EXHIBIT 1027
`
`EXHIBIT 1027
`
`

`

`eproductive
`1docrinology
`
`Physiology, Pathophysiology, and
`Clinical Management
`
`p ~ & t e
`Euii -~ I Oll
`
`S. C. Yen, M.D., D.Sci.
`':"!~ Professor of Reproductive Medicine
`::.-f California, San Diego
`~biicine
`: ~i~ornja
`
`B. Jaffe, M.D.
`-:: ?rofessor of Reproductive Medicine and Biology
`t.-::;,ro.juctive Endocrinology Cemer
`·,; .1f Obstetrics, Gynecology and Reproductive Sciences
`·:i~ California, San Francisco
`
`:s...J. California
`L. Barbieri, lVJ.D.
`. :.. . .1~d Professor of Obstetrics and Gynecology
`D-<:parrment of Obstetrics, Gynecology and Reproductive Biology
`~ i.\ "omen's Hospital
`f =i :cai School
`::<~-s-;::husetts
`
`Vi/.8. Sl-UJNDERS COMPANY
`A Division of Harcourt Brace & Company
`Philadelphia London Toronto Montreal Sydney Tokyo
`
`Petitioner Exhibit 1027
`Petition for Inter Partes Review of U.S. Patent No. 7,704,984
`Page 1
`
`

`

`W.B. SAUNDERS COMPANY
`A Divisio11 of Harcourt Brace & Compmry
`The Curtis Center
`Independence Square West
`Philadelphia. Pennsylvania 19106
`
`Library of Congress Cataloging-in·Publlcation Data
`
`Reproductive endocrinology: physio'ogy, pathophysiology, and clinical management I
`(edited by) Samuel S.C. Yen, Robert B. Jaffe, Robert L Barbieri.-41h eel.
`
`p.
`
`em.
`
`Includes brbhographical references and index.
`
`ISBN o-7216-6897-6
`
`2. Human reproductiOn-
`1. Generative organs-Diseases-Endocrine aspeclS.
`I. Yen. Samuel S.C.
`3. Endocrine gynecology.
`Endocrine aspecls.
`II. Jaffe, Robert B.
`Ill. Barbieri, Robert L
`(DNLM:
`1. Reproduction-physiology.
`2. Endocrine Glands-
`3 . Endocrine Diseases--physiopathology. WQ 205 R4287
`physiology.
`1998)
`
`RC877.R457 1999
`612.6-<lc21
`DNLMIOLC
`
`97-36836
`
`Cover: Logo
`
`The three-dimensional structure of lGF based on x-ray of rhombohedral 2-Zn
`insulin crystals and proposed confinnation based on model building for IGF.
`(Redrawn from ER Froesch, J Zapf, E Rinderknecht, et al. Cold Spring Harbor
`C01if. Cell Proliferation 6:62. 1979.)
`
`REPRODUCTIVE ENDOCRINOLOGY: Physiology. Pathophysiology. and Clinical Management
`
`ISBN 0-721 6-689i-6
`
`Copyright 10 1999, 1991 . 1986, 1978 by W.B. Saunders Company
`
`All rights reserved. No part of this publication may be reproduced or transmitted in any Corm or by any means, electronic or mech;mjcat. inclcdir.,:
`photocopy, recording, or nny informntion storage and retrieval system. without permis~ion in writing from the publisher.
`
`Printed in the United States of America.
`
`Petitioner Exhibit 1027
`Petition for Inter Partes Review of U.S. Patent No. 7,704,984
`Page 2
`
`

`

`Chapter 251
`
`CHAPTER OUTLINE
`
`I ~·
`
`,IJ !•
`
`\ r:::~ ·;\J tt;,
`Diaphragm
`Cervical Cap
`Male Condom
`Female Condom
`! !{jl:) • ;i) 4- I!V" j
`Phannacology
`Mechanisms of Action
`Metabolic Effects
`Cardiovascu Jar Events
`Heproductive Effects
`Neoplastic Effects
`Contraindications to Usa
`Contraceptive Use
`Drug Interactions
`Noncontraceptivo Health Benefits
`... : U·'.L' v·
`1 j:.
`. ·J:
`Injectable Suspensions
`Subdermal Implants
`
`,
`
`'\.\ •I\\; '''J,!;
`I ' .. ;ltt.• !:>II
`/\,; tl iHNI l .. i V'C ·s
`•I
`Types
`Mechanisms of Action
`Time of Insertion
`Adverse Effects
`Overa II Safety
`
`.. l' •. )1ft i ::-
`
`The effectiveness and incidence of use in the
`United States of the variou:-; types of
`contraceptives currently avai lable are discussed.
`Information about. spermicidal and barrier
`contraception is presented.
`c The effectiveness, m~hunisms or action,
`pharmacodynamics. and endocrioologic effects or
`the various type.'\ or steroid contraceptives
`currently available arc rcviewc<l.
`.. fnformation about Lhc most commonly used
`steroid contmceptivc. the oral combination
`formulations, i~ pn:scnrcd.
`
`676
`
`(: (J f\1 TRACE PT I CJ N
`
`Daniel R. Misheli, 11:
`
`• Progestins given by injection as well as in
`subdermal capsules are described.
`"" For use of these agents, data are summarized
`regarding their adv~rse clinical and metabolic
`effects as well as their neoplastic effects and
`effects on future reproduction after use is
`discontinued.
`Information about the various types of postcoital
`contraceptive agents is presented as well as the
`data involving use of the progesterone receptor
`agonist mifepristone as an oral agent to induce
`abortion in early gestation.
`>.~ The types of intrauterine devices and their
`mechanisms of aclion as well as the adverse
`effects of these contraceptive agents are
`summarized.
`
`Reversible contraception is defined as the tempomry pre(cid:173)
`vention of fertility and includes all the currently available
`contraceptive methods except sterilization. Sterilization
`should be considered a permanent prevention of ft:rtility
`even though both vasectomy and tubal interruption cun
`usually be reversed by a meticulous surgical procedure,
`The reversible methods arc also called active methods:
`sterilization is also caJled a terminal method. 1\ perfect
`method of contraception for all individuals is not cutTCI\lly
`available and probably will never be developed. Each of
`the various methods of contraception currently available
`has certain advantages and disadvantages. 11lercrorc. whc1
`giving advice about contraception, the clinician ~hould
`explain to the couple the advantages and disadvantage~ 111
`each method so that they will be fully informetl and can
`rationally choose the method most suitable for them.
`
`CONTRACEPTIVE USF. IN THE UNITED
`STATES
`In 1995, it was estimated that there were 69.5 million
`women between the ages of 15 and 50 years in the United
`States, and 53 percent of them were married.' or the ncurl\
`70 million women in the reproductive age group in th~
`United States in 1995, slightly more than half used i!
`reversible method of contraception, about one fourth hat
`one member of the couple sterilized by tubal ligmion ()•
`vasectomy, and about one fifth used no method. Among
`the group using no method of contraception, about half ha;l
`
`Petitioner Exhibit 1027
`Petition for Inter Partes Review of U.S. Patent No. 7,704,984
`Page 3
`
`

`

`• TABLE 25-1
`Contraceptive Methods Used by U.S. Women Aged 15 to 50
`Years
`
`Oral contraceptives
`Sterilizmioo
`Tubal ligation
`Va~cctomy
`Conunm
`Withurnwal
`Rhythm
`Diaphmgm
`Sponge
`V.o~ginal suppo~;tory
`Doucha
`Foam
`IUO
`Cream/jelly alone
`Progc$lin implant
`Progestin injection
`Ccrvicnl cap
`Female condom/pouch
`Nn method
`Hysterectomy/menopause
`Pregnant
`Trying to conceive
`
`1995 (%)
`1994 (%)
`\993 (%)
`-·--,..··--·-- -- ----
`25
`26
`24
`24
`27
`26
`15
`15
`15
`12
`10
`13
`19
`19
`19
`6
`5
`6
`3
`3
`3
`2
`2
`2
`2
`I
`I
`2
`I
`I
`I
`I
`I
`I
`I
`I
`I
`I
`I
`I
`*
`,,
`•
`..
`"
`•
`•
`20
`19
`19
`9
`8
`6
`2
`2
`3
`2
`2
`2
`- ----
`·----
`'' l-ess thun I percent.
`From 1995 Onho llinh Control Survey. Rarit.un. NJ. Ortho Pharmaceutical. 1996.
`
`a prior hysterectomy or were pregnant, infertile, or trying
`to conceive. The other half either were not sexually active
`or were having infrequent episodes of coitus or otherwise
`<lid not believe there was a need for contraception. Thus,
`about 56 million women, approximately 80 percent of those
`in lhe reproductive age group in the United States, used
`~ome method of contraception in 1995t (Table 25- 1).
`Of the nonsurgical, reversible methods of contraception,
`oral contraceptives (OCs) ~ere most popular, used by 26
`pcn.:cnt of all women in this age group. OCs were followed
`in freq uency of use by the condom, withdrawal, progestin
`injection, peiiodic abstinence, diaphragm, and spermicides
`alone. The intrauterine device (IUD) and progestin im(cid:173)
`plants, the two most effective methods of reversible contra(cid:173)
`ception, were each used by less than 1 million women.
`Of women who initiated contraception in 1995, about
`one third selected OCs. Of all women currently in the
`reproductive age group in the United States, more than
`three fourths, 77 percent, have taken OCs at some time in
`their life. The average length of time of OC use by an
`individual woman is 5.8 years. Condom use has increased
`in the United States in the pac;t two decades and is the
`third most popular method of contraception used by about
`one fifth of reproductive age women.
`
`CONTRACEPTIVE Ef=FEGTJ VEN ~~SS
`h is difficull to determine the actual effectiveness of a
`contraceptive method because of the many factors that
`aiTet:l contraccptjve failure. The terms method effective(cid:173)
`ness and use effectiveness (or method failure and patient
`failure) were previously used t.o describe conception oc(cid:173)
`curring while the contraceptive method was being used
`
`Chapter 25
`
`CONTRACEPTION
`
`sn
`
`correctly or incorrectly. These have now been replaced by
`the terms typical use and perfect use.
`The perce ntage of failure rates with the first year of use
`for the various methods of contrace ption available in the
`United States is shown in Table 25-2. ln this table is an
`estimate of the percentage of women continuing to usc lhe
`method after I year has elapsed since starting to usc the
`method. 2 The actual use failure rates for durations more
`than I year are available for certain methods of long-acting
`contraceptives. The failure rate f0r 5 years of use of the
`six progestin implants, Norplant, in clinical trials is 1.1
`percent. 3 The cumulative fail ure rate of the copper T380
`IUD was 1.0, 1.4, and 1.6 per 100 women after 3, 5, and
`7 years of use in a large World Health Organization (WHO)
`study." The failure rate of all types of tubal sterilization is
`1.3 1 after 5 years and L85 per 100 women after 10 years,
`being highest for tubal fulguration and lowest for segmental
`resection in the I 0 years after the procedure.s In counseling
`women about long-term failure rates, they should be in-
`
`TABLE 25-2
`Failure Rates of Various Contraceptive Methods
`
`PERCENTAGE OF WOMEN
`EXPERIENCING AN
`ACCIDENTAL PREGNANCY
`WITHIN THE FIRST YEAR
`OF USE
`
`METHOD
`
`Typical Usc
`
`Perfect Use
`
`PERCENTAGE
`OF WOMEN
`CONTINUING
`USE /IT
`t YEAR
`
`85
`21
`20
`
`19
`
`36
`18
`
`36
`18
`18
`
`21
`12
`3
`
`85
`6
`
`9
`3
`2
`I
`4
`
`26
`9
`
`20
`9
`6
`
`5
`3
`
`0.5
`0.1
`
`43
`67
`
`1\5
`58
`
`45
`58
`58
`
`56
`63
`72
`
`Chance
`Spermicide.~
`Periodic abstinence
`Calendar
`Ovulation method
`Symptothermal
`Post ovulation
`Withdrawal
`Cap
`Parou.~ women
`Nulliparous women
`Sponge
`Parous women
`Nulliparous women
`Diaphragm
`Condom
`Female (Reality)
`Mate
`Pill
`Progestin-only
`Combined
`IUD
`1.5
`2.0
`81
`Progesterone T
`78
`0.6
`0.8
`Copper 1'3801\
`81
`0.1
`0.1
`LNg20
`70
`0.3
`0.3
`Dcpo-Prover.J
`85
`0.09
`0.09
`Norptam (six capsules)
`100
`0.4
`0.4
`Female srcrilil'.<ltion
`100
`0.10
`0.15
`Male sterilization
`Emergency contraceptive pills treatment initialed within 72 hours arter
`unprotected intercourse reduces the risk of pregnlll!CY by at least 75%.
`Lactational amonorrhea methods a highly effecti ve, temporary method
`of contraception.
`
`From Comrnccptive Technology update. Monlhty newsletter from Health Proru~·
`sionals, American Health Con~ultants. Don•t n<~gtcct pc,·fcct-use failure rates when
`talking to patients. Contraceptive Technology. Feb. 1996. Vol, 17, No. I. pp 13-24.
`
`Petitioner Exhibit 1027
`Petition for Inter Partes Review of U.S. Patent No. 7,704,984
`Page 4
`
`

`

`678
`
`Part II "' PATHOPHYSIOLOGY
`
`formed about the high incidence of ectopic pre1,'11aucics
`that occur in women who conceive using progestin-only
`_ methods, the IUD, and female sterilization. Ectopic preg(cid:173)
`nancy rates for women conceiving while they are using
`these methods range f.-om about 30 percent with tubal
`sterilization failure, 25 percent with implant failure, and 5
`percent with copper IUD failurc. 5· <•
`
`u~ • rc" i ~
`All spermicidal agent'> contain a surfactant, usually nonox(cid:173)
`ynol 9, that immobilizes or kills sperm on contact 'D1ey
`also provide a mechanical barrier and need to be placed
`into the vagina before each coital act The effectiveness of
`these agents increases with increasing age of the woman
`and is similar to that of the diaphragm in all age and
`income groups. Although a few early swdies linked the
`usc of a spermkide at the lime or conception with an
`increased risk of some congenital malformations, several
`well-pcrl'ormed studies have shown no increased 1isk of
`congenital malformation in the newborns7-v or karyotypic
`abnormalities in the spontaneous abortuscs 10 of women
`who conceived while using spermicides.
`
`FHI~ '1 Tf';' 1N1 1 H ~!:t
`Diaphragm
`A diaphragm must be carefully fttted by the health care
`provider. The largest size that docs not cause discomfort or
`undue pressure on the vaginal epithelium should be used.
`After the fitting, the woman should remove the diaphragm
`and reinsert it herself. She should then be examined to
`make sure the diaphragm is covering the cervix. The dia(cid:173)
`phragm should he used with a spermicide and be left in
`place for at least 8 hour~ after the last coital act If repeated
`intercourse takes place or coitus occurs more than 8 hours
`after insertion of the diaphragm, additional spermicide
`should be used.
`Although it is advisable to usc a spermicide with the
`diaphragm, it may not be necessary because it has not been
`conclusively demonstnlled that pregnancy rates arc lower
`when a spermicide is used with a diaphragm than when
`the diaphragm is used alone. 11 The number or UTinary tract
`infections in women who usc diaphragms is significantly
`higher than in nonusers, probably because of the mechani(cid:173)
`cal obstruction of the outflow of urine by the diaphragm. 12
`Diaphragm users shou ld also be cautioned not to leave the
`device in place for more than 21J- hours, because ulceration
`of the vaginal epithelium may occur with prolonged usage.
`
`Cervical Cap
`The cervical cap, a cup-shaped plastic or rubber device
`that fits around the cervix, has been used as a barrier
`contraceptive for decades, mainly in Britain and other parts
`of Europe.
`There has been a recent resurgence of interest in the usc
`of this older method because the cervical cap can be left
`in place longer than the diaphragm and is more comfort(cid:173)
`able. The various types of caps are manufac£urcd in differ-
`
`ent sizes and should be fitted to the cervix by a clinician_
`The Prcntif cavity-rim cervical cap was approved for gen(cid:173)
`eral use in the United States in 1988. The productlahclin!.!
`stipulates that the cap should be left on the cervix l"or n~>
`more than 48 hours and that a spermicide should alwavs
`be placed inside the cap before useY The cap is maml f'a~­
`tured in four sizes and requires more training than the
`diaphragm, both for the provider to fit it and for the u~cr
`to place it cOITectly. railurc rates with the cervical cap arc
`similar to those observed with the diaphragm. Because of
`concern about a possible adverse effect of the cap on
`cervical tissue, the cervical cap should be used on ly hy
`women with normal cervical cytology, and it is 1\!<.:l>m(cid:173)
`mended that users have another cervical cytologic examina(cid:173)
`tion 3 months after starting to usc this method.
`
`Male Condom
`Use of the male condom by individuals with multiple se:>.
`pattners should be encouraged. The male condom is the
`most effective method of contraception to prevent transmis(cid:173)
`sion of sexually transmitted diseases. The male condom
`should not be applied lightly. The lip should extend beyond
`the end of the penis by aboul 1h. inch to collect the ejacu(cid:173)
`late. Care must be taken on withdrawal not to :;pill the
`ejaculate. When used by strongly motivated couples, the
`male condom is highly effective.
`
`Female Condom
`A female condom was approved for marketing in the
`United States in 1994. It consists of a sofr. loosc-lilling
`sheath and two flexible polyurethane rings. One ring lies
`inside the vagina at the dosed end of the sheath and scrw~
`as an insertion mechanism and internal anchor. The outer
`ring forms the external edge of the device and remain~
`outside the vagina after insertion, thus providing protection
`to the labia and the base of the penis during intcrcour~e­
`The condom is prelubricated and is intended for one-time
`use only. Fitting by a health professional is not required."
`In comparison to the male condom, the female condom
`has the advantage of being able to be inserted hcfnre
`beginning sexual activity and to be left in place for a
`longer time aner ejaculation occurs. 13ecause thl! female
`condom also covers the external genitalia, it shou ld nfJ'cr
`greater protection against the transfer of certl!in scxuall)
`transmitted organisms, particularly genital herpes. Bccau~<:
`polyurethane is stronger than the latex used in male con(cid:173)
`doms. the female condom is less likely to rupture. In a
`multicenter clinical trial, the cumulative pregnancy rate in
`U.S. centers at 6 months was 12.4 percent Thl· 6-month
`pregnancy rate with perfect usc was 2.6 percent, indicming
`that the probable 1-year pregnancy rate with perfect ll \l'
`would be slightly more than 5 pcrcent.15 At the end or n
`months in the U.S. study. about one third ol' the women
`had discontinued use of this method. Because clinical tri;lls
`with use of the female condom have not comp<~rc<.l its u~c
`with other barrier techniques, an exact comparison with
`other contraceptive methods cannot be made. Trussel :tnd
`co lleagues, ' ~ using the data of other studies. COIH.:Iude<.lt hat
`the efficacy rate of the female condom with pcrll.·ct UM::
`would be similar to that of the diaphragm and ccrvi<:;d cap.
`
`Petitioner Exhibit 1027
`Petition for Inter Partes Review of U.S. Patent No. 7,704,984
`Page 5
`
`

`

`but the failure rate of the female condom with typical use
`would be higher than that of the diaphragm. Because of
`the lack of prospective clinical trials with the male condom,
`no statistical comparison of the effectiveness of the two
`types of condoms can be made. No data exist in which the
`effectiveness of the female condom for reducing sexual
`disease transmission is analyzed. Because polyurethane
`docs not allow virus transmission, it should reduce the risk
`or a woman's acquiring human immunodeficiency virus
`infection.
`
`ORAL STEROID CONTRACEPTIVES
`Oral steroid contraceptives (OCs) were initially marketed
`in the United States in 1960. Because contraceptive steroid
`formulations with more than 50 1.1..g of estrogen were asso(cid:173)
`ciated with a greater incidence of adverse effects without
`greater efHcacy, they are no longer marketed for contracep(cid:173)
`tive usc in the United States, Canada, and Great Britain.
`Indications for prescribing formulations with 50 f.Lg of
`estrogen are uncommon. In 1996, only about 2.5 percent
`of all OC prescriptions in the United States were for
`rormulations with 50 1-Lg of estrogen. OC formulations
`currently marketed in the United States, excluding generic
`brands, arc listed in Table 25-3.
`
`Pharmacology
`There are three major types of OC formulations: Hxed-dosc
`combination, combination phasic, and daily progestin. The
`combination formulations are the most widely used and
`most effective. They consist of tablets containing both an
`estrogen and progestin given continuously for 3 weeks. No
`steroids arc given for the next 7 days, after which time the
`active combination is given for- an additional 3 weeks.
`Uterine bleeding usually occurs in the week when no
`steroid is ingested. Without estrogenic stimulation, the en(cid:173)
`I to 3 days after
`dometrium usually begins to slough
`steroid ingestion is stopped. Withdrawal bleeding usually
`lasts 3 to 4 days and uterine blood loss averages about 25
`ml, less than the mean of about 35 ml that occurs during
`menses in a normal ovulatory cycle.
`All currently marketed formulations are made from syn(cid:173)
`thetic steroids and contain no nalllral estrogens or proges(cid:173)
`tins. There are two major types of synthetic progestins:
`derivatives of 19-nortestosteronc and derivatives of 17a(cid:173)
`acctoxyprogcsterone. The latter group are C2 , progestins,
`called pregnancs, and are structurally related to progeste(cid:173)
`rone. Medroxyprogcsterone acetate and megestrol acetate
`arc C2, progestins marketed as tablets for noncontraceptive
`usage. In contrast to the 19-nortestosterone derivatives,
`when high dosages of the c21 progestins were given to
`female beagle dogs (an animal previously used for OC
`toxicology testing), the animals developed an increased
`incidence of mammary cancer. Because of this carcinogenic
`effect, oral contraceptives containing these progcstins are
`no longer marketed despite Lhc fact that the beagle, unlike
`the human, metabolizes C2 1 progcstins to estrogen, which
`then stimulates mammary nodules that can become carcino(cid:173)
`genic in this anjmal.
`T he steroid structure of the 19-nortestosterone progcstins
`more closely resembles testosterone than the C21 acetoxy-
`
`Chapter 25 • CONTRACEPTION
`
`679
`
`f6CaCH
`0~indrone
`
`OH m·C=cH
`0~hynodrel
`~1
`1o CO""'- ~~
`
`0
`
`H,cro
`
`Ethynodlol
`Norethindrone
`Dlacetate
`Acetate
`I iul.rin :Z~i
`' 1'1 Chemical structures of the estrane progestins used
`in oml contraceptives.
`
`progcstins. Therefore, all progestational agents currently
`used in OCs have some degree of androgenic activity. The
`19-nortestosterone progestins used in OCs are of two major
`types, called estranes and gonanes. Although the original
`estrane, norethynodrel, is no longer used in currently mar··
`l<cted OCs, other estrancs, norethindrone and its derivatives
`with one or two acetates, norethindrone acetate and ethy··
`nodiol diacctate, are used in several marketed formulations
`(Fig. 25-1). Gonancs have greater progestational activity
`per unit weight than estrancs do, and thus a smaller amount
`of the gonane type of progestin is used in OC formulations.
`The parent compound of the gonancs is d/-norgcstrel ,
`which consists of two isomers, dcxtro and levo. Only the
`lcvo form is biologically active. Both dl-norgestrcl and its
`active isomer lcvonorgcstrel arc present in several OC
`formulations. Three less androgenic derivatives of lcvo(cid:173)
`norgcstrcl, namely, dcsogcstrel, norgestimate, and gesto(cid:173)
`dene, have also been synthesized (Fig. 25- 2). Formulations
`with each of these three progestins have been marketed in
`Europe for many years, and formulations with desogcstrel
`and norgestimate, but not gestodene, have been marketed
`in the United States since 1992.
`With the exception of two daily progestin-only formula (cid:173)
`tions, the progestins arc combined with varying dosages of
`two estrogens. cthinyl estradiol and ethinyl estradiol 3-
`methyl ether, also known as mestranol (Fig. 25·-3). All. the
`older, higher dosage OC formulations contained mestranol,
`and this steroid is still present in some 50··~-Lg formu lations.
`All formulations with less than 50 j.Lg of estrogen contain
`only the parent compound ethinyl estradiol. In common
`
`011
`-.._ .m- CECI·I
`
`Oli
`
`0~~'""
`~~~
`CXYoo~strol
`
`oUJLov:orgoslrel
`
`OH
`~,Cm-C'<CH
`
`HON
`
`Norgeslunato
`
`! iq11::• :J.;) :' • Chemical structure of the gonane progestins used
`in oral contraceptives.
`
`Petitioner Exhibit 1027
`Petition for Inter Partes Review of U.S. Patent No. 7,704,984
`Page 6
`
`

`

`680
`
`Part II
`
`PATHOPHYSIOLOGY
`
`TABLE 25-3
`Estrogen and Progestin Components of Oral Contraceptives
`
`MANUFACTURER
`
`PRODUCT TYPE
`
`PROGESTIN
`
`ESTROGEN'
`
`Rcrlex
`Levien
`Tri-Lcvlcn 61
`51
`10/
`Bnstol-Mycl" Squibb
`()vcon 35
`Ovcon 50
`Organon
`J)esogcn
`Ortho-MucNcil Pharmaccuticnl
`Micronor
`Mod icon
`Ortho-Ccpt
`Ortho-Cyclcn
`011ho-Novurn 1/35
`Ortho-Novum 1/50
`Ortho-Novum 7/
`71
`7/
`Ortho-Novum 10/
`I 1/
`Onho-Tricychn
`
`J>arkc-Davis
`l!strostcp
`
`Loestrin 1no
`Locstrin 1.5/30
`Norlcstrin 1150
`Norlcstrin 2.5150
`Roche Laboratoncs
`Brcvicon
`Norinyl I I 35
`Norinyl I I 50
`Nor-QD
`Tri-Norinyl 11
`9/
`51
`
`Scurlc
`Dcmulcn J/35
`Dcmulcn 1150
`Wyeth-Aycrst
`AI esse
`Lo/Ovml
`Nordethl
`Ovrnl
`Ovrenc
`Triphasil 61
`51
`10/
`
`tilhinyt c.<tradlol unless 1101ed
`t Mcstr.mol.
`
`Combination
`Combination, triphasic
`
`Combin.1tion
`Combination
`
`Combination
`
`Progestin-only
`Combination
`Combination
`Combination
`Combination
`Combination
`Combination. tripha.~ic
`
`Combination, biphasic
`
`Combination. triphasic
`
`Combination
`
`Combination
`Combination
`Combination
`Combination
`
`Combination
`Combination
`Combination
`Progestin-only
`Combination, triphasic
`
`Combination
`Combination
`
`Combination
`Combination
`Combination
`Combination
`Progestin-only
`Combination, triphasic
`
`0. 15 mg lcvonorgcstrcl
`0.05 mg lcvonorgestrel
`0.075 mg levonorgcstrcl
`0. 125 mg levonorgc.~trel
`
`0.4 mg norethindrone
`1.0 mg norethindrone
`
`0.15 mg dcsogcstrel
`
`0.35 mg norethindrone
`0.5 mg norerhindrone
`0.15 mg clcsogcstrel
`0.25 mg norgcstimate
`1.0 mg norethindrone
`1.0 mg norethindrone
`0.5 mg norethindrone
`0.75 mg norethindrone
`1.0 mg norcrhinclrone
`0.5 mg norethindrone
`1.0 mg norethindrone
`0. 18 mg norgestimatc
`0.215 mg norgestimatc
`0.25 mg norgcstimate
`
`1.0 mg norethindrone acetate
`1.0 mg norethindrone acetate
`1.0 mg norethindrone acetate
`1.0 mg norcthi ndronc acetau:
`1.5 mg norethindrone acetate
`1.0 mg norethindrone acetate
`2.5 mg norethindrone acetate
`
`0.5 mg norethindrone
`1.0 mg norethindrone
`1.0 mg norethindrone
`0.35 mg norethindrone
`0.5 mg norethindrone
`I mg norethindrone
`0.5 mg norethindrone
`
`1.0 mg cthynodiol diacetatc
`1.0 mg ethynodiol diacctatc
`
`311 ll!l
`:l() J.lll
`<\() J.ll\
`JO J.lll
`
`:l5 I.I.J:!
`
`35 IJ.!l
`:lO J.l!!
`:l.'\ Ill!.
`35 J.l!!
`50 J.l!!t
`35 J.lj!
`:15 l' l!
`J5 J.lll
`.15 J.l!.!
`.15 14&
`:15 11!!.
`.l5 J.lj!
`·'5 J.l8
`
`~0 J.lg
`3<1 1'-tt
`35 u
`211 J.lg
`J() J.ll!
`50 J.ll!t
`511 J.lgt
`
`J5 J.lg
`.3.'\ J.lll
`50 J.l!:
`
`J5 J.ll.l
`.l5 ILl!
`J5 IJ.ll
`
`0.1 mg lcvonorgcstrcl
`2!1 11!:
`3.0 mg norethindrone
`:10 11g
`JO 11g
`0. 15 mg norethindrone
`0.5 mg norgcstrel
`50 11l!
`0.075 IL8 norgcstrel
`.Ill J.lJ;
`0.05 J.l& lcvonorgestrcl
`.lll J.ll.l
`-10 !Lg
`0.75 J.l& lcvonorgestrel
`JO 11g
`1.25 J.l& lcvonorgcstrcl
`---------
`.~------------------~~-
`
`usage, formu lations with 50 J.Lg or more of estrogen (ethi(cid:173)
`nyl esLradiol or mestranol) have been termed first-genera(cid:173)
`tion OCs. Those with less than 50 J.Lg of estrogen, 20 to
`35 J.LB of ethinyl estradiol, arc called second-generation
`products if they contain any progestin except the three
`newest lcvonorgcstrel d erivatives. Those fonnul ations with
`dcsogestrcl, norgcstimate, and gestodene are called third(cid:173)
`generation formulations. /\II the synthetic estrogens and
`progestins in OCs have an ethinyl group at position 17. The
`
`presence of this cthinyl group enhances the oral activity nf
`these agents, because their essential functional groups arc
`not as rapidly metabolized as they pass through the intesti·
`nal mucosa and the liver through the portal ~ystem. in
`contrast to what occurs when natural sex steroids are iu(cid:173)
`gested orally. The synthetic steroids thus have greater oral
`potency per unit of weight than the natural steroids. It hu,
`b~en estimated that cthinyl estradiol has about 100 time).
`the potency of an equivalent weight of conjugated cquino.:
`
`Petitioner Exhibit 1027
`Petition for Inter Partes Review of U.S. Patent No. 7,704,984
`Page 7
`
`

`

`Chapter 25
`
`CONTRACEPTION
`
`681
`
`no! than after ingestion of ethinyl estradiol.22 The delay is
`due to the time necessary for mestranol to be demethylated
`to ethinyl estradiol in the liver.
`When different doses of dl-norgcstrcl were administered
`to women, it was found that the serum levels of levonorgcs(cid:173)
`trel were related to the dosage.23 Peal< serum levels were
`found 0.5 to 3 hours after oral administration, followed by
`a rapid, sharp decline (Fig. 25-4). However, 24 hours after
`ingestion, 20 to 25 percent of the peak level of levonorges(cid:173)
`trel was still present in the serum. After 5 days of norgestrel
`administration, measurable amounts of levonorgestrel were
`present for at least the following 5 days.
`Brenner and coworkers24 measured serum levels of levo(cid:173)
`norgestrel, follicle-stimulating hormone (FSH), luteinizing
`hormone (LH), estradiol, and progesterone 3 hours after
`ingestion of a combination OC containing 0.5 mg of d/(cid:173)
`norgcstrel and 50 j.Lg of ethinyl estradiol in three women
`during two consecutive cycles as well as during the in(cid:173)
`tervening pill-free interval. Daily levels of levonorgestrel
`rose during the first few days of ingestion, reached a
`plateau thereafter, and declined after ingestion of the last
`pill (Fig. 25- 5). Ne vertheless, substantial amounts of levo(cid:173)
`norgestrel remained in the serum for at least the first 3 to
`4 days after the last pill was ingested. These steroid levels
`were sufficient to suppress gonadotropin release during the
`J -week interval when no steroid was administered. Thus,
`follicle maturation, as evidenced by rising estradiol levels,
`
`8
`
`t
`
`t
`
`+
`) :·· ..
`
`+ I .. .. ··. : ', . . : ...
`
`0.5 mg norgestrel
`
`·.:
`·.:
`'
`
`'
`
`· .....
`
`· ..
`
`:·. : \.
`i \:
`: · ..
`~·.
`'•i
`:
`.
`·~
`\
`:
`\]
`
`7
`:::r6
`~ .s5
`!4
`7ii e-3
`~2
`1
`
`0
`
`0
`
`2
`
`3
`
`4
`
`5
`
`6
`
`7
`
`8
`
`......
`9
`10
`
`+
`
`+ +
`
`··
`
`:.
`
`0.3 mg norgestrel
`
`:::r5 +
`~4 .S
`
`,: rl, ,_r-··· ... r\.\,1'\ ...
`~:l : + + + +
`
`"'
`
`~ 1
`0
`...J 123456 7
`E
`
`•• •••
`·····-·····--~
`8
`9
`10
`
`0.075 mg norgestrel
`
`t··. t·-. :--.. :
`& 1 A
`
`(5
`'.-.;
`·.;
`.. ~
`zo
`-o 1 2 3 4 5 6
`Days
`r llJ!i!:: ·;~,- 1· • Serum d-norgostrellevels in lhree subjects receiv(cid:173)
`ing 500 f-1.9 of dJ.norgestrel and 50 J.L9 of ethinyl estradiol (Ovral).
`Arrows indicate time of ingestion. (f-rom Brenner PF. Mishell DR
`Jr. Stanczyk FZ, Goebelsmann U. Sorum levels of d-norgestrel.
`luteinizing hormone. follicle-stimulating hormone. estradiol. and pro·
`gesterone in women during and following ingestion of combination
`oral contraceptives containing dJ.norgestrel. 1\rn J Obstot Gynocol
`129:133-140. 1977.)
`
`~...
`
`7
`
`8
`
`9
`
`10
`
`Petitioner Exhibit 1027
`Petition for Inter Partes Review of U.S. Patent No. 7,704,984
`Page 8
`
`1,
`
`OH
`
`Ethlnyteatradlol
`Mestranol
`r.I~UITl t!l ·3 Ill Structures of the two estrogens used in combina(cid:173)
`IIOn oral contraceptives.
`
`estrogen or estrone sulfate for stimulating synthesis of
`various hepatic globulins.
`The various modifications in chemical structure of the
`different synthetic progestins and estrogens also affect their
`biologic activity. Thus, one cannot define the pharmaco(cid:173)
`logic activity of the progestin or estrogen in a particular
`contraceptive steroid formulation on the basis of only the
`amount of steroid present. The biologic activity of each
`steroid also has to be considered. By use of established
`tests for progestational activity in animals, it has been
`round that a given weight of norgestrel is several times
`more potent than the same weight of norethindrone. Studies
`in humans, using delay of menses 16 or endometrial histo(cid:173)
`logic alterations such as subnuclcar vacuolization 17• 18 as
`endpoints, also determined that norgestrel is about 10 times
`more potent than the same weight of norethindrone. Nor(cid:173)
`ethindrone acetate and ethynodiol diacetate are metabolized
`in the body to norethindrone. Studies in humans, measuring
`progestational activity as described before, as well as other
`studies comparing the effects of serum lipids in humans
`indicate that each of these three progestins has approxi(cid:173)
`mately equal potency per unit of weight, whereas levonor(cid:173)
`gcstrel is I 0 to 20 times as potent. 19 Each of the three most
`recently developed levonorgcstrel derivatives has been
`shown in animal but not human studies to have similar or
`greater progestogenic potency than an equivalent weight of
`lcvonorgestrel, with less androgenic activity.20 The magni(cid:173)
`tude of difference in androgenic and progestational effects
`produced by each progestin is called selectivity.
`·nlC two estrogenic compounds used in OCs, ethinyl
`estradiol and its 3-mcthyl ether, mestranol, also have differ(cid:173)
`ent biologic activity in women. To become biologically
`effective, mestranol must be demethylatcd to ethinyl estra(cid:173)
`tliol, because mestranol does not bind to the estrogen cyto(cid:173)
`sol receptor. The degree of conversion of mestranol to
`cthi nyl estradiol varies among individuals; some are able
`to convert it completely, whereas others convert only a
`portion of it. Thus, in some women, a given weight of
`·ncstranol is as potent as the same weight of ethinyl estra(cid:173)
`tliol; in other women, it is only about half as potent.
`Overall, it has been estimated, by use of human endome(cid:173)
`trial response and effect on liver corticosteroid-binding
`globulin prod