Estrogen and Progestin (Oral Contraceptives) (patient information)

# IMPORTANT WARNING
Cigarette smoking increases the risk of serious side effects from oral contraceptives, including heart attacks, blood clots, and strokes. This risk is higher for women over 35 years old and heavy smokers (15 or more cigarettes per day). If you take oral contraceptives, you should not smoke.

# Why this medication is prescribed
Oral contraceptives (birth-control pills) are used to prevent pregnancy. Estrogen and progestin are two female sex hormones. Combinations of estrogen and progestin work by preventing ovulation (the release of eggs from the ovaries). They also change the lining of the uterus (womb) to prevent pregnancy from developing and change the mucus at the cervix (opening of the uterus) to prevent sperm (male reproductive cells) from entering. Oral contraceptives are a very effective method of birth control, but they do not prevent the spread of human immunodeficiency virus  and other sexually transmitted diseases.
Some brands of oral contraceptives are also used to treat acne in certain patients. Oral contraceptives work to treat acne by decreasing the amounts of certain natural substances that can cause acne.

# How this medication should be used
Oral contraceptives come in packets of 21, 28, or 91 tablets to take by mouth once a day, every day or almost every day of a regular cycle. To avoid nausea, take oral contraceptives with food or milk. Take your oral contraceptive at the same time every day. Follow the directions on your prescription label carefully, and ask your doctor or pharmacist to explain any part you do not understand. Take your oral contraceptive exactly as directed. Do not take more or less of it, take it more often, or take it for a longer time than prescribed by your doctor.
Oral contraceptives come in many different brands. Different brands of oral contraceptives contain slightly different medications or doses, are taken in slightly different ways, and have different risks and benefits. Be sure that you know which brand of oral contraceptives you are using and exactly how you should use it. Ask your doctor or pharmacist for a copy of the manufacturer's information for the patient and read it carefully.
If you have a 21-tablet packet, take one tablet daily for 21 days and then none for 7 days. Then start a new packet.
If you have a 28-tablet packet, take one tablet daily for 28 days. The last set of tablets in most 28 day packets are a different color. These tablets are reminder tablets. They do not contain any active ingredients but may contain iron. Taking one of these tablets every day will help you remember to start your next packet of birth control pills on time. One type of 28-tablet packet contains tablets that are all the same color. All of the tablets in this type of packet contain active ingredients. Whether your packet includes reminder tablets or only active tablets, you should take one tablet daily continuously for 28 days in the order specified in your packet. Start a new packet the day after you take your 28th tablet.
If you have a 91-day tablet packet, take one tablet daily for 91 days. Your packet will contain three trays of tablets. Start with the first tablet on the first tray and continue taking one tablet every day in the order specified on the packet until you have taken all of the tablets on all of the trays. The last days
days tablets are a different color. These tablets may contain an inactive ingredient, or they may contain a very low dose of estrogen. Start your new packet the day after you take your 91st tablet.
Your doctor will tell you when you should start taking your oral contraceptive. Oral contraceptives are usually started on the first or fifth day of your menstrual period or on the first Sunday after or on which bleeding begins. Your doctor will also tell you whether you need to use another method of birth control during the first 7 days that you take your oral contraceptive and will help you choose a method. Follow these directions carefully.
You will probably experience withdrawal bleeding similar to a menstrual period while you are taking the inactive tablets or the low dose estrogen tablets or during the week that you do not take your oral contraceptive. If you are taking the type of packet that only contains active tablets, you will not experience any scheduled bleeding, but you may experience unexpected bleeding and spotting, especially at the beginning of your treatment. Be sure to start taking your new packet on schedule even if you are still bleeding.
You may need to use a backup method of birth control if you vomit or have diarrhea while you are taking an oral contraceptive. Talk to your doctor about this before you begin to take your oral contraceptive so that you can prepare a backup method of birth control in case it is needed. If you vomit or have diarrhea while you are taking an oral contraceptive, call your doctor to find out how long you should use the backup method.
If you have recently given birth, wait until 4 weeks after delivering to begin taking oral contraceptives. If you have had an abortion or miscarriage, talk to your doctor about when you should begin taking oral contraceptives.
Oral contraceptives will work to prevent pregnancy or treat acne only as long as they are taken regularly. Continue to take oral contraceptives every day even if you are spotting or bleeding, have an upset stomach, or do not think that you are likely to become pregnant. Do not stop taking oral contraceptives without talking to your doctor.

# Other uses for this medicine
Oral contraceptives are also sometimes used to treat heavy or irregular menstruation and endometriosis (a condition in which the type of tissue that lines the uterus  grows in other areas of the body and causes pain, heavy or irregular menstruation , and other symptoms). Talk to your doctor about the risks of using this medication for your condition.
This medication may be prescribed for other uses; ask your doctor or pharmacist for more information.

# Special precautions
Before taking oral contraceptives:
- tell your doctor and pharmacist if you are allergic to estrogen, progestin, or any other medications.
- tell your doctor and pharmacist what prescription and nonprescription medications, vitamins, and nutritional supplements you are taking. Be sure to mention any of the following: acetaminophen (APAP, Tylenol); antibiotics such as ampicillin (Principen), clarithromycin (Biaxin),erythromycin (E.E.S., E-Mycin, Erythrocin),isoniazid (INH, Nydrazid), metronidazole (Flagyl), rifabutin (Mycobutin), rifampin (Rifadin, Rimactane), tetracycline (Sumycin), and troleandomycin (TAO) (not available in the U.S.); anticoagulants ('blood thinners') such as warfarin (Coumadin); antifungals such as griseofulvin (Fulvicin, Grifulvin, Grisactin), fluconazole (Diflucan), itraconazole (Sporanox), and ketoconazole (Nizoral); atorvastatin (Lipitor); clofibrate (Atromid-S); cyclosporine (Neoral, Sandimmune); danazol (Danocrine); delavirdine (Rescriptor);diltiazem (Cardizem, Dilacor, Tiazac); fluoxetine (Prozac, Sarafem, in Sympbyax); HIV protease inhibitors such as indinavir (Crixivan) and ritonavir (Norvir); medications for seizures such as carbamazepine (Tegretol), felbamate (Felbatol), lamotrigine (Lamictal), oxcarbazepine (Trileptal), phenobarbital (Luminal, Solfoton), phenytoin (Dilantin), primidone (Mysoline), and topiramate (Topamax); modafinil (Provigil); morphine (Kadian, MS Contin, MSIR, others); nefazodone; oral steroids such as dexamethasone (Decadron, Dexone), methylprednisolone (Medrol), prednisone (Deltasone), and prednisolone (Prelone); temazepam (Restoril); theophylline (Theobid, Theo-Dur); thyroid medication such as levothyroxine (Levothroid, Levoxyl, Synthroid); verapamil (Calan, Covera, Isoptin, Verelan); vitamin C; and zafirlukast (Accolate). Before taking Yasmin, also tell your doctor and pharmacist if you are taking angiotensin-converting enzyme (ACE) inhibitors such as benazepril (Lotensin), enalapril (Vasotec), and lisinopril (Prinivil, Zestril); angiotensin II antagonists such as irbesartan (Avapro), losartan (Cozaar), and valsartan (Diovan); aspirin and other nonsteroidal anti-inflammatory medications (NSAIDs) such as ibuprofen (Advil, Motrin) and naproxen (Aleve, Naprosyn); diuretics ('water pills') such as amiloride (Midamor), spironolactone (Aldactone), and triamterene (Dyrenium); or heparin. Your doctor may need to change the doses of your medications or monitor you carefully for side effects.
- tell your doctor what herbal products you are taking, especially St. John's wort.
- tell your doctor if you have or have ever had blood clots in your legs, lungs, or eyes; thrombophilia (condition in which the blood clots easily); coronary artery disease (clogged blood vessels leading to the heart); cerebrovascular disease (clogging or weakening of the blood vessels within the brain or leading to the brain); stroke or stroke; an irregular heartbeat; heart disease; a heart attack; chest pain; diabetes that has affected your circulation; headaches that come along with other symptoms such as vision changes, weakness, and dizziness; high blood pressure; breast cancer; cancer of the lining of the uterus, cervix, or vagina; liver cancer; liver tumors; yellowing of the skin or eyes during pregnancy or while you were using hormonal contraceptives (birth control pills, patches, rings, implants, or injections); or unexplained abnormal vaginal bleeding. Also tell your doctor if you have recently had surgery or have been unable to move around for any reason. Your doctor may tell you that you should not take oral contraceptives if you have or have had any of these conditions.
- Also tell your doctor if anyone in your family has had breast cancer and if you have or have ever had problems with your breasts such as lumps, an abnormal mammogram (breast x-ray), or fibrocystic breast disease (swollen, tender breasts and/or breast lumps that are not cancer); high blood cholesterol or fats; diabetes; asthma; toxemia (high blood pressure during pregnancy); heart attack; chest pain; seizures; migraine headaches; depression; gallbladder or kidney disease; adrenal insufficiency (for Yasmin); jaundice (yellowing of the skin or eyes); and excessive weight gain and fluid retention (bloating) during the menstrual cycle.
- do not take oral contraceptives if you are pregnant, plan to become pregnant, or are breast-feeding. If you become pregnant while taking oral contraceptives, call your doctor immediately.
- if you miss periods while you are taking oral contraceptives, you may be pregnant. If you are using a 91-tablet packet and you miss one period, call your doctor. If you are using another type of packet according to the directions and you miss one period, you may continue to take your tablets. However, if you have not taken your tablets as directed and you miss one period or if you have taken your tablets as directed and you miss two periods, call your doctor and use another method of birth control until you have a pregnancy test. If you are using a 28-tablet packet that contains only active tablets, you will not expect to have periods on a regular basis, so it may be hard to tell if you are pregnant. If you are using this type of oral contraceptive, call your doctor and have a pregnancy test if you experience symptoms of pregnancy such as nausea, vomiting, and breast tenderness, or if you suspect you may be pregnant.
- if you are having surgery, including dental surgery, tell the doctor or dentist that you are taking oral contraceptives.
- tell your doctor and pharmacist if you wear contact lenses. If you notice changes in vision or ability to wear your lenses while taking oral contraceptives, see an eye doctor.

# Special dietary instructions
Unless your doctor tells you otherwise, continue your normal diet.

# What to do if you forget a dose
If you miss doses of your oral contraceptive, you may not be protected from pregnancy. You may need to use a backup method of birth control for 7 days or until the end of the cycle. Every brand of oral contraceptives comes with specific directions to follow if you miss one or more doses. Carefully read the directions in the manufacturer's information for the patient that came with your oral contraceptive. If you have any questions, call your doctor or pharmacist. Continue to take your tablets as scheduled and use a backup method of birth control until your questions are answered.

# Side effects

## Minor side effects
Oral contraceptives may cause side effects. Tell your doctor if any of these symptoms are severe or do not go away:
- nausea
- vomiting
- stomach cramps or bloating
- diarrhea
- constipation
- gingivitis (swelling of the gum tissue)
- increased or decreased appetite
- weight gain or weight loss
- brown or black skin patches
- acne
- hair growth in unusual places
- bleeding or spotting between menstrual periods
- changes in menstrual flow
- painful or missed periods
- breast tenderness, enlargement, or discharge
- difficulty wearing contact lenses
- swelling, redness, irritation, burning, or itching of the vagina
- white vaginal discharge

## Severe side effects
Some side effects can be serious. The following symptoms are uncommon, but if you experience any of them, call your doctor immediately:
- severe headache
- severe vomiting
- speech problems
- dizziness or faintness
- weakness or numbness of an arm or leg
- crushing chest pain or chest heaviness
- coughing up blood
- shortness of breath
- pain, warmth, or heaviness in the back of the lower leg
- partial or complete loss of vision
- double vision
- bulging eyes
- severe stomach pain
- yellowing of the skin or eyes
- loss of appetite
- extreme tiredness, weakness, or lack of energy
- fever
- dark-colored urine
- light-colored stool
- swelling of the hands, feet, ankles or lower legs
- depression, especially if you also have trouble sleeping, tiredness, loss of energy, or other *mood changes
- unusual bleeding
- rash
- menstrual bleeding that is unusually heavy or that lasts for longer than 7 days in a row
Oral contraceptives may increase the chance that you will develop liver tumors. These tumors are not a form of cancer, but they can break and cause serious bleeding inside the body. Oral contraceptives may also increase the chance that you will develop breast or liver cancer, or have a heart attack, a stroke, or a serious blood clot. Talk to your doctor about the risks of using oral contraceptives.
Oral contraceptives may cause other side effects. Call your doctor if you have any unusual problems while taking this medication.
If you experience a serious side effect, you or your doctor may send a report to the Food and Drug Administration's (FDA) MedWatch Adverse Event Reporting program online  or by phone .

# Storage conditions needed for this medication
Keep this medication in the packet it came in, tightly closed, and out of reach of children. Store it at room temperature and away from excess heat and moisture (not in the bathroom). Throw away any medication that is outdated or no longer needed. Talk to your pharmacist about the proper disposal of your medication.

# In case of emergency/overdose
In case of overdose, call your local poison control center at 1-800-222-1222. If the victim has collapsed or is not breathing, call local emergency services at 911.
Symptoms of overdose may include:
- nausea
- vaginal bleeding

# Other information
Keep all appointments with your doctor and the laboratory. You should have a complete physical examination every year, including blood pressure measurements, breast and pelvic exams, and a Pap test. Follow your doctor's directions for examining your breasts; report any lumps immediately.
Before you have any laboratory tests, tell the laboratory personnel that you take oral contraceptives.
If you wish to stop taking oral contraceptives and become pregnant, your doctor may tell you to use another method of birth control until you begin to menstruate regularly again. It may take a long time for you to become pregnant after you stop taking oral contraceptives, especially if you have never had a baby or if you had irregular, infrequent, or complete absence of menstrual periods before taking oral contraceptives. However, it is possible to become pregnant within days of stopping certain oral contraceptives. If you want to stop taking oral contraceptives but do not want to become pregnant, you should begin using another type of birth control as soon as you stop taking oral contraceptives. Discuss any questions that you may have with your doctor.
Oral contraceptives may decrease the amount of folate in your body. Folate is important for the development of a healthy baby, so you should talk to your doctor if you want to become pregnant soon after you stop taking oral contraceptives.
Do not let anyone else take your medication. Ask your pharmacist any questions you have about refilling your prescription.

# Brand names
- Alesse
- Apri
- Aviane
- Brevicon
- Demulen
- Desogen
- Estrostep
- Estrostep Fe
- Genora
- Jenest
- Levlen
- Levlite
- Levora
- Lo/Ovral
- Loestrin
- Loestrin Fe
- Low-Ogestrel
- Lybrel
- Microgestin
- Microgestin Fe
- Mircette
- Modicon
- Necon
- Norinyl
- Nordette
- Nortrel
- Ogestrel
- Ortho-Cept
- Ortho-Cyclen
- Ortho-Novum
- Ortho Tri-Cyclen
- Ovcon
- Ovral
- Seasonale
- Seasonique
- Tri-Levlen
- Tri-Norinyl
- Triphasil
- Trivora
- Yasmin
- Zovia

# Other names
- Birth-control pills
- ethinyl estradiol and desogestrel
- ethinyl estradiol and drospirenone
- ethinyl estradiol and ethynodiol
- ethinyl estradiol and levonorgestrel
- ethinyl estradiol and norethindrone
- ethinyl estradiol and norgestimate
- ethinyl estradiol and norgestrel
- mestranol and norethindrone