HK1058622B - Pharmaceutical form of administration for peptides, method for its production and use - Google Patents

Description

Pharmaceutical dosage forms for administration of peptides, method for the production and use thereof

The present invention relates to novel pharmaceutical formulations for the parenteral administration of aggregation-prone peptides, in particular LHRH analogues or LHRH agonists and antagonists, as well as to processes for their preparation and use.

It is known from EP 0299402 to use pharmaceutically active decapeptides such as SB-030, SB-075 (cetrorelix) and SB-088 in the form of their pharmaceutically acceptable non-toxic acid addition salts, such as the hydrochloride, hydrobromide, sulphate, phosphate, fumarate, gluconate, tannate, maleate, acetate, citrate, benzoate, succinate, alginate, pamoates, ascorbate and tartrate salts and the like.

Lyophilized peptide and protein formulations containing gluconate as stabilizer are further known from JP 06321800-a. In one embodiment, the solution contains 2.5% magnesium gluconate, in particular vasopressin, LHRH and insulin are described as active compounds.

From the literature, in particular from Powell, M.F., Pharmaceutical Research, 1258-1263(8) 1991; date M.int.J.peptide Protein Res.344-349(36)1990, and Szejtli, J.pharmaceutical technology International 16-22, 1991, learned that oligopeptides, i.e., especially those having terminal acid amide functionality, have a tendency to form gels.

EP 0611572 describes a process for the preparation of a lyophilisate of peptides having 3-15 amino acids, in which 100-10,000 parts by weight of the peptide are dissolved in acetic acid and treated with a leavening agent such as mannitol, and then filtered in order to obtain a sterile lyophilisate of the peptide and avoid gel formation.

DE a 19542873 describes a pharmaceutical dosage form for the administration of complex compositions in the form of microparticles, in which an ABA triblock copolymer is used, the block a of which is a polymer of lactic acid and glycolic acid (glycolic acid) and the B polymer of which is a polyethylene glycol chain carrying a moiety selected from the group consisting of serum proteins, polyamino acids, cyclodextrins, cyclodextrin derivatives, sugars, amino acids, detergents or carboxylic acids and mixtures of these substances. The microparticles described herein should also provide for the continuous release of the polypeptide over a relatively long period of time after entrapping a small or agglutinating-sensitive amount of the polypeptide.

DD 141996 describes a pharmaceutical dosage form formulation of native LHRH which is stable over a relatively long period of time and meets the requirements for parenteral administration of the formulation. The key point here is to improve the storability of these formulations (page 2, lines 19-23). There is no statement regarding the filterability of the solution. In addition, to improve storability, a buffer substance (also acetic acid) is also used in order to bring the pH range to pH 3.5-6.5. The problem of preparing sterile lyophilisates from gel-forming peptide salts is not solved.

In EP 0175506 an aqueous solution of the peptide is treated with 1N acetic acid and then lyophilized in order to obtain the acetate salt of the peptide. The subject of the invention is therefore the synthesis of peptide salts.

However, it was shown that in the case of the known acetates of peptides with an aggregating effect, such as LHRH antagonists, it is indeed possible to prepare sterile solutions for parenteral administration by filtration, in particular at high concentrations, but aggregates can form shortly after dissolution of the lyophilisate and before injection. The aggregates then lead to a concentration-dependent decrease in bioavailability from 0.5mg/ml of peptide.

The above problems are not only encountered with injection solutions which are administered for the purpose of rapid release of the active compound, but also found with injection formulations which exhibit delayed release. Thus, peptides incorporated into matrices that control the release of active compounds exhibit an undesirably low release due to their tendency to aggregate. Thus, here too, the bioavailability is reduced.

Since the administration of pharmaceutically active peptides such as LHRH agonists and antagonists, such as antarex (antarelix) and cetrorelix, is preferred to be parenteral pharmaceutical dosage forms, there is a need for the preparation of stable injectable formulations with acceptable bioavailability, which can be conveniently prepared, sterile filtered and formulated. This applies in particular to injectable formulations in the form of reconstituted lyophilisates of soluble peptide salts and to microparticles, microcapsules or implants. This is even more important in the various fields of use of LHRH antagonists, which are increasingly known. In view of the rapidly growing field of indications for this class of substances, a wider choice of stable peptide solutions for parenteral, in particular subcutaneous, injection is desired.

Pharmaceutical administration forms suitable for parenteral administration have now been developed which contain the aggregation-prone peptides in dissolved or dispersed form, with the difference that the peptides are present in the form of their acetates, gluconates, glucuronates, lactates, citrates, ascorbates, benzoates or phosphates, and these administration forms may additionally contain one of the acids mentioned immediately above as the free acid and, if appropriate, further additives and excipients selected from the group consisting of acids, surface-active substances, polymers, lipids or sugars.

These pharmaceutical administration forms can be present in dissolved or dispersed form in water or in aqueous solvent mixtures.

According to another embodiment of the invention, the pharmaceutical administration form can also be in the form of a physiologically tolerable oil, preferably a medium chain triglyceride (neutral oil, Miglyol)^®) Or in dissolved or dispersed form in castor oil, sesame oil, cottonseed oil, corn oil, peanut oil, olive oil or mixtures of these oils.

The peptides used are LHRH antagonist anti-oviridin, A-75998, ganirelix and Nal-Glu antagonists, but in particular cetrorelix, amadorelix and antagonists according to U.S. Pat. Nos. 5,942,493 and DE 19911771.3.

Acids used in the function of the excipient are gluconic acid, glucuronic acid, galacturonic acid, glucaric acid, citric acid, ascorbic acid and amino acids.

It is therefore possible to inhibit the aggregation of peptides and thus to meet the requirements of preparations with good bioavailability, thus enriching the medical resources and working with effective pharmaceutical techniques.

It has further been surprisingly found that the stability of various cetrorelix salts is greatly improved by the addition of gluconic acid, glucuronic acid, citric acid, lactic acid or ascorbic acid.

The preparation and formulation of sterile-filtered stable preparations according to the invention is thus possible without problems.

Another advantage is the addition of suitable excipients. These excipients may be acids, surface active substances, polymers, lipids or sugars. Examples of acids are gluconic acid, glucuronic acid, galacturonic acid, glucaric acid, lactic acid and citric acid, ascorbic acid and amino acids. The surfactant used may be polyethylene glycol 12- (hydroxy)) Stearate (Solutol)^®) Polyoxyethylene ricinoleate (Cremophor)^®) Polysorbate, poloxamers, phospholipids, lecithin or benzalkonium chloride. Suitable polymers are albumin, polyethylene glycol, cellulose derivatives, starch derivatives or polyvinylpyrrolidone. Examples of sugars are cyclodextrins and cyclodextrin derivatives. A "Chaotropic" substance such as urea may also be used as an additive or excipient.

The field of application of the formulations according to the invention is in particular the prevention and treatment of all sex hormone-dependent conditions and diseases which can be influenced by LHRH analogues, i.e. LHRH agonists and LHRH antagonists.

The following are emphasized here:

benign prostatic hyperplasia, prostate cancer, prematurity, hirsutism, endometrial hyperplasia and its associated symptoms, endometrial cancer, in vitro fertilization (IVF/COS/ART), contraception, premenstrual syndrome (PMS), uterine fibroids, breast cancer, tubal occlusion (PTO), ovarian cancer, uterine cancer. The following substances are particularly preferred as LHRH antagonists for use in the compositions according to the invention:

cetrorelix, astarelix, antiestrodin, a-75998, ganirelix, Nal-Glu antagonists, and LHRH antagonists according to us patent nos. 5,942,493 and DE 19911771.3.

Example 1

Aggregation studies were performed using polarization microscopy on various solutions of cetrorelix salt with or without excipients.

In a polarized light microscope with crossed polarizers, the aggregated peptide solution shows an image very similar to a liquid crystal structure. In contrast, a peptide solution that is not aggregated does not produce such an effect.

Table 1: effect of gluconic acid addition on aggregation Properties of cetrorelix acetate solutions

Cetrorelix acetate concentration, mg/ml	Reconstituting gluconic acid in the medium,%	pH	Days without aggregation
2.5	0	4.7	1
				2.5	0.0071	4.5	2
2.5	0.071	3.7	2
				2.5	0.71	3.1	12

The addition of gluconic acid therefore causes an increase in the stability of the solution of cetrorelix acetate by delaying or preventing aggregation.

Another experiment focused on cetrorelix gluconate with no gluconic acid added or with gluconic acid added. Table 2 summarizes the most important results.

Table 2: aggregation Properties of various solutions prepared from bulk (bulk) cetrorelix gluconate product

Gluconic acid addition:	is provided with		Is not provided with
					Cetrorelix concentration, mg/ml	pH	Days without aggregation	pH	Days without aggregation
					2.5	3.0	＞30
					5	3.6	4	4.8	1
5	3.8	4	4.7	1
7.5	3.4	1	4.7	0
					7.5	3.7	1	4.8	0

Thus, cetrorelix gluconate provides an advantage over acetate. The addition of gluconic acid extends the shelf life of the cetrorelix gluconate solution.

In addition, the effect of its aggregation properties on the stabilization of the solution of glucuronic acid on the solution of cetrorelix acetate and on the stabilization of cetrorelix glucuronate as another salt was tested. Table 3 summarizes the results.

Table 3: cetrorelix without or with glucuronic acid addedAggregation Performance of acetate and cetrorelix glucuroniate solutions at various concentrations

	Glucuronic acid addition:	is provided with		Is not provided with
						Salt form	Cetrorelix concentration, mg/ml	pH	Days without aggregation	pH	Days without aggregation
						Acetic acid salt	2.5	3.0	＞21	4.7	0
						Acetic acid salt	5	3.0	0
						Glucuronate salt	2.5	2.9	＞30	4.5	3
						Glucuronate salt	5	2.7	＞30	4.6	0

A significant improvement in aggregation stability for cetrorelix solutions can also be obtained by replacing the acetate with a glucuronide salt similar to gluconate. The aggregation stability of these solutions can be even further improved by adding glucuronic acid to the cetrorelix glucuronide salt solution.

Table 4: aggregation free period of cetrorelix acetate solution expressed in days after addition of 10% alpha-cyclodextrin, 20% hydroxypropyl-beta-cyclodextrin or 20% gamma-cyclodextrin

Cetrorelix concentration, mg/ml	Alpha-cyclodextrin	Hydroxypropyl-beta-cyclodextrin	Gamma-cyclodextrin
				2.5	7	24	98+(168，182，189)
5	0	7	31+(140，147，182)
				7.5	0	10	5+(20，20，20)
10	0	2	2+(4，4，4)
				15		0	0

The aggregation stability of the cetrorelix acetate solution can be significantly improved by adding hydroxypropyl-beta-cyclodextrin, in particular gamma-cyclodextrin.

Table 5: aggregation free period of 2.5mg/ml cetrorelix gluconate solution expressed in days after addition of alpha-cyclodextrin, hydroxypropyl-beta-cyclodextrin or gamma-cyclodextrin

Cyclodextrin type	Cyclodextrin concentration,%	Days without aggregation
			Gamma-cyclodextrin	20	182
	6.8	126
			Hydroxypropyl-beta-cyclodextrin	206.8	18991
Alpha-cyclodextrin	10	140
				5	1

The aggregation stability of the cetrorelix gluconate solution may also be significantly improved by the addition of hydroxypropyl-beta-cyclodextrin or gamma-cyclodextrin.

Table 6: adding polyvinylpyrrolidone (Kollidon)^®12 PF or 17 PF) in days, of the cetrorelix acetate solution

Cetrorelix concentration, mg/ml	Kollidon®Concentration of%	Using Kollidon®12 PF days without aggregation	Using Kollidon®17 days without aggregation of PF
				2.5	0	0	0
	5	1	2
					10	1	2
	15	77	63
					20	84	98
				5	15	0	1
	20	0	1

The aggregation stability of the cetrorelix acetate solution can also be significantly improved by the addition of various types of polyvinylpyrrolidone.

Table 7: evaluation of aggregation Properties of cetrorelix solutions with various excipients added thereto by means of a polarizing microscope and according to visual images (appearance)

Excipient	Concentration of excipients	Cetrorelix concentration	Aggregation (microscopic examination)	Appearance of the product
					Solutol®HS15	5.00％	2.5mg/ml	After 14 days, some time	Clear solution
	10.00％	2.5mg/ml	No aggregation for more than 112 days	Clear solution
						20.00％	2.5mg/ml	No aggregation for more than 112 days	Clear solution
Cremophor®EL	5.00％	2.5mg/ml	After 10 days, the product has	Clear solution
						10.00％	2.5mg/ml	No aggregation for more than 112 days	Clear solution
	20.00％	5mg/ml	After 1 day, the day	Clear and viscous
					L-glutamic acid	0.80％	2.5mg/ml	After 2 days, the product has	Clear solution, pH3.8
Glucaric acid	2.50％	2.5mg/ml	No aggregation for more than 12 days	Clear solution pH2.5
					Glucuronic acid	2.50％	2.5mg/ml	No aggregation for more than 12 days	Clear solution pH2.6

Example 2

The cetrorelix stock was dissolved in 30% strength acetic acid at a concentration of 10mg/ml and diluted with an aqueous solution of the additive to a final concentration of 1mg/ml of peptide in 3% acetic acid. The solution was then sterilized and lyophilized (5 mg per vial).

After reconstitution of these lyophilisates, the solutions (2.5mg/ml cetrorelix) were investigated for their aggregate formation and release properties in the following tests:

polarization microscope (pol. mic.): days without aggregation.

Filtration rate%:

cetrorelix solutions were prepared according to standard methods and filtered through 0.22 micron or 0.45 micron filters using centrifugation. The concentration of cetrorelix in the filtrate was determined by HPLC and expressed as% values based on the starting concentration before filtration (filtration rate%).

In vitro release abbreviation form (RRS, release in green solution):

percentage released after 1 hour and 6 hours%

The in vitro release properties were determined by the flow-through method (flow-through process) using a Green's solution as medium at 37 ℃. Concentration determination was performed by HPLC. A sample of cetrorelix corresponding to 10mg of cetrorelix base was weighed into a flow-through cell, mixed with 4ml of water and stirred for 10 minutes. After 6ml of the Green's solution was added to the sample, the Green's solution was uniformly pumped through the flow cell with stirring at a flow rate of 0.5 ml/min.

Rat animal test: the residual amount of cetrorelix in muscle was administered 168 hours after injection expressed as%.

Table 8a gives the corresponding test results for some preparation batches (batch) of cetrorelix acetate lyophilisate and 2.5mg/ml cetrorelix acetate solution prepared therefrom.

Table 8 a:

batch (5 mg) of cetrorelix lyophilisate.	Mic, days without aggregation	0.22 micron filterable	RRS，[％]1 or 6 hours later		Intramuscular% in rats 168 hours after administration
						Excipient		[％]	1 hour	6 hours	168 hours
Mannitol only (control)	0				About 55
						Solutol®Mannitol	48	100
Cremophor®Mannitol	46	101
						Solutol®Alanine	16	98	17	24
Solutol®Alanine/gluconic acid	19	101	57	68	5.7
						Solutol®Mannitol/gluconic acid	＞45	100	84	88	3.8
Cremophor®Mannitol/gluconic acid	＞45	101
						Solutol®Tryptophan/mannitol	It is impossible to use
Solutol®Tryptophan/gluconic acid	6				9.6
						Cyclodextrin/mannitol molar ratio 1: 10	2	101	16	27	10
Cyclodextrin molar ratio 1: 10/mannitol/gluconic acid	＞45	102	68	74
						Cyclodextrin/mannitol molar ratio of 1: 30	17	100	68	76
Cyclodextrin molar ratio 1: 10/alanine/gluconic acid	5	101	39	52	6.3
						Mannitol/citric acid	1	102	45	53
Solutol®Mannitol/citric acid	＞36	100	84	91	7.4
						Solutol®Alanine/citric acid	1	99	47	54
Solutol®Glycine	＞36	97	24	31
						Solutol®Urea	21	100	32	40
Solutol®Glycine/gluconic acid	＞36	99	82	89
						Solutol®Urea/gluconic acid	＞36	100
Cremophor®Alanine/gluconic acid	(36)
						Cremophor®Urea/gluconic acid	(36)
Pluronic®F127/mannitol	1
						5% Tween®80/mannitol	＞16
Polyethylene glycol 4000/mannitol	1
						Glucan/mannitol	1
Phenyl mercuric acetate/mannitol	2

From the examples mentioned, it is evident that both in vitro (polarising microscopy, filtration rate, in vitro release) and in vivo stabilization can be achieved with a large number of excipients of the respective test substance groups (surface-active substances, acids, amino acids, polymers, sugars, sugar alcohols, cyclodextrins, preservatives), either individually or in mixtures with these excipients. It reduces the aggregation tendency and thus improves the in vitro release of the active compound, which also leads to an increased bioavailability of the peptide active compound in rat experiments and thus to a reduction of residual amounts in the muscle of rats.

Additional in vitro and in vivo data for batches containing various cetrorelix salts without or with stabilizing excipients are listed in table 8b below:

TABLE 8b

Cetrorelix salt (reconstituted with water)	Lyophilized cetrorelix concentration	Mic, days without aggregation	RRS，[％]1 or 6 hours later		Intramuscular% in rats 168 hours after administration
						Excipient	mg/ml		1 hour	6 hours	168 hours
-acetate salt	2.5	0	12	24.5	About 55
						-acetate salt	2.5	0	13	35.9	About 55
-acetate salt	5	0	10	35
						-acetic acid salt reconstituted with gluconic acid	2.5	18	50	63.2	15.2
-acetate + Kollidon®12PF	2.5	84	15	43.4	20.2
						-acetate + Kollidon®12PF	2.5	98	22	50.6
-acetate + benzalkonium chloride	2.5		6.3	30.3
						-acetate + phospholipid	2.5		7.3	23.3
-acetate + gamma-cyclodextrin (1: 10)	2.5		22.6	44.5	10
						-acetate + gamma-cyclodextrin (1: 30)	2.5		28	56.7
-acetate + gamma-cyclodextrin (1: 50)	2.5		35.1	56.6
						-acetate + gamma-cyclodextrin (1: 90)	2.5	＞168	34.5	60.2	3.6
-acetate + gamma-cyclodextrin (1: 90)	5	140	19	47.8
						-acetate + gamma-cyclodextrin (1: 90)	7.5	20
-acetate + gamma-cyclodextrin (1: 90)	10	4			45.2
						-acetic acid salt reconstituted with gluconic acid	15				49.1
-gluconate	2.5		18	45.3
						-gluconate	2.5		11.3	46
Gluconate reconstituted with gluconic acid	2.5		77.5	83.6
						-citric acid salt	15	-	9	20.3
Lactate salt	A large number of		20	55.2
						-Embonate	15		13	43

Example 3

In the rat muscle experiment, the preparations of cetrorelix which have substantially no tendency to aggregate/delayed aggregation (better filtration rate/polarising microscopy) and which show a faster in vitro release in the solution of the geline became prominent because they reduced the residual amount of cetrorelix after 168 hours. Such formulations are expected to have higher bioavailability.

Tables 8a and 8b have listed some results of the rat muscle experiments.

In another rat muscle experiment shown in table 9, the cetrorelix content in plasma was determined in addition to the residual amount in the muscle. Also with the aid of these data, the stabilizing effect of the tested excipients is clear.

Furthermore, it is possible to replace the acetate with other salt forms of cetrorelix to obtain an increase in bioavailability in rat muscle experiments with a concomitant reduction in residual amounts.

TABLE 9

Substance (cetrorelix)	Dosage (mg/kg)	Cetrorelix concentration of injection (mg/ml)	Percentage of cetrorelix content (168 hours) dose in muscle%	Percentage of cetrorelix content dose in plasma%
					Acetate + Solutol®+ alanine + gluconic acid	1.5	2.5	5.7
Acetate + Solutol®+ Tryptophan + gluconic acid	1.5	2.5	9.6
					Acetate + Cyclodextrin 1: 10	1.5	2.5	10.0	83.4
Acetate + cyclodextrin 1: 10, alanine, gluconic acid	1.5	2.5	6.3	81.8
					Acetate + Solutol®+ gluconic acid	1.5	2.5	3.8
Acetate + Solutol®+ citric acid	1.5	2.5	7.4
Acetic acid salt	1.5	3	55.1	92.2
					Miglyol®Acetate salt of (1)	1.5	3	22.3	74.2
Second stepAcid salt + benzalkonium chloride	1.5	3	76.9	39.8
					Acetate + 20% cyclodextrin	1.5	3	3.6	106.2
Acetate + 20% Kollidon®	1.5	3	20.2	88.4
					Acetate + glucuronic acid	1.5	3	23.6	106.1
Acetate + gluconic acid	1.5	3	15.2	95.5
Acetate + 20% cyclodextrin	3.0	10	25.2	60.9
Acetic acid salt	3.0	15	56.5	28.7
					Miglyol®Acetate salt of (1)	3.0	15	24.2	57.2
Acetate + 0.025% benzalkonium chloride	3.0	15	10.5	21.4
					Acetate + glucuronic acid	3.0	15	78.1	43.8
Acetate + gluconic acid	3.0	15	49.1	45.5
Gluconate	1.5	15	37.9	46.9
					Gluconate in mannitol	1.5	3	24.6	58.0
Gluconate in mannitol	1.5	3	25.4	75.2
					Miglyol®Gluconate of (1)	1.5	3	28.8	46.3
Gluconate in gluconic acid	1.5	3	13.2	120.0
					Gluconate in gluconic acid	3.0	3	29.2
Gluconate in gluconic acid	3.0	15	43.5	74.2
Glucuronate salt	1.5	3	16.5	78.6
					Glucuronate salt	3.0	15	18.8
					Lactate salt	3.0	15	33.2	72.1
Lactate salt	1.5	3	30.7	67.1
					Citrate-lyophilizate/aqueous solution	1.5	3	22.8	36.6
Miglyol®Citrate salt of (1)	1.5	3	14.8	53.1
					Alkali	1.5	3	27.2	122.2
Miglyol®Alkali of (1)	1.5	3	38.9	55.9
					Benzoic acid salts in mannitol	1.5	3	34.2	32.7
Miglyol®Benzoic acid salt of (1)	1.5	3	33.1	21.1
					Phosphate salts	1.5	3	32.9	22.6

Claims (10)

1. Pharmaceutical administration form suitable for parenteral administration in the form of an injection comprising a peptide in dissolved or dispersed form of cetrorelix, characterized in that the cetrorelix is present in the form of a salt selected from the group consisting of acetate, gluconate, glucuronate, lactate, citrate, ascorbate, benzoate or phosphate, and in that the administration form additionally contains one of gluconic acid, glucuronic acid, citric acid, lactic acid and ascorbic acid as free acid, and optionally amino acids, surface-active substances, polymers or sugars as further additives and excipients;

the amino acid is selected from L-glutamic acid, alanine, tryptophan and glycine;

the surface active substance is selected from polyethylene glycol 12- (hydroxy) stearate, polyoxyethylene ricinoleate, polysorbate, poloxamer, phospholipid, lecithin and benzalkonium chloride;

the polymer is selected from albumin, polyethylene glycol and polyvinylpyrrolidone;

the saccharide is selected from cyclodextrin, cyclodextrin derivative and mannitol.

2. The pharmaceutical administration form according to claim 1, which is present in dissolved or dispersed form in water or in an aqueous solvent mixture or in a physiologically tolerable oil.

3. The pharmaceutical administration form according to claim 1, which is present in dissolved or dispersed form in a physiologically tolerable oil or a mixture thereof.

4. Pharmaceutical administration form according to claim 2, characterized in that the physiologically tolerable oil is a medium chain triglyceride or is castor oil, sesame oil, cottonseed oil, corn oil, peanut oil or olive oil.

5. Pharmaceutical administration form according to any of claims 1 to 3, characterized in that urea is used as excipient.

6. Pharmaceutical administration form according to claim 1 or 2, characterized in that the acetic acid, gluconic acid, glucuronic acid, lactic acid, citric acid or ascorbate of cetrorelix is present in the solution in a concentration of from above 0.5mg/ml to 15 mg/ml.

7. The pharmaceutical administration form according to claim 1 or 2, said cyclodextrin or cyclodextrin derivative being selected from the group consisting of α -cyclodextrin, hydroxypropyl- β -cyclodextrin and γ -cyclodextrin.

8. Process for the preparation of a pharmaceutical administration form according to claim 1, characterized in that cetrorelix is metathesized with acetic acid, glucuronic acid, gluconic acid, lactic acid, citric acid or ascorbic acid to prepare the corresponding salt, dissolved in water for injection, optionally mixed with excipients as described in claim 1, then sterile filtered, dispersed in injection vials and lyophilized.

9. Use of a pharmaceutical administration form according to any of claims 1 to 7 for the preparation of a medicament for parenteral administration for sex hormone-dependent benign and malignant diseases.

10. Use according to claim 9, wherein the disease is benign prostatic hyperplasia, prostate cancer, prematurity, hirsutism, endometrial hyperplasia and its attendant symptoms, endometrial cancer, in vitro fertilization, contraception, premenstrual syndrome, uterine fibroids, breast cancer, fallopian tube obstruction, ovarian cancer and uterine cancer.