hormonal intrauterine device, vasectomized partner, abstinence, male / female condom with or without spermicide, spermicide - containing cap, diaphragm or sponge) during the study period (from screening to follow - up).

[0303] 5. Voluntary and able to sign the ICF.

[0304] 6. Willing and able to comply with the study procedures.

[0305] 2.3.1.2 Subjects with liver injury (additional)

[0306] 7. Diagnosed with cirrhosis due to parenchymal liver disease, confirmed and documented by at least one of the following methods: liver ultrasound, computed axial tomography (CT), magnetic resonance imaging (MRI), and / or liver biopsy.

[0307] 8. Stable liver injury, defined as no clinically significant change in condition within 1 month as judged by the investigator.

[0308] 2.3.1.3 Subjects with normal liver function (additional)

[0309] 9. Subjects determined by the investigator to have no liver disease and normal liver function.

[0310] 10. Based on medical history and medical evaluation showing no clinically relevant abnormalities, the investigator considers the subject to be in good physical and mental health (including physical examination, medical history, vital signs [systolic blood pressure ≥ 100 mmHg and ≤ 140 mmHg, diastolic blood pressure ≥ 60 mmHg and ≤ 90 mmHg], and biochemical results, coagulation and hematology tests, and urine analysis at screening and on Day 1).

[0311] Subjects with chronic (> 3 months) stable non - neoplastic diseases (e.g., hypertension, diabetes) under clinical control may participate.

[0312] 2.3.2 Exclusion criteria

[0313] Subjects meeting any of the following exclusion criteria are not eligible for this study:

[0314] 2.3.2.1 All subjects

[0315] 1. Abnormal medical history related to clinical practice, abnormal findings in physical examinations (including gynecological examinations), vital signs, or laboratory test results, which are judged by the investigator to potentially interfere with the purpose of the trial or the safety of the volunteers, except for diseases related to liver damage in subjects with impaired liver function (Groups 2 to 4).

[0316] 2. Surgery (e.g., gastric bypass) or medical conditions (e.g., pancreatic injury or pancreatitis, gastritis) that are judged by the investigator to potentially significantly affect drug absorption.

[0317] 3. Recorded congenital QT syndrome.

[0318] 4. Unstable ischemic heart disease or severe heart failure (New York Heart Association Class III or IV).

[0319] 5. Uncontrolled hypertension / untreated hypertension (defined as the mean of 3 repeated measurements of systolic blood pressure ≥ 180 mmHg and / or diastolic blood pressure ≥ 110 mmHg); current or recorded history of repeated clinically significant hypotension or severe orthostatic hypotensive episodes (systolic blood pressure < 90 mmHg and / or diastolic blood pressure < 50 mmHg).

[0320] 6. Primary biliary cirrhosis.

[0321] 7. History of hormone-related (estrogen / progesterone) cancer or other cancer history where it is judged that there is no complete remission and there is cancer (basal cell skin cancer or squamous cell skin cancer).

[0322] 8. Acute illness within 14 days before the administration of the study drug, unless the severity is mild and approved by the investigator and the medical representative of the sponsor.

[0323] 9. Presence of active infection requiring antibiotics.

[0324] 10. Consumption of Seville oranges, grapefruit, or grapefruit juice, pomelo, star fruit, cranberry, or menthol (in beverages or foods) from 7 days before the administration of the study drug until the end of the evaluation period.

[0325] 11. Use of any prescription drugs or herbal supplements (e.g., St. John's wort) as strong inducers and inhibitors of CYP3A4 function from 14 days before Day 1 until the follow-up period. For the treatment of pain such as headache or musculoskeletal pain, acetaminophen is allowed as a first-line drug, ibuprofen, indomethacin, and metamizole containing pipolphen. The dose of the analgesic is determined by the investigator. The sponsor reserves the right to review any drugs used long-term by subjects with liver injury to assess their eligibility for the study.

[0326] 12. Use of any over-the-counter medications or dietary supplements (including vitamins) within 14 days prior to the administration of the investigational drug up to the end of the study.

[0327] 13. Consumption of alcohol between 48 hours prior to the administration of the investigational drug and Day 9. Outside of this period, regular weekly alcohol consumption is permitted not exceeding 17 units (1 unit is equivalent to 250 mL of beer, 75 mL of wine, or 25 mL of spirits).

[0328] 14. Smoking more than 10 cigarettes per day (or equivalent nicotine intake). Use of tobacco products containing menthol is prohibited.

[0329] 15. Exposure to another investigational drug within 30 days prior to the administration of the investigational drug (or 5 times the drug half-life, whichever is longer), or exposure to more than 3 new investigational drugs within 12 months prior to the administration of the investigational drug. Previous participation in the current study and exposure to E4.

[0330] 16. Donation or loss of more than 450 mL of blood during the 3-month period prior to the start of screening.

[0331] 17. Female subjects who are pregnant, breastfeeding, or planning to become pregnant during the study and have not had a hysterectomy.

[0332] 18. Clinically significant renal disease (creatinine clearance [CLCr] calculated by the Cockcroft-Gault formula < 60 mL / min during the screening period, see Table 4).

[0333] 19. Serologically positive for human immunodeficiency virus antibody (anti-HIV)-1 / 2 screening.

[0334] 20. History of drug addiction (including soft drugs such as cannabis products).

[0335] 21. Positive urine drug screening (opioids, methadone, cocaine, amphetamines [including methamphetamine], cannabinoids, barbiturates, benzodiazepines, tricyclic antidepressants) during the screening period and / or on Day -1 (not permitted without a medical prescription, and cannabinoid drugs are not permitted under any circumstances) or positive alcohol breath test.

[0336] 22. History of relevant drug and / or food allergies.

[0337] 23. Legal incompetence or limited capacity.

[0338] 24. Unexplained vaginal bleeding in the past 12 months.

[0339] 25. History of venous or arterial thromboembolic disease (e.g., deep vein thrombosis, pulmonary embolism, stroke, myocardial infarction, angina, etc.) or history of known coagulopathy.

[0340] 26. The cervical Pap smear of cervical cancer subjects is abnormal and clinically significant (documented in the previous test or screening within 12 months), with evidence of cervical dysplasia. Women diagnosed with atypical squamous cells of undetermined significance (ASCUS) are allowed.

[0341] 27. Subjects with non-euthyroid status (including hyperthyroidism or hypothyroidism), and those receiving thyroid-related medications (such as levothyroxine or antithyroid drugs).

[0342] 2.3.2.2 Subjects with liver injury (additional)

[0343] 28. History of esophageal bleeding within 3 months before the administration of the study drug.

[0344] 29. Severe hepatic encephalopathy (grade > 2) or the degree of central nervous system damage considered by the investigator to have reached the following criteria: affecting the informed consent process, interfering with the study implementation or result interpretation, or posing an unacceptable risk to the subject

[0345] 30. History of liver transplantation.

[0346] 31. Ascites judged by the investigator to be advanced and requiring drainage and albumin supplementation.

[0347] 32. Hemoglobin concentration < 105 g / L.

[0348] 2.3.2.3 Subjects with normal liver function (additional)

[0349] 33. Positive serological test for hepatitis B surface antigen (HBsAg) or anti-hepatitis C virus (HCV), unless confirmed by polymerase chain reaction (PCR) test that there is no active hepatitis B / C infection.

[0350] 2.3.3 Excluding subjects from the assessment

[0351] Participation in this study is completely voluntary. Subjects have the right to withdraw from the study at any time for any reason without any retaliation.

[0352] The investigator has the right to terminate the participation of subjects for any of the following reasons: difficulty in obtaining blood samples, violation of the protocol, serious adverse event (AE) or serious adverse event (SAE), or any other reason related to the safety of the subject or the integrity of the study data.

[0353] If a subject withdraws from the study, the sponsor should be notified immediately. If the withdrawal is due to medical reasons, the subject should still be under the supervision of the research staff until recovery.

[0354] If a subject is withdrawn by the researcher for reasons related to the investigational drug (at the researcher's discretion), the subject will be considered withdrawn. If the sponsor deems it necessary, the withdrawn subject should be replaced.

[0355] If a subject fails to complete the study for reasons unrelated to the drug, he / she will be considered a non-completed subject and will be replaced to ensure there are a sufficient number of 6 evaluable subjects.

[0356] The decision to replace a subject needs to be recorded.

[0357] The CRO should make every effort to ensure that subjects who have received the investigational drug but have not completed the trial and subjects who have withdrawn midway complete the safety follow-up assessment.

[0358] 2.3.4 Early termination of the study

[0359] The procedures for early termination of the trial are described in detail in the study protocol.

[0360] 2.4 Treatment

[0361] 2.4.1 Dosage regimen

[0362] Each enrolled subject receives a single oral dose of 20 mg of E4 (estetrol) monohydrate as a film-coated tablet.

[0363] 2.4.2 Identification information of the investigational product

[0364] Active Drug

[0365] Active ingredient: Estetrol monohydrate

[0366] Activity: Estrogen receptor (ER) agonist, with higher affinity for ERα

[0367] Indication: Not applicable

[0368] Dosage: 20 mg

[0369] Strength: 1 x 20 mg

[0370] Dosage form: Film-coated tablet for oral administration.

[0371] The packaging and labeling are carried out in accordance with Volume 4 of the EU Pharmaceutical Administration Rules: Good Manufacturing Practice (GMP). The label of the investigational medicinal product (IMP) includes all the information required by Annex 13 of GMP.

[0372] 2.4.3 Method for grouping subjects by liver function

[0373] After obtaining oral and written informed consent, subjects with liver injury and normal liver function were screened according to the inclusion and exclusion criteria. Subjects with liver insufficiency were assigned to one of three liver injury groups according to the Child-Pugh classification (see Section 2.2). If liver function tests were repeated during screening, the most recent results were used for grouping. Control subjects were determined by the investigator to have no liver disease and normal liver function. Subjects meeting all selection criteria received a unique subject number upon enrollment in the study. Subject numbers were assigned sequentially in the order of subjects enrolled. The investigator or designated person entered the corresponding subject number in the electronic case report form (eCRF) for each subject. The subject number ensured identification prior to follow-up.

[0374] Prior to enrollment, subjects who withdrew or were withdrawn for any reason were considered screening failures. Such subjects did not receive a subject number. The investigator maintained a screening log of all screened subjects to assess the number and characteristics of excluded subjects and the reasons for their exclusion.

[0375] 2.4.4 Selection of Study Dose

[0376] E4 was well tolerated and safe at single doses up to 100 mg and at doses up to 40 mg once daily for 28 days. A human mass balance study showed that hepatic elimination accounted for approximately 20% of total elimination. It was assumed that a 20 mg oral dose of E4 would provide sufficient safety margin even in subjects with severe liver injury, where the expected exposure was 5 times that of subjects with normal liver function.

[0377] 2.4.5 Administration Time in the Study

[0378] The study drug should be administered in the morning after the subject has fasted for at least 8 hours.

[0379] The study drug should be swallowed with 240 mL of tap water (room temperature). The study drug should not be chewed. Fasting should continue for 4 hours after administration. During the fasting period, no liquids other than water are permitted; however, no water is permitted from 2 hours before until 1 hour after administration (except for the water taken with the administration as described above). When not fasting, liquids can be consumed at will, subject to the restrictions listed in Section 2.4.8.

[0380] Administration of the study drug was supervised by the investigator or proxy. Oral and hand checks were performed after administration.

[0381] Whenever possible, routine medications should be avoided within 2 hours before and 2 hours after administration of the IMP, unless they are medications prescribed at specific times or taken with meals.

[0382] 2.4.6 Diet during the Study

[0383] Before obtaining clinical laboratory samples at all time points, i.e., before screening, on Day - 1, Day 2, Day 3, Day 5, Day 9 of admission, and before follow - up, a fasting period of at least 8 hours is required.

[0384] Except for the restrictions on caffeinated and alcoholic beverages or foods as described in Section 2.4.8, there are no special requirements for food and beverage intake. When not fasting, meals and snacks are provided according to clinical standards.

[0385] 2.4.7 Blinding

[0386] This is an open - label study.

[0387] 2.4.8 Prior and Concomitant Treatments and Other Restrictions During the Study

[0388] All medications (prescription and non - prescription) taken from 30 days before screening until the follow - up period are recorded in the corresponding section of the eCRF.

[0389] In addition to the restrictions listed in the inclusion and exclusion criteria (Section 2.3), the following restrictions must also be adhered to:

[0390] All subjects:

[0391] · Alcohol is not permitted within 48 hours before the administration of the study drug until the end of the evaluation period.

[0392] · From 7 days before the administration of the study drug until the end of the evaluation period, foods or beverages containing grapefruit, Seville oranges, pomelos, starfruit, or cranberries are not permitted.

[0393] · Any caffeinated foods or beverages are not permitted from 48 hours before the administration of the study drug until the end of the evaluation period.

[0394] · Postmenopausal women must use the same contraceptive measures as described for non - hysterectomized women, unless postmenopausal status is confirmed by an FSH test and amenorrhea for more than 12 months.

[0395] · From 96 hours (4 days) before entering the clinical research center until the last follow - up, strenuous activities, sunbathing, or contact sports are not permitted.

[0396] · Smoking is prohibited during hospitalization.

[0397] · For the treatment of pain such as headache or musculoskeletal pain, paracetamol as a first - line drug, ibuprofen, indomethacin, and metamizole containing pitofenone are permitted. The dose of the analgesic is determined by the investigator.

[0398] Subjects with liver injury (Supplementary):

[0399] · Within 14 days before the study drug administration, it is not allowed to start using any new drugs (except for pain treatment) or make any arbitrary changes to the current dose.

[0400] 2.4.9 Treatment compliance

[0401] Responsibility and subject compliance are evaluated by maintaining adequate records of the study drug distribution. The investigator is responsible for ensuring that the drug is administered in accordance with the protocol. Any delegation of this task must be clearly documented and approved by the investigator. Compliance is further confirmed by the bioanalysis of E4 in plasma samples (see Section 2.5.5.1).

[0402] 2.5 Pharmacokinetics, safety, and exploratory measurements and variables

[0403] This study aims to evaluate the safety and PK parameters after a single dose of E4; this study does not include efficacy or pharmacodynamic evaluations.

[0404] 2.5.1 Evaluation schedule

[0405] The evaluation schedule is shown in Table 2. PK sampling is shown in Table 3.

[0406]

[0407]

[0408] Table 3. Pharmacokinetic blood sampling schedule for estetrol and its metabolites

[0409]

[0410] 2.5.2 Pharmacokinetic measurements

[0411] The evaluation schedule is shown in Table 2. PK sampling is shown in Table 3.

[0412] 2.5.2.1 Blood sample collection

[0413] The laboratory manual prepared by the CRO describes the details of sample collection, processing, storage, and transportation.

[0414] 2.5.3 Safety and tolerability measurements

[0415] Safety and tolerability evaluations include treatment-emergent AEs (TEAEs), clinical laboratories, vital signs, physical examinations, and gynecological examinations. The evaluations are conducted according to Tables 2 and 3 in Section 2.5.1.

[0416] 2.5.3.1 Adverse events

[0417] AE / TEAEs are recorded from the time of ICF signature until the completion of follow-up. Any clinically significant observations in clinical laboratory, vital signs, or physical examination findings are recorded as AEs.

[0418] A TEAE is defined as any event that was not present prior to the administration of the investigational medicinal product or any pre-existing event that worsens in severity or frequency following exposure to the investigational medicinal product.

[0419] Adverse events (AEs) occurring after ICF signature and before administration of the investigational medicinal product are considered pre-treatment AEs.

[0420] At several time points before and after dosing, open-ended questions are asked of the subjects to identify the occurrence of AE / TEAEs. Subjects are regularly asked general questions about any AE / TEAEs during the study. In addition, all spontaneously reported AE / TEAEs during the study are recorded.

[0421] The investigator interprets all responses for AE / TEAEs using the Medical Dictionary for Regulatory Activities (MedDRA; version 22.1) and records them in the AE record.

[0422] Pregnancy is monitored during follow-up if there is a justifiable reason.

[0423] 2.5.3.2 Clinical Laboratory

[0424] The tests listed below are performed by the local laboratory at the time points shown in the assessment schedule (Table 2).

[0425] Table 4. Clinical Laboratory Examinations

[0426]

[0427]

[0428] CLCr = creatinine clearance; FSH = follicle-stimulating hormone; HBsAg = hepatitis B surface antigen; HCV = hepatitis C virus; HIV = human immunodeficiency virus; PCR = polymerase chain reaction.

[0429] a) Absolute measurements and percentages of total white blood cell subsets

[0430] b) If positive, confirm by PCR

[0431] c) For calculation of CLCr using Cockcroft-Gault:

[0432] CLCr = ((140 - age [years]) * weight [kg]) / (72 * serum creatinine [μmol / l] / 88.4) * 0.85

[0433] (If female)

[0434] Clinical laboratories clearly label all laboratory test values outside the normal range, and the investigator indicates the clinical significance according to the applicable CRO standard operating procedures (SOP). The procedures for collection, handling, and transportation of laboratory samples are specified in the laboratory manual provided to the study sites.

[0435] During the entire study period, a total volume of 285 mL of blood is expected to be collected from each subject.

[0436] 2.5.5.3 Vital Signs

[0437] After the subject has been supine and at rest for at least 5 minutes, systolic blood pressure, diastolic blood pressure, and pulse are recorded at the time points specified in the assessment schedule (Table 2). These assessments are performed using automated equipment. Subsequently, body temperature and respiratory rate are measured.

[0438] 2.5.3.4 Physical Examination

[0439] A full physical examination, including examination of all body systems, is performed at the time points specified in the assessment schedule (Table 2). Physical examinations for symptoms can be performed at any time at the discretion of the investigator.

[0440] Height is recorded only at the screening visit. Body weight is measured, and BMI is calculated at the time points specified in the assessment form (Table 2).

[0441] A gynecological examination (including breast examination, transvaginal ultrasound, and Pap smear [performed only if a Pap smear has not been performed within the previous 1 year before screening]) is performed according to the assessment schedule in Table 2.

[0442] 2.5.4 Applicability of Measurements

[0443] The assessments performed in this study are standard and are generally considered to be reliable, accurate, and relevant. Valid PK assays are the standard measurements for determining changes in drug blood levels and their pharmacological effects in subjects with different liver functions. Collection of AE / TEAE, safety laboratory tests, and physical examinations are standard methods for evaluating the safety of new drugs. Overall, these are appropriate measures to achieve the study objectives.

[0444] All procedures are documented in the CRO SOP.

[0445] 2.5.4.1 Assessment Time

[0446] For PK, pre-dose samples are obtained after an overnight fast within 60 minutes before dosing. Post-dose samples are collected at the time margins specified in Table 3.

[0447] For safety assessment, a pre-dose assessment is conducted between waking and dosing. For safety assessment up to 2.5 h after dosing, a time window of ±15 minutes is allowed. Thereafter, serial post-dose assessments (e.g., multiple assessments on any given day) should be completed within a ±10% time allowance from the time of the last dose; occasional post-dose assessments (e.g., 1 or 2 assessments on a given day) should be completed within ±3 hours of the scheduled time in the protocol, provided that the assessment remains within the same day phase and there is no adjustment from the pre-dose phase to the post-dose phase or vice versa. If event assessments are scheduled at the same protocol time, the following order should be followed: (1) physical examination; (2) vital signs assessment; (3) blood sampling, with PK blood samples collected on time, and (4) meal (if applicable).

[0448] 2.5.5 Pharmacokinetic and safety variables

[0449] 2.5.5.1 Pharmacokinetic variables

[0450] Non-compartmental PK parameters are calculated using WinNonlinTM Professional version 6.3 or higher.

[0451] 2.5.5.1.1 Primary pharmacokinetic parameters

[0452] Primary PK parameters to be analyzed for E4 in plasma:

[0453] C max = Maximum observed plasma concentration

[0454] AUC inf = Area under the concentration-time curve from time 0 to infinity.

[0455] 2.5.5.1.2 Secondary pharmacokinetic parameters

[0456] Secondary PK parameters to be analyzed for E4 and its metabolites in plasma:

[0457] C max = Maximum observed plasma concentration (only for metabolite)

[0458] AUC inf = AUC from time 0 to infinity (only for metabolite)

[0459] AUC 0-24h = AUC from 0 to 24 h after dosing

[0460] AUC last = AUC up to the last time point with concentration above the lower limit of quantification

[0461] T max = Time to reach C maxTime

[0462] T 1 / 2 = Terminal elimination half-life

[0463] CL / F = Apparent clearance (for E4 only)

[0464] Λz = Terminal elimination phase rate constant

[0465] Vz / F = Apparent volume of distribution at the end stage (for E4 only)

[0466] Other PK parameters can be calculated as appropriate.

[0467] 2.5.5.2 Safety variables

[0468] Safety variables to be measured include but are not limited to the variables given below:

[0469] · Clinical laboratory

[0470] · Vital signs

[0471] · Physical examination

[0472] · TEAE

[0473] 2.5.6 Drug concentration measurement

[0474] Analysis of E4 and metabolites E4-3-glucuronide and E4-16-glucuronide in plasma samples was performed using a validated liquid chromatography-tandem mass spectrometry method in the bioanalytical laboratory of the CRO.

[0475] 2.6 Statistical methods and determination of sample size planned in the protocol

[0476] 2.6.1 Analysis datasets

[0477] 2.6.1.1 Safety dataset

[0478] All subjects who received a dose of E4 monohydrate.

[0479] 2.6.1.2 Pharmacokinetic dataset

[0480] All subjects who received at least 1 dose of E4 monohydrate and provided sufficient bioanalytical assessment results to calculate a reliable estimate of PK parameters.

[0481] 2.6.2 Statistical and analysis plan for pharmacokinetics, safety, and exploratory evaluation

[0482] Use Appropriate procedures in version 9.4 or higher for statistical analysis.

[0483] All data were summarized using descriptive statistics and presented and summarized in tables and / or figures.

[0484] 2.6.2.1 Pharmacokinetic evaluation

[0485] Individual and mean plasma concentrations of E4 at each sampling time point were presented by listing and descriptive summary statistics, including mean, geometric mean (GM), median, range, standard deviation (SD), and coefficient of variation (CV). Semi-logarithmic plots of individual concentration, mean concentration, and / or median concentration over time were plotted separately for each liver function group.

[0486] PK parameters were calculated by non-compartmental analysis. PK parameters were analyzed using descriptive statistics and presented by liver function group.

[0487] Summary statistics of PK parameters, including mean, GM, median, range, SD, and CV, were presented by liver function group.

[0488] Analysis of variance (ANOVA) was used in an exploratory approach to compare the main PK parameters (C max and AUC inf ) of E4 between subjects with liver injury and those with normal liver function, using the log-transformed values of each PK parameter as the dependent variable and liver injury group (normal, mild, moderate, and severe) as the fixed categorical factor. Ratios of the main PK parameters of each liver injury group to the control group, along with 90% confidence intervals (CI), were calculated using geometric least-squares means.

[0489] In addition, ANOVA models similar to the above ANOVA model were used to evaluate the effects of age and BMI on the liver injury effect, but the interaction between each factor and the liver injury group was included as an additional factor.

[0490] The relationship between the log-transformed PK parameters (C max and AUC inf ) and the continuous parameters (albumin, total bilirubin, and prothrombin time) used for the Child-Pugh score was explored by linear regression methods. In cases where there was a significant interaction with the liver injury group determined using the ANOVA model, additional linear regressions stratified by BMI or age group could be performed. If indicated, further exploratory analysis of the relationship between liver injury and PK could be conducted.

[0491] Descriptive analysis was performed on the secondary PK parameters.

[0492] 2.6.2.2 Safety and tolerability evaluation

[0493] Safety and tolerability are evaluated by TEAE, clinical laboratory, vital signs, and physical examination findings, as well as any other parameters relevant to safety assessment.

[0494] List all individual safety outcomes and, where applicable, calculate descriptive statistics, including change values relative to baseline.

[0495] 2.6.2.2.1 Adverse Events

[0496] A list of all individual AEs is provided. The summary table of TEAEs is presented by System Organ Class (SOC) based on the MedDRA term list (Preferred Terms): a table of the number of subjects with AEs by liver function, a table of the number of subjects with SAEs by liver function (if applicable), a table by liver function and relationship, and a table by liver function and severity.

[0497] All TEAE summaries are presented in alphabetical order of SOC, with Preferred Terms (PTs) sorted in descending frequency within each SOC based on MedDRA.

[0498] Summarize and report the number and percentage of subjects with TEAEs, SAEs, TEAEs leading to study drug discontinuation, or TEAEs graded by severity by liver function group.

[0499] Summarize and report the number and percentage of subjects with each TEAE by liver function group. Count only by subject, not by event; a subject is counted only once in each body system or PT.

[0500] Summarize and report the number and percentage of subjects with each TEAE by relationship to the study drug (as recorded on the eCRF) and liver function group. Subjects with multiple events within a specific SOC or PT are counted as relevant, unless there are no events related in that SOC / PT.

[0501] Summarize and report the number and percentage of subjects with each TEAE by severity (as recorded on the eCRF) and liver function group. Subjects with multiple events within a specific SOC or PT are counted under the category of the most severe event within that SOC or PT.

[0502] All AEs (including non-treatment emergent events) recorded on the eCRF are listed by subject.

[0503] Provide a separate list of AEs leading to study drug discontinuation by subject.

[0504] 2.6.2.2.2 Clinical Laboratory

[0505] For reporting and processing purposes, all laboratory data are converted to the International System of Units.

[0506] If the parameters are outside the reference range, list the clinical laboratory data and note it, and compile a summary list of all data evaluated by the investigator as clinically significant.

[0507] Provide descriptive statistical summaries of the serial laboratory results of clinical chemistry by liver function group and at pre-specified time points, including hematology, coagulation, and changes derived relative to baseline.

[0508] All laboratory data are listed by subject.

[0509] A separate list of outliers considered to be clinically significant is provided.

[0510] 2.6.2.2.3 Physical Examination

[0511] Physical examination data are listed by subject.

[0512] 2.6.3 Determination of Sample Size

[0513] No formal sample size calculation was performed because there was no existing information on the variability of E4 PK in subjects with liver injury. Based on practical considerations and in accordance with the applicable guidelines for clinical studies in subjects with liver impairment, the number of subjects enrolled was selected.

[0514] 2.7 Review of Safety Laboratory Data

[0515] Prior to the enrollment of subsequent subjects, the safety laboratory test results of the first 2 subjects in each group need to be reviewed to evaluate the potential impact of E4 on liver function (elevated liver enzymes). The results on Day 2, Day 3, and Day 5 are considered and compared with the results on Day -1 (baseline).

[0516] Potential fluctuations in liver function are expected. If the results of liver enzymes exceed 1.5 times the baseline value (the upper limit of normal or the actual value if higher than the upper limit of normal on Day -1), the case will be further discussed within the CRO and with the sponsor to follow up the situation before further subjects are included in the group.

[0517] 2.8 Demographics

[0518] A total of 32 female subjects aged 48 to 70 years with a BMI of 18.5 to 34.7 kg / m 2 participated in the study. All subjects were white, none were multi-racial, and none were Hispanic or Latino (Table 7).

[0519] Table 5. Summary of Demographic Characteristics

[0520]

[0521] BMI = Body Mass Index; Max = Maximum; Min = Minimum; N = number of subjects; n = number of subjects as a unit; SD = Standard Deviation

[0522] The medical history of the group of subjects with normal liver function is appropriate for the age of the population. The disease characteristics exhibited by the subjects with liver injury are consistent with or secondary to the cause of their underlying liver dysfunction. Among the 32 female subjects, 3 had childbearing potential.

[0523] 3. Pharmacokinetic Results

[0524] 3.1 Pharmacokinetic Results

[0525] 3.1.1 E4 Plasma Concentration

[0526] E4 was rapidly absorbed, reaching its main plasma peak concentration within an average of 30 min after dosing, within 15 min in the group with severe liver impairment, and no subject exceeded 2 h. The plasma concentration of E4 then rapidly declined, with a smaller secondary peak occurring in all groups except the group of subjects with severe liver injury. After approximately 12 h, E4 entered the log-linear terminal elimination phase ( Figure 1 and Figure 2 ).

[0527] Compared with the groups with mild liver injury and normal liver function, the groups with moderate and severe liver injury showed a faster decline rate. For the group with severe liver function impairment, the concentration of E4 remained above the LLOQ in at least half of the subjects until 48 h after dosing, until 96 h for the group with moderate liver injury, and until 144 h after dosing for the groups with mild liver injury and normal liver function subjects, respectively ( Figure 2 ).

[0528] 3.1.2 E4-3-Glucuronide Plasma Concentration

[0529] The relationship between the arithmetic mean plasma concentration of E4-3-glucuronide and time is shown in Figure 3 , and the GM plasma concentration is shown in Figure 4 . The GM plasma concentration reached a main value of similar values within approximately 1 h in all groups, and all groups except the group with severe liver injury showed a secondary peak.

[0530] Compared with the groups with moderate liver injury, mild liver injury and normal liver function, the group with severe liver injury showed the fastest decline. For the group with severe liver function impairment, the concentration of E4-3 remained above the LLOQ in at least half of the subjects until 36 h after dosing, until 48 h for the group with moderate liver injury, and until 96 h for the group with mild liver function impairment and normal liver function subjects.

[0531] 3.1.3 Plasma Concentration of E4-16-Glucuronide

[0532] The relationships of the arithmetic mean and GM plasma concentrations of E4-16-glucuronide with time are shown in Figure 5 and Figure 6 . In all groups, the GM plasma concentration reached the main peak within approximately 1 hour. The peaks in the 3 groups of subjects with liver injury were similar and higher than those in the group of subjects with normal liver function. In the groups with normal liver function and mild liver injury, a secondary peak was reached before entering the elimination phase.

[0533] Compared with the groups with moderate liver injury, mild liver injury, and normal liver function, the group with severe liver injury showed the fastest decline. For the group with severe liver function injury, the concentration of E4-16 remained above the LLOQ in at least half of the subjects within 48 hours after dosing, up to 72 hours for the group with moderate liver injury, and up to 96 hours for the group with mild liver injury and subjects with normal liver function.

[0534] 3.1.4 Pharmacokinetic Parameters of E4 in Plasma

[0535] The effects of liver injury on individual C max and AUC inf in relation to the Child-Pugh score are shown in Figure 7 . All groups showed significant inter-individual differences - the C max and AUC inf values in the group with moderate liver injury had the largest range of fluctuations. In all subjects with severe liver injury, C max was higher than the maximum value measured in the control group. In the groups with mild and moderate liver injury, the maximum C max was higher than that in the control group. The minimum AUC inf measured in the group with severe liver injury was similar to the maximum AUC inf measured in the control group. In the groups with mild and moderate liver injury, the maximum AUC inf was higher than that in the control group.

[0536] Summary statistics of the primary and secondary PK parameters of E4 are shown in Table 8.

[0537] Compared with normal liver function, the GM C max of the parent compound E4 increased in all liver injury groups. This effect was most obvious in the group with severe liver injury, less in mild or moderate injury, and the latter was uncertain due to high variability.

[0538] The mean, median, and GM AUC inf values in the group with severe injury were elevated (GM AUC infApproximately 1.9 times), but it was comparable between the mild injury group and the normal liver function group. Although a similar trend was also presented in the moderate liver injury group, due to the high variability in this group, the results were inconclusive (Table 12). The median Tmax was in the range of 0.25 h to 0.50 h and did not show any relationship with the degree of liver injury. T 1 / 2 The GM values of were similar among subjects with normal liver function, mild injury, and moderate injury, with high variability. Only in subjects with severe liver injury was it shown that GM T 1 / 2 was significantly lower compared to other groups. The last measurable concentration (Clast) of E4 was measured at 192 h (the last measurement time point) after dosing in subjects with normal liver function or mild liver injury, 144 h in the moderate liver injury group, and 168 h in the severe liver injury group. The apparent clearance CL / F was similar between the normal liver function group and the mild and moderate injury groups, and showed a slight decrease in the severe injury group.

[0539] In subjects with normal liver function, the GM of Vz / F was 5996.6 L, which decreased to 1201.4 L in subjects with severe liver impairment.

[0540] The variability of the main PK parameters of E4 was moderate to high ( Figure 7 ).

[0541] Table 6. Pharmacokinetic parameters of E4 (pharmacokinetic dataset)

[0542]

[0543]

[0544]

[0545] AUC = Area under the concentration-time curve; AUC inf = AUC from time 0 to infinity; AUC last = AUC at the last time point when the drug concentration is higher than the lower limit of quantification; AUC 0-24h = AUC from 0 to 24 hours after dosing; CL / F = Apparent clearance; C max = Maximum observed plasma concentration; Geo = Geometric; GM = Geometric mean; λz = Terminal elimination phase rate constant; Max = Maximum; Min = Minimum; N = Number of subjects in the PK dataset; n = Number of subjects analyzed; PK = Pharmacokinetics; SD = Standard deviation; T max = Time to reach C max ; T 1 / 2 = Terminal elimination half-life; Vz / F = Apparent volume of distribution at the terminal stage; %CV = Coefficient of variation percentage.

[0546] 3.1.5 Pharmacokinetic Parameters of E4-3-Glucuronide in Plasma

[0547] Summary statistics for metabolite E4-3-glucuronide are presented in Table 9.

[0548] The GM of C max and AUC 0-24 of E4-3-glucuronide were comparable across all liver function groups. Compared with the normal liver function group, the GM of AUC inf showed a slight decrease in the moderate and severe liver injury groups.

[0549] Compared with the normal liver function group, the median C max increased in the liver injury groups. Compared with the normal liver function group, the median AUC inf showed a slight decrease in the moderate and severe liver injury groups. The median AUCinf was the lowest in the severe liver injury group. The median AUC 0-24h in the mild and moderate liver injury groups was comparable to that in the normal liver function group, while it showed a slight decrease in the severe liver injury group. Compared with the normal liver function group, the median AUC last decreased, with the largest decrease in the severe liver injury group.

[0550] The maximum values of C max , AUC inf , AUC 0-24h and AUC last in the severe liver injury group were comparable to those in the control group.

[0551] T max in the severe liver injury group was reached in approximately 1 hour, in the mild and moderate liver injury groups in approximately 2 hours, and in the normal liver function group in approximately 6 hours due to the presence of outliers. However, the median was approximately 0.5 hours in all groups except 1 hour in the moderate liver injury group. max

[0552] Compared with the normal liver function group, the GM T1 / 2 decreased in the moderate and severe liver injury groups, while it increased in the mild liver injury group. The mean and GM T1 / 2 were the lowest in the severe liver injury group.

[0553] Table 7. Pharmacokinetic Parameters of E4-3-Glucuronide (Pharmacokinetic Dataset)

[0554]

[0555]

[0556] AUC = Area under the concentration-time curve; AUC inf = AUC from time 0 to infinity; AUC​last = AUC from the last time point with drug concentration above the lower limit of quantification; AUC 0-24h = AUC from 0 to 24 hours after dosing; CL / F = apparent clearance; C max = maximum observed plasma concentration; Geo = geometric; GM = geometric mean; λz = terminal elimination phase rate constant; Max = maximum; Min = minimum; N = number of subjects in the PK dataset; n = number of subjects analyzed; PK = pharmacokinetics; SD = standard deviation; T max = time to reach C max ; T 1 / 2 = terminal elimination half-life; Vz / F = apparent volume of distribution at the terminal stage; %CV = coefficient of variation percentage.

[0557] 3.1.6 Pharmacokinetic parameters of E4-16-glucuronide in plasma

[0558] Summary statistics for metabolite E4-16-glucuronide are presented in Table 10.

[0559] The C max , AUC inf , and AUC 0-24h of E4-16-glucuronide in the liver injury group were all increased, with the most significant increase in the severe injury group. It should be noted that the %CV of C max in normal subjects and AUC in the severe liver injury group was high.

[0560] Compared with the control group, the maximum values of C max , AUC inf , AUC 0-24h , and AUC last in the severe liver function injury group increased several-fold (C max： : about 2-fold; AUC inf : about 4-fold; AUC 0-24h : about 5-fold, and AUC last : about 4-fold).

[0561] Except that the median T max in the moderate liver injury group was about 1.0 hour, the median T max in all groups was about 0.5 hour.

[0562] Compared with the normal liver function group, the GM T 1 / 2 in the moderate and severe liver injury groups decreased, while it increased in the mild liver function injury group.

[0563] Table 8. Pharmacokinetic parameters of E4-16-glucuronide (pharmacokinetic dataset)

[0564]

[0565]

[0566] AUC = Area Under the Concentration-Time Curve; AUC inf = AUC from time 0 to infinity; AUC last = AUC to the last time point when the drug concentration is higher than the lower limit of quantification; AUC 0-24h = AUC from 0 to 24 hours after dosing; CL / F = Apparent Clearance Rate; C max = Maximum Observed Plasma Concentration; Geo = Geometric; GM = Geometric Mean; λz = Terminal Elimination Phase Rate Constant; Max = Maximum; Min = Minimum; N = Number of Subjects in the PK Dataset; n = Number of Subjects Analyzed; PK = Pharmacokinetics; SD = Standard Deviation; T max = Time to reach C max ; T 1 / 2 = Terminal Elimination Half-Life; Vz / F = Apparent Volume of Distribution at the Terminal Phase; %CV = Coefficient of Variation Percentage.

[0567] 3.1.7 Pharmacokinetic Statistical Analysis

[0568] The C max (Maximum Plasma Concentration) and AUC inf (Area Under the Curve to Infinity) of E4 were subjected to linear regression analysis with the laboratory parameters used to evaluate the severity of liver dysfunction in the Child-Pugh classification. The results showed a negative correlation with albumin and positive correlations with bilirubin and prothrombin time (Table 11). The 90% CI indicated the correlation in all regressions (excluding 0).

[0569] Table 9. Linear Regression of the Main PK Parameters of E4 with the Laboratory Parameters Used in the Child-Pugh Score (Pharmacokinetic Dataset)

[0570]

[0571] AUC inf = Area Under the Concentration-Time Curve from time 0 to infinity; C max = Maximum Observed Plasma Concentration.

[0572] Note: The dependent variable is the logarithmically transformed main PK parameter. The estimates and confidence intervals refer to the slopes of the continuous laboratory parameters used in the Child-Pugh score in the linear regression. Using one-way ANOVA, compared with the control group, the C maxApproximately 5.4-fold higher in subjects with severe liver injury (90% CI: 3.198 - 8.981), and approximately 1.9-fold higher in subjects with moderate liver injury (90% CI: 1.132 - 3.178). In the mild liver injury group, C max There was no significant difference compared with the control group [-1.7-fold (90% CI: 0.992–2.783)] (Table 12, Figure 8 ).

[0573] In the severe liver injury group, the AUC inf was approximately 1.9-fold higher than that in the control group (90% CI: 1.367 - 2.625) (Table 12, Figure 9 ). Compared with the control group, there were no significant differences in the AUC inf of the mild and moderate liver injury groups, which were approximately 1.1-fold (90% CI: 0.808 - 1.552) and approximately 1.0-fold (90% CI: 0.745 - 1.431), respectively.

[0574] Table 10. One-way ANOVA of the main pharmacokinetic parameters of E4 in the liver function groups (pharmacokinetic dataset)

[0575]

[0576] ANOVA = analysis of variance; AUC inf = area under the concentration-time curve from time 0 to infinity; CI = confidence interval; C max = maximum observed plasma concentration; LS = least squares; PK = pharmacokinetics.

[0577] In the two-way ANOVA, four liver function groups (mild, moderate, severe, and normal) and two BMI groups (18.5 kg / m 2 to <25 kg / m 2 , and >= 25 kg / m 2 ) were compared with the main PK parameters (C max and AUC inf ) (Table 13). The results showed that liver function had a significant effect on the PK parameters, while BMI had no effect on these PK parameters. In addition, there was no interaction between the liver function groups and the BMI groups, indicating that liver function was not related to BMI. This study was an exploratory trial and no power test was conducted, so the P values should be interpreted with caution.

[0578] Table 11. Two-way ANOVA of the main pharmacokinetic parameters of E4 between the liver function subgroups and the BMI subgroups (pharmacokinetic dataset).

[0579]

[0580] ANOVA = Analysis of Variance; AUC inf = Area under the concentration-time curve from time 0 to infinity; BMI = Body Mass Index; C max = Maximum observed plasma concentration; DF = Degrees of freedom.

[0581] Note: Liver and BMI refer to the liver function group and the BMI group respectively here.

[0582] 3.2 Pharmacokinetic evaluation

[0583] 3.2.1 E4 Pharmacokinetics

[0584] · Compared with the control group, the GM C in the mild liver injury group was approximately 1.7 times higher, in the moderate liver injury group was approximately 1.9 times higher, and in the severe liver injury group was approximately 5.4 times higher (Table 12). max · The GM AUC in the mild liver injury group increased by approximately 1.1 times (116.80 h*ng / mL), the GM AUC in the moderate liver injury group increased by approximately 1.0 times (107.64 h*ng / mL), and the GM AUC in the severe liver injury group increased by approximately 1.9 times (197.53 h*ng / mL) (Table 12).

[0585] · Compared with the group with normal liver function, the estimated values of C inf and AUC inf in the severe group and the estimated value of C inf in the moderate group, and the 90% CI of the estimated value of C

[0586] in the moderate group did not include the ratio 1, thus indicating that these differences were relevant (Table 12). In fact, the 90% CI completely exceeded the usual bioequivalence limit (0.80 - 1.25). max and AUC inf in the severe group and the estimated value of C max in the moderate group, and the 90% CI of the estimated value of C

[0587] · The GM T 1 / 2 in the group with normal liver function, mild injury group, and moderate injury group was basically similar. Compared with other groups, significantly lower T 1 / 2 was observed in the severe liver injury group. (Table 8).

[0588] · The median T max was comparable in all liver function groups (T max range was from 0.23 h to 1.92 h) (Table 8).

[0589] · The GM of the apparent clearance rate (CL / F) of E4 was basically equivalent among the group with normal liver function, mild and moderate injury groups, and the severe liver injury group (191.77 L / h) was approximately half of that in the group with normal liver function (101.25 L / h) (Table 8).

[0590] · Except for the severe liver injury group, the GM Vz / F of each liver function group was basically equivalent. The GM Vz / F of the severe liver injury group was 1201.4 L, while that of the normal liver function group was 5996.6 L.

[0591] · Two-way ANOVA confirmed that liver function was a variable affecting the PK parameters C max and AUC inf , while BMI had no effect (Table 13).

[0592] 3.2.3 Pharmacokinetics of E4-16-glucuronide

[0593] · GM C max was equivalent in all liver function groups (Table 9).

[0594] · When compared with the group with normal liver function, the GMAUC inf in the moderate and severe liver injury groups decreased slightly, while the GM AUC 0-24h was equivalent among groups (Table 9).

[0595] · Except for one liver function group, the median T max was equivalent in all liver function groups. It was 1 h in the moderate liver damage group and about 0.5 h in the other three groups (Table 9).

[0596] · Compared with the normal liver function group, the GM T 1 / 2 GM decreased in the moderate and severe liver injury groups, and the GM T1 / 2 increased in the mild liver injury group (Table 9).

[0597] 3.2.3 Pharmacokinetics of E4-16-glucuronide

[0598] · GM C max increased in all liver injury groups and was most obvious in the severe injury group (Table 10).

[0599] · The GM of GM AUC inf and GM AUC 0-24 increased in the liver injury groups and was most obvious in the severe liver damage group (Table 10).

[0600] · The median T max seemed to be equivalent in all liver function groups (Table 10).

[0601] · The GM T 1 / 2 seemed to be similar in the normal liver function group, mild or moderate liver injury groups, and decreased in the severe liver injury group.

[0602] 4. Safety Assessment

[0603] 4.1 Exposure level

[0604] All subjects in all groups received 20 mg of E4 as described in the protocol.

[0605] 4.2 Adverse Events

[0606] 4.2.1 Brief Overview of Adverse Events

[0607] During the study period, 9 subjects (28.1%) had at least 1 treatment-emergent adverse event (TEAE): 2 subjects in the normal liver function group and 2 subjects in the mild liver impairment group; 4 subjects in the moderate liver impairment group; 1 subject in the severe liver impairment group.

[0608] No subject had a serious adverse event (SAE).

[0609] Six subjects (18.8%) had TEAEs of mild severity, and 3 subjects (9.4%) had TEAEs of moderate severity. TEAEs in 8 subjects (25.0%) were considered by the investigator to be unrelated to the study drug, and TEAEs in 1 subject (3.1%) were considered to be related to the study drug (Table 14).

[0610] The most frequently reported TEAEs were diarrhea in 3 subjects (9.4%), followed by headache, back pain, and hypertension, each in 2 subjects (6.3%).

[0611] Table 12. Overall Summary of Adverse Events (Safety Dataset)

[0612]

[0613] AE = Adverse Event; N = Total number of subjects; n = Number of subjects evaluated; SAE = Serious Adverse Event; TEAE = Treatment-Emergent Adverse Event

[0614] Note: Subjects are counted only once in the category of their most severe event.

[0615] Note: Subjects are counted only once in the category of their most relevant drug event, regardless of the number of drug-related events reported and without double counting.

[0616] 4.2.2 Presentation of Adverse Events

[0617] Table 15 presents a summary of TEAEs classified by System Organ Class (SOC) and Preferred Term. Table 16 presents a summary of TEAEs graded by severity.

[0618] Table 13. Summary of Adverse Events Occurring During Treatment by System Organ Class and Preferred Term (Safety Dataset)

[0619]

[0620] N = Total number of subjects; n = Number of subjects evaluated; TEAE = Treatment-emergent adverse event

[0621] Note: Coding was performed using the Medical Dictionary for Regulatory Activities version 22.1

[0622] Note: n - Subjects were only counted once under each System Organ Class and Preferred Term

[0623] Table 14. Summary of treatment-emergent adverse events by severity (safety dataset)

[0624]

[0625]

[0626] N = Number of exposed subjects; n = Number of subjects with an AE

[0627] Note: Coding was performed using the Medical Dictionary for Regulatory Activities version 22.1

[0628] Note: n - Subjects were only counted once for their most serious adverse event under each System Organ Class and Preferred Term category

[0629] 4.2.3 Analysis of adverse events

[0630] AE data were analyzed by frequency, severity, outcome, and relationship to the study drug. No other analyses of AEs were performed. The most common TEAE was diarrhea (gastrointestinal disorder), in 3 subjects. In addition, 2 subjects each reported back pain (musculoskeletal and connective tissue disorders), headache (nervous system disorders), and hypertension (vascular disorders) (Table 15).

[0631] 11 TEAEs were considered mild in intensity and 4 were considered moderate in intensity. 1 subject in the normal group and 2 subjects in the moderate group reported diarrhea. The event was considered moderate in normal group subjects and mild in moderate impairment group subjects. 2 subjects in the moderate group reported headache; 1 was of moderate intensity and the other was of mild intensity. 1 subject in the normal group and 1 subject in the severe group reported back pain. The event was considered moderate in normal group subjects and mild in moderate impairment group subjects. 2 subjects in the mild group had hypertension recorded, and both were evaluated as mild in the subjects (Table 16).

[0632] All TEAEs reported in this study were considered unrelated to the study drug, except for 1 diarrhea TEAE reported by 1 subject in the moderate group, which was considered mild

[0633] 4.3 Deaths, other serious adverse events, and other important adverse events

[0634] No deaths, SAEs, or other serious AEs occurred during the study. There were no study discontinuations due to TEAEs.

[0635] 4.3.1 Evaluation of Laboratory Parameters

[0636] 4.3.1.1 Laboratory Test Values over Time

[0637] In subjects with mild, moderate, or severe liver injury and in subjects with normal liver function, the summary of laboratory test values, their changes from baseline, and their deviations from baseline did not show any deviation or trend indicating safety concerns for hematological or clinical biochemical parameters after E4 administration.

[0638] 4.3.1.2 Changes in Individual Subjects

[0639] During the course of the clinical study (screening, Day –1, and follow-up), most laboratory test values were within the normal range. Many individual deviations of the laboratory parameters evaluated during the study from the normal range were already present at screening or baseline and may be attributed to the general health status or underlying diseases of the study population. Deviations of individual subjects from the normal laboratory ranges in hematology, clinical chemistry, coagulation, and urine analysis were considered clinically insignificant due to slightly out-of-range values; except for 2 subjects with out-of-range values judged to be clinically significant.

[0640] 4.3.1.3 Clinically Significant Abnormalities in Individual Subjects

[0641] Subject 3022 in the normal liver function group, without a history of gallbladder infection or pancreatitis, had a clinically significant increase in amylase levels on Days 3 and 5, an increase in lipase on Days 9 and during the follow-up period, and further increases in alanine aminotransferase, alkaline phosphatase, aspartate aminotransferase, γ-glutamyltransferase, and lactate dehydrogenase during the follow-up period. This condition was diagnosed as subclinical pancreatitis. The subject had no symptoms throughout the event, did not receive treatment, and was not hospitalized. The subject was monitored until all parameters returned to near baseline levels within 9 days after follow-up (judged to be clinically insignificant).

[0642] Subject 3028 in the severely impaired liver function group had isolated increases in creatinine and urea levels measured on Day –1.

[0643] 4.4 Vital Signs, Physical Examination Findings, and Other Safety-Related Observations

[0644] 4.4.1 Vital Signs

[0645] Although several individual changes relative to baseline were observed, blood pressure, pulse rate, respiratory rate, and body temperature did not show trends or clinically relevant changes.

[0646] 4.4.2 Physical examination

[0647] Except for 1 abnormality, the remaining observed abnormalities were determined to have no clinical relevance. One subject in the mild liver function impairment group had congestion (diffuse hematoma) in the left elbow on day 3 (MedDRA preferred term: hemarthrosis), which was considered clinically significant and reported as a TEAE. The severity of this event was mild, and the investigator considered it unrelated to the study drug. The congestion resolved without additional treatment.

[0648] 4.5 Safety conclusions

[0649] · In female subjects with normal liver function, mild, moderate, or severe liver injury, a single oral dose of 20 mg of E4 monohydrate is safe and well-tolerated.

[0650] · No deaths, SAEs, or other serious AEs occurred during the study.

[0651] · The most common TEAE was diarrhea (gastrointestinal disorder), which occurred in 3 subjects. One subject in the normal liver function group and 2 subjects in the moderate liver injury group reported diarrhea. The event was considered moderate in the subject in the normal liver function group and mild in the subjects in the moderate liver injury group.

[0652] · All TEAEs reported in this study were considered unrelated to the study drug, except for 1 TEAE of diarrhea reported by 1 subject in the moderate liver injury group, which was considered mild.

[0653] · In subjects with mild, moderate, or severe liver injury and subjects with normal liver function, the summary of laboratory test values, their changes from baseline, and deviations from baseline did not show any deviations or trends indicating safety problems with hematological or clinical biochemical parameters after administration of E4 monohydrate.

[0654] · The results of the physical examination were generally insignificant.

[0655] 5. Discussion and Overall Conclusions

[0656] This was a phase I, multicenter, open-label, PK and safety study of a single oral dose of 20 mg of E4 monohydrate in female subjects with different degrees of liver injury and subjects with normal liver function. Previous studies on absorption, distribution, metabolism, and excretion have shown that this drug involves hepatic metabolic pathways, which is also a well-known metabolic characteristic of other estrogenic substances.

[0657] 5.1 Pharmacokinetics

[0658] E4 was rapidly absorbed and reached C within 2 hours after oral administration max, independent of liver function status. The average C max ranges from approximately 24 ng / mL in patients with normal liver function, more than approximately 38 ng / mL in patients with mild liver injury, approximately 52 ng / mL in patients with moderate liver injury, and approximately 117 ng / mL in patients with severe liver injury.

[0659] The C of subjects with moderate and severe liver injury and those with normal liver function max comparisons showed relevant differences (1.896-fold, 90% CI: 1.132 - 3.178 and 5.359-fold, 90% CI: 3.198 - 8.981), while this was not the case for the comparison of mild liver injury with normal liver function (1.661-fold, 90% CI: 0.991 - 2.783).

[0660] The distribution and resorption phases ultimately led to an increase in AUC according to the degree of liver function impairment 0-24 with geometric means of 69.7554 h*ng / mL, 88.7526 h*ng / mL, and 179.0494 h*ng / mL for subjects with mild, moderate, and severe liver impairment, respectively, compared to 60.4146 h*ng / mL for subjects with normal liver function.

[0661] For AUC inf , these differences were not significant between mild and moderate compared to the normal group (1.120-fold, 90% CI: 0.808 - 1.552 and 1.032-fold, 90% CI: 0.745 - 1.431, respectively), but were significant between severe and the normal group (1.894-fold, 90% CI: 1.367 - 2.625).

[0662] The elimination phase of the concentration-time profile showed that the half-life of E4 decreased with the degree of liver dysfunction, with a geometric mean T 1 / 2 of 21.67 h for subjects with normal liver function, followed by 20.07 h for subjects with mild liver injury, 14.79 h for subjects with moderate liver injury, and 8.22 h for subjects with severe liver injury. Accordingly, subjects with normal or mild liver injury reached the last measurable concentration of E4 (Clast) at 192 h (last measurement time point) after dosing, subjects with moderate liver injury at 144 h after dosing, and subjects with severe liver injury at 168 h after dosing.

[0663] The current results are consistent with the effects of liver injury on distribution and resorption cycles, particularly with the effects of severe liver injury on enterohepatic recirculation.

[0664] In particular, the plasma concentration of E4 24 hours after dosing was in the same range among different liver function groups, indicating that similar accumulation may occur under a once-daily multiple-dose dosing regimen.

[0665] 5.2 Safety

[0666] In this study, female subjects with normal liver function, mild, moderate or severe liver impairment were safe and well tolerated after a single oral dose of 20 mg of E4 monohydrate.

[0667] The most common TEAE was diarrhea (gastrointestinal disorder), reported in 3 subjects. One subject in the normal group and two subjects in the moderate liver injury group reported diarrhea. The event was considered moderate in the normal group subjects and mild in the moderate liver injury group subjects.

[0668] All TEAEs reported in this study were considered not related to the study drug, except for one diarrhea TEAE reported by one subject in the moderate liver injury group, which was considered mild.

[0669] In subjects with mild, moderate or severe liver injury and subjects with normal liver function, the summary of laboratory test values, their changes from baseline and deviations from baseline did not show deviations or trends indicating safety issues with hematological or clinical biochemical parameters after E4 administration.

[0670] The results of physical examinations were generally insignificant.

[0671] 5.3 Conclusions

[0672] 5.3.1 Pharmacokinetics

[0673] · GM C of E4 after a single dose of 20 mg max Significantly increased in subjects with moderate (about 1.9-fold, 90% CI: 1.132 - 3.178) and severe liver injury (about 5.4-fold, 90% CI: 3.198 - 8.981), but not significantly increased between subjects with mild liver injury and subjects with normal liver function (about 1.7-fold and 90% CI: 0.991 - 2.783).

[0674] · Peak exposure of metabolites was related to the degree of liver injury, but the changes were negligible due to their low pharmacological activity and small proportion of the drug components.

[0675] · GM AUC of E4 inf In the mild liver injury group (about 1.1-fold, 90% CI 0.808 - 1.552), comparable to the normal liver function group in the moderate liver injury group (about 1.0-fold, 90% CI 0.745 - 1.431), and elevated about 1.9-fold (90% CI 1.367 - 2.625) in the severe liver injury group.

[0676] · GM AUC of E4-3-glucuronideinf There appears to be a slight decrease in moderate and severe liver injury compared to normal liver function, however the results showed great variability. For E4-16-glucuronide, GM AUC inf showed an increase in the liver injury group, most pronounced in the severe group.

[0677] ·GM T1 / 2 generally appears to shorten with the degree of liver injury, although the variability is high.

[0678] 5.3.2 Safety

[0679] Single oral administration of 20 mg of E4 monohydrate to female subjects with normal liver function, mild, moderate or severe liver injury was safe and well tolerated.

[0680] The most common TEAE was diarrhea (gastrointestinal disorder). Diarrhea was reported by 3 subjects: 1 subject in the normal group and 2 subjects in the moderate liver injury group. The event was considered moderate in the normal group subject and mild in the moderate liver injury group subjects.

[0681] [[ID=!8]]All TEAEs reported in this study were considered not related to the study drug, except for 1 diarrhea TEAE reported by 1 subject in the moderate liver injury group, and it was considered mild.

[0682] There were no abnormalities in vital signs, laboratory test values and physical examinations.

[0683] Example 2: A Dose-Exploration Study Aimed at Selecting a Single-Dose Oral Dose of Estetrol (E4) for the Treatment of Vasomotor Symptoms in Postmenopausal Women

[0684] Study Enrollment and Duration

[0685] The enrollment period was approximately 18 months. Individual subjects participated for up to 27 weeks: up to 6 weeks of pre-screening and washout period, up to 4 weeks of screening and lead-in period, up to 91 days (13 weeks) of E4 monohydrate or placebo treatment, followed by 2 weeks (14 days) of progesterone treatment, and a 1-week follow-up only after progesterone treatment was completed in non-hysterectomized subjects.

[0686] Primary Efficacy Objective

[0687] The minimum effective dose (MED) of the oral E4 dose was determined by evaluating the changes in the frequency and severity of moderate to severe vasomotor symptoms (VMS).

[0688] Methods

[0689] This was a prospective, multicenter, randomized, placebo-controlled, double-blind, dose-escalation study.

[0690] Subject Population

[0691] Eligible subjects are postmenopausal women, with or without hysterectomy, aged 40 to 65 years (inclusive), presenting at least 7 moderate to severe hot flushes / day or at least 50 moderate to severe hot flushes / week.

[0692] Diagnosis and Inclusion Criteria

[0693] Subjects must meet all of the following inclusion criteria at the randomization visit. These criteria are evaluated during the screening period:

[0694] 1. Women aged 40 to 65 years (inclusive), who have had at least 7 moderate to severe hot flushes / day or at least 50 moderate to severe hot flushes / week within one week prior to randomization.

[0695] 2. Body Mass Index (BMI) of 18.0 - 35.0 kg / m² (inclusive).

[0696] 3. Postmenopausal status is defined as Follicle Stimulating Hormone (FSH) level > 40 IU / L, and:

[0697] - amenorrhea for at least 12 consecutive months or,

[0698] - amenorrhea for at least 6 months, with Estradiol (E2) < 20 pg / mL, or,

[0699] - subjects must be at least 6 weeks post bilateral oophorectomy (with or without hysterectomy) and submit a copy of the pathology report or a statement on official letterhead from the attending physician certifying that both ovaries have been completely removed.

[0700] 4. For women without hysterectomy: TVUS shows an intact uterus with a double-layer endometrial thickness ≤ 5 mm.

[0701] 5. Negative pregnancy test.

[0702] 6. In the opinion of the Principal Investigator (PI), based on the medical history, surgical history, and gynecological history, physical examination, gynecological examination, clinical laboratory tests, and vital signs, the subject is in good physical and mental health.

[0703] 7. The subject has provided a signed and dated written informed consent form prior to entering the study.

[0704] 8. The subject is able to understand and comply with the protocol requirements, instructions, and restrictions specified in the protocol.

[0705] Exclusion Criteria

[0706] If any of the following exclusion criteria are present at the randomization visit, potential study subjects are excluded. These criteria are evaluated during the screening period:

[0707] 1. For women without hysterectomy: uterine diseases or medical conditions, including:

[0708] a. The double-layer endometrial thickness measured by TVUS > 5 mm;

[0709] b. The presence of uterine fibroids obscures the TVUS assessment of the endometrium;

[0710] c. History or presence of uterine cancer;

[0711] d. Presence of endometrial hyperplasia;

[0712] e. Presence of endometrial polyps with hyperplastic or malignant epithelium.

[0713] 2. Unexplained vaginal bleeding not diagnosed in the past 12 months.

[0714] 3. History of any malignancy other than basal cell carcinoma of the skin (excluded if within the previous 2 years) or squamous cell carcinoma (excluded if within the previous 1 year). Any clinically significant findings detected on breast examination and / or a suspicious breast malignancy detected on mammography require additional clinical examinations to rule out breast cancer (however, simple cysts confirmed by ultrasound are excluded). Note: Screening mammography is required unless the subject has a written record of a mammogram within the past 9 months.

[0715] 4. Abnormal cervical Pap smear in non-hysterectomy subjects (written documentation of a previous examination within 18 months or a written document of the examination at the time of screening), with evidence of cervical dysplasia greater than low-grade squamous intraepithelial lesion (LSIL). Women diagnosed with atypical squamous cells of undetermined significance (ASCUS) are enrolled.

[0716] 5. Systolic blood pressure (BP) outside the range of 90 to 140 mmHg, diastolic BP outside the range of 60 to 90 mmHg, and / or heart rate outside the range of 40 to 100 bpm. Mild to moderate hypertensive subjects controlled with a stable antihypertensive regimen are enrolled if they meet the inclusion / exclusion criteria.

[0717] 6. Any clinically significant abnormalities detected on screening 12-lead electrocardiogram examination.

[0718] 7. History of venous or arterial thromboembolic disease (e.g., deep vein thrombosis, pulmonary embolism, stroke, myocardial infarction, angina, etc.), history of known coagulopathy or coagulation factor abnormality.

[0719] 8. Diabetes with poor glycemic control in the past 6 months, evaluated by laboratory test values of blood glucose outside the normal range and glycated hemoglobin higher than 7%.

[0720] 9. Dyslipidemia renders subjects susceptible to atherosclerotic cardiovascular disease (ASCVD). Subjects with a 10-year ASCVD risk score ≥ 5% calculated according to the ASCVD risk assessment tool (American College of Cardiology / American Heart Association Guidelines on Cardiovascular Risk Assessment, 2013) shall not be included in the trial. In all cases, an LDL cholesterol level ≥ 190 mg / dL or a plasma triglyceride level > 400 mg / dL is excluded.

[0721] If the subject is receiving lipid-lowering therapy, her treatment must be at a stable dose for at least 1 month prior to screening and the same eligibility criteria must be used.

[0722] 10. Smoking > 10 cigarettes / day or using > 1 ml / day of nicotine-containing liquid for electronic cigarettes.

[0723] 11. Presence of gallbladder disease or a history of gallbladder disease, unless cholecystectomy has been performed.

[0724] 12. Systemic lupus erythematosus.

[0725] 13. Multiple sclerosis.

[0726] 14. Acute or chronic liver disease.

[0727] 15. Acute or chronic kidney injury, including severe kidney injury.

[0728] 16. Uncontrolled thyroid disease.

[0729] 17. The subject has a history of major depressive disorder or post-traumatic stress disorder (PTSD) within 2 years, or a history of other severe mental illnesses (such as schizophrenia, bipolar disorder, etc.) at any time.

[0730] 18. Use of drugs containing estrogen or progesterone. In the case of using the following substances, an elimination period needs to be set before the lead-in period:

[0731] a. Vaginal hormone products (ring, cream, gel): at least 4-week elimination;

[0732] b. Transdermal estrogen / progesterone: at least 4-week elimination;

[0733] c. Oral estrogen and / or progesterone: at least 4-week elimination;

[0734] d. Intrauterine progesterone therapy: at least 4-week elimination;

[0735] Current users of progesterone implants or single estrogen injection drug therapy are not allowed to participate, unless the treatment has been stopped for more than 3 months. Current users of estrogen pill therapy or progesterone injection drug therapy are not allowed to participate, unless the treatment has been stopped for more than 6 months.

[0736] 19. Use of non-hormonal therapy for reducing hot flashes. In the case of using non-hormonal prescription and over-the-counter (OTC) drugs to treat hot flashes (such as the antidepressants paroxetine, escitalopram, venlafaxine, desvenlafaxine, and clonidine; or phytoestrogens, black cohosh, etc.), a 1-week washout period is required before the lead-in period. If one of these treatments is carried out concurrently with estrogen or a progesterone-containing drug, the washout periods can be combined and do not have to be sequential.

[0737] 20. Use of drugs within 28 days before the lead-in period that may affect the VMS endpoint outcome. This includes (but is not limited to): SSRI [selective serotonin reuptake inhibitor], SNRI [serotonin and norepinephrine reuptake inhibitor], dopaminergic or antidopaminergic drugs, or gabapentin.

[0738] 21. Presence or history of allergy to the investigational drug or drugs of the same class, or history of allergy to other drugs or substances that the investigator deems may contraindicate the subject's participation.

[0739] 22. Presence or history of allergy or intolerance to any component of the investigational drug.

[0740] 23. History of alcohol or drug abuse or dependence within 12 months as determined by the investigator, i.e., the subject has consumed excessive alcohol, abused drugs, or a condition that the investigator believes may impair the subject's ability to comply with the study requirements.

[0741] 24. Employees of the sponsor or contract research organization (CRO), or personnel in the investigator's department and relatives associated with the study.

[0742] 25. Subjects with porphyria and subjects with a history of a known or suspected clinically significant systemic disease, unstable medical condition, life-threatening disease, or current malignancy that the investigator believes may pose a risk to the subject.

[0743] 26. Participation in another investigational drug clinical study within 1 month (30 days) or receipt of investigational drug treatment within the past 3 months (90 days).

[0744] 27. Judged by the investigator as unfit for any reason.

[0745] Number of Subjects

[0746] Intention-to-Treat Principle

[0747] This principle states that the effect of a treatment strategy can be most accurately determined by evaluating based on the intention-to-treat of the subjects (i.e., the planned treatment regimen) rather than the actual administered treatment. As a result, subjects assigned to a treatment group should be followed up, evaluated, and analyzed as members of that group, regardless of whether they adhered to the planned course of treatment.

[0748] In addition, the intention-to-treat principle means that the primary analysis should include all randomized subjects.

[0749] Maintaining the initial randomization in the analysis is important in preventing bias and providing a secure basis for statistical tests. In many clinical trials, using the full analysis dataset provides a conservative strategy. In many cases, it can also provide an assessment of the treatment effect that is more likely to reflect the effect observed in subsequent practice.

[0750] In this study, the intention-to-treat group included a total of 257 patients.

[0751] Subjects were randomly assigned to one of five treatment groups in a 1:1:1:1:1 ratio. Randomization was stratified by center.

[0752] Study Visits

[0753]

[0754] Test Article and Reference Treatments, Doses, and Routes of Administration

[0755] All treatments (estetrol, hereinafter E4 as monohydrate, [2.5 mg, 5 mg, 10 mg, 15 mg] capsules) were administered orally once daily (QD) for at least 12 weeks until the last biological assessment (up to day 91).

[0756] The placebo, 1 capsule orally once daily, for at least 12 weeks until the last biological assessment (up to day 90).

[0757] If during the trial, TVUS examination reveals that the endometrial bilayer thickness of non-hysterectomized female subjects is ≥ 15 mm and / or abnormal uterine bleeding is reported (as judged by the gynecologist in combination with estrogen treatment), then the subject shall undergo endometrial biopsy and, on the basis of E4 / placebo treatment, sequential progesterone treatment (dydrogesterone 10 mg once daily) shall be added until the end of week 11 (i.e., 14 days of progesterone treatment followed by 14 days of progesterone treatment suspension period). If the endometrial biopsy shows endometrial hyperplasia, the subject's participation shall be terminated immediately and hyperplasia treatment shall be carried out in accordance with local guidelines. If abnormal uterine bleeding occurs again after the first normal endometrial biopsy, a thorough gynecological examination and TVUS shall be performed. If the gynecologist determines it necessary, a second endometrial biopsy shall be carried out.

[0758] After the E4 monohydrate or placebo treatment period, all non-hysterectomized subjects (including those who have previously received progesterone) received progesterone treatment for 14 days (dydrogesterone 10 mg daily).

[0759] Results

[0760] A. Vasomotor Parameters in Each of the 5 Treatment Groups

[0761] a. VMS Frequency

[0762] i) The absolute change value of the weekly frequency of moderate to severe VMS (average change based on baseline)

[0763] a) For each group, it is carried out week by week

[0764]

[0765] To analyze the data recorded in this study, ANCOVA (analysis of covariance) was used to compare the changes in the weekly frequency of moderate to severe VMS from baseline to week 4 and week 12 in the treatment groups. The ANCOVA model included treatment ("trt 1") and study center ("SITEPOOL") as fixed effects, and baseline ("base") as a covariate.

[0766] b) Covariate significance

[0767] The following table lists the comparisons of all treatment groups.

[0768] Analysis Time Points (N) Covariates p-Value 4 trt1 0.0164 4 base <.0001 4 SITEPOOL 0.2214 12 trt1 0.0384 12 base <.0001 12 SITEPOOL 0.2706

[0769] In the review, it was considered that the influence of the study center was not very important, so a second ANCOVA was carried out without considering the study center.

[0770] No Site Effect

[0771] Analysis Time Points (N) Covariates p-Value 4 trt1 0.0130 4 base <.0001 12 trt1 0.0254 12 base <.0001

[0772] c) The following table shows the mean change relative to baseline based on week and treatment:

[0773]

[0774] No Site Effect

[0775]

[0776]

[0777] All statistical tests were supported by listing the least squares adjusted means (LS adjusted means: group means after controlling for covariates; also known as marginal means or estimated marginal means) of the corresponding treatment effects and 95% confidence intervals. These LS adjusted means and confidence intervals were based on the statistical models used for the analysis.

[0778] A confidence interval means that if the same population is sampled in many cases and an interval estimate is made each time, then in approximately 95% of the cases, the resulting interval will contain the true population parameter.

[0779] d) The following table shows the differences from placebo based on week and treatment

[0780]

[0781] No Site Effect

[0782]

[0783] From these tabular data, it can be seen that the daily dosing regimen of 15 mg of estetrol (E4) monohydrate showed differences approaching statistical significance compared to the placebo group at week 4 (first statistical analysis p-value = 0.10653, unpooled study center analysis p-value = 0.06834) and week 12 (first statistical analysis p-value = 0.10838, unpooled study center analysis p-value = 0.07057).

[0784] ii. Relative change in the weekly frequency of moderate to severe VMS (% relative to baseline).

[0785] a) For each group, performed weekly

[0786]

[0787] From this table, it can be seen that compared to baseline, the single daily dose of 15 mg of estetrol monohydrate resulted in a reduction in the frequency of moderate to severe VMS of more than 80%.

[0788] b) Covariate significance

[0789] The following table shows the comparison of all treatment groups.

[0790] Analysis Time Points (N) Covariates p-Value 4 trt1 0.0147 4 base 0.3684 4 SITEPOOL 0.3236 12 trt1 0.0100 12 base 0.1490 12 SITEPOOL 0.0958

[0791] No Site Effect

[0792] Analysis Time Points (N) Covariates p-Value 4 trt1 0.0107 4 base 0.2264 12 trt1 0.0065 12 base 0.0774

[0793] c) The following table shows the mean relative change (%) from baseline by week and treatment

[0794]

[0795] No Site Effect

[0796]

[0797] d) The following table shows the differences from placebo by week and treatment

[0798]

[0799] It can be seen from this table that the daily dose of 15 mg estetrol monohydrate showed a statistically significant difference from placebo at 12 weeks (p-value = 0.03771) and an almost statistically significant difference from placebo at 4 weeks (p-value = 0.05622).

[0800] Notably, a lower p-value was observed for the 15 mg estetrol monohydrate dose compared to the elevated p-value obtained for the 10 mg estetrol monohydrate dose.

[0801] No Site Effect

[0802]

[0803] It can be seen from this table that in the statistical analysis without considering the site effect, the single daily dose of 15 mg estetrol monohydrate showed a statistically significant difference from placebo at 4 weeks (p = 0.03206) and 12 weeks (p = 0.02210).

[0804] Notably, a lower p-value was observed for the 15 mg estetrol monohydrate dose compared to the elevated p-value obtained for the 10 mg estetrol monohydrate dose.

[0805] iii. Frequency change of moderate to severe VMS weekly frequency in the responder group.

[0806] The VMS frequency was also studied by grouping patients according to their degree of response.

[0807] A first group of patients showing a 50% or higher response (change relative to baseline) was prepared. According to this analysis, at week 12, the single - daily - dose group of 15 mg estetrol monohydrate contained 91.8% responders, while the placebo group contained 65.5% responders. The difference between these two groups had a p - value of less than 0.01, while the difference between the 10 mg estetrol monohydrate single - daily - dose group and the placebo group was not statistically significant (p - value > 0.1).

[0808] A second group of patients showing a 75% or more response was prepared. According to this analysis, at week 12, the single - daily - dose group of 15 mg estetrol monohydrate contained 77.6% responders, while the placebo group contained 43.6% responders. The difference between these two groups had a p - value of less than 0.001, while the difference between the 10 mg estetrol monohydrate single - daily - dose group and the placebo group was not statistically significant (p - value > 0.05).

[0809] b. VMS Severity

[0810] i. Absolute change in weekly severity of moderate to severe VMS (mean change from baseline)

[0811] a) For each group, it was carried out week by week

[0812]

[0813]

[0814] To better analyze the data recorded in this study, ANCOVA (analysis of covariance) was used to compare the changes in severity of moderate to severe VMS from baseline to mild, moderate, and severe VMS for each active treatment with placebo in the treatment groups at week 4 and week 12. For women who experienced 100% VMS remission at week 4 and / or week 12, the value was set to zero. The ANCOVA model included treatment ("trt1") as a fixed effect and baseline ("base") as a covariate.

[0815] b) Covariate significance

[0816] The following table shows the comparison of all treatment groups.

[0817] Analysis Time Points (N) Covariates p-Value 4 trt1 0.0119 4 base 0.3781 12 trt1 0.0032 12 base 0.7990

[0818] c) The following table shows the mean change relative to baseline based on week and treatment:

[0819]

[0820]

[0821] d) The following table shows the differences from the placebo in terms of weeks and treatments.

[0822]

[0823] As can be seen from this table, the daily dose of 15 mg of estetrol monohydrate showed statistically significant differences from the placebo at 4 weeks (p-value = 0.0486) and 12 weeks (p-value = 0.0489). Therefore, compared with the placebo, the 15 mg dose of estetrol monohydrate significantly improved the severity of VMS at 4 weeks and 12 weeks.

[0824] For the severity parameter, the difference between the 10 mg and 15 mg doses of estetrol monohydrate was also impressive: this was first reflected in the mean change from baseline presented in the table in part c) above, where for example at 12 weeks, the LS adjusted mean for 10 mg was -0.69 (compared with -0.66 in the placebo group), while for the 15 mg single daily dose group it was -1.04. This obvious difference was reflected in that when the dose was increased from 10 mg to 15 mg per day, the p-value improvement at 4 weeks was nearly 8 times, and at 12 weeks it was more than 20 times.

[0825] ii. Relative change in the weekly severity of moderate to severe VMS (% relative to baseline)

[0826] a) For each group, week by week

[0827]

[0828]

[0829] As can be seen from this table, when compared with the baseline, the single daily dose of 15 mg of estetrol monohydrate led to a reduction in the severity of moderate to severe VMS by more than 40%.

[0830] b) Covariate significance

[0831] The following table shows the comparison of all treatment groups.

[0832] Analysis Time Points (N) Covariates p-Value 4 trt1 0.0126 4 base 0.6594 12 trt1 0.0031 12 base 0.1651

[0833] c) The following table shows the mean relative change from baseline by week and treatment.

[0834]

[0835] d) The following table shows the differences from the placebo in terms of weeks and treatments.

[0836]

[0837]

[0838] As can be seen from the table, the single - day dose of 15 mg estetrol monohydrate showed a nearly statistically significant difference from the placebo at 12 weeks (p - value = 0.0568). Compared with the placebo, the single - day dose of 15 mg estetrol monohydrate improved the severity of VMS at 4 weeks and 12 weeks, while the single - day dose of 10 mg estetrol monohydrate was again hardly distinguishable from the placebo, especially at 12 weeks.

[0839] c. Weekly Weighted Score for Hot Flashes

[0840] i. Absolute change in weekly weighted score (mean change from baseline)

[0841] a) For each group, carried out weekly

[0842]

[0843] b) Covariate significance

[0844] The following table shows the comparison of all treatment groups.

[0845]

[0846]

[0847] c) The following table shows the mean change based on weeks and treatment relative to baseline:

[0848]

[0849] d) The following table shows the differences from the placebo in weeks and treatment

[0850]

[0851] ii. Relative change in weekly weighted score (% relative to baseline)

[0852] a) For each group, carried out weekly

[0853]

[0854]

[0855] b) Covariate significance

[0856] The following table shows the comparison of all treatment groups.

[0857] Analysis Time Points (N) Covariates p-Value 4 trt1 0.0108 4 base 0.4181 12 trt1 0.0024 12 base 0.0593

[0858] c) The following table shows the mean relative change from baseline by week and treatment

[0859]

[0860] d) The following table shows the differences from placebo by week and treatment

[0861]

[0862]

[0863] It can be seen from this table that the single - day dose of 15 mg estetrol monohydrate showed statistically significant differences from placebo at 4 weeks (p - value = 0.0267) and 12 weeks (p - value = 0.0276).

[0864] Notably, a lower p - value was observed for the 15 mg estetrol monohydrate dose compared to the elevated p - values obtained with the 10 mg estetrol monohydrate dose.

[0865] B. Vasomotor Parameters in the 10 mg and 15 mg Estetrol Monohydrate Groups Compared with the Placebo and Inactive Dose (2.5 mg and 5 mg Estetrol Monohydrate) Groups Analysis Time Points (N)

[0866] Based on the results observed in Part A above, it is evident that the two lowest test doses (2.5 mg and 5 mg estetrol monohydrate per day) did not show effectiveness. Therefore, a further analysis of the results was prepared, in which the data from these two doses were grouped with the placebo dose and compared with the 10 mg and 15 mg estetrol monohydrate doses.

[0867] 1. Relative change in the weekly frequency of moderate - to - severe VMS (% relative to baseline).

[0868] a) For each group, performed weekly

[0869]

[0870] b) Covariate significance

[0871] Covariates p-Value trt1 4 base 0.0039 4 SITEPOOL 0.3935 4 trt1 0.3308 12 base 0.0017 12 SITEPOOL 0.1244 12 Analysis Time Points (N) 0.0957

[0872] c) Paired comparison with placebo (including the ineffective doses 2.5 mg and 5 mg estetrol monohydrate grouped together)

[0873]

[0874] d) Difference from placebo (including the ineffective doses 2.5 mg and 5 mg estetrol monohydrate grouped together)

[0875]

[0876] *The placebo and the ineffective doses (2.5 and 5 mg estetrol monohydrate) were combined and abbreviated as “0”.

[0877] As already mentioned above in part A), it is particularly striking that, compared to the elevated p-values obtained with the 10 mg single-day dose, a low p-value was observed for the 15 mg estetrol monohydrate single-day dose, demonstrating a unique remission obtained with the 15 mg estetrol monohydrate single-day dose.

[0878] 2. Relative change in the weekly weighted score for hot flushes (% relative to baseline):

[0879] a) For each group, it was carried out week by week

[0880]

[0881] b) Covariate significance

[0882] Covariates p-Value trt1 4 base 0.0037 4 SITEPOOL 0.5294 4 trt1 0.3783 12 base 0.0015 12 SITEPOOL 0.0770 12 C. Menopause Rating Scale 0.0487

[0883] c) Paired comparison with the placebo (including the ineffective doses 2.5 mg and 5 mg estetrol monohydrate)

[0884]

[0885]

[0886] d) Difference from the placebo (including the ineffective doses 2.5 mg and 5 mg estetrol monohydrate)

[0887]

[0888] *The placebo and the ineffective doses (2.5 and 5 mg estetrol monohydrate) were combined and abbreviated as “0”.

[0889] As already mentioned above in part A), it can be seen that the 15 mg estetrol monohydrate single-day dose produced a statistically significant difference from the placebo at 4 weeks (p-value of 0.00178) and 12 weeks (p-value of 0.00097).

[0890] Furthermore, it is particularly striking that, compared to the elevated p-values obtained with the 10 mg estetrol monohydrate dose, a low p-value was observed for the 15 mg estetrol monohydrate dose.

[0891] Total MRS Score

[0892] The Menopause Rating Scale (MRS) is a health-related quality of life scale that measures the severity of age / menopause-related complaints by assessing symptom profiles (Heinemann et al., 2003, “International versions of the Menopause Rating Scale (MRS)". Health Qual Life Outcomes 1:28; Heinemann et al., 2004, "The Menopause Rating Scale (MRS) scale: A methodological review". Health Qual Life Outcomes 2:45; Heinemann et al., 2004, "The Menopause Rating Scale (MRS) as outcome measure for hormone treatment? A validation study". Health Qual Life Outcomes 2:67).

[0893] As the severity of the subjectively perceived complaints increases for each of the 11 items, the score increases point by point (the severity of each item is represented by a score from 0 to 4). By checking these 5 possible “severity” boxes for each item in the questionnaire, the respondent provides her personal feelings. The total MRS score ranges from 0 (asymptomatic) to 44 (most severe illness). The minimum / maximum scores vary between the three dimensions, depending on the number of complaints assigned to the respective symptom dimensions (Heinemann et al., 2003, Health Qual Life Outcomes 1:28):

[0894] 1. Psychological symptoms: 0 to 16 points (4 symptoms: depression, irritability, anxiety, exhaustion);

[0895] 2. Somatic vegetative symptoms: 0 - 16 points (4 symptoms: sweating / flushing, heart discomfort, sleep disorders, joint and muscle discomfort);

[0896] 3. Urogenital symptoms: 0 - 12 points (3 symptoms: sexual problems, urinary discomfort, vaginal dryness).

[0897] D. Genitourinary Symptoms (GSM)

[0898]

[0899] The Menopause Rating Scale (MRS) indicated an overall improvement in quality of life, with the strongest effect for the 15 mg estetrol monohydrate dose. At this dose, a statistically significant effect was observed at week 4 compared to placebo, with a p-value of 0.0113, and a nearly statistically significant effect was observed at week 12, with a p-value of 0.0694.

[0900] E. Measurements Related to Treatment Side Effects

[0901] Record the changes in the following GSM symptoms (self-assessment by VVA subjects) from baseline to week 12:

[0902] a) Vaginal dryness (feeling of dryness or burning in the vagina; none = 0, mild = 1, moderate = 2, or severe = 3):

[0903]

[0904] *p < 0.05, compared to placebo at week 12.

[0905] b) Vaginal and / or vulvar irritation / itching (feeling of abnormal irritation or sensitivity in the vagina; none = 0, mild = 1, moderate = 2, or severe = 3):

[0906]

[0907] c) Dysuria (feeling of pain or difficulty in urination; none = 0, mild = 1, moderate = 2, or severe = 3):

[0908]

[0909] d) Vaginal pain related to sexual activity (pain during intercourse; none = 0, mild = 1, moderate = 2, or severe = 3):

[0910]

[0911] *p < 0.05, compared to placebo at week 12; **p < 0.001, compared to placebo at week 12.

[0912] e) Vaginal bleeding related to sexual activity (blood loss during intercourse; present = 1, absent = 0):

[0913]

[0914]

[0915] # Some patients had no sexual activity

[0916] The evolution of VVA symptoms indicates overall improvement, with the strongest effect seen with a single daily dose of 15 mg estetrol monohydrate. For vaginal pain related to sexual activity, significant differences were observed for single daily doses of 5, 10, and 15 mg estetrol monohydrate compared to placebo, with p-values of 0.0246, 0.0004, and 0.0006, respectively. However, vaginal dryness, which is generally considered the most bothersome symptom, was significantly improved only with a single daily dose of 15 mg estetrol monohydrate, with a p-value of 0.0291.

[0917] F. Measured at Single-Dose Doses of 15 mg and 20 mg Estetrol Monohydrate

[0918] 1. Number of patients biopsied

[0919]

[0920] 2. Adverse events (AE)

[0921]

[0922] As can be seen from the above table, fewer treatment-emergent adverse events (TEAEs) occurred in patients in the 15 mg estetrol monohydrate group than in the 10 mg estetrol monohydrate group. Among patients who experienced AEs in the 10 mg estetrol monohydrate group, the average number of AEs per patient was 3.2. In contrast, in the 15 mg estetrol monohydrate group, the average number of AEs per patient who experienced AEs was 2.6. Overall, these data suggest that a single daily dose of 15 mg estetrol monohydrate can significantly relieve VMS without imposing additional AEs on patients. In addition, the 15 mg single daily dose group had fewer biopsy requirements compared to the 10 mg estetrol monohydrate single daily dose group.

[0923] This was confirmed by the following statistical analyses. Using a Poisson regression model with random effects for patients and treatment groups as covariates to model the TEAE counts in the different treatment groups, the results showed no statistical difference between treatment groups (p-value = 0.099). Second, a chi-square test was used to assess whether the prevalence of patients reporting TEAEs was similar across treatment groups. No statistical difference was found between treatment groups (p-value = 0.575).

[0924] 3. Patients who withdrew from the study

[0925]

[0926] G. Measured at Single-Dose Doses of 15 mg and 30 mg Estetrol Monohydrate

[0927] To better evaluate the possibility of increasing the single daily dose beyond the minimum effective dose of 15 mg estetrol monohydrate per day, multiple parameters were followed in a study in which estetrol monohydrate was administered at an increasing dose of 20 mg per day.

[0928] 1. Triglyceride level (mmol / L)

[0929]

[0930] * The treatment end time was 28 days after administration in the 20 mg dose group and 12 weeks after administration in the 15 mg dose group.

[0931] 2. Blood glucose level (mmol / L)

[0932]

[0933] * The treatment end time was 28 days after administration in the 20 mg dose group and 12 weeks after administration in the 15 mg dose group.

[0934] 3. Cholesterol level (mmol / L)

[0935]

[0936]

[0937] * The treatment end time was 28 days after administration in the 20 mg dose group and 12 weeks after administration in the 15 mg dose group.

[0938] 4. HDL-cholesterol level (mmol / L)

[0939]

[0940] * The treatment end time was 28 days after administration in the 20 mg dose group and 12 weeks after administration in the 15 mg dose group.

[0941] 5. LDL-cholesterol level (mmol / L)

[0942]

[0943] * The treatment end time was 28 days after administration in the 20 mg dose group and 12 weeks after administration in the 15 mg dose group.

[0944] It can be observed from the above 5 tables that when the single-day dose of 20 mg estetrol monohydrate is used instead of the single-day dose of 15 mg estetrol monohydrate, there is no significant difference in the performance of these lipid parameters and blood glucose levels.

[0945] 6. C-terminal peptide (CTX-1) (ng / L)

[0946]

[0947] * The treatment end time was 28 days after administration in the 20 mg dose group and 12 weeks after administration in the 15 mg dose group.

[0948] CTX-1 is a specific marker of bone resorption.

[0949] As can be seen in the above table, a single daily dose of 15 mg of estetrol monohydrate resulted in a slight decrease in bone resorption, and this effect was more pronounced with a daily dose of 20 mg of estetrol monohydrate after 28 days of treatment.

[0950] Example 3: Comparison between 15 mg and 20 mg Estetrol Monohydrate

[0951] The following treatments were administered to healthy women (aged 15 - 50 years inclusive) according to a random code.

[0952] · Placebo (n = 16);

[0953] · 15 mg group: A single oral administration of 15 mg of estetrol monohydrate / 3 mg of drospirenone (n = 10), and after a 14-day washout period, 15 mg of estetrol monohydrate / 3 mg of drospirenone (n = 10)

[0954] Multiple oral administrations once daily for 14 days;

[0955] · 30 mg group: A single oral administration of 30 mg of estetrol monohydrate / 6 mg of drospirenone (n = 10), and after a 14-day washout period, 30 mg of estetrol monohydrate / 6 mg of drospirenone (n = 10)

[0956] Multiple oral administrations once daily for 14 days.

[0957] Adverse events were recorded from the first admission until the follow-up was completed (between 37 and 42 days after the first day of treatment).

[0958]

[0959] % = The percentage of subjects reporting one or more AEs out of the total number of subjects in the corresponding treatment group

[0960] Overall, single-dose administration and 14 days of once-daily oral administration of estetrol monohydrate / drospirenone in the dose range of 15 mg of estetrol monohydrate / 3 mg of drospirenone to 30 mg of estetrol monohydrate / 6 mg of drospirenone were safe and well-tolerated in healthy female subjects in this study. As the single or multiple dosing dose of estetrol monohydrate / drospirenone increased (doubled), no increase was observed in the percentage of subjects reporting TEAEs or the number of TEAEs.

[0961] Therefore, it is reasonable to consider a hormone replacement therapy for alleviating menopausal-related symptoms, which uses a single daily dose of 15 mg (the minimum effective dose) to 20 mg or even 25 mg of estetrol monohydrate, which will allow for a better benefit-risk ratio. Increasing the dose of estetrol monohydrate above the minimum effective dose of 15 mg per day does provide even better efficacy in terms of VMS alleviation and parameters such as parameters of bone resorption, while maintaining excellent safety (including but not limited to the adverse events presented in Sections E)2) and G) above, especially the lipid parameters and blood glucose levels presented in Sections F)1) to 5) above. When a patient starts hormone replacement therapy, increasing the estetrol monohydrate dose above the minimum effective dose of 15 mg per day will also allow for a faster onset of alleviation.

[0962] Endpoints

[0963] Further clinical studies were aimed at evaluating the effect of 15 or 20 mg of estetrol (E4) monohydrate or placebo on the severity and frequency of vasomotor symptoms (VMS) and the safety of 20 mg of E4. This example (i.e., Example 3) maintained the inclusion and exclusion criteria described in Example 2.

[0964] Primary Outcome Measures

[0965] Secondary Outcome Measures

[0966] 1. Mean change in the weekly frequency of moderate to severe vasomotor symptoms (VMS) from baseline to Week 4 (efficacy study section) [Time range: baseline and Week 4]:

[0967] The weekly frequency of moderate to severe VMS at baseline and Week 4 was defined as the total number (sum) of all moderate to severe VMS recorded within the last consecutive 7 days before baseline randomization and at Week 4. Mean change = mean weekly frequency at Week 4 - mean weekly frequency at baseline.

[0968] 2. Mean change in the weekly frequency of moderate to severe vasomotor symptoms (VMS) from baseline to Week 12 (efficacy study section) [Time range: baseline and Week 12]

[0969] The weekly frequency of moderate to severe VMS at baseline and Week 12 was defined as the total number (sum) of all moderate to severe VMS recorded within the last consecutive 7 days before baseline randomization and at Week 12. Mean change = mean weekly frequency at Week 12 - mean weekly frequency at baseline.

[0970] 3. Mean change in the severity of moderate to severe vasomotor symptoms (VMS) from baseline to Week 4 (efficacy study section) [Time frame: baseline and Week 4)

[0971] The severity score is obtained as follows: mild = 1, moderate = 2, and severe = 3. The mean severity score of VMS at baseline and week 4 is defined as the arithmetic mean of the daily severity score values of moderate and severe VMS observed in the last 7 days before baseline randomization and moderate and severe VMS observed at week 4. Baseline and week 4 severity score = [(2 x number of moderate VMS) + (3 x number of severe VMS)] / (total number of moderate and severe VMS). Mean change = mean severity score at week 4 - mean severity score at baseline.

[0972] 4. Mean change in severity of moderate to severe vasomotor symptoms (VMS) from baseline to week 12 (efficacy study section) [Time frame: baseline and week 12]

[0973] The severity score is obtained as follows: mild = 1, moderate = 2, and severe = 3. The mean severity score of VMS at baseline and week 12 is defined as the arithmetic mean of the daily severity score values of moderate and severe VMS observed in the last 7 days before baseline randomization and moderate and severe VMS observed at week 12. Baseline and week 12 severity score = [(2 x number of moderate VMS) + (3 x number of severe VMS)] / (total number of moderate and severe VMS). Mean change = mean severity score at week 12 - mean severity score at baseline.

[0974] 5. Incidence of endometrial hyperplasia with up to 12 months of treatment based on endometrial biopsy (endometrial and general safety study section) [Time frame: screening and week 53]

[0975] The endometrial biopsies will be centrally evaluated by three independent pathologists from different institutions, blinded to the treatment group and to each other's readings. Agreement of two of the three pathologists will be accepted as the final diagnosis. If there is disagreement among the three pathologists, the most severe pathological diagnosis, i.e., atypical hyperplasia > complex hyperplasia > simple hyperplasia > benign endometrium, will be used as the final diagnosis.

[0976] Results

[0977] 1. Weekly frequency and mean change in severity of moderate to severe vasomotor symptoms (VMS) from baseline to week n (efficacy study section) [Time frame: baseline and week n] (where n is an integer selected from 1 to 12).

[0978] The weekly frequency of moderate to severe VMS at baseline and week n is defined as the total number (sum) of all moderate to severe VMS recorded within the last consecutive 7 days before baseline randomization and at week n. Mean change = mean weekly frequency at week n - mean weekly frequency at baseline. The severity score is obtained as follows: mild = 1, moderate = 2, and severe = 3. The mean severity score of VMS at baseline and week n is defined as the arithmetic mean of the daily severity score values of moderate and severe VMS observed in the last 7 days before baseline randomization, and the arithmetic mean of the daily severity score values of moderate and severe VMS observed at week n. Baseline and week 4 severity score = [(2 x number of moderate VMS) + (3 x number of severe VMS)] / (total number of moderate VMS + severe VMS). Mean change = mean severity score at week n - mean severity score at baseline.

[0979] 2. Mean change in weekly frequency and severity of moderate to severe vasomotor symptoms (VMS) from baseline to week n (efficacy study section) [Time frame: baseline and week n] (where n is an integer selected from 1 to 12).

[0980] The severity score is obtained as follows: mild = 1, moderate = 2, and severe = 3. The mean severity score of VMS at baseline and week n is defined as the arithmetic mean of the daily severity score values of moderate and severe VMS observed in the last 7 days before baseline randomization, and the arithmetic mean of the daily severity score values of moderate and severe VMS observed at week n. Baseline and week n severity score = [(2 x number of moderate VMS) + (3 x number of severe VMS)] / (total number of moderate VMS + severe VMS). Mean change = mean severity score at week n - mean severity score at baseline

[0981] 3. Percentage of subjects with a 50% reduction in weekly frequency of moderate to severe vasomotor symptoms (VMS) at weeks 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, and 12 compared to baseline (efficacy study section) [Time frame: baseline, weeks 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, and 12]

[0982] The weekly attack frequency of moderate to severe VMS at baseline and week X is defined as: the total number (sum) of all moderate to severe VMS recorded in the last consecutive 7 days (baseline) before randomization, and the total number (sum) of all moderate to severe VMS recorded from day [(X - 1)×7 + 1] to day X×7 (week X).

[0983] 4. Percentage of participants with a 50% reduction in the weekly frequency of mild, moderate, and severe vasomotor symptoms (VMS) at weeks 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, and 12 compared to baseline (efficacy study section) [Time Frame: Baseline, weeks 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, and 12]

[0984] The weekly attack frequency of moderate to severe VMS at baseline and week X is defined as: the total number (sum) of all moderate to severe VMS recorded in the last consecutive 7 days (baseline) before randomization, and the total number (sum) of all moderate to severe VMS recorded from day [(X - 1)×7 + 1] to day X×7 (week X).

[0985] 5. Percentage of participants with a 75% reduction in the weekly frequency of moderate to severe VMS at weeks 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, and 12 compared to baseline (efficacy study section) [Time Frame: Baseline, weeks 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, and 12]

[0986] The weekly attack frequency of moderate to severe VMS at baseline and week X is defined as: the total number (sum) of all moderate to severe VMS recorded in the last consecutive 7 days (baseline) before randomization, and the total number (sum) of all moderate to severe VMS recorded from day [(X - 1)×7 + 1] to day X×7 (week X).

[0987] 6. Percentage of participants with a 75% reduction in the weekly frequency of mild, moderate, and severe VMS at weeks 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, and 12 compared to baseline (efficacy study section) [Time Frame: Baseline, weeks 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, and 12]

[0988] The weekly attack frequency of moderate to severe VMS at baseline and week X is defined as: the total number (sum) of all moderate to severe VMS recorded in the last consecutive 7 days (baseline) before randomization, and the total number (sum) of all moderate to severe VMS recorded from day [(X - 1)×7 + 1] to day X×7 (week X).

[0989] 7. Percentage of subjects with a clinically important difference (CID) in the weekly frequency of moderate to severe VMS at weeks 4 and 12 compared to baseline, using the Clinical Global Impression (CGI) questionnaire (efficacy study section) [Time Frame: Weeks 4 and 12]

[0990] The CGI score is a 7-point scale in which subjects are asked to rate their overall improvement compared to their condition at entry into the study, regardless of whether their judgment is due entirely to drug treatment. Ordinal scale: marked improvement, moderate improvement, slight improvement, no change, slight worsening, moderate worsening, marked worsening.

[0991] 8. Change in VVA symptoms from baseline to Week 12 (efficacy study section) [Time Frame: Baseline and Week 12]

[0992] GSM will be evaluated by the subject using the VVA self-assessment questionnaire. The following GSM symptoms will be evaluated:

[0993] - Vaginal dryness

[0994] - Vaginal and / or vulvar irritation / itching

[0995] - Dysuria

[0996] - Vaginal pain related to sexual activity

[0997] - Vaginal bleeding related to sexual activity

[0998] All GSM symptoms except vaginal bleeding related to sexual activity will be graded by the participant using the following scale: [0] None, [1] Mild, [2] Moderate, or [3] Severe. Vaginal bleeding related to sexual activity will be recorded using 2 categories: [0] Absent or [1] Present. A negative change from the baseline score indicates improvement in symptoms.

[0999] 9. Change in the VVA symptom initially identified by the participant as most bothersome at baseline through the VVA questionnaire from baseline to Week 12 (efficacy study section) [Time Frame: Baseline and Week 12]

[1000] GSM will be evaluated by the subject using the VVA self-assessment questionnaire. The following GSM symptoms will be evaluated:

[1001] - Vaginal dryness

[1002] - Vaginal and / or vulvar irritation / itching

[1003] - Dysuria

[1004] - Vaginal pain related to sexual activity

[1005] - Vaginal bleeding related to sexual activity

[1006] All GSM symptoms, except for vaginal bleeding associated with sexual activity, were graded by the participants using the following scale: [0] None, [1] Mild, [2] Moderate, or [3] Severe. Vaginal bleeding associated with sexual activity was recorded using 2 categories: [0] Absent or [1] Present. A negative change from the baseline score indicated improvement in symptoms. At baseline, the subjects will be asked which of the above symptoms they consider to be the most bothersome.

[1007] 10. Changes in plasma triglyceride concentration, low-density lipoprotein (LDL)-cholesterol plasma concentration, total cholesterol plasma concentration, total cholesterol / high-density lipoprotein (HDL) cholesterol ratio, HDL-cholesterol ratio, lipoprotein(a) plasma concentration, fasting blood glucose, insulin plasma concentration, glycated hemoglobin plasma concentration, homeostasis model assessment of insulin resistance index (HOMA-IR), and health-related quality of life (HRQoL) assessed using the Menopause Quality of Life Scale (MENQOL) from baseline to week 12 (efficacy study section) [Time range: baseline to week 12]

[1008] MENQOL is a self-administered questionnaire used to assess changes in quality of life over a one-month period. It consists of 29 questions that instruct the subject to indicate whether they are experiencing a problem (yes / no), and if so, the rating scale ranges from 0 = not bothered at all to 6 = very bothered. For analysis, the original scores will be converted to analysis scores of 1-8, where No = 1, 0 = 2, 1 = 3... 6 = 8. The scale includes four domains: vasomotor, psychosocial, physical, and sexual function. Each domain is scored independently.

[1009] Vasomotor domain score = mean of Q1, Q2, Q3, where 1 represents "not bothered at all"

[1010] And 8 is "extremely bothered".

[1011] 11. Total treatment satisfaction score using the Clinical Global Impression (CGI) questionnaire (efficacy study section) [Time range: weeks 4 and 12]

[1012] The CGI score is a seven-point scale in which the subject is asked to rate the overall improvement compared to their condition at the time of entering the study, regardless of whether their judgment is solely due to drug treatment. Rating scale: marked improvement, much improvement, slight improvement, no change, slight worsening, much worsening, severe worsening.

[1013] 12. Number of participants who experienced treatment-emergent adverse events (TEAEs) (efficacy study section) [Time range: from baseline to follow-up (up to week 16)]

[1014] TEAE refers to adverse events that occurred from the first administration of the study product to the last visit, or any pre-existing events that worsened in intensity or frequency after treatment.

[1015] 13. Number of participants with changes in physical examination and gynecological examination results (efficacy study section) [Time range: at screening and week 13]

[1016] Physical examination includes examinations of general appearance, head, eyes, ears, nose, throat, skin, neck, lungs, breasts, lymph nodes, abdomen, and cardiovascular, musculoskeletal, and nervous systems. Gynecological examination includes manual pelvic examination.

[1017] 14. Number of participants with changes in vital signs results (efficacy study section) [Time range: from screening to week 13]

[1018] Vital signs include height, weight, body mass index, sitting systolic and diastolic blood pressure, and heart rate.

[1019] 15. Number of participants with changes in electrocardiogram (ECG) results (efficacy study section) [Time range: screening and week 13]

[1020] The ECG interpretation protocol will include analysis of morphology, rhythm, conduction, ST segment, PR, QRS, QT and corrected QT (QTc) intervals, T wave, U wave, and the presence or absence of any pathological changes.

[1021] 16. Number of participants with changes in breast examination results (efficacy study section) [Time range: screening and week 13]

[1022] Number of participants with changes in routine clinical laboratory examination results (efficacy study section) [Time range: screening, baseline, and week 13]. Routine laboratory tests include hematology and chemistry.

[1023] 17. Change in endometrial thickness from baseline to each measurement time point (efficacy study section) [Time range: screening, week 13, week 16]

[1024] Endometrial thickness will be evaluated by transvaginal ultrasound (TVUS). Baseline: Data will be recorded during screening.

[1025] 18. Frequency of subjects in different endometrial categories according to Blaustein pathology (efficacy study section) [Time range: screening and week 13]

[1026] Endometrial biopsies will be centrally evaluated by three independent pathologists from different institutions, blinded to the treatment group and to each other's readings. Agreement by two of the three pathologists will be accepted as the final diagnosis. If there is disagreement among the three pathologists, the most severe pathological diagnosis, i.e., atypical hyperplasia > complex hyperplasia > simple hyperplasia > benign endometrium, will be taken as the final diagnosis.

[1027] 19. Number of participants with vaginal bleeding and / or spotting in each 28-day E4 treatment cycle (efficacy study section) [Time frame: from baseline to follow-up period (week 16)]

[1028] Participants will record vaginal bleeding daily in a diary. The following criteria will be used to assess the presence or absence of vaginal bleeding / spotting: 0 = no vaginal bleeding or spotting; 1 = spotting: evidence of minimal blood loss, requiring no or at most one sanitary napkin, tampon, or pad per day; 2 = bleeding: evidence of blood loss requiring more than one sanitary napkin, tampon, or pad per day.

[1029] 20. Number of days with bleeding and / or spotting in each 28-day treatment cycle (efficacy study section) [Time frame: from baseline to follow-up period (week 16)]

[1030] Participants will record vaginal bleeding daily in a diary. The following criteria will be used to assess the occurrence or disappearance of vaginal bleeding / spotting: 0 = no vaginal bleeding or spotting; 1 = spotting: evidence of minimal blood loss, requiring no or at most one sanitary napkin, tampon, or pad per day; 2 = bleeding: evidence of significant blood loss, requiring more than one sanitary napkin, tampon, or pad per day.

[1031] 21. Number of participants with amenorrhea (no bleeding or spotting) in each 28-day E4 treatment cycle (efficacy study section) [Time frame: from baseline to follow-up period (week 16)]

[1032] Participants will record vaginal bleeding daily in a diary. The following criteria will be used to assess the presence or absence of vaginal bleeding / spotting: 0 = no vaginal bleeding or spotting; 1 = spotting: evidence of minimal blood loss, requiring no or at most one sanitary napkin, tampon, or pad per day; 2 = bleeding: evidence of blood loss requiring more than one sanitary napkin, tampon, or pad per day.

[1033] 22. Cumulative amenorrhea rate (efficacy study section) [Time frame: from baseline to follow-up period (week 16)] The amenorrhea rate is defined as the percentage of women reporting consecutive amenorrhea within a given time period.

[1034] 23. Number of subjects with treatment-emergent adverse events (TEAE) (endometrium and general safety section) [Time frame: from baseline to week 53]

[1035] TEAE is an adverse event that occurs from the first administration of the study product to the last visit, or any pre-existing event that worsens in intensity or frequency after treatment.

[1036] 24. Number of participants with changes in physical examination and gynecological examination findings, vital signs, breast examination findings, electrocardiogram (ECG) findings, mammography findings, and routine clinical laboratory test findings (endometrium and general safety section) [Time frame: screening and week 53]

[1037] Physical examination includes examination of general appearance, head, eyes, ears, nose, throat, skin, neck, lungs, breasts, lymph nodes, abdomen, and cardiovascular, musculoskeletal, and nervous systems. Gynecological examination includes manual pelvic examination. Vital signs include height, weight, body mass index, sitting systolic and diastolic blood pressure, and heart rate. The ECG interpretation protocol will include analysis of morphology, rhythm, conduction, ST segment, PR, QRS, QT, and corrected QT (QTc) intervals, T wave, U wave, and the presence or absence of any pathological changes. Routine laboratory tests include hematology and chemistry.

[1038] 25. Number of women with vaginal bleeding and / or spotting in each 28-day E4 treatment cycle (endometrium and general safety section) [Time frame: from baseline to week 53]

[1039] Participants will record vaginal bleeding in a diary every day. The following criteria will be used to evaluate the occurrence or disappearance of vaginal bleeding / spotting: 0 = no vaginal bleeding or spotting; 1 = spotting: evidence of minimal blood loss, requiring no or at most one sanitary napkin, tampon, or pad per day; 2 = bleeding: evidence of significant blood loss, requiring more than one sanitary napkin, tampon, or pad per day.

[1040] 26. Number of days with bleeding and / or spotting in each 28-day treatment cycle (endometrium and general safety section) [Time frame: from baseline to week 53]

[1041] Participants will record vaginal bleeding in a diary every day. The following criteria will be used to evaluate the occurrence or disappearance of vaginal bleeding / spotting: 0 = no vaginal bleeding or spotting; 1 = spotting: evidence of minimal blood loss, requiring no or at most one sanitary napkin, tampon, or pad per day; 2 = bleeding: evidence of significant blood loss, requiring more than one sanitary napkin, tampon, or pad per day.

[1042] Number of participants with amenorrhea (no bleeding or spotting) in each 28-day E4 treatment cycle (endometrial and general safety sections) [Time frame: from baseline to week 53]

[1043] Participants will record vaginal bleeding in a diary every day. The following criteria will be used to evaluate the occurrence or disappearance of vaginal bleeding / spotting: 0 = no vaginal bleeding or spotting; 1 = spotting: evidence of minimal blood loss, requiring no or at most one sanitary napkin, tampon, or pad per day; 2 = bleeding: evidence of significant blood loss, requiring more than one sanitary napkin, tampon, or pad per day.

[1044] 28. Cumulative rate of amenorrhea (endometrial and general safety sections) [Time frame: from baseline to week 53]

[1045] The rate of amenorrhea is defined as the percentage of women reporting consecutive amenorrhea within a given time period.

[1046] 29. Change in health-related quality of life (HRQoL) assessed using the Menopause-Specific Quality of Life (MENQOL) questionnaire (endometrial and general safety sections) from baseline to weeks 12 and 52 [Time frame: baseline, week 12, and week 52]

[1047] The MENQOL is a self-administered questionnaire used to assess changes in quality of life over a one-month period. It consists of 29 questions that ask the subject whether they have experienced a problem (yes / no), and if so, rate it on a scale from 0 = not bothered at all to 6 = very bothered. For analysis, the raw scores are converted to analysis scores ranging from 1 - 8, where No = 1, 0 = 2, 1 = 3... 6 = 8. The scale has four domains: vasomotor, psychosocial, somatic, and sexual function. Each domain is scored independently. The vasomotor domain score = the average of Q1, Q2, and Q3, where 1 represents "not bothered at all" and 8 is "extremely bothered".

[1048] 30. Total treatment satisfaction score assessed using the Clinical Global Impression (CGI) questionnaire (endometrial and general safety sections) at 4, 12, and 52 weeks of treatment [Time frame: weeks 4, 12, and 52]

[1049] The CGI score is a seven-point scale in which the subject is asked to rate the overall improvement compared to their condition at the start of the study, regardless of whether their judgment is due entirely to drug treatment. Rating scale: marked improvement, moderate improvement, minimal improvement, no change, minimal worsening, moderate worsening, marked worsening.

[1050] 31. Plasma concentrations of triglycerides, high-density lipoprotein (HDL)-cholesterol, low-density lipoprotein (LDL)-cholesterol, total cholesterol, total cholesterol / high-density lipoprotein (HDL) cholesterol ratio, lipoprotein(a) plasma concentration, fasting blood glucose, insulin plasma concentration, glycated hemoglobin plasma concentration, homeostasis model assessment-estimated insulin resistance (HOMA-IR), endometrial thickness (endometrium and general safety section) changes from baseline to week 12 and week 52 [Time range: baseline, week 12, and week 52]

[1051] Endometrial thickness will be evaluated by transvaginal ultrasound (TVUS).

[1052] 32. Frequency of subjects in different endometrial categories according to Blaustein pathology (endometrium and general safety study section) [Time range: screening and week 53]

[1053] Endometrial biopsies will be centrally evaluated by three independent pathologists from different institutions, blinded to the treatment group and to each other's readings. Agreement of two of the three pathologists will be accepted as the final diagnosis. If there is disagreement among the three pathologists, the most severe pathological diagnosis, i.e., atypical hyperplasia > complex hyperplasia > simple hyperplasia > benign endometrium, will be taken as the final diagnosis.

[1054] 1. VMS

[1055] Figure 10

[1056] It can be inferred from the data that estetrol significantly reduces the frequency of moderate to severe VMS ( Figure 11 ). In addition, compared with placebo, estetrol treatment results in a greater reduction in the frequency of VMS in more women ( Figure 12 ). Finally, estetrol monohydrate significantly reduces the severity of moderate to severe VMS ( 2. Endometrial Thickness ).

[1057] 3. MENQOL

[1058] There was no significant difference in endometrial thickness between the 15 mg estetrol monohydrate treatment group and the 20 mg estetrol monohydrate treatment group, with an adjusted p-value of 0.8560 for ANCOVA analysis. Both doses resulted in an expected equivalent increase in estrogen treatment.

[1059] 4. Diabetes

[1060] When compared to placebo treatment, the total MENQOL score of subjects treated with estetrol monohydrate was significantly improved. This improvement was derived from several different parameters contributing to the total MENQOL score, including but not limited to reported muscle soreness, difficulty sleeping, anxiety and / or nervousness, impatience, dissatisfaction related to personal life, and improvement in the psychosocial domain score.

[1061]

[1062] Figure 13

[1063] Treatment of subjects with 15 mg or 20 mg of estetrol monohydrate had a positive effect on glucose metabolism in terms of reducing hemoglobin A1C ( Figure 14 ) and fasting blood glucose ( Example 4: Dose-Exploration Study to Select a Single-Dose Oral Dose of Estropipate (E4) for the Treatment of Vasomotor Symptoms in Postmenopausal Women with Mild, Moderate, or Severe Liver Injury ).

[1064] Hemoglobin A1C:

[1065]

[1066]

[1067] Fasting blood glucose:

[1068]

[1069] ​ ​

[1070] The study described in Example 2 was conducted again, also including women with mild, moderate, or severe liver injury. Among women with mild, moderate, or severe liver injury, women with mild or moderate liver injury were preferred. Compared to women with normal liver function, there were no statistically significant differences in efficacy and safety. It should be particularly emphasized that there would be no difference in the number of biopsies at 15 and 20 mg doses of estetrol monohydrate between the liver injury group and the non-liver function insufficiency group. In particular, when the sample sizes of different groups were standardized, the number of biopsies of women with mild or moderate liver injury was not different from that of women with normal liver function. In summary, the metabolism of estetrol monohydrate in women with liver injury was not affected to the extent that the dose needed to be adjusted. On the contrary, women with liver injury could directly receive the same dose as women with normal liver function.

Claims

1. A composition formulated as an oral dosage unit for relieving estrogen deficiency symptoms in subjects with liver injury, wherein the composition comprises an estetrol component, and the composition is administered in a single daily dose equivalent to about 15 mg to about 25 mg of estetrol.

2. The composition for use according to claim 1, wherein the subjects with liver injury are characterized by being classified as having mild liver injury (Child-Pugh score of 5 or 6), moderate liver injury (Child-Pugh score of 7 to 9), or severe liver injury (Child-Pugh score of 10 to 15) according to the Child-Pugh scoring system.

3. The composition for use according to claim 1 or 2, wherein the estrogen deficiency symptoms are menopausal-related symptoms in female perimenopausal, peri-menopausal or post-menopausal subjects.

4. The composition for use according to any one of the preceding claims, which is for reducing the frequency of vasomotor symptoms (VMS), the severity of VMS, the weekly weighted score of hot flushes, vaginal dryness, dyspareunia, or any combination thereof, or for improving the quality of life according to the Menopause Rating Scale (MRS) and / or the Menopause-Specific Quality of Life (MENQOL) questionnaire.

5. The composition for use according to any one of the preceding claims, wherein the VMS are selected from hot flushes, sweating attacks, night sweats, chills, increased sweating, palpitations, and combinations thereof.

6. The composition for use according to any one of the preceding claims, which is for relieving the emotional aspects of the menopausal transition, which are selected from depression, irritability, mood changes, insomnia, sleep disorders, anxiety, nervousness, and combinations thereof.

7. The composition for use according to any one of the preceding claims, for relieving the physiological aspects of the menopausal transition, which are selected from joint pain, decreased bone density, urinary tract infections, urinary incontinence, vaginal dryness, uterine prolapse, skin tissue changes, weight gain, dyspareunia, cardiovascular diseases, diabetes, and combinations thereof.

8. The composition used according to any one of the preceding claims, wherein a single administration of the oral dosage unit provides pharmacokinetic characteristics for a subject with liver injury, characterized in that The geometric mean (GM) C of estetrol (E4) max is less than twice the corresponding GM C in subjects with normal liver function max , preferably, where the geometric mean (GM) C max is 1.7 times or less of the corresponding GM C in subjects with normal liver function max .

9. The composition used according to any one of the preceding claims, wherein a single administration of the oral dosage unit provides pharmacokinetic characteristics for a subject with liver injury, characterized by GM AUC of E4 inf is less than twice that of subjects with normal liver function inf , preferably, wherein the GM AUC of E4 inf is 1.1 times or lower than that of subjects with normal liver function inf .

10. A composition for use according to any one of the preceding claims, wherein a single administration of the oral dosage unit provides pharmacokinetic characteristics for a subject with liver injury, characterized by GM AUC of E4-3 glucuronide inf was not significantly different from that of the corresponding E4-3 glucuronide in subjects with normal liver function inf There was no significant difference 11. The composition for use according to any one of the preceding claims, wherein a single administration of the oral dosage unit provides pharmacokinetic characteristics for a subject with liver injury, characterized by GM T of E4 1 / 2 is similar to the corresponding GM T in subjects with normal liver function 1 / 2 Similar 12. The composition for use according to any one of the preceding claims, wherein the number, frequency, and / or severity of adverse reactions do not differ between the group of subjects with liver injury and the group of subjects with normal liver function.

13. The composition for use according to any one of the preceding claims, wherein the estetrol component is estetrol monohydrate, and preferably, wherein the estetrol component is about 15 mg or about 20 mg of estetrol monohydrate.

14. The composition for use according to any one of the preceding claims, wherein the composition further comprises a progestogen component, and preferably, wherein the progestogen component is selected from progesterone, drospirenone, norethisterone, norethisterone acetate (NETA), dydrogesterone, levonorgestrel (LNG), etonogestrel, norgestrel, nomegestrol, nomegestrol acetate (NOMAC), trimegestone, allylestrenol acetate, dydrogesterone, gestodene, desogestrel, norgestimate, cyproterone acetate, dienogest, and chlormadinone, or wherein the composition further comprises bazedoxifene.

15. The composition used according to claim 14, wherein the progestogen component is drospirenone, preferably from about 1 mg to about 4 mg of drospirenone, more preferably about 3 mg of drospirenone, or wherein the progestogen component is administered in an amount equivalent to from about 1 mg to about 4 mg of drospirenone, preferably in an amount equivalent to about 3 mg of drospirenone.

16. The composition used according to any one of the preceding claims, wherein the composition is formulated corresponding to a daily dosage unit.

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