Contraceptive compositions with reduced adverse effects

Abstract

The present invention relates to a combined oral contraceptive that has a reduced risk of side effects compared to other combined oral contraceptives, including a reduced risk of QT interval prolongation, a reduced risk of decreased testosterone, and a reduced risk of increased C-reactive protein levels. The estetrol / drospirenone combined oral contraceptive described herein exhibits favorable pharmacokinetics for the progestogen component. The use of a specific estrogen component in the combined oral contraceptive offers several advantages over currently available combined oral contraceptives.

Description

[Technical Field]

[0001] The present invention relates to oral contraceptives. In particular, the present invention relates to a combined oral contraceptive containing estetrol and a progestogen component, such as drospirenone, which exhibits a desirable pharmacokinetic profile of progestogens and reduced adverse effects. The present invention also relates to contraceptive methods and their uses. [Background technology]

[0002] Over the years, numerous contraceptives have been developed, enabling women to enjoy greater freedom and reproductive empowerment (Non-Patent Document 1). One class of contraceptives that is particularly popular among women worldwide is the family of combined oral contraceptives (COCs). These COCs typically contain a combination of estrogen and progestin and are often preferred over progestin-only pills, which are characterized by very strict daily dosing timing and unpredictable bleeding patterns. Initially, COCs contained high doses of estrogen (>50 μg) and progestogens, such as norethindrone, lynestrenol, ethynodiol acetate, norethynodrel, and norethisterone (i.e., first-generation COCs), which carried significant risks of adverse effects, including cardiovascular effects. Driven by ongoing research and post-marketing safety evaluation, newer COC formulations have been developed, including those combining ethinyl estradiol (typically less than 50 μg) with testosterone-derived progestins, such as norgestrel and levonorgestrel (i.e., second-generation COCs), and those combining ethinyl estradiol with levonorgestrel-derived progestins, such as desogestrel or gestodene (i.e., third-generation COCs). More recently, fourth-generation COCs have been developed that combine drospirenone and ethinyl estradiol as progestin components. This more recent generation of progestins binds more specifically to the progesterone receptor, thereby reducing androgen-, estrogen-, or glucocorticoid-related side effects and exhibiting more neutral effects on metabolic parameters (Non-Patent Document 2).

[0003] Nevertheless, the use of fourth-generation COCs has been reported to be associated with an increased risk of adverse effects, including venous thromboembolism, compared with second-generation COCs (Non-Patent Document 3). Furthermore, fourth-generation COCs have been reported to contribute to QT interval prolongation in subjects, caused by both the QT-lengthening effects of estrogen and drospirenone (Non-Patent Document 4). QT prolongation reflects delayed ventricular repolarization and is associated with the occurrence of abnormal heart rhythms and even sudden cardiac arrest events. Furthermore, the overall antiandrogenic effect of COCs causes a decrease in free testosterone, a phenomenon that has been attributed in the art primarily to the presence of potent estrogens in the formulations. Low levels of free testosterone have been associated with female sexual dysfunction, including, but not limited to, lack of sexual desire (Non-Patent Document 5). Free testosterone has also been reported to have a general shortening effect on the QT interval (Non-Patent Document 4). Finally, increases in the inflammatory marker C-reactive protein have been observed in subjects using COCs. C-reactive protein is the most widely studied biomarker of inflammation in atherosclerotic cardiovascular disease (ASCVD). Multiple epidemiological studies have agreed that there is a significant association between elevated serum or plasma levels of C-reactive protein and the prevalence of underlying atherosclerosis, an increased risk of recurrent cardiovascular events among patients with established disease, and an increased incidence of first cardiovascular events among individuals at risk for atherosclerosis (Non-Patent Document 6). To date, it remains unclear whether C-reactive protein is a nonspecific marker of the acute phase response to inflammatory stimuli or whether it is directly related to the clinical manifestations of atherosclerosis.

[0004] Estetrol is a natural estrogen produced during pregnancy (Non-Patent Document 7). When estetrol is combined with the progestogen drospirenone, it provides good ovulation inhibition with a desirable vaginal bleeding profile, good tolerability, and high user satisfaction (Non-Patent Document 8).

[0005] In summary, although advances in the COC field have resulted in COCs with fewer adverse effects, there remains an unmet need in the art to resolve certain side effects associated with COCs, particularly those associated with fourth-generation COCs, particularly to resolve or avoid QT prolongation, avoid elevated C-reactive protein levels, and avoid reduced free testosterone in subjects. [Prior art documents] [Non-patent literature]

[0006] [Non-Patent Document 1] Liao and Dollin, Half a century of the oral contraceptive pill, CanFam Physician. 2012 [Non-patent document 2] Bastianelli et al.,Pharmacodynamics of combined estrogen-progestin oral contraceptives: 1. Effectson metabolism, Expert Rev Clin Pharmacol, 2017 [Non-patent document 3] Dinger et al., Riskof venous thromboembolism and the use of dienogest- and drospirenone-containingoral contraceptives: results from a German case-control study, J Fam PlannReprod Health Care. 2010 [Non-patent document 4] Sedlak et al., Sexhormones and the QT interval: a review, J Womens Health, 2012 [Non-Patent Document 5] de Castro Coelho and Barros, The Potential of Hormonal Contraceptionto Influence Female Sexuality, Int J Reprod Med, 2019 [Non-patent document 6] Crea and Morrow, C-reactive protein in cardiovascular disease, UpToDate, 2019 [Non-Patent Document 7] Holinka et al., Estetrol: a unique steroid in human pregnancy, J Steroid Biochem Mol Biol, 2008 [Non-patent document 8] Apter et al.,Estetrol combined with drospirenone: an oral contraceptive with highacceptability, user satisfaction, well-being and favorable body weightcontrol, Eur J Contracept Reprod Health Care, 2017 Summary of the Invention

[0007] The inventors have unexpectedly observed that estetrol / drospirenone (E4 / DRSP) COCs having the composition as described herein exhibit a number of previously unknown advantages when compared to currently available combined oral contraceptives, particularly when compared to fourth-generation oral contraceptives, which are generally considered in the art to be the latest generation of COCs. Thus, in response to a clearly unmet need in the art to provide drospirenone-containing COCs with minimal adverse side effects, the E4 / DRSP COCs as described herein have been developed. Accordingly, the present invention provides the following aspects:

[0008] Embodiment 1. A contraceptive kit comprising one or more packaged units, each packaged unit containing 21 to 28 daily active dosage units of a combined oral contraceptive (COC), each daily active dosage unit comprising: (a) drospirenone (DRSP) in an amount of 1 mg to 5 mg as a progestogen component; (b) estetrol (E4) in an amount of 10 mg to 20 mg as an estrogen component; Including, The dosage unit, when administered orally daily, produces the following results for DRSP in plasma: (i) Geometric mean AUC of DRSP 0-24 is between about 150 ng·h / ml and about 1000 ng·h / ml, and / or (ii) Geometric mean C of DRSP max is about 10 ng / ml to about 100 ng / ml, 1. A contraceptive kit that results in a pharmacokinetic profile that is

[0009] More specifically, in such a kit, in the case of a typical dose of DRSP of about 3 mg (2.5 mg to 3.5 mg), (i) Geometric mean AUC of DRSP 0-24 may be between about 200 ng·h / ml and about 600 ng·h / ml, and / or (ii) Geometric mean C of DRSPmax may be between 20 ng / ml and about 50 ng / ml.

[0010] More particularly, the present invention provides drospirenone in plasma with the following pharmacokinetic profile when administered daily: (i) Geometric mean AUC of drospirenone 0-24 is between about 150 ng·h / ml and about 1000 ng·h / ml, and / or (ii) Geometric mean C of drospirenone max is about 10 ng / ml to 100 ng / ml, The contraceptive kit includes one or more packaged units each containing 21 to 28 daily active dosage units of a combined oral contraceptive (COC) having drospirenone (DRSP) in an amount of 1 mg to 5 mg as a progestogen component, the kit being used to provide the above-mentioned contraceptive. The kit also includes estetrol in an amount of 10 mg to 20 mg as the estrogen component in the daily active dosage unit, wherein preferably one or more adverse effects of DRSP are reduced compared to a subject using a COC containing an equally effective amount of DRSP and another estrogen.

[0011] More specifically, in the above-mentioned use, in the case of a typical dose of DRSP of about 3 mg (2.5 mg to 3.5 mg), (i) Geometric mean AUC of DRSP 0-24 may be between about 200 ng·h / ml and about 600 ng·h / ml, and / or (ii) Geometric mean C of DRSP max may be between 20 ng / ml and about 50 ng / ml.

[0012] Aspect 2. The contraceptive kit of Aspect 1 or estetrol in an amount of 10 mg to 20 mg, for use in reducing the side effects of DRSP in a subject using a COC comprising equieffective amounts of DRSP and another estrogen, preferably a COC comprising equieffective amounts of DRSP and ethinyl-estradiol (EE).

[0013] Aspect 3. The contraceptive kit or estetrol in an amount of 10 mg to 20 mg according to Aspect 1 or 2, wherein the pharmacokinetic profile of DRSP in plasma is a steady-state pharmacokinetic profile, preferably after a daily dose of 10 units, more preferably after a daily dose of 14 units.

[0014] Aspect 4. A contraceptive kit according to any one of Aspects 1 to 3, or estetrol in an amount of 10 mg to 20 mg, for use in reducing the decrease in serum free testosterone associated with use of a COC comprising equieffective amounts of DRSP and another estrogen, preferably a COC comprising equieffective amounts of DRSP and EE, in a subject.

[0015] Aspect 5. The contraceptive kit or estetrol in an amount of 10 mg to 20 mg according to aspect 4, wherein the reduction in the subject using a COC as defined in aspect 1 is reduced by 10%, preferably 15%, more preferably 20%, when compared to a subject using a COC comprising an equieffective amount of DRSP and another estrogen, preferably an equieffective amount of DRSP and EE.

[0016] Aspect 6. The contraceptive kit or estetrol in an amount of 10 mg to 20 mg according to Aspect 4 or 5, wherein the serum concentration level of free testosterone is at least 25%, preferably at least 40%, more preferably at least 50% of a baseline value, the baseline value being the serum expression level of free testosterone prior to use of a COC containing DRSP in the subject.

[0017] Aspect 7. The contraceptive kit or estetrol in an amount of 10 mg to 20 mg according to any one of Aspects 4 to 6, wherein the free testosterone serum concentration is at least 0.09 ng / dL, preferably at least 0.20 ng / dL, in the subject when using a COC comprising DRSP and E4 as defined in Aspect 1.

[0018] Embodiment 8. A contraceptive kit according to any one of embodiments 1 to 3, or estetrol in an amount of 10 mg to 20 mg, for use in reducing the risk of QT interval prolongation associated with use of a COC comprising DRSP in a subject, preferably by reducing the risk of a mean and / or median QT interval prolongation of more than 5 msec.

[0019] Aspect 9. The contraceptive kit or estetrol in an amount of 10 mg to 20 mg according to Aspect 8, wherein the risk of QT interval prolongation in the subject using the COC is reduced by 10%, 25%, preferably 50%, more preferably 90%, or 100% compared to a subject using a COC containing EE as the estrogen component and an equieffective amount of DRSP.

[0020] Aspect 10. The contraceptive kit of Aspect 8 or 9, or estetrol in an amount of 10 mg to 20 mg, wherein the QT interval is considered to be prolonged if the time between the onset of the Q wave and the end of the T wave in a subject's electrocardiogram is prolonged by at least 5 milliseconds compared to the QT interval of said subject prior to use of a COC comprising DRSP.

[0021] Aspect 11. The contraceptive kit or estetrol in an amount of 10 mg to 20 mg according to any one of Aspects 8 to 10, wherein the mean QT interval prolongation in subjects using said COC is 20% shorter, preferably 35%, and more preferably 50% shorter than in subjects using a COC comprising an equieffective amount of DRSP as the progestogen component and EE as the estrogen component.

[0022] Aspect 12. The contraceptive kit of any one of Aspects 8 to 11, or estetrol in an amount of 10 mg to 20 mg, wherein the E4 inhibits QT interval lengthening by counteracting DRSP-induced QT interval lengthening in a subject using the COC as defined in Aspect 1.

[0023] Aspect 13. The contraceptive kit or estetrol in an amount of 10 mg to 20 mg according to any one of Aspects 8 to 12, wherein the COC has reduced estrogen-related effects on the QT interval when compared to a subject using a COC comprising an equieffective amount of DRSP as the progestogen component and EE as the estrogen component.

[0024] Aspect 14. The estrogen-related effect is prolongation of the QT interval, preferably I Kr and / or I Ks , and / or I K1 14. The contraceptive kit according to aspect 13, or estetrol in an amount of 10 mg to 20 mg, wherein the prolongation of the QT interval is due to estrogen-mediated inhibition of channel current.

[0025] Aspect 15. A contraceptive kit according to any one of Aspects 1 to 3, or estetrol in an amount of 10 mg to 20 mg, for use in reducing or preventing an increase in serum C-reactive protein concentration associated with use of a COC containing DRSP in a subject.

[0026] Aspect 16. The contraceptive kit or estetrol in an amount of 10 mg to 20 mg according to Aspect 15, wherein the C-reactive protein serum concentration level is considered to be elevated if the level is 10% higher, preferably 20% higher, preferably 30% higher than a baseline value, the baseline value being the C-reactive protein serum concentration level prior to use of a COC comprising DRSP in the subject.

[0027] Aspect 17. The contraceptive kit or estetrol in an amount of 10 mg to 20 mg according to Aspect 15 or 16, wherein the C-reactive protein serum concentration level is less than 2.00 mg / L, preferably less than 1.75 mg / L, and more preferably less than 1.5 mg / L in the subject when using a COC comprising DRSP and E4 as defined in Aspect 1.

[0028] Embodiment 18. The contraceptive kit according to any one of embodiments 1 to 17, or estetrol in an amount of 10 mg to 20 mg, wherein the COC comprising DRSP and E4 as defined in embodiment 1 is administered in a periodic cycle, and optionally, the administration scheme comprises a 4 to 7 day administration-free period or comprises placebo administration during said 4 to 7 days.

[0029] Aspect 19. The contraceptive kit according to any one of Aspects 1 to 18, wherein E4 is present in the COC as defined in Aspect 1 in an amount of 12 mg to 18 mg, preferably 14 mg to 16 mg, such as about 15 mg, or estetrol in an amount of 10 mg to 20 mg. In a further embodiment and in relation to all aspects defined herein, E4 can be present in the E4 / DRSP COC described herein in an amount of 14.2 mg to 15.5 mg. In a still further embodiment, estetrol (E4) can be estetrol monohydrate, which is present in the E4 / DRSPC COC described herein in an amount of about 14.5 mg to about 15.5 mg, preferably about 15 mg. In a further alternative embodiment, estetrol (E4) can be anhydrous (i.e., water-free) estetrol, which is present in the E4 / DRSP COC described herein in an amount of about 14 mg to 15 mg, preferably about 14.2 mg.

[0030] Aspect 20. A contraceptive kit according to any one of aspects 1 to 19, wherein DRSP is present in said COC as defined in aspect 1 in an amount of 2.5 mg to 3.5 mg, more preferably in an amount of about 3 mg; or estetrol in an amount of 10 mg to 20 mg.

[0031] Aspect 21. The contraceptive kit of any one of aspects 1 to 20, wherein a single dosage unit of said COC as defined in aspect 1 comprises about 2.5 mg to 3.5 mg of DRSP and about 14 mg to 16 mg of the E4 component; or estetrol in an amount of 10 mg to 20 mg.

[0032] Embodiment 22. A composition comprising E4 for use in reducing the bioavailability of DRSP in a subject taking a combined oral contraceptive containing DRSP.

[0033] Aspect 23. An E4 composition for use according to Aspect 22, wherein said E4 functions as the estrogen component of said combined oral contraceptive in which DRSP functions as the progestogen component.

[0034] Aspect 24. The E4 composition for use according to aspect 22 or 23, for use in reducing the side effects of DRSP in a subject who is continuously using a combined oral contraceptive containing DRSP.

[0035] Embodiment 25. The E4 composition for use according to any one of embodiments 22 to 24, for use in reducing the risk of elevated serum C-reactive protein (CRP) levels associated with continuous use of a combined oral contraceptive containing DRSP.

[0036] Embodiment 26. E4 used to reduce the steady-state bioavailability of DRSP in a COC by at least 15%, preferably at least 20%, more preferably at least 25%, e.g., about 30% or more, when compared to a COC containing equieffective amounts of DRSP and EE.

[0037] Aspect 27. E4 for use in reducing peak plasma concentrations of DRSP in a subject undergoing continuous use of a COC containing DRSP.

[0038] Embodiment 28. A method for reducing the risk of adverse effects of DRSP in a subject receiving a continuous regimen of COCs containing DRSP, the method comprising providing a COC containing DRSP as a progestogen component and E4 as an estrogen component.

[0039] Aspect 29. A COC comprising E4 and DRSP for use in reducing the side effects of DRSP associated with continuous use of a combined oral contraceptive containing DRSP. "Continuous use" includes the meaning that the dosing regimen is applied for multiple cyclical cycles. Typically, one cyclical cycle involves the application of 21 to 28 daily dosage units of a COC containing the active ingredient. The above use can optionally be interrupted by 4 to 7 days between different cyclical cycles, optionally by providing a placebo dosage unit that does not contain the active ingredient of the COC, or simply by not taking any pills during those 4 to 7 days. Typically, a regimen of 21 to 28 dosage units of the active COC ingredient is applied, interrupted by 4 to 7 days of use of a placebo dosage unit for compliance reasons.

[0040] Aspect 30. Use of E4 for the manufacture of a medicament for preventing or treating adverse effects resulting from the use of DRSP in COCs.

[0041] Aspect 31. Use of E4 for the manufacture of a composition (i.e., a medicament or contraceptive) for preventing or treating QT interval prolongation in a subject using DRSP with a COC.

[0042] Aspect 32. Use of E4 for the manufacture of a composition (i.e., a medicament or contraceptive) for preventing or treating reduced free testosterone serum levels in a subject using a DRSP containing COC.

[0043] Aspect 33. Use of E4 for the manufacture of a composition (i.e., a medicament or contraceptive) for preventing or treating elevated C-reactive protein levels in a subject using DRSP containing COC.

[0044] In any one of the aspects or embodiments listed herein above, the suitable amount of estetrol in the COC is equivalent to an amount of 14 mg to 16 mg of estetrol, which can be present in the form of estetrol monohydrate in the range of 14 mg to 16 mg, preferably 15 mg of estetrol monohydrate or its equivalent of 14.2 mg of estetrol.

[0045] In any one of the above-listed aspects or embodiments, the preferred amount of drospirenone in said COC is equal to about 2 mg to 4 mg or about 2.5 mg to 3.5 mg of drospirenone.

[0046] The above and further aspects and preferred embodiments of the present invention are described in the following sections and in the appended claims, the subject matter of which is specifically incorporated herein by reference. [Brief explanation of the drawings]

[0047] [Figure 1] Figure 1. Subject stratification. 98 subjects were enrolled in treatment with E4 / DRSP 15 / 3 mg (n=38), EE / LNG 0.03 / 0.15 mg (n=29), or EE / DRSP 0.02 / 3 mg (n=31). AE: adverse effect. [Figure 2] Figure 1 shows the change in QTcF interval on day 24 of treatment cycle 3. Treatment group: E4 / DRSP 15 / 3 mg, reference group: EE / DRSP 0.02 / 3 mg. [Figure 3] Figure 1 shows the change in QTcF interval on day 27 of treatment cycle 3. Treatment group: E4 / DRSP 15 / 3 mg, reference group: EE / DRSP 0.02 / 3 mg. DETAILED DESCRIPTION OF THE INVENTION

[0048] As used herein, the singular forms "a," "an," and "the" include both singular and plural referents unless the context clearly dictates otherwise.

[0049] The terms "comprising," "comprises," and "comprised of," as used herein, are synonymous with "including," "includes," or "containing," and these terms are inclusive or open-ended and do not exclude additional, unrecited components, elements, or method steps. These terms also encompass "consisting of" and "consisting essentially of," which enjoy well-established meanings in patent terminology.

[0050] The recitation of numerical ranges by endpoints includes all numbers and fractions falling within the particular range, as well as the recited endpoints. This applies to numerical ranges whether the numerical range is introduced by the phrase "from to," or "between," or otherwise.

[0051] The terms "about" or "approximately," as used herein, when referring to a measurable value such as a parameter, amount, time interval, etc., are meant to encompass variations from the value relative to the specified value, such as variations of ±10% or less, preferably ±5% or less, more preferably ±1% or less, and even more preferably ±0.1% or less, from the value relative to the specified value, provided that such variations are appropriate for practicing the disclosed invention. It will be understood that values ​​modified by "about" or "approximately" are themselves specifically and preferably disclosed.

[0052] On the other hand, the term "one or more" or "at least one," e.g., one or more members or at least one member of a group of members, is self-explanatory and, by way of further example, encompasses, among other things, reference to any one of said members, or any two or more of said members, e.g., any three or more, four or more, five or more, six or more, seven or more, etc. of said members, up to all of said members. As another example, "one or more" or "at least one" may refer to 1, 2, 3, 4, 5, 6, 7, or more.

[0053] The background discussion to the invention herein is included to explain the context of the invention and is not an admission that any of the material referred to was published, known, or common general knowledge in any country as of the priority date of any of the claims.

[0054] Throughout this disclosure, various publications, patents, and published patent specifications are referenced with an identifying citation. All publications cited herein are incorporated by reference in their entirety. In particular, the teachings or sections of such publications specifically mentioned herein are incorporated by reference.

[0055] Unless otherwise defined, all terms used in disclosing the present invention, including technical and scientific terms, have the meanings commonly understood by those skilled in the art to which this invention belongs. For further guidance, definitions of terms are included so that the teachings of the present invention can be better understood. When a particular term is defined in relation to a particular aspect of the present invention or a particular embodiment of the present invention, such relation or meaning is meant to apply throughout this specification, i.e., in the context of other aspects or embodiments of the present invention, unless otherwise defined. For example, an embodiment relating to a product is also applicable to corresponding features of the method and use.

[0056] In the following sections, different aspects or embodiments of the invention are defined in more detail. Each aspect or embodiment so defined can be combined with any other aspect(s) or embodiment(s), unless expressly stated to the contrary. In particular, any feature indicated as being preferred or advantageous can be combined with any other feature or features indicated as being preferred or advantageous.

[0057] Throughout this specification, references to "one embodiment" or "an embodiment" mean that a particular feature, structure, or characteristic described in connection with that embodiment is included in at least one embodiment of the present invention. Thus, the appearances of the phrase "in one embodiment" or "in an embodiment" in various places throughout this specification do not necessarily all refer to the same embodiment. Furthermore, particular features, structures, or characteristics may be combined in any suitable manner in one or more embodiments, as would be apparent to one of ordinary skill in the art from this disclosure. Furthermore, even if some embodiments described herein include some features but not other features included in other embodiments, combinations of features from different embodiments are intended to be within the scope of the present invention and form different embodiments, as would be understood by one of ordinary skill in the art. For example, the appended claims encompass alternative combinations of the claimed embodiments, as would be understood by one of ordinary skill in the art.

[0058] The term "subject" or "patient" as used herein refers to an animal, preferably a warm-blooded animal, more preferably a vertebrate, most preferably a mammal, such as a human or non-human mammal. Particularly suitable is a female human subject, more preferably a premenopausal and / or postmenopausal female subject. The female subject contemplated herein may be a subject who is in need or is considered to be in need of a contraceptive as described herein, i.e., an estetrol-containing composition as described herein, for contraceptive reasons, to improve bleeding patterns (i.e., to achieve a reduction in the severity or irregularity of bleeding patterns), to improve hormone-induced psychological or physical changes, or any combination thereof.

[0059] As will be appreciated by those skilled in the art, terms such as "quantity," "amount," and "level" are synonymous and have clearly defined meanings in the art. As used herein, these terms may refer specifically to the absolute amount of a molecule, such as a steroid, in a subject (a sample taken from the subject), or may refer to the relative amount of a molecule or analyte in a sample, i.e., a relative value relative to another value, such as a reference value or a range of values ​​representing the baseline of a particular parameter as taught herein. These values ​​or ranges of values ​​may be obtained from a single subject or from a group of subjects (i.e., at least two subjects). Furthermore, the AUC or C maxWhen referring to the (absolute or relative) amount of a parameter such as blood plasma, blood plasma, or serum plasma, such amount should be interpreted as the amount as measured in (a sample of) one or more subjects. Alternatively, when referring to the (absolute or relative) concentration or amount of a parameter such as free testosterone and C-reactive protein, such amount should be interpreted as the amount as measured in (a sample of) one or more subjects. Both "plasma" and "serum plasma" are commonly accepted terms in medical and clinical contexts, and there is no ambiguity regarding their interpretation by those skilled in the art (Matthew and Varacallo, Physiology, blood plasma, StatPearls, 2019).

[0060] "Estetrol," or "E4" for short, is an estrogenic steroid produced in the human fetal liver (PubChem CID: 27125). Estetrol can also be described as a 3-hydroxysteroid corresponding to 17beta-estradiol, in which the 15α and 16α positions are substituted with two additional hydroxy groups. Estetrol is known to be an estrogen receptor agonist (Coelingh Bennink et al., Estetrol review: profile and potential clinical applications, Climacteric, 2008). The estetrol as referred to herein may be endogenous estetrol. Alternatively, estetrol may be chemically synthesized, synthesized using a (mutated) recombinant enzyme, or synthesized by any combination thereof. Estetrol is known in the art by its molecular formula: C 18 H 24 O4 or by structural formula (I): [ka] Formula (I) It may alternatively be indicated by

[0061] It should be understood that throughout this specification, whenever estetrol is mentioned in any section, any estetrol-containing component (i.e., compound) and / or estetrol derivative is also intended. Examples include, but are not limited to, estetrol esters and estetrol hydrates. In a preferred embodiment, if present, the estetrol contained in the COC disclosed herein is estetrol monohydrate.

[0062] The terms "progestogen," "progestogen," "gestagen," or "gestogen," and their derivatives, "progestogenic compounds," as used herein and in the art, refer to any molecule that produces an effect in a subject's body similar to that of the natural female hormone progesterone. Progestogens are considered to be agonists of the progesterone receptor, and their functions have been thoroughly investigated in the art (see, inter alia, Kuhl, "Pharmacology of estrogens and progestogens: influence of different routes of administration," Climateric, 2005). Progestins are a subgroup of progestogens, which includes synthetic progestogens. While the terms are sometimes used interchangeably in the art, it is generally understood that when progestins are mentioned, they refer to synthetic progestogens. "Drospirenone" (abbreviated DRSP, PubChem CID: 68873) is an example of a progestin that has been widely used in COCs due to its anti-mineralocorticoid and anti-androgenic activity combined with generally low off-target activity. Drospirenone-containing COCs are generally referred to as fourth-generation COCs. Non-limiting examples of commercially available drospirenone-containing COCs include "Yaz™" and Yasmin™. An ​​exemplary drospirenone-only progestogen pill is "Slynd™," which is also commercially available. Drospirenone is known in the art by its molecular formula:24 H 30 O3 or by structural formula (II): [ka] Formula (II) It can alternatively be shown by:

[0063] It will be appreciated that when the term "drospirenone" is used herein, any drospirenone derivative is also contemplated. Moreover, it is more generally accepted that in COCs, a drospirenone dosage of 2.5 mg to 3.5 mg per day, preferably about 3 mg per day, is required to achieve ovulation inhibition.

[0064] By way of example and not limitation, other progestogens or progestins that have been used in COCs include norethisterone, norethindrone, levonorgestrel (LNG), norgestrel, gestodene, desogestrel, norgestimate, cyproterone acetate, dienogest, and chlormadinone.

[0065] "Combination oral contraceptive," abbreviated herein as COC, refers to any oral contraceptive containing both estrogen and progestogen molecules, thereby achieving clinical efficacy based on the combined activity of the estrogen and progestogen. COCs are typically classified based on the progestogen they contain. First-generation COCs contain progestogens such as norethynodrel, norethindrone, lynestrenol, ethynodiol acetate, or norethisterone. Second-generation COCs contain progestogens such as levonorgestrel or norgestrel. Third-generation COCs contain desogestrel, gestodene, or norgestodene. Fourth-generation COCs contain drospirenone as the progestogen component. Numerous COCs have been developed and are commercially available, such as Yaz™. As will be apparent to those skilled in the art throughout this specification, when reference is made herein to "the E4 / DRSP COC" or "the COC as described herein," unless expressly stated otherwise, it is intended that the COC contain the estrogen compound estetrol and the progestogen compound drospirenone. A comparison is made herein between a COC having the estrogen component estetrol and the progestogen component drospirenone and a COC having drospirenone or levonorgestrel (LNG) as the progestogen component and ethinylestradiol (EE) as the estrogen component. Examples, but not limitations, include products available under the trade names Yaz™ (0.02 mg EE / 3 mg DRSP), Yasmin™ (0.03 mg EE / 3 mg DRSP), or Melleva™ (0.03 mg EE / 0.15 mg LNG). Most preferably, a COC as described herein (i.e., containing both E4 and DRSP) is compared to a COC containing about 0.02 or about 0.03 mg of ethinylestradiol and about 3 mg of drospirenone.

[0066] A "contraceptive kit," preferably in the context of the present invention's packaging unit of a COC, refers to any package containing a packaged unit of contraceptives. As those skilled in the art will recognize, contraceptive kits can be designed to vary in size, shape, and the number of packaging units and / or dosage units they contain. A contraceptive kit can include an information leaflet included with the kit and / or instructions printed on the kit. As used herein, the term "active dosage unit" can be used synonymously with the term "dosage form" and refers to a pharmaceutical product having a specific mixture of active ingredients (in the context of a COC, specific amounts of estrogen and progestogen) contained in a specific structure; examples of such pharmaceutical products include, but are not limited to, capsules and tablets. It is clear that in the context of a COC, the active dosage unit must be (considered to be) suitable for oral administration.

[0067] Because the COCs disclosed herein are intended for oral administration, a structure that facilitates oral administration is preferred. Thus, the daily dosage units as described herein may be in solid or semisolid dosage form. Further suitable, but non-limiting, examples include tablets, (soft or hard) capsules, cachets, granules, pills, pellets, cachets, buccal films, pastes, crystals, dissolving films, caplets, meltlets, and the like. Obviously, some oral dosage forms, such as capsules, can contain an aqueous or oily solution containing estetrol and drospirenone. Suitable manufacturing methods for each of these dosage formulations are disclosed in the art. Typical examples of manufacturing methods for tablets, caplets, and meltlets are wet granulation (i.e., steam granulation, moisture-activated dry granulation, moist granulation, thermoplastic granulation, melt granulation, freeze granulation, foam granulation, or reverse wet granulation), dry granulation, such as pneumatic dry granulation, or compression (Shanmugam, Granulation techniques and technologies: recent progresses, Bioimpacts, 2015). Hard capsule shells can be made by dip molding or injection molding techniques, while an example of a soft capsule manufacturing method is to form a heat seal between two gelatin ribbons. Both hard and soft capsules have been thoroughly evaluated and reviewed in the art (e.g., the reference book Augsburger and Hoag, Pharmaceutical dosage forms: Capsules, CRCpress, 2017).

[0068] As used throughout this specification, phrases such as "under use of," "using," and similar expressions are used to designate one or more subjects who have used the COC or active ingredient referred to in the sentence or paragraph at least once. In preferred embodiments, "under use" can be interpreted as "under continuous use" or "a continuous, uninterrupted period of administration cycles." In certain embodiments referring to a subject who is using or has used a COC containing drospirenone, the subject has used the COC containing drospirenone for at least one administration cycle, preferably at least two, at least three, at least four, at least five, at least six, or seven or more administration cycles.

[0069] The present invention describes several surprising and valuable findings resulting from the results of several studies by the inventors. Essentially, the inventors have discovered that some of the aforementioned side effects of COCs containing drospirenone as the progestogen component may be due, in part or entirely, to the use of estetrol (E4) rather than ethinylestradiol (EE) as the estrogen component in such COCs. These findings thus have substantial value to the field of COCs. Accordingly, the benefits of COCs described herein include a reduced risk of adverse effects, reflected in improvements in several molecular parameters indicative of such adverse effects. Therefore, the immediate effect can be summarized as an improvement in the health of subjects using COCs. A secondary effect of the reduced incidence of COC adverse effects is that improved user compliance will be achieved in subjects using COCs. Over time, these findings represent a significant contribution to risk-free female reproductive autonomy. Given the widespread inclusion of drospirenone in fourth-generation COCs, the industrial applicability of the uses, methods, and compositions described herein is self-evident.

[0070] In a first finding, the inventors observed a significantly smaller decrease in serum free testosterone levels in subjects using E4 / DRSP COCs. This decrease may be typically observed in subjects using COCs containing drospirenone, such as EE / DRSP COCs. More specifically, the typical decrease, or "dip," in serum free testosterone observed in subjects taking EE / DRSP COCs is significantly reduced in subjects taking E4 / DRSP COCs. Drospirenone has been described in the art as contributing to the decrease in serum free testosterone because drospirenone is a progesterone receptor agonist, and progesterone receptor activation leads to antigonadotropin and antiestrogenic effects (Kuhl et al., Pharmacology of Estrogens and Progestogens: Influence of Different Routes of Administration, Climacteric, 2005). One of the antigonadotropic effects of drospirenone is the suppression of gonadal hormone production, including estradiol, progesterone, and testosterone production. Thus, the decrease in testosterone production is directly related to drospirenone, as would be understood by those skilled in the art. Surprisingly, however, when ethinylestradiol in EE / DRSP COCs was replaced with estetrol, the decrease in free testosterone in COC-using subjects was significantly reduced. This is the first observation showing that estetrol has a beneficial (clinical) effect on free testosterone levels in subjects using COCs containing drospirenone while still providing satisfactory contraceptive efficacy. The improvement in testosterone levels contributes to the reduction of side effects frequently reported in such subjects, such as lack of sexual desire, decreased libido, and lack of sexual arousal. This effect of E4 / DRSP COCs has not been described in the art. In a related observation, the inventors observed that the use of E4 / DRSP COCs did not increase or tend to increase the QT interval in subjects using COCs containing drospirenone.The effects of known COCs on prolonging the QT interval in subjects have been discussed in the art (see Salem et al. (2016) and Non-Patent Document 4, both of which are incorporated herein). The overall effect of sex hormones on QT interval prolongation is the result of a complex interplay between testosterone, progestogens, and estrogen due to their opposing effects on myocyte ion (potassium) channels. The general consensus in the art is that both endogenous and exogenous sex hormones affect the QT interval. Because COCs contain significant amounts of progestogens and estetrol, significant changes in the QT interval may be observed in some cases. In general, testosterone and progestogens shorten the action potential and therefore appear to have a beneficial effect on QT interval prolongation. In contrast, estrogen appears to have a QT interval-lengthening effect. Furthermore, it has been stated that during the menstrual cycle, progestogens are the primary factor affecting ventricular repolarization in women. However, drospirenone does not behave like a typical progestogen; instead, rather than counteracting estrogen, it appears to induce QT prolongation and enhance the effects of estrogen on QT interval prolongation (Salem et al., Association of Oral Contraceptives With Drug-Induced QT Interval Prolongation in Healthy Nonmenopausal Women, JAMA Cardiol, 2018). Therefore, the following summary of the effects of different contraceptives is accepted in the art (adapted from Non-Patent Document 4):

[0071] [Table 1]

[0072] Based on this, it can be inferred that fourth-generation COCs (e.g., EE / DRSP COCs) have an overall lengthening effect on the QT interval. As a result, subjects using fourth-generation COCs are at considerable risk of QT prolongation. Generally, a QT interval is considered to be prolonged if it increases by at least 5 ms, and such an increase can be caused by any type of intervention, such as the administration or use of a pharmaceutical active ingredient, particularly in the context of the present disclosure, by the (continuous) use of a fourth-generation COC. Unexpectedly, the inventors observed that replacing the ethinyl estradiol component of fourth-generation COCs with estetrol reduced the risk of QT prolongation. Without wishing to be bound by any theory, it is hypothesized that estetrol contributes to this surprising effect through two molecular mechanisms. First, estetrol appears to be a milder estrogen than ethinylestradiol, and therefore its estrogen-related effects on QT lengthening may be less pronounced. Estrogens have been reported to affect the QT interval at the molecular level by reducing potassium channel current (and / or expression), and estetrol's effects on these channels may be less pronounced. Second, as shown above, E4 / DRSP COCs can reduce the degree of free testosterone reduction or suppression. Testosterone has a shortening effect on the QT interval, likely due to its positive contribution to ionic potassium channel current and / or expression, which may counteract the lengthening effect of drospirenone. Thus, through this proposed dual mechanism of action, estetrol may be able to avoid the QT lengthening observed with EE / DRSP fourth-generation COCs. This effect of estetrol, and consequently of E4 / DRSP COCs, has never been reported in the art.

[0073] In a third unexpected observation, the inventors observed that subjects using E4 / DRSP contraceptives were less likely to experience COC-induced elevations in serum C-reactive protein levels, i.e., were at lower risk of such elevations, compared with subjects using common fourth-generation COCs, such as EE / DRSP COCs. Elevated C-reactive protein levels during and after COC use have been reported in the art (van Rooijen et al., "Treatment with combined oral contraceptives induces a rise in serum C-reactive protein in the absence of a general inflammatory response," J Thromb Haemost, 2006). It is hypothesized that elevated C-reactive protein levels are likely related to a direct effect on hepatocyte C-reactive protein synthesis, but do not reflect IL-6-mediated inflammation, endothelial activation, or the induction of insulin resistance, although this remains under debate. There is an association between elevated serum and / or plasma levels of C-reactive protein associated with atherosclerosis and atherosclerotic cardiovascular disease (ASCVD). Although the exact contribution of C-reactive protein remains unclear, it is clear that any elevation of C-reactive protein should be avoided in view of its relationship to atherosclerosis. The reduced effect of E4 / DRSPCOCs on C-reactive protein elevation compared to fourth generation COCs (e.g., EE / DRSP) has not been reported in the art.

[0074] Thus, a first aspect of the present invention relates to a contraceptive kit comprising one or more packaged units, each packaged unit containing 21 to 28 daily active dosage units of a combined oral contraceptive (COC), each daily active dosage unit containing (a) drospirenone as the progestogen component in an amount of 1 mg to 5 mg, and (b) estetrol as the estrogen component in an amount of 10 mg to 20 mg, said dosage units, when administered orally daily, producing the following in terms of drospirenone in plasma: (i) Geometric mean AUC for drospirenone doses of 1 mg to 5 mg, respectively 0-24 is about 150 ng·h / ml to about 1000 ng·h / ml for DRSP, and / or (ii) a geometric mean Cmax of about 10 ng / ml to about 100 ng / ml for doses of 1 mg to 5 mg drospirenone, respectively; This results in a pharmacokinetic profile that is

[0075] For a typical dose of DRSP of approximately 3 mg (2.5 mg to 3.5 mg), (iii) Geometric mean AUC of drospirenone 0-24 is believed to be between about 200 ng·h / ml and about 550 ng·h / ml, and / or (iv) The geometric mean Cmax of drospirenone appears to be between 20 ng / ml and about 50 ng / ml.

[0076] It should be understood that when the abbreviation "AUC" is used herein, it refers to "area under the curve" and should be interpreted as it is commonly meant in the art, i.e., to mean the definite integral of the curve that describes the variation of drug concentration in plasma as a function of time. AUC 0-24 As used herein, AUC represents the AUC from time "0", which is the time when the COC is administered to the subject, to the time 24 hours later. In the context used herein, "AUC" may be interpreted as bioavailability. Thus, AUC inf indicates the total AUC (from the "0" time point to infinity).

[0077] "C max " as referred to herein is the maximum or peak plasma concentration reached by a drug, e.g., drospirenone. Unless otherwise specified, AUC values ​​and C max The values ​​can be measured by radioimmunoassay, and / or HPLC and LC MS / MS, which are assays known to those skilled in the art (see, e.g., Jaffe, Methods of Hormone Radioimmunoassay, 2002).nd 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 apharmacokinetic study, J of Food and Drug Anal, 2013).

[0078] In certain embodiments, each active daily dosage unit contains the same or approximately the same amount of estetrol and drospirenone as defined elsewhere herein. In alternative embodiments, some active daily dosage units may contain higher or lower doses of E4 and / or DRSP, as long as E4 and / or DRSP are maintained at equal levels during the periodic cycle. In exemplary embodiments of this alternative, different active daily dosage units may be configured for multi-phase administration (e.g., biphasic, triphasic, or quadruple administration), with each phase achieving somewhat different concentrations of E4 and / or DRSP.

[0079] In certain embodiments, the pharmacokinetic profile of drospirenone is characterized by a geometric mean AUC of drospirenone after a single COC dose when administered at a daily dose of about 3 mg (e.g., 2.5 mg to 3.5 mg): 0-24 In certain embodiments, the drospirenone pharmacokinetic profile after a single COC dose is characterized by a geometric mean AUC of drospirenone of less than 425 ng·h / ml, preferably less than 400 ng·h / ml, preferably less than 350 ng·h / ml, more preferably less than 325 ng·h / ml, more preferably less than 300 ng·h / ml, more preferably less than 275 ng·h / ml, more preferably less than 250 ng·h / ml, more preferably less than 225 ng·h / ml. 0-24In certain embodiments, the drospirenone pharmacokinetic profile after a single COC dose is characterized by a geometric mean C of drospirenone of 450 ng·h / ml to 200 ng·h / ml, preferably 350 ng·h / ml to 150 ng·h / ml, more preferably 300 ng·h / ml to 200 ng·h / ml, and most preferably 260 ng·h / ml to 220 ng·h / ml. max In certain embodiments, the drospirenone pharmacokinetic profile after a single COC dose is characterized by a geometric mean C of drospirenone of less than about 45 ng / ml, preferably less than 40 ng / ml, preferably less than 35 ng / ml, preferably less than 30 ng / ml. max In certain embodiments, the pharmacokinetic profile of drospirenone after a single COC administration is characterized by a geometric mean AUC of drospirenone of 20 ng / ml to 50 ng / ml, preferably 20 ng / ml to 45 ng / ml, preferably 24 ng / ml to 40 ng / ml, preferably 24 ng / ml to 35 ng / ml. inf In certain embodiments, the drospirenone pharmacokinetic profile after a single COC dose is characterized by a geometric mean AUC of drospirenone of less than 300 ng·h / ml, preferably less than 275 ng·h / ml, preferably less than 260 ng·h / ml, preferably less than 250 ng·h / ml, preferably less than 230 ng·h / ml. inf In certain embodiments, the drospirenone pharmacokinetic profile after a single COC dose is characterized by a geometric mean AUC 0-24 is less than 250 ng·h / ml, preferably less than about 224 ng·h / ml, and the geometric mean C max is less than 45 ng / ml, preferably less than 40 ng / ml, preferably less than 35 ng / ml, and optionally the geometric mean AUC infIn certain embodiments, the drospirenone pharmacokinetic profile after a single COC dose is characterized by a geometric mean AUC 0-24 is about 200 ng·h / ml to about 250 ng·h / ml, and C max is about 20 ng / ml to about 30 ng / ml, and optionally the geometric mean AUC inf is 350 ng·h / ml to 450 ng·h / ml.

[0080] In certain embodiments, the pharmacokinetic profile of drospirenone after multiple dosing of COCs at a daily dose of about 3 mg (e.g., 2.5 mg to 3.5 mg), preferably after 10, 12, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, or 28 daily doses, is measured by the geometric mean AUC 0-24 is less than 650 ng·h / ml, preferably less than 600 ng·h / ml, preferably less than 550 ng·h / ml, preferably less than 625 ng·h / ml, and optionally a geometric mean C max In certain embodiments, the pharmacokinetic profile of drospirenone after multiple daily doses of the COC, preferably 10, 12, 14, 21, or 21-28 doses, is characterized by a geometric mean AUC of drospirenone of less than 50 ng / ml. 0-24 is 400 ng·h / ml to 625 ng·h / ml, preferably 425 ng·h / ml to 550 ng·h / ml, preferably 425 ng·h / ml to 525 ng·h / ml, and optionally a geometric mean C max In certain embodiments, the pharmacokinetic profile of drospirenone after 10 daily doses is characterized by a geometric mean AUC of drospirenone of less than 50 ng / ml. 0-24 is less than 450 ng·h / ml, and C max is less than 40 ng / ml.

[0081] In certain embodiments, the pharmacokinetic profile of drospirenone after 14 daily doses is 0-24 is less than 525 ng·h / ml, and C max The COCs are characterized by a mean terminal elimination half-life (t) of E4 of 14 days or less, preferably 14 days or less. The COCs described herein are, of course, representative of subjects who receive or will receive the COCs described herein at approximately regular intervals, preferably 18 to 28 hours, preferably about 24 hours, between doses. The parameters described herein may be observed after a single dose of the COC. These parameters were confirmed in a multiple-dose study at 14 days after the start of daily administration. Obviously, as will be appreciated by those skilled in the art, other time points may be selected for multiple-dose studies once drospirenone steady state has been reached. For COCs, the mean terminal elimination half-life (t) of E4 is 14 days or less. 1 / 2 ) is approximately 20 to 30 hours. In combination drugs, the average t 1 / 2 The decline in plasma levels of E4 is biphasic, and therefore the range of the AUC is approximately 30 to 40 hours. 1 / 2The steady state is defined by a decline faster than 56 hours, and steady state is expected to occur more than five half-lives before. The worst-case period to reach steady state is five times 56 hours (280 hours or 11.6 days). Therefore, assuming a linear dose rate, daily administration for 12 days should be sufficient to reach steady state. If trough levels are similar during the last few days of administration, steady state has been reached. Therefore, a 14-day period with multiple administrations is appropriate to achieve a steady state of estetrol and / or drospirenone in the blood. In the results of the multiple-dose study described in the Examples, when using the E4 / DRSP COC as described herein, steady state for estetrol was reached after about five daily doses, and steady state for drospirenone was reached after about ten daily doses. Therefore, in an embodiment of the present invention, the pharmacokinetic profile as disclosed herein is a steady-state pharmacokinetic profile. In certain embodiments, the steady-state pharmacokinetic profile is the pharmacokinetic profile measured after administering 10 daily doses. In further embodiments, the steady-state pharmacokinetic profile is the pharmacokinetic profile after administering 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, or more daily doses.

[0082] In certain embodiments, the contraceptive kit includes one packaging unit. In alternative embodiments, the contraceptive kit includes at least two packaging units, preferably at least three, and preferably four or more packaging units. In certain embodiments, the packaging unit is a blister pack or a strip pack. The packaging unit of the contraceptive kit disclosed herein may be a "compliance package." As known in the art, a "compliance package" is a packaging unit of various sizes and styles intended to provide appropriate storage for one or more medications within the context of this COC, and subsequently to provide assistance and / or guidance for subject compliance with the intended cyclical administration of the COC (Peck Gossel, Packaging the Pill, Manifesting Medicine: Bodies and Machines, New York: Taylor & Francis, 1999). By way of example and not limitation, the packaging unit may be provided with numerical designations and / or symbols to enable a subject to keep track of her menstrual cycle. In an alternative example, but not by way of limitation, the packaging unit may comprise a means for transmitting an electrical signal to a subject when the scheduled administration time (i.e., a certain date) arrives, if the COC for that time is still in the packaging unit. In these examples, the electrical signal may be transmitted to a data storage means and / or transmitted to a user-defined electronic device, a smartphone, or a wearable device (smart wear), which are exemplary herein. In certain embodiments, different portions of the packaging unit(s) provide different sensory triggers to the subject, such as, by way of example and not limitation, different colors or textures.

[0083] In certain embodiments, each packaged unit contains 21, 22, 23, 24, 25, 26, 27, or 28 daily dose units of the COC. In further embodiments, each packaged unit contains 21 to 24 daily dose units of the COC and one or more placebo dose units, preferably 4 to 7 placebo units. The placebo units are provided to increase patient compliance because taking one pill daily is much easier to maintain than spacing out pill intakes. In certain embodiments, the order of the COC and placebo daily dose units is arranged in a grouped manner (i.e., 21 to 24 daily dose units of the COC first, followed by 4 to 7 placebo units, or vice versa). In further embodiments, the packaged units are devoid of indicia that provide the subject with information as to which of the daily dosage units are COC dosage units and which of the daily dosage units are placebo dosage units. In certain embodiments, the placebo dosage units comprise lactose, magnesium stearate, and starch. In further embodiments, the placebo dosage units comprise lactose monohydrate, magnesium stearate, and corn starch.

[0084] In certain embodiments, the contraceptive kit as described herein is administered in a periodic cycle, which includes a seven-day administration-free period. In further embodiments, the cycle includes a four-day administration-free period. "Administration-free period" herein refers to a seven-day or four-day time interval during which a subject is not administered a COC. Thus, during the administration-free period, the subject is not administered estetrol or a progestogen. In certain embodiments, during the administration-free period, a placebo formulation may be administered, which optionally has an appearance visually indistinguishable from an active dosage unit.

[0085] The placebo formulation contemplated herein does not contain estrogen such as estetrol or progestin such as drospirenone.The administration-free period can be considered as a hormone-free period in the art.During the administration-free period, withdrawal bleeding may occur, which may last for about 3 days, 4 days, 5 days, 6 days, or 7 days.In certain embodiments, the placebo formulation contains iron supplement and / or folic acid.

[0086] In certain embodiments, estetrol is present in the E4 / DRSP COCs described herein in an amount of 12 mg to 18 mg. In certain embodiments, estetrol is present in the E4 / DRSP COCs described herein in an amount of 14 mg to 16 mg. In a further embodiment, estetrol is present in the E4 / DRSP COCs described herein in an amount of 14.2 mg to 15.5 mg. In yet a further embodiment, estetrol is estetrol monohydrate, which is present in the E4 / DRSP COCs described herein in an amount of about 14 mg to about 16 mg, or about 14.5 mg to about 15.5 mg, preferably about 15 mg. In an alternative further embodiment, estetrol is anhydrous (i.e., water-free) estetrol, which is present in the E4 / DRSP COCs described herein in an amount of about 13.5 mg to about 15.5 mg, or about 14 mg to about 15 mg, preferably about 14.2 mg. In certain embodiments, drospirenone is present in the E4 / DRSP COCs described herein in an amount of 2 mg to 4 mg. In a further embodiment, drospirenone is present in the E4 / DRSP COCs described herein in an amount of 2.5 mg to 3.5 mg. In yet a further embodiment, drospirenone is present in the E4 / DRSP COCs described herein in an amount of 2.75 mg to 3.25 mg. In yet a further embodiment, drospirenone is present in an amount of about 3 mg. In certain embodiments of the E4 / DRSP COCs described herein, a single dosage unit of the COC contains about 3 mg of drospirenone and about 15 mg of estetrol.

[0087] In certain embodiments, the pharmacokinetic profile of drospirenone after a single dose of a COC containing about 3 mg drospirenone and about 15 mg estetrol is 0-24 is less than 250 ng·h / ml, preferably less than 230 ng·h / ml, and the geometric mean C max is less than 45 ng / ml, preferably less than 40 ng / ml, preferably less than 35 ng / ml, and optionally the geometric mean AUC inf is less than about 600 ng·h / ml, or less than about 550 ng·h / ml.

[0088] In certain embodiments, a contraceptive kit as described herein is contemplated for use in reducing the side effects of drospirenone in a subject using a standard COC containing drospirenone and another estrogen other than estetrol. In certain embodiments, the standard COC containing drospirenone is a COC containing ethinyl estradiol and drospirenone, preferably a standard COC containing about 0.02 mg or about 0.03 mg ethinyl estradiol and about 3 mg drospirenone.

[0089] The side effects described herein may be clinical symptoms, i.e., undesirable or pathogenic symptoms, but may also include changes in molecular parameters, such as the decrease or increase of certain molecules, such as hormones or enzymes, or even transmembrane channels. As those skilled in the art will recognize, many molecular changes do not necessarily result in clinical symptoms, but they may nonetheless be indicators of or contribute to the risk of a clinical event occurring at a later time point. Of course, different molecular changes may result in a single clinical event, effect, or symptom. In certain embodiments, the reduction in drospirenone side effects in subjects using COCs containing estetrol and drospirenone is compared to subject(s) using COCs containing drospirenone and an estrogen other than estetrol. In a further embodiment, the estrogen other than estetrol is an equivalent amount of ethinylestradiol (EE). "Ethinylestradiol" is a molecule well-defined in the art and has the molecular formula C 20 H 24 As those skilled in the art will appreciate, the findings, assumptions, and conclusions described herein can be readily applied to COCs having additional alternative estrogens as the estrogen component, including estradiol (E2) (molecular formula C 18 H 24 O2, PubChem CID: 5757).

[0090] In certain embodiments, the percentage of subjects who observe or report a reduction in one or more drospirenone-associated side effects is at least 20%, preferably at least 40%, at least 50%, at least 75%, or at least 100%. In certain embodiments, the one or more drospirenone-associated side effects are independently selected from the group consisting of: QT interval prolongation of at least 5 milliseconds (ms), decreased or suppressed free testosterone, elevated C-reactive protein, decreased libido, headache, nausea, vomiting, abdominal bloating, cramps, breast pain, breast tenderness, breast swelling, fatigue, hair loss, elevated potassium levels, etc.

[0091] In a further aspect, a COC containing estetrol and drospirenone is contemplated for reducing drospirenone side effects associated with continuous use of a combined oral contraceptive containing drospirenone. "Continuous use" refers to the application of a dosing regimen over multiple cyclical cycles, e.g., 2, 3, 4, 5, 6, or more cyclical cycles. In certain embodiments, one cyclical cycle involves the application of 21 to 28 daily dosage units of an E4 / DRSP COC as described herein, followed by 4 to 7 days during which the subject does not use a COC and optionally uses a placebo product for compliance reasons, i.e., provides a daily pill for each day during the period so that the subject does not have to count COC-free days in the dosing regimen. In certain embodiments, drospirenone side effects are induced in the subject by use of a drospirenone-containing COC without estetrol. In certain embodiments, the subject is a first-time COC user. A "first-time COC" user refers to a subject who has not previously used a COC containing estrogen and a progestogen in the subject's lifetime. In a further embodiment, the subject is part of a first-time COC user family (i.e., a biological family, where family members are related by genetic inheritance) in which neovascular problems have been reported. In a further alternative embodiment, the subject is part of a first-time COC user family in which female sexual dysfunction has been reported.

[0092] In certain embodiments, the COCs comprising estetrol and drospirenone further comprise one or more excipients. The term "excipient" as used herein refers to any solvent, diluent, buffer (e.g., neutral buffered saline, phosphate buffered saline, Tris-HCl, acetate buffer, phosphate buffer), solubilizer (e.g., Tween 80, polysorbate 80), colloid, dispersion medium, vehicle (e.g., petrolatum, dimethyl sulfoxide, mineral oil), bulking agent, anti-caking agent (e.g., magnesium stearate, talc), chelating agent (e.g., EDTA, glutathione), amino acid (e.g., glycine, (L-) glutamic acid, (L-) arginine, (L-) histidine), protein, disintegrant (e.g., corn starch, sodium starch glycolate (type A)), binder (e.g., gelatin, polysorbate 80), or the like. Examples of suitable excipients include synthetic polymers such as vinylpyrrolidone (PVP, povidone) and polyethylene glycol, sugars such as sucrose, lactose, (corn) starch, cellulose, hydroxypropyl cellulose, xylitol, sorbitol, mannitol, etc., lubricants, humectants, stabilizers, emulsifiers, sweeteners (e.g., sugars), colorants, flavorings (both natural flavors such as fruit extracts and artificial flavors are contemplated), fragrances, thickeners, agents for providing a depot effect, coating agents, antifungal agents, preservatives (e.g., thimerosal (trademark), benzyl alcohol), antioxidants (ascorbic acid, sodium metabisulfite, butylated hydroxyanisole, and / or toluene), tonicity controlling agents, absorption delaying agents, adjuvants, bulking agents (e.g., lactose, mannitol), etc. The term "excipient" may be referred to by synonyms in the art, including, but not limited to, "carrier." It will be further apparent to those skilled in the art that certain excipients can fulfill multiple functions, or that certain excipients, such as (purified) water, may be used during the manufacturing process of COCs but are no longer detectable in the final product.

[0093] A typical (single) tablet composition representative of the compositions contemplated herein may contain estetrol monohydrate, drospirenone, lactose monohydrate, sodium starch glycolate type 1, corn or maize starch, povidone K30, and magnesium stearate, optionally coated with AquaPolish Pink 044.08 MS. When coating, a suspension may first be prepared, which is then applied to the tablet by any suitable coating process. Coating processes have been extensively discussed in the art and are therefore known to those skilled in the art (e.g., Ankit et al., Tablet Coating Techniques: Concepts and Recent Trends, IRJP, 2012). More specifically, a typical (single) tablet composition may contain about 10 mg to 20 mg, preferably about 12 mg to 18 mg, more preferably 14 mg to 16 mg, of estetrol monohydrate; about 1 mg to 5 mg, preferably about 2 mg to 4 mg, of drospirenone; about 25 mg to 50 mg, preferably about 30 mg to 45 mg, of lactose monohydrate; about 1 mg to 10 mg, preferably about 2 mg to 8 mg, of sodium starch glycolate type A; about 5 mg to 20 mg, preferably about 10 mg to 20 mg, of corn or maize starch; about 0.5 mg to 5 mg of povidone K30; and about 0.1 mg to about 5 mg, preferably about 0.2 mg to about 3 mg, of magnesium stearate. The optional coating suspension, when dry, may add about 1 mg to 10 mg, preferably about 1 mg to 5 mg, to the tablet weight.In certain embodiments, the formulation may contain pharmaceutically acceptable auxiliary substances as needed to approximate physiological conditions, such as pH adjusting and buffering agents, preservatives, complexing agents, osmolality adjusting agents, wetting agents, etc., including, but not limited to, sodium acetate, sodium lactate, sodium phosphate, sodium hydroxide, hydrogen 20 chloride, benzyl alcohol, parabens, EDTA, sodium oleate, sodium chloride, potassium chloride, calcium chloride, sorbitan monolaurate, and triethanolamine oleate. The use of such media and agents in the formulation of pharmaceutical compositions is known in the art (see, for example, Kalasz and Antal, Drug excipients, Curr Med Chem, 2006). Furthermore, methodologies and information for the formulation and administration of pharmaceutical compositions are disclosed in the art (e.g., reference book: Remington: The Science and Practice of Pharmacy (which is periodically revised)).

[0094] Also contemplated herein is a method for reducing the risk of (alleviating) adverse effects of drospirenone in a subject receiving a continuous regimen of COCs containing drospirenone, the method comprising providing the subject with a COC containing drospirenone as the progestogen component and estetrol as the estrogen component. In certain embodiments, the subject has been diagnosed with or is suspected of experiencing adverse effects from the use of COCs containing drospirenone. In certain embodiments, the subject has experienced adverse effects from previous use of drospirenone-containing COCs. In certain embodiments, the adverse effects are selected from the group consisting of: a decrease in free testosterone serum concentration of at least 0.25 ng / dL, or a decrease of more than 50%, preferably more than 60%, or more than 70% relative to baseline concentration; a QT interval prolongation of at least 5 ms; or an increase in C-reactive protein serum concentration to 1.5 mg / L serum or greater, e.g., 2 mg / L serum or greater. In certain embodiments, the COC is provided to the subject by daily oral administration, preferably for a period of at least 21 days or up to 28 days. In certain embodiments, the subject is a first-time COC user. In alternative embodiments, the subject has previously used a COC containing drospirenone, has changed COC types, or has discontinued COC use for more than 4 weeks.

[0095] Without limitation, "predict" or "prediction" generally refers to the description, announcement, declaration, or forecast of a disease or condition in a subject who does not (yet) exhibit any or limited clinical symptoms of the disease, condition, or (adverse) side effect. A prediction of a disease, condition, or adverse effect in a subject may indicate the likelihood, chance, or risk that the subject will develop the disease, condition, or (adverse) side effect, for example, within a certain period of time, at a certain age, or within a certain time frame of taking a certain medication, i.e., a contraceptive in the context of the present invention. This likelihood, chance, or risk may be expressed in any appropriate qualitative or quantitative terms, including, but not limited to, absolute values, ranges, or statistics. Alternatively, the likelihood, chance, or risk may be expressed relative to a suitable control subject or group of control subjects (i.e., a population of control subjects) (e.g., relative to a typical, normal, or healthy subject or subject population). Therefore, any possibility, chance, or risk that a subject will develop a disease, a condition, or a (harmful) side effect can be advantageously expressed as an increase or decrease, as up-regulation or down-regulation, or as a fold increase or decrease, relative to a suitable control subject or group of subjects, or relative to a baseline value, and the baseline value can be derived from either a control subject (population) or a reference standard value. It is clear that when a subject population is used to define a baseline value, the baseline value will be the central dimension of one or more values ​​(parameters) of the population, for example, the mean or median of the values. The term "prediction" of a condition, disease, or a (harmful) side effect as described herein can also particularly mean that the subject has a "positive" prediction for them, i.e., the subject is at risk of having them (e.g., the risk is significantly elevated compared to a control subject or a control or overall subject population).

[0096] "Diagnosed with," "diagnose," and diagnosis refer to the process of recognizing, determining, or concluding that a disease, condition, or (adverse) side effect is present in a subject based on symptoms and signs and / or from the results of various diagnostic procedures (e.g., knowing the presence, absence, and / or amount of one or more biomarkers of the diagnosed disease or condition or clinical symptoms that characterize the diagnosed disease or condition). "Diagnosing" a disease, condition, or (adverse) side effect as taught herein in a subject can specifically mean that the subject has such disease or condition. A subject can also be diagnosed as not having such a disease or condition, despite exhibiting one or more of the usual symptoms or signs associated with such a disease or condition.

[0097] As will be appreciated by those skilled in the art, monitoring a disease, pathological condition, or (adverse) side effect may make it possible to predict the occurrence of said disease, pathological condition, or (adverse) side effect, or to monitor the progression, exacerbation, alleviation, or recurrence of said disease, pathological condition, or (adverse) side effect, or the response to a treatment or to other external or internal factors, circumstances, stressors, etc. Furthermore, monitoring can be applied during the course of a subject's medical treatment. Such monitoring may be involved, for example, in deciding whether a patient can be discharged from a supervised clinical or healthcare setting, whether a change in treatment or therapy is required, or whether (further) hospitalization is necessary.

[0098] In certain embodiments, a contraceptive kit as described herein is contemplated for use in a subject to reduce the decline in serum free testosterone levels associated with the use of COCs containing drospirenone. In a further embodiment, the contraceptive kit and COCs are used for at least six cycles. "Decrease in free testosterone levels," as used in this context, refers to a decrease in free testosterone serum levels, or the median decrease in free testosterone serum levels when multiple subjects are studied. In a further embodiment, the decrease in free testosterone serum levels is reduced by 10% in subjects using E4 / DRSP COCs as described herein compared to subjects using COCs containing ethinyl estradiol as the estrogen component and an equieffective amount of drospirenone. In a further embodiment, the decrease in free testosterone serum concentration is reduced by 12%, preferably 14%, preferably 15%, preferably 16%, preferably 18%, preferably 20% in subjects using an E4 / DRSP COC as described herein for at least 6 cycles, when compared to subjects using a COC containing ethinyl estradiol as the estrogen component and an equieffective amount of drospirenone for the same number of cycles.

[0099] In certain embodiments, a subject using a COC containing ethinyl estradiol as the estrogenic component and an equieffective amount of drospirenone for at least six cycles has a free testosterone serum concentration of about 0.09 ng / dL to 0.20 ng / dL, when the subject's pre-use free testosterone serum concentration was 0.20 ng / dL to 0.80 ng / dL. In certain embodiments, a subject using an E4 / DRSP COC as described herein for at least six cycles has a reduction in free testosterone serum concentration of about 0.09 ng / dL to 0.60 ng / dL, when the subject's pre-use free testosterone concentration was 0.100 ng / dL to 1.0 ng / dL. In certain embodiments, the median free testosterone serum concentration in subjects using a COC having an estrogen component, ethinyl estradiol, for at least six cycles is about 0.086 ng / dL, and the median free testosterone serum concentration in subjects using a COC as described herein for at least six cycles is about 0.20 ng / dL.

[0100] In certain embodiments, the free testosterone concentration is at least 25%, preferably at least 30%, preferably at least 35%, preferably at least 40%, and more preferably at least 50% of the baseline value, the baseline value being the free testosterone serum expression level in the subject prior to use of a COC containing drospirenone. In certain embodiments, subjects using a COC containing ethinyl estradiol as the estrogenic component and an equieffective amount of drospirenone for at least six cycles experience a reduction in free testosterone serum concentration of 89% to 50% of the baseline value. In further embodiments in which multiple subjects are considered, COCs containing ethinyl estradiol as the estrogenic component and an equieffective amount of drospirenone experience a median reduction in free testosterone serum concentration of 71% of the baseline value. In certain embodiments, subjects using an E4 / DRSP COC as described herein for at least six cycles experience a reduction in free testosterone serum concentration of 80% to 0% of the baseline value. In further embodiments in which multiple subjects are studied, E4 / DRSP COCs as described herein reduce free testosterone serum concentrations by a median of 50% of baseline. In certain embodiments, the baseline value is the median free testosterone concentration prior to use of any COCs; as will be apparent to those skilled in the art, baseline values ​​will vary due to subject-to-subject variability. By way of guidance and not limitation, suitable testosterone serum concentration baseline values ​​can be any value between about 0.10 ng / dL and about 1.20 ng / dL, e.g., about 0.10 ng / dL, about 0.20 ng / dL, about 0.35 ng / dL, 0.50 ng / dL, 0.80 ng / dL, 1.00 ng / dL, etc. In certain embodiments, the free testosterone serum concentration is at least 0.09 ng / dL, preferably at least 0.20 ng / dL, in the subject when using an E4 / DRSP COC as described herein.In certain embodiments, the free testosterone serum concentration is at least 0.09 ng / dL, preferably at least 0.20 ng / dL, in the subject when using an E4 / DRSP COC as described herein for at least six cycles.

[0101] "Free testosterone" or "free T," as used herein, refers to testosterone that is not bound to proteins, including albumin and sex hormone-binding globulin (SHBG). Free testosterone is transported to the cytoplasm of target tissue cells, where it can bind to the androgen receptor or be reduced to 5α-dihydrotestosterone (DHT) by the cytoplasmic enzyme 5α-reductase (Goldman et al., "A Reappraisal of Testosterone's Binding in Circulation: Physiological and Clinical Implications," Endocrine Reviews, 2017). COCs have been shown in the art to reduce androgen levels, particularly testosterone (free testosterone and total testosterone). It has been reported that in female subjects, approximately 65% ​​to 70% of circulating testosterone is bound and inactivated by SHBG, and approximately 30% to 35% is bound to albumin, resulting in approximately 0.5% to 3% free testosterone. Numerous suitable methods for measuring free testosterone in a subject (sample) have been described in the art, including, but not limited to, liquid chromatography-tandem mass spectrometry (LC-MS / MS), equilibrium dialysis, and immunoassays. Alternatively, the free testosterone level in a female subject (sample) may be derived from total testosterone, SHBG, and albumin concentrations.

[0102] The term "baseline value" as used herein should be construed as having the meaning generally accepted in the art. In the medical field, a baseline value represents a value in a subject (sample) before the start of an experiment or test, or may even be a standard value known in the art for a subject population. The use of a baseline value allows a person skilled in the art to establish a baseline value and express changes over time due to one or more interventions that affect a parameter (Chiolero et al., Assessing the Relationship between the Baseline Value of a Continuous Variable and Subsequent Change Over Time, Front Public Health, 2013). In the context of this specification, unless otherwise specified, the intervention is administration of COC.

[0103] In certain embodiments, a contraceptive kit as described herein is contemplated for use in a subject to reduce the risk of QT interval prolongation associated with the use of a COC containing drospirenone, preferably by reducing the risk of a mean and / or median QT interval prolongation of more than 5 ms. In a further embodiment, the contraceptive kit and COC are used for at least six cycles. In the context of the present disclosure, the "risk of QT interval prolongation" is considered to be the chance that a subject will experience a prolongation of the QT interval (mean or median) due to the use of a COC. In certain embodiments, the risk of QT interval prolongation in the subject is reduced by 10%, preferably 25%, preferably 30%, preferably 40%, preferably 50%, preferably 60%, preferably 75%, preferably 90%, and more preferably 100% in subjects using an E4 / DRSP COC as described herein, compared to subjects using a COC containing ethinyl estradiol as the estrogen component and an equieffective amount of drospirenone. In certain embodiments, the mean QT interval in subjects using a COC containing ethinyl estradiol as the estrogenic component and an equieffective amount of drospirenone for at least six cycles is prolonged by a mean and / or median interval of 5 ms to 15 ms, preferably 5 ms to 10 ms, whereas the mean and / or median QT interval in subjects using an E4 / DRSP COC as described herein for at least six cycles is prolonged by a mean and / or median interval of 0 ms to 5 ms. In certain embodiments, the QT interval is considered to be prolonged if the (mean and / or median) time between the onset of the Q wave and the end of the T wave in the subject's electrocardiogram is prolonged by at least 5 milliseconds, compared to the subject's QT interval before using a COC containing drospirenone. In further embodiments, the QT interval is considered to be prolonged if the time between the onset of the Q wave and the end of the T wave in the subject's electrocardiogram is prolonged by at least 6 milliseconds, preferably at least 7 milliseconds, preferably at least 8 milliseconds, compared to the subject's QT interval before using a COC.

[0104] In certain embodiments, the difference in lengthening from baseline QT interval to the mean QT interval after at least 6 cycles of use of an E4 / DRSP COC as described herein is 4 to 10 units shorter, preferably 5 to 10 units shorter, preferably 5.5 to 10 units shorter, than the difference in lengthening from baseline QT interval to the mean QT interval after at least 6 cycles of use of a COC containing ethinyl estradiol as the estrogenic component and an equieffective amount of drospirenone. In certain embodiments, the difference in lengthening from baseline QT interval to median QT interval after at least 6 cycles of use of an E4 / DRSP COC as described herein is 8 to 15 units shorter, preferably 8 to 12 units shorter, preferably 7 to 10 units shorter, than the difference in lengthening from baseline QT interval to mean QT interval after at least 6 cycles of use of a COC containing ethinyl estradiol as the estrogenic component and an equieffective amount of drospirenone.

[0105] "QT interval," as used herein, refers to a parameter that can be derived from an electrocardiogram and describes the time from the onset of the Q wave to the end of the T wave. The QT interval indicates the (approximate) time it takes a subject's heart to transition from the onset of ventricular contraction to the end of ventricular diastole. Alternatively, the QT interval is equal to the time it takes the ventricles to contract from the moment they begin to contract to the moment they end diastole. The length of the QT interval can be manually measured on an electrocardiogram complex by various methods, including the tangent method and the threshold method. The tangent method identifies the end of the T wave by determining the point where the T wave crosses (i.e., overlaps) the isoelectric baseline of the electrocardiogram. The threshold method identifies the end of the T wave by the point where a tangent extrapolated from the T wave at its point of maximum downward slope intersects the isoelectric baseline (Panicker et al., Intra- and interreader variability in QT interval measurement by tangent and threshold methods in a central electrocardiogram laboratory, J Electrocardiol, 2009).

[0106] Because the length of the QT interval is inversely related to heart rate (i.e., faster heart rates reflect shorter QT intervals), the QT interval can be corrected for differences in heart rate using various correction formulas, including, but not limited to, the Bazett's correction, the Fridericia correction, the Sagie correction, and the Framingham correction. Generally, the longer the QT interval, the greater the subject's chance of sudden cardiac death (Algra et al., "QTc prolongation measured by standard 12-lead electrocardiography is an independent risk factor for sudden death due to cardiac arrest," Circulation, 1991). In certain embodiments, the mean QT interval according to the Fridericia correction formula (hereinafter referred to as QTcF interval) in subjects using a COC containing ethinyl estradiol as the estrogenic component and an equieffective amount of drospirenone for at least six cycles is prolonged by a mean and / or median interval of 3 ms to 10 ms, preferably 3 ms to 8 ms, preferably about 4 ms, whereas the mean and / or median QTcF interval in subjects using an E4 / DRSP COC as described herein for at least six cycles is prolonged by a mean and / or median interval of 0 ms to 3 ms, preferably 0 ms to 2.5 ms. In certain embodiments, the difference in lengthening from the baseline QTcF interval to the mean QTcF interval after at least six cycles of use of an E4 / DRSP COC as described herein is 2 to 5 units shorter, preferably 2.5 to 4 units shorter, and preferably about 2.8 units shorter, than the difference in lengthening from the baseline QTcF interval to the mean QTcF interval after at least six cycles of use of a COC containing ethinyl estradiol as the estrogenic component and an equieffective amount of drospirenone.In certain embodiments, the difference in lengthening from baseline QTcF interval to median QTcF interval after at least 6 cycles of use of an E4 / DRSP COC as described herein is 1 to 4 units shorter, preferably 1 to 3 units shorter, preferably 1.5 to 2.5 units shorter, than the difference in lengthening from baseline QTcF interval to median QTcF interval after at least 6 cycles of use of a COC comprising ethinyl estradiol as the estrogenic component and an equieffective amount of drospirenone.

[0107] In certain embodiments, the mean and / or median QT interval prolongation in subjects using an E4 / DRSP COC as described herein is 20% shorter, preferably 25% shorter, preferably 30% shorter, preferably 35% shorter, preferably 40% shorter, more preferably 45% shorter, and most preferably 50% shorter than the mean and / or median QT interval prolongation, respectively, in subjects using a COC comprising an equieffective amount of drospirenone as the progestogen component and ethinyl estradiol as the estrogen component. In certain embodiments, the mean and / or median QTcF interval prolongation in subjects using an E4 / DRSP COC as described herein is 20% shorter, preferably 25% shorter, preferably 30% shorter, preferably 35% shorter, preferably 40% shorter, more preferably 45% shorter, and most preferably 50% shorter than the mean and / or median QTcF interval prolongation, respectively, in subjects using a COC comprising an equieffective amount of drospirenone as the progestogen component and ethinyl estradiol as the estrogen component.

[0108] In certain embodiments, estetrol inhibits QT interval prolongation in a subject using an E4 / DRSP COC as described herein by counteracting drospirenone-induced QT interval prolongation. Those skilled in the art will recognize that progestogens generally shorten the QT interval in a subject, but drospirenone in particular exerts the opposite effect on QT interval length (i.e., drospirenone induces QT interval prolongation, as discussed, inter alia, in Salem et al., Association of Oral Contraceptives With Drug-Induced QT Interval Prolongation in Healthy Nonmenopausal Women, JAMA Cardiology, 2018). In certain embodiments, estetrol inhibits QT interval prolongation in a subject by counteracting drospirenone-induced QT interval prolongation. In a further embodiment in which the drospirenone-induced QT interval prolongation effect is reversed by estetrol in an E4 / DRSP COC as described herein, the estrogenicity of estetrol is the sole cause of the QT prolongation occurring in a subject using the COC. In an alternative embodiment in which the drospirenone-induced QT prolongation effect is reversed by estetrol in an E4 / DRSP COC as described herein, the antiandrogenicity of estetrol is the sole cause of the QT prolongation occurring in a subject using the COC. "Antiandrogenicity" refers to the ability of a molecule to prevent androgens, such as testosterone and dihydrotestosterone, from exerting their biological effects in a subject. Antiandrogens can function either by inhibiting binding to the androgen receptor and / or by suppressing the production of one or more androgens themselves. Antiandrogens are generally considered the functional opposite of androgen receptor agonists. In general, antiandrogenicity can be related to estrogenicity.

[0109] In certain embodiments, the E4 / DRSP COCs described herein have reduced estrogen-related effects on the QT interval compared to subjects using COCs containing an equally effective amount of drospirenone as the progestogen component and ethinylestradiol as the estrogen component. Estrogens have generally been described in the art as a cause of QT prolongation in subjects using COCs (Salem et al., Influence of steroid hormones on ventricular polarization, Pharmacology & Therapeutics, 2016). In further embodiments, the estrogen-related effects include QT interval prolongation, preferably I Kr and / or I Ks The QT interval is prolonged due to estrogen-mediated inhibition of the channel current. Kr ) and slow-acting type (I Ks ) delayed rectifier potassium channels, and a decrease in either of these channels can cause QT prolongation and potentially the development of long QT syndrome, a cardiac disorder characterized by a high risk of sudden cardiac arrest (Chiamvimonvat et al., Potassium currents in the heart: functional roles in repolarization, arrhythmia and therapeutics, J Physiol, 2017). In certain embodiments, I Kr and / or I KsThe estrogen-mediated inhibition of the channel current is 25% less, preferably 50% less, preferably 75% less than the estrogen-mediated inhibition of an estrogen selected from the group consisting of: ethinylestradiol, estradiol, and estrogen. In a further embodiment, the estrogen to which the effect of estetrol is compared is ethinylestradiol. In a further embodiment, the estrogen-related effect is prolongation of the QT interval, preferably I Kr , I Ks , and inward rectifying channels (I K1 The prolongation of the QT interval is due to estrogen-mediated inhibition of the I channel current. K1 The role of the channel has been described in the art (Dhamoon and Jalife, The inward rectifier current (I K1 ) controls cardiac excitability and is involved in arrhythmogenesis, Heart Rhythm, 2005).

[0110] In certain embodiments, the contraceptive kit as described herein is intended for use in a subject to reduce or prevent an increase in C-reactive protein serum concentration levels associated with the use of COCs containing drospirenone and ethinyl estradiol. As intended herein, a C-reactive protein serum concentration level is considered elevated if the level is 10% higher, preferably 15% higher, preferably 20% higher, preferably 25% higher, or preferably 30% higher than a baseline value, the baseline value being the C-reactive protein serum concentration level in the subject prior to COC use. As will be appreciated by those skilled in the art, baseline C-reactive protein concentration levels may be attributable to an individual subject or may be based on reference values ​​from one or more reference textbooks. By way of guidance, and not limitation, a suitable baseline value for CRP is 0.100 mg / dL (1.00 mg / L). In certain embodiments, subjects using E4 / DRSP COCs as described herein for at least six cycles experience a 0% median increase in C-reactive protein serum levels compared to baseline, while subjects using COCs containing ethinyl estradiol as the estrogen component and an equieffective amount of drospirenone for at least six cycles experience a 30% median increase in C-reactive protein serum levels. In certain embodiments, the C-reactive protein serum levels of subjects using E4 / DRSP COCs as described herein for at least six cycles experience an increase of less than 1.5 times the baseline levels and the C-reactive protein serum levels of subjects using COCs containing ethinyl estradiol as the estrogen component and an equieffective amount of drospirenone for at least six cycles. In certain embodiments, the C-reactive protein serum levels are less than 1.75 mg / L in subjects using E4 / DRSP COCs as described herein. In certain embodiments, C-reactive protein serum concentration levels are less than 2.00 mg / L in subjects using an E4 / DRSP COC as described herein for at least six cycles.In a further embodiment, the C-reactive protein serum concentration is less than 1.75 mg / L, preferably less than 1.5 mg / L, in a subject using an E4 / DRSP COC as described herein, preferably for at least six cycles. Use of a COC of the invention reduces the risk of elevated CRP levels associated with long-term and continuous use of COCs containing DRSP and another estrogen other than E4. Typically, CRP levels in healthy subjects without inflammation over a period of time are less than 2 mg / L serum, and continuous use of a COC of the invention does not result in a substantial elevation of CRP levels above this threshold in healthy subjects without inflammation over a period of time.

[0111] C-reactive protein has been extensively described in the art and is a pentameric protein present in serum. It is known that circulating C-reactive protein concentrations increase, i.e., rise in response to inflammation. Elevated C-reactive protein levels have been associated with atherosclerotic cardiovascular disease (ASCVD). However, it remains unclear whether C-reactive protein is a nonspecific marker of the acute phase response to inflammatory stimuli or whether C-reactive protein is directly related to the clinical manifestations of ASCVD. It is generally accepted in the art (Note: 2019 ACC / AHA Guideline on the Primary Prevention of Cardiovascular Disease: A Report of the American College of Cardiology / American Heart Association Task Force on Clinical Practice Guidelines) that serum C-reactive protein levels can be classified into different categories according to cardiac risk classification: low-risk category (<2 mg / L) and intermediate-high risk (≥2 mg / L). Thus, in a preferred embodiment, the C-reactive protein serum concentrations observed in subjects using E4 / DRSP COCs as described herein correspond to low-risk category concentration levels. Routine assays for measuring C-reactive protein levels in subjects (samples) are available, including, but not limited to, immunoassays such as enzyme-linked immunosorbent assays (ELISAs) and turbidimetric assays. It is self-evident that changes in C-reactive protein concentrations as disclosed herein are small after a single dose, or even after a limited number of daily doses. Nevertheless, over the long term, increases in C-reactive protein with E4 / DRSP COCs are significantly lower than increases in C-reactive protein with COCs containing ethinyl estradiol and drospirenone, which are compared throughout this specification.Thus, the reduction in C-reactive protein increase in subjects using E4 / DRSP COCs becomes more pronounced when the daily dosage units administered to the subjects is increased.The long-term effect of this is that subjects using E4 / DRSP COCs as described herein are classified into a low cardiovascular risk group.For example, a subject who initially shows a low-risk profile (less than 2 mg / L) will be more likely to remain in the same risk group upon (long-term) use of E4 / DRSP COCs as described herein, compared to the same subject using EE / DRSP COCs.In the EE / DRSP regimen, subjects are more likely to experience an increase in C-reactive protein concentration, thereby changing their risk category from low risk to medium-high risk (2 mg / L or more).

[0112] Also contemplated is an estetrol-containing composition used to reduce the bioavailability of drospirenone in a subject using a COC containing drospirenone. In certain embodiments, the estetrol-containing composition is included in the same contraceptive kit as the COC, optionally in the same packaging unit. In certain embodiments, the estetrol-containing composition is administered as a separate active dosage unit to a subject using a COC containing drospirenone and an estrogen other than estetrol. In certain embodiments, the bioavailability of drospirenone is reduced by at least 5%, preferably at least 10%, preferably at least 15%, preferably at least 25%, preferably at least 50% due to the presence of estetrol. In a further embodiment, the estetrol serves as the estrogen component of the combined oral contraceptive, and drospirenone serves as the progestogen component. In a further alternative embodiment, the estetrol serves as the primary estrogen component of the combined oral contraceptive, and drospirenone serves as the primary progestogen component. Therefore, the specifications as described herein do not exclude embodiments in which the amounts of estetrol disclosed herein in the E4 / DRSP COCs described herein are combined with a different estrogen and / or do not exclude embodiments in which the amounts of drospirenone disclosed herein in the E4 / DRSP COCs described herein are combined with a different progestogen or progestin.

[0113] "Bioavailability," which has the commonly accepted abbreviations "BA" and "F" and is intended to have its commonly accepted meaning in the art, refers to an expression, preferably a quantitative expression, of the rate and extent to which a drug may reach the systemic circulation and thus perform its intended function. In other words, bioavailability is a subclassification of absorption and is the proportion of an administered drug that reaches the systemic circulation, typically expressed as a percentage (%). It is generally accepted that bioavailability is considered 100% when administered intravenously, while lower bioavailability is typically obtained when other administration routes are used, primarily due to the first-pass effect or first-pass metabolism and absorption metabolism of the subject (Herman and Santos, First pass effect, StatPearls, 2019). Bioavailability is typically calculated or derived from the area under the curve (AUC) (plasma drug concentration) by comparing extravascular and intravascular formulations. AUC is a good means of assessing the bioavailability of a drug, i.e., in the context of the present invention, a contraceptive, since it is proportional to the amount of drug present in the systemic circulation.

[0114] In certain embodiments, the estetrol composition as described herein is intended for use in reducing the side effects of drospirenone in subjects using a combined oral contraceptive containing drospirenone. In a further embodiment, the estetrol composition is administered orally to the subject. In certain embodiments, the estetrol composition is administered simultaneously with a combined oral contraceptive containing drospirenone. In an alternative embodiment, the estetrol composition as described herein is intended for use in reducing the side effects of drospirenone in subjects using a progestin-containing oral contraceptive, for example, an oral contraceptive that contains a progestin other than drospirenone and lacks an estrogen component. In certain embodiments, a progestin-only oral contraceptive (i.e., "progestin-only pill," a common abbreviation in the art: "POP"). In certain embodiments, the estetrol composition is intended for use in reducing the risk of elevated C-reactive protein (CRP) serum levels associated with the use of a combined oral contraceptive containing drospirenone. In a further embodiment, no elevation in C-reactive protein serum levels is observed in subjects using E4 / DRSP COCs.

[0115] A further aspect of the present invention relates to estetrol used to reduce the steady-state bioavailability of drospirenone in a COC by at least 15% compared to COCs containing ethinylestradiol or estradiol. Thus, E4 / DRSP COCs as described herein are intended to achieve a relatively low steady-state bioavailability of DRSP compared to subjects using COCs containing drospirenone as the progestogen component and an estrogen other than estetrol as the estrogen component. In certain embodiments, the steady-state bioavailability of drospirenone is reduced by at least 20%, preferably at least 25%, at least 30%, at least 35%, at least 40%, at least 45%, or at least 50%. In certain embodiments, the bioavailability of drospirenone is compared to the steady-state bioavailability of a COC containing estetrol and drospirenone, which contains an equivalent amount of drospirenone and ethinyl estradiol in an amount of about 0.015 mg to about 0.05 mg, preferably about 0.02 mg to about 0.03 mg, more preferably about 0.02 mg, about 0.025 mg, or about 0.03 mg. In yet a further embodiment, the equivalent amount of drospirenone is 3 mg. In certain embodiments, the steady-state bioavailability of drospirenone is the total bioavailability.

[0116] Another aspect of the present invention relates to estetrol for use in reducing the peak plasma concentration of drospirenone in subjects using COCs containing drospirenone. In certain embodiments, the drospirenone-containing COCs contain drospirenone in an amount of about 3 mg. In certain embodiments, the drospirenone-containing COCs contain an estrogen component other than estetrol. In further embodiments, the estrogen component is ethinylestradiol or estradiol. In certain embodiments, the peak plasma concentration of drospirenone in subjects using COCs containing about 3 mg of drospirenone is reduced by at least 5%, preferably at least 10%, at least 15%, at least 20%, at least 25%, at least 30%, at least 35%, at least 40%, at least 45%, or at least 50% compared to when estetrol is not used to reduce bioavailability in the subject. In certain embodiments, the peak plasma concentration of drospirenone in a subject using a COC containing about 3 mg of drospirenone is reduced by at least 5%, preferably at least 10%, at least 15%, at least 20%, at least 25%, at least 30%, at least 35%, at least 40%, at least 45%, or at least 50% compared to when estetrol is not used to reduce bioavailability in the subject.

[0117] A further aspect of the present invention relates to the use of estetrol for the manufacture of a composition (i.e., a medicament or contraceptive) for the prevention or treatment of adverse effects resulting from the use of drospirenone in COCs. In a further embodiment, the use of estetrol for the manufacture of a composition (i.e., a medicament or contraceptive) for the prevention or treatment of QT interval prolongation in subjects using drospirenone-containing COCs is contemplated. In a further alternative embodiment, the use of estetrol for the manufacture of a composition (i.e., a medicament or contraceptive) for the prevention or treatment of decreased serum free testosterone levels in subjects using drospirenone-containing COCs is contemplated. In a still further alternative embodiment, the use of estetrol for the manufacture of a composition (i.e., a medicament or contraceptive) for the prevention or treatment of elevated C-reactive protein levels in subjects using drospirenone-containing COCs is contemplated.

[0118] The term "treatment" or "treating" should be construed as both therapeutic treatment of a disease or condition that has already occurred and is resulting in clinical symptoms, such as treatment of established long QT syndrome, sexual dysfunction (e.g., decreased libido), etc., and prophylactic or preventative measures in which the purpose of treatment is to prevent, reduce, or lessen the chance of an unwanted affliction occurring, such as preventing the onset, development, and progression of a clinical condition or disease. Beneficial or desired clinical results can include, but are not limited to, alleviation of one or more symptoms, improvement of one or more biomarkers, attenuation of the extent of disease, stabilization of the disease state (i.e., no progression), delay or slowing of disease progression, remission or palliation of the disease state, etc. "Treatment" can also mean prolonging survival, i.e., reducing the risk of death, as compared to expected survival if not receiving treatment.

[0119] As used herein, the terms "therapeutic treatment" or "therapy" refer to a treatment whose purpose is to change a subject's body or a portion of a subject's body from an undesirable physiological condition, disease, or disorder, such as one or more adverse side effects induced by the use of a COC containing drospirenone, to a desirable condition, such as a less severe condition (e.g., remission or alleviation), or even to its normal health state (e.g., restoring the subject's health, physical integrity, and physical well-being), to maintain (e.g., stabilize) the undesirable physiological condition (i.e., no progression) of the subject's body or a portion of the subject's body, or to delay progression to a more severe or worse condition compared to the undesirable physiological change or disorder. A measurable decrease includes any statistically significant decline in a measurable marker or symptom. Statistically significant, as used herein, refers to a p-value of less than 0.05, which, as those skilled in the art will recognize, is a commonly accepted cutoff score in statistical analysis. "Treatment" encompasses both curative treatment and treatment directed to reducing symptoms and / or slowing progression and / or stabilizing the disease. As one skilled in the art will be aware, in order to achieve effective therapeutic treatment, a therapeutically effective dose must be administered to the subject.

[0120] "Prevention" or "preventing," as used in the context of the present invention, refers to the avoidance of the manifestation of a disease state in a subject, i.e., the establishment of a preventative or prophylactic measure. Prophylactic treatment refers to a treatment aimed at preventing the subject's body or its components from exhibiting undesirable physiological changes or clinical symptoms of a disorder. As will be appreciated by those skilled in the art, a prophylactically effective dose must be administered to the subject in order to achieve effective therapeutic treatment. In the context of the present invention, E4 / DRSP COCs may be administered to a subject to prevent the manifestation of a medical condition, disease, or (adverse) side effect that would or is likely to occur in the subject if the subject were to use a COC containing drospirenone and an estrogen other than estetrol as the progestogen component.

[0121] The term "therapeutically effective dose" or "therapeutically effective amount," as used herein, refers to an amount of a therapeutic protein or peptide as taught herein that, when administered, results in a positive therapeutic response for the treatment of a subject suffering from a disease, such as a patient selected (e.g., diagnosed) as having a particular disease. The term "prophylactically effective dose" or "prophylactically effective amount" refers to an amount of a gene product that will inhibit or delay the onset of a disorder in a subject, as determined by a researcher, veterinarian, medical doctor, or other clinician.

[0122] While the present invention has been described in conjunction with specific embodiments thereof, it is evident that many alternatives, modifications, and variations will be apparent to those skilled in the art in light of the foregoing description. Accordingly, it is intended to embrace all such alternatives, modifications, and variations within the spirit and broad scope of the appended claims. Aspects and embodiments of the present invention disclosed herein are further supported by the following non-limiting examples. [Example]

[0123] Example 1. Comparison of pharmacokinetic profiles among oral contraceptives containing DRSP (3 mg), EE / DRSP (0.02 mg / 3 mg), E4 / DRSP (15 mg / 3 mg), and DRSP (4 mg) A clinical study was conducted to evaluate the different pharmacokinetic profiles of different COCs after multiple dose testing. The pharmacokinetic parameters after single (Table 2) or repeated (Table 3) oral administration of DRSP alone or different COCs are shown below. From the single-dose results, the E4 / DRSP combination showed similar C values ​​when compared with ethinylestradiol-containing COCs (EE / DRSP COCs). max While achieving a lower DRSP AUC value (AUC 0-24 :224 ng·h / mL vs. 268 ng·h / mL~288 ng·h / mL;AUC infIt can be inferred that the AUC values ​​of 358 ng⋅h / ml and 444 ng⋅h / ml were significantly higher than those of 458 ng⋅h / ml. Furthermore, a more significant difference was observed between the multiple-dose administration schemes E4 / DRSP and EE / DRSP (AUC 0-24 The AUC values ​​were sufficient to achieve contraceptive efficacy, but the relatively lower AUC compared to EE / DRSP COCs may contribute to improvements in observed (adverse) side effects (discussed further in Examples 2 and 3).

[0124] Table 2. Pharmacokinetic parameters after single oral administration of DRSP alone or in combination with estrogen (EE and E4). AUC: area under the plasma concentration versus time curve, AUC 0-24 : AUC from time 0 to 24 hours after administration, AUC 0-inf : AUC from time 0 to infinity, C max : Maximum plasma concentration, geometric mean (coefficient of variation [CV]%), DRSP: drospirenone, E4: estetrol, EE: ethinylestradiol, ND: No data. For comparison purposes, this table reports data from Caucasian subjects only. *Blode et al., Pharmacokinetics of drospirenone and ethinylestradiol in Caucasian and Japanese women, Eur J Contracept Reprod Health Care, 2012, Table 2, Study 1 / 3. **MIT-Es0001-C103 / C101 / C109 / C110: Clinical trials conducted by the inventors.

[0125] [Table 2]

[0126] Table 3. Pharmacokinetic parameters after repeated oral administration of DRSP alone or in combination with estrogen (EE and E4). AUC = area under the plasma concentration versus time curve, AUC0-24 = AUC from time 0 to 24 hours after dosing, AUC 0-inf = AUC from time 0 to infinity, C max = maximum plasma concentration, GM CV = coefficient of variation of the geometric mean, DRSP = drospirenone, E4 = estetrol, EE = ethinyl estradiol, GM = geometric mean, ND = not available. For comparison with data obtained by investigators, only data from Caucasian subjects are reported in this table. *Richter et al., Comparative pharmacokinetic estimates of drospirenone alone and in combination with ethinyl estradiol after single and repeated oral administration in healthy women, Contraception, 2020) **Blode et al., Pharmacokinetics of drospirenone and ethinylestradiol in Caucasian and Japanese women, Eur J Contracept Reprod Health Care, 2012, Table 2, study 3. ***Wiesinger et al., Pharmacokinetic interaction between the CYP3A4 inhibitor ketoconazole and the hormone drospirenone in combination with ethinylestradiol or estradiol, Br J Clin Pharmacol, 2015, Table 4. **MIT-Es0001-C103 / 106: Clinical trials conducted by the present inventors.

[0127] [Table 3]

[0128] Example 2. Comparative bioavailability study between a combined oral contraceptive (COC) containing 15 mg estetrol (E4) and 3 mg drospirenone (DRSP) and a COC containing 0.02 mg ethinylestradiol (EE) and 3 mg DRSP (single dose study) 2.1. Study Concept and Objectives An open-label, single-dose, randomized, two-period, two-treatment, two-way crossover, comparative bioavailability study in healthy female volunteers between a combined oral contraceptive (COC) containing estetrol (E4) 15 mg and drospirenone (DRSP) 3 mg (i.e., Treatment A) and a COC containing ethinyl estradiol (EE) 0.02 mg and DRSP 3 mg (Yaz™ or Yasmin™, i.e., Treatment B).

[0129] The primary objective of this study was to compare the rate and extent of DRSP absorption after single oral doses of a 15 / 3 mg E4 / DRSP combination (test product) and a 0.02 / 3 mg ethinyl estradiol (EE) / DRSP combination (reference product) administered under fasting conditions. A secondary objective of this study was to evaluate the overall stability of single oral doses of the 15 / 3 mg E4 / DRSP combination and the 0.02 / 3 mg EE / DRSP combination in healthy female volunteers. Subjects were selected from a volunteer panel recruited by Quotient Sciences, and study participants were screened up to 28 days prior to dosing. For details of inclusion and exclusion criteria, please refer to the publicly available clinical trial report under study number MIT-Es001-C112 (QSC203723).

[0130] A two-period, two-way crossover design was optimal for comparing the PK of two different treatments because it allowed for within-subject comparisons and reduced the influence of potential timing effects. This study design was in line with the U.S. Food and Drug Administration (FDA) recommendations for conducting bioavailability studies (US Department of Health and Human Services Food and Drug Administration Center for Drug Evaluation and Research, Guidance for Industry; Bioavailability and Bioequivalence Studies Submitted in NDAs or INDs - General Considerations, March 2014). Subjects were allowed to withdraw consent at any time for any reason. Subjects could be discontinued by the investigator if they experienced adverse effects that resulted in an unacceptable risk / benefit ratio, poor compliance, or protocol violations. In this PK study, subjects could also be discontinued if blood sampling was difficult.

[0131] Subjects received their first treatment (Treatment A or Treatment B, depending on randomization) on Day 1 of Period 1. After a period of at least 14 days (washout), subjects received their second treatment (Treatment B or Treatment A) on Day 1 of Period 2. After each dose, subjects had blood drawn for PK measurements periodically for up to 5 days.

[0132] It is emphasized herein that the study described in this section (Section 2) is a single-dose study. Clearly, certain parameters will yield more statistically relevant results in a multiple-dose study, as outlined in Section 3. Nevertheless, certain trends achieved herein, such as reduced DRSP AUC values, are already evident even after analysis of the pharmacokinetic profile of single-dose administration. Therefore, the results of Example 2 do not affect the validity of the multiple-dose studies described in Examples 1, 3, and 4.

[0133] 2.2. Pharmacokinetic measurements 2.2.1. Sample Collection - DRSP Bioanalysis Venous blood samples were collected into 4.0 mL sodium heparin tubes. The tubes were gently inverted 8 to 10 times to mix with the anticoagulant. Immediately after mixing, the tubes were placed in an ice bath and centrifuged at 1500 g for 10 minutes at <4°C. This occurred within 60 minutes of collection. Immediately after centrifugation, aliquots of the separated plasma were transferred to cryotubes for storage. For Treatment A, three plasma samples, each containing approximately 0.5 mL, were prepared. For Treatment B, two plasma samples were prepared, one containing approximately 0.5 mL and the other approximately 1.0 mL. The tubes were immediately capped and stored upright in a freezer at -20°C (±5°C) until shipment. The time from sample collection to shipment was within 90 minutes.

[0134] 2.2.2.Analysis method The exact time of blood collection was recorded in a source workbook, and the actual collection time was used for PK analysis. DRSP determination in plasma was performed using a validated liquid chromatography-tandem mass spectrometry (LC-MS / MS) method in accordance with the GLP requirements applicable to this type of study, as identified in the Organization for Economic Co-operation and Development (OECD) principles on Good Laboratory Practice (ENV / MC / CHEM(98)17. 1998.).

[0135] 2.3. Pharmacokinetic Results and Statistical Evaluation The results of the statistical analysis are shown in Table 4.

[0136] Table 4. Statistical evaluation of pharmacokinetic values. Geometric mean (geometric CV%) plasma pharmacokinetic parameters of DRSP after single oral administration of DRSP in combination with E4 (E4 / DRSP 15 / 3 mg test formulation) and EE (EE / DRSP 0.02 / 3 mg [Yaz™] reference formulation) to healthy female subjects. Tlag: time to first measurable concentration. T max : Time to reach maximum observed concentration. Tlast: Time to last measurable concentration. C max : Maximum observed concentration. AUC 0-24 : AUC from time 0 to 24 hours after administration. AUC 0-tlast : AUC from time 0 to the last time of measurable concentration. AUC 0-inf : AUC extrapolated from time 0 to infinity.

[0137] [Table 4] Table 4: Statistical evaluation of pharmacokinetic values

[0138] For statistical evaluation of pharmacokinetic values, the relative bioavailability (Frel) can be calculated from Table 4.1 according to formula (III): [ka] Formula (III) Frel={(AUC or C max (Test)) / (AUC or C max (Standard)}×100

[0139] Table 5. Evaluation of relative bioavailability: PK analysis settings. Plasma pharmacokinetic parameters of DRSP after a single oral dose of DRSP in combination with E4 (E4 / DRSP 15 / 3 mg test formulation) and EE (EE / DRSP 0.02 / 3 mg [Yaz™] reference formulation) to healthy female subjects. (1) Adjusted geometric mean = geometric mean corrected from the model, (2) Ratio of adjusted geometric means is the comparison expressed as test / standard, (3) CI = confidence interval of the ratio of adjusted geometric means, (4) p-value is two-sided (null hypothesis of no difference), (5) CVw = within-subject variability.

[0140] [Table 5] Table 5. Evaluation of relative bioavailability: PK analysis settings

[0141] The results showed that the mean combined exposure level of DRSP for the 15 / 3 mg test formulation of E4 / DRSP was ≥ 100% AUC 0-tlast The AUC was 92.11% of the EE / DRSP 0.02 / 3 mg (Yaz™) reference formulation. The lower and upper limits of the 90% CI indicate that the true measure of relative bioavailability cannot be less than 88.68% or greater than 95.68%. 0-tlast The difference between treatments in was statistically significant (p = 0.001). The period effect (i.e., slightly higher exposure levels in Period 2 compared to Period 1) was statistically significant at the 10% level (p = 0.037), but the order effect was not statistically significant (p = 0.46). There was no evidence of any carryover effect from Period 1 to Period 2; i.e., all predose concentrations in Period 2 could not be quantified.

[0142] AUC 0-inf Regarding AUC 0-tlast A similar pattern of results was obtained, i.e., the mean combined DRSP exposure level for the E4 / DRSP 15 / 3 mg test formulation was greater than AUC 0-infThe AUC was 91.65% of the 0.02 / 3 mg (Yaz™) reference formulation of EE / DRSP. The lower and upper limits of the 90% CI indicate that the true measure of relative bioavailability cannot be less than 87.89% or greater than 95.56%. 0-inf The difference between treatments in was statistically significant (p = 0.002). The period effect (i.e., slightly higher exposure levels in period 2 compared to period 1) was statistically significant at the 10% level (p = 0.010), but the order effect was not statistically significant (p = 0.40).

[0143] 2.4. Pharmacokinetic and statistical considerations Following a single oral dose of DRSP in the 0.02 / 3 mg (Yaz™) standard formulation of EE / DRSP, DRSP was rapidly absorbed and max The median was 1.50 hours. The geometric mean terminal time of DRSP was 1 / 2 The mean mean time to presentation was 37.73 hours, consistent with previous observations (Estetra SPRL. Clinical Study Protocol: An open-label, single-dose, randomized, two-period, two-treatment, two-way crossover, comparative bioavailability study between a combined oral contraceptive (COC) containing estetrol (E4) 15 mg and drospirenone (DRSP) 3 mg and a COC containing ethinylestradiol (EE) 0.02 mg and DRSP 3 mg (Yaz®) in healthy female volunteers. Version 1.1. 18 December 2019).

[0144] Administration of the E4 / DRSP 15 / 3 mg test formulation showed no change in DRSP absorption compared to the EE / DRSP 0.02 / 3 mg (Yaz™) reference formulation.max The median was 2.00 hours. DRSP elimination was unchanged in the 15 / 3 mg test formulation of E4 / DRSP, with a geometric mean terminal t 1 / 2 was 38.20 hours.

[0145] Variability in exposure was similar between treatments, with geometric mean CV% across both treatments being C max The ranges were 22.4% to 25.0% for β and 20.5% to 28.0% for AUC.

[0146] The peak plasma exposure to DRSP after administration of the 15 / 3 mg test formulation of E4 / DRSP was C max Based on the data, which is equivalent to the 0.02 / 3 mg (Yaz™) reference formulation of EE / DRSP, the resulting relative bioavailability (90% CI) was 97.26% (88.63%, 106.72%), confirming that there was no statistically significant difference.

[0147] AUC after administration of the 15 / 3 mg test formulation of E4 / DRSP 0-tlast and AUC 0-inf The overall exposure based on the EE / DRSP 0.02 / 3 mg (Yaz™) reference formulation was lower than that of the EE / DRSP 0.02 / 3 mg (Yaz™) reference formulation, and the difference in values ​​was statistically significant, with ratios (90% CI) of 92.11% (88.68%, 95.68%) and 91.65% (87.89%, 95.56%), respectively. Of note, the within-subject variability associated with the results of formal statistical analysis was very low, resulting in relatively small differences between treatments and time being deemed statistically significant. Time effects were not considered to affect the overall interpretation of the results or conclusions.

[0148] Example 3. Comparative bioavailability study between a combined oral contraceptive (COC) containing estetrol (E4) 15 mg and drospirenone (DRSP) 3 mg and a COC containing ethinylestradiol (EE) 0.03 mg and DRSP 3 mg (single-dose and multiple-dose study). 3.1. Study Concept and Objectives An open-label, single- and multiple-dose, randomized, two-period, two-treatment, two-way crossover, comparative bioavailability study between a combined oral contraceptive (COC) containing estetrol monohydrate (E4) 15 mg and drospirenone (DRSP) 3 mg and a COC (Yasmin™) containing ethinyl estradiol (EE) 0.03 mg and DRSP 3 mg in healthy female volunteers.

[0149] The primary objective of this study is to compare the rate and extent of DRSP absorption after single and 14-day multiple dosing of the E4 / DRSP 15 / 3 mg combination (test product) and the EE / DRSP 0.03 / 3 mg combination (reference product) under fasting conditions. In the case of multiple doses, only the final dose (before pharmacokinetic [PK] measurements) will be administered under fasting conditions. A secondary objective of this study is to evaluate the overall stability of the E4 / DRSP 15 / 3 mg combination and the EE / DRSP 0.03 / 3 mg combination after single and 14-day multiple dosing in healthy female volunteers.

[0150] The study consists of a screening period of up to 28 days, two treatment periods of 24 days each, and a follow-up visit on the last day of Treatment Period 2. Subjects will receive two treatments: E4 / DRSP 15 / 3 mg (Treatment A) and EE / DRSP 0.03 / 3 mg (Treatment B). Treatments will be administered sequentially, starting with A (AB) or B (BA). Subjects will be randomized to receive treatment sequence AB or BA on the morning of Day 1 of Period 1. Subjects will receive one single oral dose of either Treatment A or Treatment B on Day 1 of Treatment Period 1, then receive the same treatment for 14 days from Days 6 to 19 after four treatment-free days (Days 2-5). After a washout period of at least 14 days, subjects will receive one single oral dose of the other treatment (Treatment B or Treatment A) on Day 1 of Treatment Period 2, followed by 4 treatment-free days (Days 2-5) followed by 14 days of the same treatment from Days 6 to 19.

[0151] Half of the subjects are randomized to receive the sequence AB (treatment A followed by treatment B) and half are randomized to receive the sequence BA (treatment B followed by treatment A).

[0152] Both test formulations (shown above) will be administered orally: Single dose: after an overnight fast of at least 10 hours. Multiple doses: once daily for 14 days at the same time of day, with the final dose to be taken after an overnight fast of at least 10 hours.

[0153] 3.2. Study endpoints (pharmacokinetics) 3.2.1. Primary PK endpoint The following non-compartmental PK parameters are calculated for DRSP after treatment with E4 / DRSP 15 / 3 mg and after treatment with EE / DRSP 0.03 / 3 mg:

[0154] Single dose maximum plasma concentration (Cmax), The area under the plasma concentration versus time curve (AUC) was measured from time 0 to the last observation of a quantifiable concentration (AUC 0-tlast ), AUC from time 0 to infinity (AUC 0-inf ).

[0155] Multiple doses (after the last dose) C max , AUC was calculated from time point 0 to 24 hours (AUC 0-24 ).

[0156] 3.2.2. Secondary PK endpoints The following non-compartmental PK parameters are calculated for DRSP after treatment with E4 / DRSP 15 / 3 mg and after treatment with EE / DRSP 0.03 / 3 mg:

[0157] Single and multiple doses (after the last dose) C max Time to reach (t max ), Apparent terminal elimination half-life (t 1 / 2 ), AUC extrapolated from the last measurable plasma concentration to infinity, AUC 0-inf as a percentage of (AUC%ext), Apparent terminal phase elimination rate constant (λz), apparent total body clearance (CL / F), Apparent volume of distribution (Vz / F).

[0158] Single dose AUC after single dose administration 0-24 .

[0159] Multiple doses (after the last dose) AUC 0-tlast , AUC 0-inf , Average concentration at steady state (Cav), the minimum concentration over the final dosing interval at steady state (Cmin); Peak to trough variation at steady state (PTF%).

[0160] In addition, the accumulation ratio (RAUC) was calculated as (AUC 0-24 ) is computed as the steady-state to single dose ratio.

[0161] 3.2.3. Safety endpoints: Safety will be assessed by monitoring treatment-emergent adverse events (TEAEs), physical examination, vital signs, clinical laboratory tests, and electrocardiogram (ECG) results.

[0162] A 12-lead ECG will be recorded at screening, on days 19 and 21 of treatment period 1, and on days -1, 19, and 21 of treatment period 2. A 12-lead ECG will also be recorded at the time of ET if it occurs by or on day 20. Measurements will be taken after a rest period of at least 10 minutes (supine position). ECG recordings will include rhythm, ventricular rate, PR, QRS, QT, and QTcF intervals.

[0163] 3.2.4. PD endpoints: PD efficacy will be assessed by measuring plasma aldosterone concentrations, plasma renin (direct renin concentration [DRC] and plasma renin activity [PRA]), angiotensinogen, angiotensin I and II, free testosterone, and CRP (raw concentrations and changes from baseline) at baseline and after the final 14-day MD administration. PD assessments will include assessment of aldosterone, plasma renin (DRC and PRA), angiotensinogen, angiotensin I and II, free testosterone, and CRP. Blood samples for PD assessment will be collected pre-dose on days -1 and 19 of each treatment period.

[0164] 3.3.Statistical methods Continuous variables will be summarized using the following descriptive statistics: arithmetic mean, standard deviation (SD), minimum, median, maximum, coefficient of variation (CV%), and number of subjects. Geometric mean and CV% of geometric mean will also be calculated for DRSP plasma concentrations and t max Calculate PK parameters other than

[0165] Frequency distributions of all categorical variables will be expressed using counts and percentages. Data tables, descriptive statistics, statistical analyses, summary tables, and graphs for this study will be generated using SAS™ software.

[0166] DRSP concentrations will be summarized by treatment and time point using descriptive statistics. Pharmacokinetic (PK) parameters based on DRSP concentrations will be summarized by treatment. Graphical displays of individual and mean DRSP concentration data will also be provided.

[0167] To compare the bioavailability of DRSP between E4 / DRSP and EE / DRSP, natural log-transformed parameters are evaluated using analysis of variance (ANOVA). This model is based on the C max , AUC 0-tlast , and AUC 0-inf C after the final multiple dose on day 19 max and AUC 0-24The model for each PK parameter includes sequence, subject within sequence (random effect), period, and treatment. Mean differences between treatments, along with their associated 90% confidence intervals (CIs), are estimated for the log-transformed values ​​of each parameter. CIs are based on mean estimates corrected using the mean squared error from the ANOVA model. Differences and CIs computed on the log scale are back-transformed to obtain geometric mean tests for test-to-standard ratios and 90% CIs for each parameter on the original scale.

[0168] Example 4. Comparative study of multiple COCs to evaluate the effects on free testosterone and C-reactive protein 4.1. Materials and Methods 4.1.1. Test Plan This was a single-center, randomized, open-label, controlled, three-arm study in healthy women conducted at Dinox BV (Groningen, The Netherlands) from September 2016 to October 2017 (EudraCT 2016-001316-37, Clinicaltrials.gov NCT02957630). The study was approved by an independent ethics committee, and all participants provided written informed consent before participating. The study was conducted in accordance with the Declaration of Helsinki and ICH Good Clinical Practice.

[0169] The study consisted of a pre-treatment cycle (baseline), followed by six 28-day treatment cycles, and five visits: a screening visit, a pre-treatment / randomization visit, two treatment visits (at cycle 3 and cycle 6), and an end-of-study visit.

[0170] 4.1.2. Study population Healthy women aged 18 to 50 years, with a body mass index (BMI) of 18.0 kg / m² to 30.0 kg / m² (inclusive) and a natural menstrual cycle of 35 days or less were eligible for enrollment. Women with contraindications to oral contraceptive use, dyslipoproteinemia, or use of antihyperlipidemic medications were excluded from participation. Use of concomitant medications that interact with hormonal contraceptives and COCs was prohibited for two cycles before treatment initiation and during study treatment.

[0171] 4.1.3. Study Treatment Eligible subjects were stratified by time since previous hormonal contraceptive use (2 or 3 or more cycles without hormonal contraceptive use before starting study treatment) and age (<35 years or >35 years) to ensure equal distribution across treatment groups. Subjects were assigned to one of the following treatments: 15 mg E4 (as the monohydrate, equivalent to 14.2 mg of the anhydrate) combined with 3 mg DRSP (E4 / DRSP), 30 mcg EE combined with 150 mcg LNG (EE / LNG), or 20 mcg EE combined with 3 mg DRSP (EE / DRSP). Subjects took one tablet daily for six consecutive 28-day cycles. E4 / DRSP and EE / DRSP treatments were provided as a 24-day active / 4-day placebo regimen, while EE / LNG was provided as a 21-day active / 7-day placebo regimen. E4 / DRSP was manufactured by Haupt Pharma (Münster, Germany) and supplied by Estetra SPRL (Liege, Belgium). EE / LNG (Melleva™ 150 / 30, Leon Farma, Spain) and EE / DRSP (Yaz™, Bayer Healthcare, Germany) were obtained from local pharmacies. Study treatment began on the first day of menstruation after the pretreatment cycle. Treatment compliance was verified by use of diaries and by checking returned packages.

[0172] 4.1.4. Study Assessments and Outcome Parameters The study included the following outcome parameters: Endocrine function: prolactin, follicle-stimulating hormone (FSH), luteinizing hormone (LH), estradiol (E2), progesterone (P), thyroid-stimulating hormone (TSH), free thyroxine (fT3) / free triiodothyronine (fT4), dihydroepiandrosterone (DHEAS), androstenedione, total testosterone (T), free T, dihydrotestosterone (DHT), total cortisol, and aldosterone. Liver proteins: C-reactive protein (CRP), cortisol-binding globulin (CBG), sex hormone-binding globulin (SHBG), thyroxine-binding globulin (TBG), and angiotensinogen.

[0173] Blood samples for measurement of these parameters were collected between days 18 and 21 at baseline, and during cycles 3 and 6. Plasma, serum, and whole blood samples were transported to a central laboratory (BARC laboratories, Ghent, Belgium) for analysis. Serum samples for E2 assessment were transported to ABL, Assen, The Netherlands. Details of the analytical methods, including reference intervals, are presented in Table 6.

[0174] [Table 6] Table 6. Details of analytical methods used and reference ranges *All measurements were performed in serum except for angiotensinogen, which was measured in plasma.

[0175] 4.1.5.Statistical analysis All randomized subjects who received at least one dose of study drug, underwent at least one post-treatment endocrine assessment, and did not have any major protocol deviations affecting the endocrine assessments were included in the endocrine parameter analysis (per protocol data set). Parameters were summarized using descriptive statistics (n, mean, standard deviation [SD], minimum, median, maximum, and coefficient of variation [CV]); no formal statistical analysis was planned.

[0176] Additional exploratory nonparametric analyses were performed on the absolute changes from baseline in endocrine parameters and liver proteins. Only data from cycle 6 were included in this analysis because this time point is most relevant for assessing the effects of long-term treatment. A signed-rank test was used to examine differences between cycle 6 and baseline. A Kruskal-Wallis test was used to examine treatment differences in the change from baseline at cycle 6. If this analysis indicated a possible difference, pairwise comparisons of treatments were performed using the Dwass-Steel-Critchlow-Fligner procedure. The alpha level was set at 0.05. Only data obtained at baseline and cycle 6 are reported herein.

[0177] 4.2.Results 4.2.1. Study population A total of 101 subjects were randomized, 98 received study treatment, and 88 subjects completed the study (Figure 1). Demographics are summarized in Table 7. There were no apparent group differences at baseline.

[0178] [Table 7] Table 7. Mean demographic data at study entry. BMI: body mass index.

[0179] 4.2.2. Endocrine parameters Androgen parameters measured during the study included androstenedione, dehydroepiandrosterone sulfate, dihydrotestosterone, testosterone, free testosterone, and SHBG. Treatment with E4 / DRSP, EE / LNG, and EE / DRSP was associated with decreased androgen concentrations. Androstenedione levels (from -31.0% of E4 / DRSP to a maximum of -49.0% of EE / DRSP) and free T levels (from -50.0% of E4 / DRSP to a maximum of -71.0% of EE / DRSP) decreased in all treatment groups, but the decrease was greater with EE / DRSP treatment. In parallel, increases in median SHBG concentrations were observed in the E4 / DRSP, EE / LNG, and EE / DRSP-treated groups, respectively, by 55%, 74%, and 251%. Decreases in median dehydroepiandrosterone concentrations (-10.5%, -16.0%, -27.0%) and dihydrotestosterone concentrations (-13.0%, -25.0%, -3.5%) were also observed in the E4 / DRSP, EE / LNG, and EE / DRSP groups. Cortisol levels increased by more than 100% during treatment with EE / LNG (109.0%) and EE / DRSP (107.0%), whereas only a modest increase of 26.0% was observed with E4 / DRSP. Aldosterone levels increased with E4 / DRSP (103.0%) and EE / DRSP (179.5%), whereas a decrease (-40.0%) was observed with EE / LNG.

[0180] In the table, the endocrine parameters listed above that showed statistically significant changes from baseline (p<0.05) are displayed in bold.

[0181] Table 8. Endocrine parameters. Median (min, max) values ​​at baseline and cycle 6 and change from baseline at cycle 6. Bold values ​​represent statistically significant changes from baseline (p<0.05) in additional exploratory analyses. CFB = change from baseline, DHEAS = dihydroepiandrostenedione, DHT = dihydrotestosterone, E2 = estradiol, FSH = follicle-stimulating hormone, free T = free testosterone, fT3 = free triiodothyronine, fT4 = free thyroxine, LH = luteinizing hormone, TSH = thyroid-stimulating hormone. #No statistical analysis was performed on the change from baseline in E2.

[0182] [Table 8]

[0183] Liver proteins CRP levels increased in the EE / DRSP group but not in the E4 / DRSP group (Table 9). In cycle 6, angiotensinogen levels increased by 170.0% and 206.5% in EE / LNG and EE / DRSP, respectively, but the increase was less significant in E4 / DRSP (75.0%). A similar pattern was observed for CBG, which increased by 152.0% and 140.0% in EE / LNG and EE / DRSP, respectively, but only 40.0% in E4 / DRSP. The increase in SHBG was highest in EE / DRSP (251.0%). Treatment with EE / LNG and E4 / DRSP increased SHBG levels by 74.0% and 55.0%, respectively. TBG levels increased by 70.0% in the EE / DRSP group, but smaller changes were observed in the EE / LNG (37.0%) and E4 / DRSP (17.0%) groups. Changes in CRP (0% vs. +30%) were not significantly greater in the E4 / DRSP group than in the EE / DRSP group. Changes in EE / DRSP were significantly greater than those in the E4 / DRSP group for all parameters.

[0184] Table 9. Liver proteins. Median (min, max) values ​​at baseline and cycle 6 and change from baseline at cycle 6. Bold values ​​represent statistically significant changes (p<0.05) in exploratory analyses. CBG = cortisol-binding globulin, CFB = change from baseline, CRP = C-reactive protein, SHBG = sex hormone-binding globulin, TBG = thyroxine-binding globulin.

[0185] [Table 9]

[0186] 4.3. Discussion and Conclusions This study was conducted over six cycles using a 15 mg E4 / 3 mg DRSP combination. The results showed that E4 / DRSP had limited effects on endocrine parameters, such as free testosterone, and liver proteins, such as C-reactive protein. Compared with two standard treatments, second-generation EE-based COCs (EE / LNG) and fourth-generation EE-based COCs (EE / DRSP), the E4 / DRSP combination demonstrated favorable profiles of endocrine and liver parameters. As expected, all treatments demonstrated reduced E2 and progesterone levels, indicating the contraceptive activity of these combinations. Interestingly, compared with EE / LNG and EE / DRSP, treatment with E4 / DRSP resulted in smaller increases in cortisol and aldosterone levels and less suppression of LH and FSH, indicating a lower overall estrogenicity of the E4 / DRSP combination. All three COCs showed increases in liver protein levels, but the magnitude of the responses was significantly greater with EE / LNG and EE / DRSP than with E4 / DRSP for angiotensinogen, CRP, CBG, and TBG. SHBG increased after EE / DRSP treatment, but only limited effects were seen after treatment with EE / LNG and E4 / DRSP. This supports previous findings that E4 has a smaller effect on SHBG and indicates a lower overall estrogenicity of the E4 / DRSP combination (Kluft et al., "Reduced hemostatic effects with drospirenone-based oral contraceptives containing estetrol versus ethinyl estradiol," Contraception, 2017, and Hammond et al., "Estetrol does not bind sex hormone-binding globulin or increase its production by human HepG2 cells," Climacteric, 2008).

[0187] These results confirm previous findings that treatment with E4 / DRSP has limited effects on liver proteins, such as C-reactive protein, and endocrine function. Effects on other endocrine parameters, including suppression of ovarian steroids, were comparable to those of the control drug. Thus, the E4 / DRSP combination has a favorable profile when compared with second-generation (EE / LNG) and fourth-generation (EE / DRSP) EE-containing COCs.

[0188] Example 5. Effect of E4 / DRSP and EE / DRSP COCs on QT Interval QT values ​​were measured at screening and at the end of cycle 3 (day 24 or 27). QT values ​​were corrected according to the Fridericia formula (QTcf) to take into account changes in heart rate. The change in QTcf was calculated as the difference between the QTcf at the end of cycle 3 and the QTcf at screening (positive values ​​indicate an increase in QTcf). Patients were measured either on day 24 or day 27. On day 24, patients were on treatment, but on day 27, treatment had already ended.

[0189] On average, the change at the end of treatment was greater in the reference group compared to the treatment group, as shown in Table 10. These results demonstrate that the E4 / DRSP COC has a smaller tendency to induce QT prolongation when compared to the reference group (EE / DRSP COC users). The results of the QTcF analysis after 24 and 27 days are also shown in Figures 2 and 3. The change in QTcf was numerically higher for the reference group at 27 days, or when all data were considered.

[0190] The change in the reference group at day 27 was above 5 ms, the threshold considered significantly associated with arrhythmia, and this change from baseline was statistically significant.

[0191] Table 10. 12-Lead ECG; Change from Baseline at Cycle 3 - Overall and by Days. N = Number of Subjects. STD = Standard Deviation. [1] Preliminary p-values ​​indicating whether there may be a difference between Cycle 3 and baseline for each treatment using a signed-rank test.

[0192] [Table 10]

[0193] The contraceptive efficacy of the treatment was evaluated by assessing ovarian function inhibition. As shown by the distribution of Hoogland scores in Table 11, most subjects had a Hoogland score of 1 (no activity). No Hoogland scores greater than 4, and thus no ovulation, were observed in the E4 / DRSP 15 / 3 mg group. One subject receiving EE / DRSP had a score of 6 (ovulation) in both treatment cycles.

[0194] Table 11. Hoogland score summary. FLS: follicle-like structures. LUF: luteinized unruptured follicles. N: total number of subjects treated. n: number of subjects in each category. (A) Ovulation was reported in one (same) subject in both treatment cycles. (B) A Hoogland score of 4 or less indicates total ovarian function inhibition. (C) In cycle 3, some subjects dropped out and no Hoogland score was obtained.

[0195] [Table 11] Table 11. Hoogland score summary

[0196] As can be inferred from the Hoogland score, the majority of subjects were characterized by a Hoogland score of 1 (no activity). No Hoogland scores >4, and thus no ovulation, were observed in the E4 / DRSP 15 / 3 mg group. Notably, one subject receiving EE / DRSP had a score of 6 (ovulation) in both treatment cycles. E4 / DRSP was able to demonstrate complete ovulation inhibition despite a lower DRSP exposure than seen with EE / DRSP.

[0197] Drawing translation Figure 1 Screened Randomized Treated treatment Started treatment Started treatment Completed treatment Discontinued due to AE not related to bleeding (n=4) and withdrawal consent (n=1) Discontinued due to other reasons (n=5) Discontinued due to withdrawal of consent (n=2) and other reasons (n=1) Figure 2 Changes in QTcF at Cycle 3 - Day 24 Treatment treatment Reference Figure 3 Changes in QTcF at Cycle 3 - Day 27 Treatment treatment Reference

Claims

1. A medicine comprising a combined oral contraceptive (COC) containing drospirenone (DRSP) as a progestogen component in an amount of 1 mg to 5 mg and estetrol as an estrogen component in an amount of 10 mg to 20 mg in a daily active dosage unit, characterized in that it has the following medical use: The pharmaceutical use reduces one or more adverse effects associated with DRSP caused in a subject by use of a COC containing DRSP and an estrogen other than estetrol, wherein the one or more adverse effects are selected from the group consisting of: - Prolongation of the QT interval by at least 5 milliseconds; - A decrease in free testosterone plasma concentrations, and - Increased plasma concentration of C-reactive protein wherein the 10 mg to 20 mg of estetrol serves as the estrogen component of the daily active dosage unit in the COC, and the 1 mg to 5 mg of DRSP serves as the progestogen component of the daily active dosage unit in the COC; The daily active dosage unit provides the following pharmacokinetic profile for DRSP in plasma when administered orally: (i) Geometric mean AUC of drospirenone 0-24 is between 150 and 1000 ng·h / ml; and / or (ii) Geometric mean C of drospirenone max is 10 ng / ml to 100 ng / ml, Medicine.

2. 2. The method of claim 1, wherein the subject is continuously using the COC in cycles of 21 to 28 active dosage units per day of the COC.

3. 3. The method of claim 1, wherein the one or more adverse effects of DRSP are reduced compared to a subject using a COC containing an equally effective amount of DRSP and another estrogen.

4. The pharmaceutical composition according to claim 3, wherein the COC containing equieffective amounts of DRSP and another estrogen is a COC containing equieffective amounts of DRSP and ethinyl-estradiol (EE).

5. 5. The medicament of claim 1, wherein the one or more adverse effects of DRSP consist of a decrease in free testosterone plasma concentrations associated with use of a COC containing an equieffective amount of DRSP and another estrogen, or an equieffective amount of DRSP and ethinyl-estradiol (EE) in a subject.

6. 6. The medicament according to claim 1, wherein the decrease in free testosterone plasma concentration is reduced by 10%, 15%, or 20% in the subject using the COC compared to a subject using a COC containing an equivalently effective amount of DRSP and another estrogen, or an equivalently effective amount of DRSP and ethinyl-estradiol (EE).

7. 7. The medicament of claim 1, wherein the free testosterone plasma concentration is at least 25%, at least 40%, or at least 50% of a baseline value, the baseline value being the free testosterone plasma concentration in the subject prior to use of a COC containing drospirenone.

8. 8. The method of claim 1, wherein the free testosterone plasma concentration is at least 0.09 ng / dL, or at least 0.20 ng / dL, in the subject when using the COC.

9. 5. The medicament of claim 1, wherein the one or more adverse effects of DRSP comprise a prolongation of the QT interval by at least 5 milliseconds associated with the use of a COC containing drospirenone in a subject, the QT interval being considered to be prolonged by at least 5 milliseconds if the time between the onset of the Q wave and the end of the T wave in the subject's electrocardiogram is prolonged by at least 5 milliseconds compared to the subject's QT interval before using a COC containing drospirenone.

10. 10. The pharmaceutical composition of claim 9, wherein the risk of a QT interval prolongation of at least 5 milliseconds occurring in the subject is reduced by 10%, 25%, 50%, 90%, or 100% in the subject using the COC compared to a subject using a COC containing ethinyl-estradiol (EE) as the estrogen component and an equieffective amount of drospirenone.

11. 11. The pharmaceutical composition of claim 9, wherein the mean QT interval prolongation in subjects using the COC is 20%, 35%, or 50% shorter than in subjects using a COC containing an equieffective amount of DRSP and another estrogen, or an equieffective amount of DRSP and ethinyl-estradiol (EE).

12. The pharmaceutical composition of any one of claims 9 to 11, wherein the COC has a reduced estrogen-related effect on the QT interval when compared to a subject using a COC containing an equivalent effective amount of DRSP and another estrogen, or a COC containing an equivalent effective amount of DRSP and ethinyl-estradiol (EE).

13. The method of any one of claims 1 to 4, wherein the one or more adverse effects of DRSP consist of an increase in C-reactive protein plasma levels associated with the use of COCs containing drospirenone in a subject.

14. 14. The medicament of claim 13, wherein the C-reactive protein plasma concentration is considered elevated if it is 10%, 20%, or 30% higher than the baseline value, the baseline value being the C-reactive protein plasma concentration in the subject before use of a COC containing drospirenone.

15. 15. The medicament of claim 13 or 14, wherein the C-reactive protein plasma concentration level is less than 2.00 mg / L, less than 1.75 mg / L, or less than 1.50 mg / L in the subject when using a COC containing drospirenone.

16. The method of any one of claims 1 to 15, wherein the COC is administered in a periodic cycle, the cycle including a 7-day administration-free period or a 4-day administration-free period.

17. 17. The method according to claim 1, wherein a single dosage unit of the COC contains 3 mg of drospirenone and 15 mg of the estetrol component.

Images