Take at the same time each day to ensure maximum contraceptive efficacy. For biphasic and triphasic products, explanation of tablet sequencing and different tablet colors may be needed. Some contraceptive packs contain 28 tablets. For most of these, 21 tablets contain active hormone and 7 contain either iron or inert ingredients, so that the daily dosage cycle can be continuous. This reduces the chance of missed doses.
The 7 extra tablets are taken at the end of the cycle. Mircette and Kariva contraceptive packs consist of 28 tablets with 21 tablets containing active progestin and estrogen hormones. Two tablets are inert, and the remaining 5 tablets contain estrogen only. The reduced hormone-free interval each month is designed to minimize migraine headaches and symptoms of dysmenorrhea that are experienced during the hormone-free week.
Missing pills can cause spotting or light bleeding. Each manufacturer has slightly different recommendations for missed pills. Patients should be instructed to review the patient information leaflet that accompanies the prescription each time it is filled.
General recommendations for missed doses: If one dose is missed, the patient should take it as soon as she remembers and then take the next pill at the regular time as usual. It may be necessary to take 2 tablets in one day. Some manufacturers recommend that a second method of non-hormonal contraception be used for at least 7 days after restarting the pills. If two doses in a row are missed, 2 tablets should be taken on both the day the missed doses are remembered and the following day.
The regular schedule should then be continued. A second method of non-hormonal contraception should be used for at least 7 days after restarting the pills. If 3 or more doses in a row are missed, the patient should not take the missed pills. Recommendations for restarting the pills can be found in the patient information leaflet that accompanies the prescription each time it is filled.
A second method of contraception should be used for at least 7 days after the pills are restarted. Use of desogestrel; ethinyl estradiol, as with other contraceptive steroids, may result in clinical changes that influence the results of certain laboratory tests, such as coagulation factors, lipids, glucose tolerance, and binding proteins.
Specific laboratory test interference has not been reported. Desogestrel; ethinyl estradiol does not protect against human immunodeficiency virus HIV infection or other sexually transmitted disease. Conversely, patients infected with HIV or with known acquired immunodeficiency syndrome AIDS should be aware that the use of the hormonal contraceptive vaginal ring will not prevent the transmission of HIV or other sexually transmitted diseases to their partner s.
Surgery can increase the risk for thromboembolism from combined hormonal contraceptives. If feasible, discontinue desogestrel; ethinyl estradiol products at least 4 weeks before and through 2 weeks after major surgery or other surgeries known to have an elevated risk of thromboembolism, and during and following any prolonged immobilization.
Because of the increased potential for embolic risk, combined oral contraceptives COCs containing desogestrel; ethinyl estradiol are contraindicated in women who currently have diabetes mellitus and are over 35 years of age, diabetes mellitus with hypertension or with vascular disease or end-organ damage, or diabetes mellitus of greater than 20 years duration.
Patients with diabetes mellitus should be observed for changes in glucose tolerance when initiating or discontinuing COCs, since estrogens may exacerbate diabetes. Altered glucose tolerance secondary to decreased insulin sensitivity has been reported.
Women who are being treated for dyslipidemia should be followed closely if they elect to use oral contraceptives. Some progestogens may elevate LDL levels and may render the control of hyperlipidemia more difficult. Females with hypertriglyceridemia, or a family history thereof, may be at an increased risk of pancreatitis when using COCs. Desogestrel; ethinyl estradiol is contraindicated in patients with migraine or other headache that is accompanied by focal neurological symptoms, such as aura, or women over age 35 with any migraine headaches.
Combined oral hormonal contraceptives COCs may cause an exacerbation of migraine or a change in headache patterns and should be used with caution in women with migraine. Patients who complain of migraine with focal neurologic visual changes should be medically evaluated, and in some patients, such changes may indicate cerebrovascular events. Consistent with potential thrombotic effects of combined oral hormonal contraceptives COCs , there have been clinical case reports of retinal thrombosis with COC use.
The COC should be discontinued if there is unexplained visual disturbance, partial or complete loss of vision, onset of proptosis or diplopia, papilledema, or retinal vascular lesions. Appropriate diagnostic and therapeutic measures should be undertaken immediately. Estrogens can increase the curvature of the cornea; patients using contact lenses wearers who develop visual changes or changes in lens tolerance should be assessed by an ophthalmologist.
Desogestrel; ethinyl estradiol is contraindicated in patients with hypersensitivity to any of the product components. Ethinyl estradiol is generally contraindicated in patients who have a history of anaphylaxis or history of angioedema to the drug. Cases of both anaphylactic reactions and angioedema have been reported in patients taking estrogens. Events have developed in minutes and have required emergency medical treatment.
Exogenous estrogens may induce or exacerbate symptoms of angioedema, particularly in women with hereditary angioedema, which may be hormonally sensitive. Given the increased prevalence of hypercoagulable states in patients with systemic lupus erythematosus SLE in particular antiphospholipid antibodies and lupus anticoagulant and the risk factors for thromboembolism, consider risks vs.
Avoid COC use in SLE patients with a history of venous or arterial thrombosis or the presence of a hypercoagulable state. Combined hormonal oral contraceptive COC use has also been reported to induce, unmask, or exacerbate SLE; more data are needed.
Discontinue desogestrel; ethinyl estradiol if pregnancy is detected; there is no reason to continue combined oral hormonal contraceptives COCs during pregnancy. Epidemiologic studies and meta-analyses have not found an increased risk of genital or nongenital birth defects including cardiac anomalies and limb-reduction defects following exposure to COCs before conception or during early pregnancy. For any patient who has missed two consecutive periods, pregnancy should be ruled out. If the patient has not adhered to the prescribed COC schedule, consider the possibility of pregnancy at the first missed period.
Discontinue COC use if pregnancy is confirmed. Manufacturers recommend avoidance of combined hormonal oral contraceptives COCs if possible during breast-feeding until a mother has completely weaned her child.
Small amounts of oral contraceptive steroids estrogens and progestins have been identified in the milk of nursing mothers and a few reports of effects on the infant exist, including jaundice and breast enlargement. Experts often recommend avoidance of estrogen-containing hormonal contraceptives, in the first 21 days postpartum due to maternal post-partum risks for thromboembolism following obstetric delivery, and the potential for COCs to interfere with the establishment of lactation.
It is generally accepted that estrogen-containing combined hormonal contraceptives may be used after this period in healthy women without other risk factors; general monitoring of the infant for effects such as appetite changes, breast changes and proper weight gain and growth should occur.
Estrogens, including ethinyl estradiol EE , have been reported to interfere with milk production and duration of lactation in some women, particularly at doses of 30 mcg per day or more. One study found that lower dose oral combined contraceptives e. However, a systematic review concluded that the available evidence, even from randomized controlled trials, is limited and of poor quality; proper trials are needed.
Consider the benefits of breast-feeding, the risk of potential infant drug exposure, and the risk of an untreated or inadequately treated condition. Alternate contraceptive agents for consideration for use during breast-feeding include non-hormonal contraceptive methods and also progestin-only contraceptives e.
Combined oral contraceptives COCs such as desogestrel; ethinyl estradiol are contraindicated in patients with hepatic disease. Because of the association with cholestasis and hepatic neoplasms, estrogens are contraindicated in the presence of hepatocellular cancer, hepatic adenoma, other liver tumors benign or malignant , or markedly impaired liver function e.
Steroid hormones may be poorly metabolized in patients with liver impairment. Acute or chronic disturbances of liver function may necessitate the discontinuation of COC use until markers of liver function return to normal and COC causation has been excluded. Hepatic adenomas are associated with COC use. An estimate of the attributable risk is 3. Rupture of hepatic adenomas may cause death through intra-abdominal hemorrhage.
Studies have shown an increased risk of developing hepatocellular carcinoma in long term more than 8 years COC users. However, the attributable risk of liver cancers in COC users is less than 1 case per million users. Use COCs with caution in patients with pre-existing gallbladder disease; however, recent studies have shown that the relative risk of developing gallbladder disease among COC users appears minimal due to the use of products that contain lower doses of hormones.
Mood disorders, like depression, may be aggravated in women taking hormones or combined oral hormonal contraceptives COCs. Data regarding the association of COCs with onset of depression or exacerbation of existing depression are limited. If significant depression occurs, desogestrel; ethinyl estradiol should be discontinued. Desogestrel; ethinyl estradiol is contraindicated in patients with a history of, or known or suspected breast cancer, as breast cancer is a hormonally-sensitive tumor.
All women taking combined oral contraceptives COCs should receive clinical breast examinations and perform monthly self-examinations as recommended by their health care professional based on patient age, known risk factors, and current standards of care.
There is substantial evidence that use of COCs does not increase the incidence of breast cancer. Although some past studies have suggested that COCs might increase the incidence of breast cancer, more recent studies have not confirmed such findings. Several large, well-designed observational studies have provided data regarding the risk of breast cancer with combined oral contraceptive COC use.
From one large study published in , the risk of breast cancer was higher among women who currently or recently used contemporary hormonal contraceptives than among women who had never used hormonal contraceptives, and this risk increased with longer durations of use; however, absolute increases in risk were small.
The absolute risk of breast cancer associated with any hormonal contraceptive use was 13 per , women-years, which corresponds to 1 extra case of breast cancer for every 7, COC users in 1 year.
Moreover, the same study data suggest that any increased risk of breast cancer usually disappears rapidly after an interruption in the use of COCs. There continues to be controversy regarding the risk of COC use in women with a family history of breast cancer e. However, evidence does not suggest that the increased risk for breast cancer among women with either a family history of breast cancer or breast cancer susceptibility genes is modified by the use of COCs.
Patients should be instructed to perform monthly self-breast examination and report any breast changes, lumps, or discharge to their health care professional. If weight gain is a concern for you or you experience it after starting birth control, reach out to us so our doctors can discuss your options with you.
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