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Desogestrel; Ethinyl Estradiol
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1 tablet (containing 0.15 mg desogestrel and 30 mcg ethinyl estradiol) PO once daily for 21 days, followed by 7 days without drug.[50744]
1 tablet PO once daily for 28 days in order indicated in the pack. Phase 1 contains 21 tablets of 0.15 mg desogestrel and 20 mcg ethinyl estradiol, followed by 2 days of inert tablets. Phase 2 contains 5 tablets with 10 mcg ethinyl estradiol only.[43312]
1 tablet PO once daily for 21 days in the order indicated in the pack, followed by 7 days without drug. Phase 1 contains 7 tablets of 0.1 mg desogestrel and 25 mcg ethinyl estradiol. Phase 2 contains 7 tablets of 0.125 mg desogestrel and 25 mcg ethinyl estradiol. Phase 3 contains 7 tablets of 0.15 mg desogestrel and 25 mcg ethinyl estradiol.[62071]
1 tablet PO once daily, in order directed on pack, following dosage as per routine contraception. Then, repeat cycles as directed for product chosen. Expected time to acne improvement with CHCs is usually within 3 to 6 months, and CHCs may be used with other acne therapies early in treatment to accelerate response. Prolonged treatment may be needed for acne control.[58791] [69506] [70323]
0.1 to 0.15 mg desogestrel; 0.02 to 0.03 mg ethinyl estradiol PO once daily for 21 days, followed by 7 days of inert, inactive tablets or 2 days of inert, inactive tablets and then 5 days of 0.01 mg ethinyl estradiol as for routine contraception.[38069] [50744] [58791] [58792] [58793] [62071] [70439] [71064]
0.1 to 0.15 mg desogestrel; 0.02 to 0.03 mg ethinyl estradiol PO once daily for 21 days, followed by 7 days of inert, inactive tablets or 2 days of inert, inactive tablets and then 5 days of 0.01 mg ethinyl estradiol as for routine contraception.[38069] [50744] [58791] [58792] [58793] [62071] [70439] [71064]
NOTE: For individuals who have no known contraindications to combined oral contraceptives, desire contraception, have achieved menarche, and have been evaluated for causes of the condition
Follow dose as for routine contraception. Alternatively, the active tablets can be given continuously in selected patients. Combined hormonal contraceptives can reduce endometriosis-associated dyspareunia, dysmenorrhea, and non-menstrual pelvic pain.[69730]
1 tablet/day PO as directed in pack.
Not indicated.
1 tablet/day PO as directed in pack.
Use before menarche is not indicated.
Steroid hormones in combined hormonal contraceptives (CHCs) may be poorly metabolized in those with impaired liver function. If jaundice develops during use, discontinue. Contraindicated for use in those with acute or chronic hepatic disease with abnormal liver function and in those with history of cholestatic jaundice of pregnancy or jaundice with prior CHC use.[43312][50744][62071][48201][70437]
No dosage adjustments for combined hormonal contraceptives (CHCs) are needed; however, depending on the cause and degree of the renal impairment/chronic kidney disease (CKD), other contraceptive agents may be preferred over CHCs. If the person with CKD is a candidate for CHC use, monitor for blood pressure increase, changes in proteinuria, and thromboembolism risk during CHC initiation and periodically thereafter.[48201][70659]
† Off-label indicationDesogestrel and ethinyl estradiol are used together as an oral combined hormonal contraceptive (CHC). Ethinyl estradiol is a potent, synthetic estrogen. Desogestrel is a third-generation progestin with lowered androgenic effects and relatively no estrogenic action compared to older progestins. Thus, desogestrel may have positive influences on acne, fluid retention, and lipid profiles. CHCs can be used in female patients from menarche to over the age of 40 years up until the time of menopause with proper selection of products. The choice of a routine contraceptive for any given patient is based on the individual's contraceptive needs, underlying medical conditions or risk factors for adverse effects, and individual preferences for use. All combined hormonal contraceptives (CHCs) have risks related to venous and arterial thromboembolism; CHC labels contain a boxed warning regarding the increased risk for thromboembolism in tobacco smokers. The Centers for Disease Control's U.S. Medical Eligibility Criteria describe considerations for risk vs. benefits, including medical conditions or attributes that contraindicate use; these criteria can help practitioners determine product selection for individual patients.[48201][66717] Some desogestrel; ethinyl estradiol products provide a reduced hormone-free interval in the cycle, which may be advantageous for patients experiencing migraines, dysmenorrhea, or other symptoms during the days they do not take active hormones. Desogestrel; ethinyl estradiol products were initially FDA approved in 1992.[43312][50744][62071]
For storage information, see the specific product information within the How Supplied section.
Hazardous Drugs Classification
General information when initiating routine CHCs: [66717]
Initiating CHCs in an individual not previously taking a CHC: There are options to start taking the first cycle of their COC.
Switching from a different CHC or other contraceptive methods:
Initiating a CHC in the person with amenorrhea:
Initiating CHCs postpartum:
Initiating CHCs following induced or spontaneous abortion:
Breakthrough bleeding and spotting are sometimes encountered, especially during the first 3 months of oral contraceptive use such as desogestrel; ethinyl estradiol. Change in menstrual flow (menstrual irregularity) and amenorrhea have also been reported and are believed to be drug-related. In the event of breakthrough vaginal bleeding, consider non-hormonal causes and take adequate diagnostic measures to rule out malignancy or pregnancy. If pathology has been excluded, time or a change to another formulation may solve the problem. In the event of amenorrhea, rule out pregnancy. Some women may encounter post-pill amenorrhea or oligomenorrhea, especially when such a condition was pre-existent.[50744] Other adverse effects may include dysmenorrhea, menorrhagia, and pelvic pain.
Breast tenderness or mastalgia, breast enlargement, and breast discharge or secretion have been reported in patients receiving oral contraceptives such as desogestrel; ethinyl estradiol and are believed to be drug-related.[50744] Galactorrhea and lactation suppression may also occur.
Vaginal discharge (leukorrhea) or vaginal irritation due to candidiasis or vaginitis can occur during therapy with hormonal contraceptive agents like desogestrel; ethinyl estradiol.[50744]
Oral contraceptives (e.g., desogestrel; ethinyl estradiol) are associated with an increased risk of thromboembolic and thrombotic disease. The risk for the development of deep venous thrombosis and/or pulmonary embolism is approximately 3 to 6 times greater in OC users than in nonusers. In several studies, the risk was reported to be higher in smokers compared with nonsmokers. The relative risk of venous thromboembolism (VTE) in women who have predisposing conditions is twice that of women without such medical conditions. The risk of VTE due to COC use gradually disappears after the combined hormonal contraceptive is discontinued. VTE risk is highest in the first year of use and when a combination oral contraceptive is started or re-started after a break in use of 4 weeks or more.[48201] Stop desogestrel; ethinyl estradiol if an arterial or venous thrombotic event occurs.[50744] Both hormone amount and hormone type may be important factors regarding rates of thromboembolic disorders. Estrogens decrease levels of antithrombin-III and increase the production of blood clotting factors VII, VIII, IX and X; risks increase with ethinyl estradiol doses more than 50 mcg/day. Women who took OCs containing certain types of progestin (e.g., desogestrel or gestodene) had an increased risk (adjusted RR = 1.9) for nonfatal VTE compared with women who took OCs containing levonorgestrel.[24588] However, association of increases in VTE risk with newer progestins cannot be proved due to limitations and inconsistencies in the results of several of these observational studies. No consistent differential effects on hemostasis with the newer progestins (e.g., desogestrel, gestodene) have been established versus older progestins.
Oral contraceptives may cause edema (fluid retention) and, thus, weight gain. Appetite stimulation may also occur. An increased risk of hypertension and of myocardial infarction has been associated with the use of oral contraceptives such as desogestrel; ethinyl estradiol. An increase in blood pressure is more likely in older oral contraceptive users and with continued use.The incidence of hypertension increases with increasing concentrations of progestogens. Close monitoring of blood pressures is recommended for patients at risk for hypertension; discontinue desogestrel; ethinyl estradiol if significant elevation of blood pressure occurs. Blood pressures usually return to normal after discontinuation of therapy, and no difference in the occurrence of hypertension exists among ever- and never-users. Myocardial infarction risk is primarily in smokers or women with other underlying risk factors for coronary artery disease such as hypertension, hypercholesterolemia, morbid obesity, and diabetes. Oral contraceptives may compound the effects of well-known risk factors. In particular, some progestogens are known to decrease HDL cholesterol and cause glucose intolerance, while estrogens may create a state of hyperinsulinism.The relative risk of heart attack for current oral contraceptive users has been estimated to be 2 to 6.2. The risk is very low under the age of 30. However, there is the possibility of a risk of cardiovascular disease even in very young women who take oral contraceptives. Smoking in combination with oral contraceptive use has been shown to contribute substantially to the incidence of myocardial infarctions in women in their mid-thirties or older, with smoking accounting for the majority of excess cases. Mortality rates associated with circulatory disease have been shown to increase substantially in smokers over the age of 35 and non-smokers over the age of 40 among women who use oral contraceptives.[50744] [25200] [25201] [33475]
An increase in both the relative and attributable risks of cerebrovascular events (thrombotic and hemorrhagic strokes) has been shown in users of oral contraceptives such as desogestrel; ethinyl estradiol. In general, the risk is greatest among older (older than 35 years), hypertensive women who also smoke. Hypertension was found to be a risk factor for both users and non-users for both types of strokes while smoking interacted to increase the risk for hemorrhagic strokes. In a large study, the relative risk of thrombotic strokes has been shown to range from 3 for normotensive users to 14 for users with severe hypertension. The relative risk of hemorrhagic stroke (intracranial bleeding) is reported to be 1.2 for non-smokers who used oral contraceptives, 2.6 for smokers who did not use oral contraceptives, 7.6 for smokers who used oral contraceptives, 1.8 for normotensive users, and 25.7 for users with severe hypertension. The attributable risk also is greater in women in their mid-thirties or older and among smokers.[50744] Regarding stroke and OC use, risk may be related to the amount of estrogen as well as the type of progestin, although this issue is controversial. Early epidemiological studies showed an increased risk for stroke, as well as MI and venous thromboembolism, however these studies assessed OCs containing more than 50 mcg of ethinyl estradiol. Use of OCs containing lower amounts of estrogen (i.e., 35 mcg or less of ethinyl estradiol) has not been associated with an overall increased risk of stroke in more recent studies. Conflicting data exist, however, regarding the association of OC use and hemorrhagic stroke. In one study, norgestrel-type progestins (e.g., levonorgestrel) were associated with a higher risk of hemorrhagic stroke (odds ratio = 3.28) compared with non-users of OCs.[24948] Another study, however, showed no increased risk of hemorrhagic stroke in users of levonorgestrel-containing OCs.[24949] Therefore, although the risk of stroke in users of OCs appears to be related to estrogen amount (i.e., increased risk has been demonstrated with products containing 50 mcg or more but not for products containing 35 mcg or less of ethinyl estradiol), further studies are needed to clarify the relationship of type of progestin to risk of stroke in users of OCs.
Clinical case reports of retinal thrombosis associated with the use of oral contraceptives exist. Optic neuritis, which may lead to partial or complete loss of vision has been reported in users of oral contraceptives, however the association has been neither confirmed nor refuted. Likewise, cataracts have been reported during oral contraceptive use without evidence of causality.[44124] Exogenous estrogen use can cause a conical cornea to develop from steepening or increased curvature of the cornea, caused by thinning of the stroma. Patients with contact lenses may develop intolerance to their lenses. Any change in vision or visual acuity should be examined by an ophthalmologist. In the event of unexplained visual impairment, onset of proptosis or diplopia, papilledema, or retinal vascular lesions, discontinue desogestrel; ethinyl estradiol. Immediately take appropriate diagnostic and therapeutic measures.[50744]
Depression has been reported in patients receiving oral contraceptives such as desogestrel; ethinyl estradiol and is believed to be drug-related. In addition to depression, nervousness or anxiety, libido decrease, libido increase, emotional lability, fatigue, asthenia, and irritability have been reported.[50744] Carefully observe women with a history of depression. Discontinue desogestrel; ethinyl estradiol if depression recurs to a serious degree. Also, stop desogestrel; ethinyl estradiol in patients who become significantly depressed to try to determine whether the depression is drug related.
Headache is a common adverse effect of oral contraceptives. Migraine has been reported in patients receiving oral contraceptives such as desogestrel; ethinyl estradiol and is believed to be drug-related. A number of changes can occur when a woman initiates oral contraceptive therapy and include 1) migraines can appear for the first time, 2) a change in frequency, severity, and duration of migraine headaches may be seen, or 3) an improvement or decrease in the occurrence of migraine headaches. When initiating therapy, observe an individual's migraine pattern. The onset or exacerbation of migraine or development of headache with a new pattern that is recurrent, persistent, or severe requires discontinuation of oral contraceptives and evaluation of the cause.[50744]
Maculopapular rash, rash, pruritus, anaphylactic or anaphylactoid reactions, urticaria, angioedema, and melasma are believed to be related to oral contraceptives like desogestrel; ethinyl estradiol. Melasma, in the form of tan or brown patches, may develop on the forehead, cheeks, temples and upper lip. These patches may persist after the drug is discontinued. Photosensitivity can be experienced with oral contraceptive use and protective clothing and sunscreens should be employed when exposed to sunlight or UV light. An association of oral contraceptives with acne vulgaris, hirsutism, alopecia, erythema multiforme, or erythema nodosum has been neither confirmed nor refuted. Although oral contraceptives can be used to treat acne vulgaris, in some cases they may induce or aggravate existing acne.[50744]
Some women taking oral contraceptives, like desogestrel; ethinyl estradiol, notice tenderness, swelling, or minor bleeding of their gums, which may lead to gingivitis. Proper attention to oral care and regular dental visits are recommended.
Nausea, vomiting, abdominal pain or cramps, bloating, and cholestatic jaundice have been reported in patients receiving oral contraceptives and are believed to be drug-related. Abdominal pain can indicate cholelithiasis, cholecystitis, cholestasis, pancreatitis, or peliosis hepatis. An increased risk of gallbladder disease is associated with oral contraceptive use, but the risk may be minimal, especially with the use of oral contraceptive formulations that contain lower hormonal doses of estrogens and progestogens. In patients with familial defects of lipoprotein metabolism receiving estrogen-containing preparations, significant elevations of plasma triglycerides (hypertriglyceridemia) leading to pancreatitis have been reported. Numerous cases of bowel ischemia (ischemic colitis) have been reported during combined estrogen and progesterone use; mesenteric vein thrombus due to hypercoagulability is the proposed mechanism.[57614] Other adverse effects may include colitis, elevated hepatic enzymes, hepatitis, hyperlipidemia, diarrhea, dyspepsia, anorexia, weight loss, and Budd-Chiari syndrome or hepatic vein obstruction. Peliosis hepatis, a very rare consequence of taking estrogens and combined oral contraceptives, is characterized by the presence of blood-filled spaces.[51257] In rare cases, oral contraceptives can cause benign but dangerous liver tumors. Indirect calculations have estimated the attributable risk of hepatoma to be in the range of 3.3 cases per 100,000 for users, a risk that increases after 4 or more years of use. These benign liver tumors can rupture and cause fatal internal bleeding.[50744] Discontinue desogestrel; ethinyl estradiol if jaundice develops, as steroid hormones may be poorly metabolized in patients with impaired liver function. Cholestatic jaundice of pregnancy or jaundice with prior pill use are contraindications for desogestrel; ethinyl estradiol use.
The issue of hormonal influences on the development of cancers (new primary malignancy) has been widely researched for many decades. Most studies have been performed with combined oral contraceptives (COCs), and the risks related to combined hormonal contraceptives, regardless of route of administration, are thought to be similar. In general, the data suggest an increased risk of cervical cancer among combined oral contraceptive (COC) users, with a decreased risk for endometrial and ovarian cancers. BREAST CANCER: Epidemiology studies have not found a consistent association between use of COCs and breast cancer risk. Studies do not show an association between ever (current or past) use of COCs and risk of breast cancer. However, some studies report a small increase in the risk of breast cancer among current or recent users (less than 6 months since last use) and current users with longer duration of COC use.[43312] [50744] [62071] [62904] Several large, well-designed observational studies have provided data regarding the risk of breast cancer with combined oral contraceptive (COC) use.[27233] [24750] [27234] Breast cancers diagnosed in current or previous COC users tend to be less advanced clinically than in never-users. The risk of breast cancer is only slightly increased in current and recent COC users (i.e., within 10 years); however, 10 years after COC cessation, the risk of breast cancer appears to be similar to that in those patients that have never used COCs.[62647] From one large study published in 2017, 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 100,000 women-years, which corresponds to 1 extra case of breast cancer for every 7,690 COC users in 1 year.[62904] Moreover, the same study data suggest that any increased risk of breast cancer usually disappears rapidly after an interruption in the use of COCs.[62904] There continues to be controversy regarding the risk of COC use in women with a family history of breast cancer (e.g., BRCA mutations). 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.[48201] Patients should be instructed to perform monthly self-breast examination and report any breast changes, lumps, or discharge to their health care professional. If breast cancer is suspected in a woman who is taking hormonal contraceptives, the contraceptive should be discontinued.[43312] [50744] [62071] CERVICAL CANCER: Some studies suggest that COC use has been associated with an increase in the risk of cervical cancer or intraepithelial neoplasia; however, such findings may be due to differences in sexual behavior, presence of the human papillomavirus (HPV) and other factors. HPV is thought to be the cause of more than 90% of all cervical cancers, although, hormonal factors may influence risk. The relative risk of invasive cervical cancer of 1.37 after 4 years of use; relative risk increased to 1.6 after 8 years of use. Because a potential for cervical dysplasia may exist, regularly evaluate patients taking COCs via cervical cytology screening as recommended per standards of care.[62647] OTHER CANCERS: A meta-analysis of 10 studies indicated significant trends for a reduced risk for endometrial and ovarian cancer with increased duration of COC use. Risk of endometrial or ovarian cancers may be reduced by up to 60% with 4 or more years of use.[25198] Data suggest COCs do not protect against hereditary forms of ovarian cancer (e.g., women who carry BRCA1 or BRCA2 gene alterations).[25199] Studies have shown an increased risk of developing hepatocellular carcinoma in long-term (more than 8 years) COC users. However, these cancers are rare in the United States, and the attributable risk (the excess incidence) of liver cancers in oral contraceptive users approaches less than 1 per million users.[62647] [43312] [50744] [62071]
Myalgia, arthralgia, back pain, systemic lupus erythematosus (lupus-like symptoms), and musculoskeletal pain have been noted with oral contraceptives such as desogestrel; ethinyl estradiol.
Rhinitis and sinusitis have been noted with oral contraceptives such as desogestrel; ethinyl estradiol.
Cystitis has been noted with oral contraceptives such as desogestrel; ethinyl estradiol.
Porphyria has been noted with oral contraceptives such as desogestrel; ethinyl estradiol.
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.[43312][50744][62071]
Combined hormonal contraceptives (CHCs), such as desogestrel; ethinyl estradiol, do not protect against human immunodeficiency virus (HIV) infection or other sexually transmitted disease. Patients infected with HIV or with known acquired immunodeficiency syndrome (AIDS) should be aware that the use of a CHC will not prevent the transmission of HIV or other sexually transmitted diseases to their partner(s).[43312] [50744] [62071]
Combined hormonal contraceptive agents are contraindicated in patients with a current or past history of stroke, cerebrovascular disease, coronary artery disease, coronary thrombosis, myocardial infarction, thrombophlebitis, thromboembolism or thromboembolic disease, or valvular heart disease with complications. Hormonal combined oral contraceptives (COCs) have been associated with thromboembolic disease such as deep venous thrombosis (DVT) and pulmonary embolism (PE). COCs are also generally contraindicated in women who have thrombogenic valvular or thrombogenic rhythm diseases of the heart (e.g., subacute bacterial endocarditis with valvular disease, or atrial fibrillation), or known inherited or acquired hypercoagulopathies (e.g., protein S deficiency, protein C deficiency, Factor V Leiden, prothrombin G20210A mutation, antithrombin deficiency, antiphospholipid antibodies). Because tobacco smoking increases the risk of thromboembolism, DVT, myocardial infarction, stroke and other thromboembolic disease, patients receiving COCs are strongly advised not to smoke. Risk is especially high for female smokers over the age of 35 years or those who smoke 15 or more cigarettes per day. Therefore, COCs are generally considered contraindicated in women over the age of 35 years who are tobacco smokers. A positive relationship between estrogen dosage and thromboembolic disease has been demonstrated, and oral products containing 50-mcg ethinyl estradiol should not be used unless medically indicated. In addition, certain progestins may increase thromboembolic risk. The overall risk of venous thromboembolism in women using COCs has been estimated to be 3 to 9 per 10,000 woman-years. Preliminary data from a large, prospective cohort safety study suggests that the risk is greatest during the first 6 months after initially starting COC therapy or restarting (following a break from therapy 4 weeks or more) with the same or different combination product. The risk of arterial thromboses, such as stroke and myocardial infarction, is especially increased in women with other risk factors for these events. Pre-existing high blood pressure, kidney disease, hypercholesterolemia, hyperlipidemia, diabetes with vascular disease, and morbidly obese patients may also increase risk. After a COC is discontinued, the risk of thromboembolic disease due to oral contraceptives gradually disappears. Because of their association with elevations in blood pressure, COCs should be used cautiously in patients with mild to moderate hypertension or kidney disease; use is contraindicated in patients with uncontrolled or severe hypertension or hypertension with vascular disease. An increase in blood pressure has been reported in women taking COCs, and this increase is more likely in older women and with extended duration of use. The incidence of hypertension increases with increasing concentration of progestin. Blood pressure should be monitored closely in individuals with high blood pressure; discontinue desogestrel; ethinyl estradiol if blood pressure rises significantly. COCs may also cause fluid retention, and patients predisposed to complications from edema, such as those with renal disease or cardiac disease, should be closely monitored.[43312] [50744] [62071] [48201]
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.[43312] [50744] [62071]
Because of the increased potential for embolic risk, combined hormonal contraceptives (CHCs) containing desogestrel; ethinyl estradiol are contraindicated in people who currently have diabetes mellitus and are more than 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. People with diabetes mellitus should be observed for changes in glucose tolerance when initiating or discontinuing CHCs, since estrogens may exacerbate diabetes. Altered glucose tolerance secondary to decreased insulin sensitivity has been reported.[30858] [43312] [50744] [62071]
People who are being treated for dyslipidemia should be followed closely if they elect to use combined hormonal contraceptives (CHCs). Some progestogens may elevate LDL levels and may render the control of hyperlipidemia more difficult. Those with hypertriglyceridemia, or a family history thereof, may be at an increased risk of pancreatitis when using CHCs.[43312] [50744] [62071]
Desogestrel; ethinyl estradiol combined hormonal contraceptive (CHC) products are contraindicated in people with migraine or other headache that is accompanied by focal neurological symptoms, such as aura, or those more than 35 years of age with any migraine headaches. The onset or exacerbation of migraine or development of headache with a new pattern which is recurrent, persistent, or severe requires discontinuation of CHCs and evaluation of the cause. A migraine with focal neurologic visual changes should be medically evaluated, as such changes may indicate cerebrovascular events.[30858] [43312] [50744] [62071]
There have been clinical case reports of retinal thrombosis associated with the use of combined hormonal contraceptives (CHCs); people with a history of retinal thrombosis should not receive CHCs. A CHC should be discontinued if there is unexplained visual disturbance, such as 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.[30858] [43312] [50744] [62071]
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.[43312] [50744] [62071]
Combined hormonal contraceptives (CHCs) are contraindicated for use in people with acute or chronic hepatic disease with abnormal liver function, such as acute hepatitis or decompensated cirrhosis. In general, CHCs are also contraindicated in those with history of cholestatic jaundice of pregnancy or jaundice with prior hormonal contraceptive use. Discontinue the CHC if jaundice or cholestasis develops during CHC use. Acute or chronic disturbances of liver function may necessitate CHC discontinuation until markers of liver function return to normal and CHC causation has been excluded. Liver conditions for which estrogen-containing birth control is inappropriate include acute hepatitis, Budd-Chiari syndrome, decompensated cirrhosis (cirrhosis with hepatic decompensation or complications, such as ascites or confusion), a liver transplant that is not working well, or benign or cancerous liver tumors. Patients with hepatitis C infection who are being treated with ombitasvir/paritaprevir/ritonavir, with or without dasabuvir, are also contraindicated to receive CHCs due to a risk for elevated hepatic enzymes and hepatotoxicity. During clinical trials with the hepatitis C combination drug regimen that contains ombitasvir/paritaprevir/ritonavir (with or without dasabuvir), ALT elevations greater than 5 times the upper limit of normal (ULN), including some cases greater than 20 times the ULN, were significantly more frequent in those using ethinyl estradiol-containing medications. Discontinue CHCs prior to starting hepatitis C therapy with ombitasvir/paritaprevir/ritonavir, with or without dasabuvir; CHCs can be restarted approximately 2 weeks following completion of treatment with these hepatitis C combination drug regimens.[43312] [50744] [62071] [48201] [70437]
Use of combined hormonal contraceptives (CHCs) is contraindicated in patients with benign or malignant liver tumors, such as hepatic adenoma or hepatocellular cancer. Benign hepatic adenomas are associated with CHC use, although the incidence of these benign tumors is rare. The attributable risk (the excess incidence) is 3.3 cases/100,000 CHC users. Rupture of hepatic adenomas may cause death through intra-abdominal hemorrhage. Rupture of rare, benign 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) CHC users. However, these cancers are extremely rare in the U.S. and the attributable risk of liver cancers in CHC users is less than 1 per million CHC users.[43312] [50744] [62071] [48201] [70437]
Studies suggest a small increased relative risk of developing gallbladder disease among combined hormonal contraceptive (CHC) users.[48201] [62071]
Given the increased prevalence of hypercoagulable states in people with systemic lupus erythematosus (SLE) (in particular antiphospholipid antibodies and lupus anticoagulant) and the risk factors for thromboembolism, consider risks vs. benefit of combined hormonal contraceptive (CHC) use. Avoid CHCs in SLE patients with a history of venous or arterial thrombosis or the presence of a hypercoagulable state. If CHCs are initiated in SLE patients without hypercoagulable states, choose a low-dose estrogen contraceptive (e.g., ethinyl estradiol 35 mcg per day or less); consider use of a progestin-only contraceptive. CHCs have also been reported to induce, unmask, or exacerbate SLE; more data are needed.[31435] [48201]
Mood disorders, like depression, may be aggravated in women taking combined hormonal contraceptives (CHCs). Data regarding the association of CHCs with onset of depression or exacerbation of existing depression are limited. If significant depression occurs, desogestrel; ethinyl estradiol should be discontinued.[43312] [50744] [62071]
Discontinue desogestrel; ethinyl estradiol if pregnancy is detected as there is no reason to continue combined hormonal contraceptives (CHCs) 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 CHCs before conception or during early pregnancy. The administration of CHCs to induce withdrawal bleeding should not be used as a test for pregnancy. CHCs should not be used during pregnancy to treat threatened or habitual abortion. For any CHC user who has missed 2 consecutive periods, pregnancy should be ruled out before continuing CHC use. If the CHC user has not adhered to the prescribed schedule, consider the possibility of pregnancy at the first missed period; discontinue the CHC until pregnancy is ruled out.[30858] [43312] [50744] [62071]
Manufacturers recommend avoidance of combined hormonal contraceptives (CHCs) during breast-feeding until the lactating individual has completely weaned their child. Small amounts of hormonal contraceptive steroids (estrogens and progestins) have been identified in human milk and a few reports of effects on the infant exist, including jaundice and breast enlargement.[43312] [50744] [62071] The U.S. Medical Eligibility Criteria state that postpartum breast-feeding individuals should not use CHCs during the first 3 weeks after obstetric delivery because of the increased risk for venous thromboembolism, and generally should not use CHCs through the fourth week postpartum because of concerns about potential effects of estrogen on breast-feeding performance during the establishment of lactation. Postpartum individuals with other risk factors for venous thromboembolism generally should not use CHCs until 4 to 6 weeks after delivery. CHCs may be used after 6 weeks postpartum without restriction as thromboembolism risk returns to baseline; if breast-feeding and taking a CHC, general monitoring of the breastfed infant for appetite changes, breast changes, and proper weight gain/growth should occur.[48201] One study found that low-dose CHCs (e.g., 10 mcg per day ethinyl estradiol) may not adversely affect lactation.[48200] However, a systematic review concluded that the available evidence, even from randomized controlled trials, is limited and of low quality; proper trials are needed.[48202] The World Health Organization (WHO) has published contraceptive criteria recommendations that are more restrictive than U.S. recommendations; the WHO criteria state CHCs should not be used in an individual who is breast-feeding before 42 days postpartum and that the disadvantages of using CHCs generally outweigh the advantages between 6 weeks and 6 months postpartum in this group.[48204] Alternate contraceptive agents to consider for the breast-feeding individual include non-hormonal contraceptive methods (e.g., copper IUD, barrier methods) and progestin-only contraceptives (e.g., medroxyprogesterone contraceptive injections, norgestrel oral contraceptive, levonorgestrel IUDs).[48201]
Combined hormonal contraceptives (CHCs) are contraindicated in people with a history of, or known or suspected breast cancer, which may be hormonally-sensitive. Individuals taking CHCs 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. Epidemiology studies have not found a consistent association between use of CHCs and breast cancer risk. Studies do not show an association between ever (current or past) use of CHCs and risk of breast cancer. However, some studies report a small increase in the risk of breast cancer among current or recent users (less than 6 months since last use) and current users with longer duration of CHC use.[43312] [50744] [62071] [48201] If breast cancer is suspected during CHC use, the contraceptive should be discontinued.[48201] Several large, well-designed observational studies have provided data regarding the risk of breast cancer with CHC use.[27233] [24750] [27234] [62647] From one large study published in 2017, the risk of breast cancer was higher among women who currently or recently used contemporary CHCs than among those who had never used CHCs, 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 100,000 women-years, which corresponds to 1 extra case of breast cancer for every 7,690 CHC users in 1 year. The same study data suggest that any increased risk of breast cancer usually disappears rapidly after an interruption in the use of CHCs.[62904] There continues to be controversy regarding the risk of CHC use by individuals with a family history of breast cancer (e.g., BRCA mutations). 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 CHCs.[48201]
Combined hormonal contraceptives (CHCs) are contraindicated in the presence of cervical cancer or other estrogen-responsive tumors. Most cervical cancers are related to the presence of the human papillomavirus (HPV), but hormonal factors influence risk. In women taking CHCs, studies have found an increased risk of cervical cancer compared with never-users. The risk appears to increase with duration of use and appears to decline when CHCs are discontinued. Clinical surveillance of all individuals using CHCs is important; perform pelvic examination and other diagnostic or screening tests, such as cervical cytology, as clinically indicated or as generally recommended based on age, risk factors, and other individual needs.[48201] [43312] [50744] [62071]
The estrogen component of combined oral hormonal contraceptives may raise the serum concentrations of thyroid-binding globulin, sex hormone-binding globulin, and cortisol-binding globulin. Doses of thyroid hormone replacement for hypothyroidism may need to be increased, as indicated by clinical and laboratory monitoring for the individual. Cortisol replacement therapy (e.g., corticosteroid therapy) may also need adjusted for some patients.[43312] [50744] [62071]
Combined hormonal contraceptives (CHCs) are contraindicated in people with known endometrial cancer or other estrogen-dependent tumors (e.g., vaginal cancer, uterine cancer, ovarian cancer), as such tumors are hormonally-sensitive. CHCs are also contraindicated in people with undiagnosed vaginal bleeding; evaluate such patients before use to determine if a contraindication to use exists.[48201] [43312] [50744] [62071] The use of CHCs appears to have a protective effect against some cancers. A meta-analysis of 10 studies indicates a significant trend in decreasing endometrial and ovarian cancer risk with increasing duration of CHC use. The beneficial effects of CHCs in this regard may persist for 15 years or more after CHC use ceases.[25198] [48201] [62647]
Avoid combined hormonal contraceptives (CHCs) in persons with a history of chloasma gravidarum or increased sensitivity to sun and/or ultraviolet radiation exposure. Chloasma (melasma) may occur with CHC use, especially in people with a history of chloasma gravidarum.[43312] [50744] [62071]
Preexisting morbid obesity is one factor that may increase cardiovascular or thromboembolic risks associated with combination hormonal contraceptives (CHCs). Consider the presence of obesity and other underlying risk factors that may increase the risk of cardiovascular disease or thromboembolism, particularly for people more than 35 years of age.[43312] [50744] [62071] Limited literature suggests that the effectiveness of some hormonal contraceptive formulations might decrease with increasing body mass index (BMI). However, the evidence is conflicting; there are also data to suggest that the efficacy of most CHC products (with a few known exceptions) does not seem to be compromised in those who are overweight.[48201] [66895]
The primary action of the combination of an estrogen with a progestin is to suppress the hypothalamic-pituitary system, decreasing the secretion of gonadotropin-releasing hormone (GnRH). Progestins blunt luteinizing hormone (LH) release, and estrogens suppress follicle-stimulating hormone (FSH) from the anterior pituitary. Both estrogen and progestin ultimately inhibit maturation and release of the dominant ovule. In addition, viscosity of the cervical mucus increases with hormonal contraceptive use, which increases the difficulty of sperm entry into the uterus. Alteration in endometrial tissues also occurs, which reduces the likelihood of implantation of the fertilized ovum. The contraceptive effect is reversible.[43312][50744][62071]
Both estrogens and progestins are responsible for a number of other metabolic changes. The summary of these changes is dependent on the net actions of the estrogen and progestin combinations. At the cellular level, estrogens and progestins diffuse into their target cells and interact with a protein receptor. Metabolic responses to estrogens and progestins require an interaction between DNA and the hormone-receptor complex. Target cells include the female reproductive tract, the mammary gland, the hypothalamus, and the pituitary. Estrogens increase the hepatic synthesis of sex hormone binding globulin (SHBG), thyroid-binding globulin (TBG), and other serum proteins. Estrogens generally have a favorable effect on blood lipids, reducing LDL and increasing HDL cholesterol concentrations. Serum triglycerides increase with estrogen administration. Folate metabolism and excretion is increased by estrogens and may lead to slight serum folate deficiency. Estrogens also enhance sodium and fluid retention. Progestins are classified according to their progestational, estrogenic and androgenic properties. Progestins can alter hepatic carbohydrate metabolism, increase insulin resistance, and have either little to slightly favorable effects on serum lipoproteins. Less androgenic progestins, like desogestrel, have only slight effects on carbohydrate metabolism. More androgenic progestins can aggravate acne. Serious adverse events, like thrombosis, are primarily associated with the estrogen component of hormonal contraceptives but may be the result of both estrogen and progestin components. The mechanism for thrombosis may be associated with increased clotting factor production and/or decreases in anti-thrombin III. Minor side effects can be addressed by choosing formulations that take advantage of relative estrogen, progestin, and androgenic potencies.[60767]
Revision Date: 10/12/2024, 02:53:00 AMDesogestrel; ethinyl estradiol is administered orally. Both hormones are widely distributed. Ethinyl estradiol is highly but non-specifically protein-bound to albumin. Ethinyl estradiol induces an increase in the serum concentrations of both sex hormone-binding globulin (SHBG) and corticosteroid binding globulin (CBG). Desogestrel is strongly protein-bound, primarily to albumin and sex hormone-binding globulin (SHBG). Estrogens are metabolized in the GI mucosa during absorption and in the liver. The major 1st-pass metabolite of ethinyl estradiol is its sulfate conjugate. Ethinyl estradiol is primarily metabolized in the liver via CYP3A4 to 2-hydroxy-ethinylestradiol. Both ethinyl estradiol and its hydroxylated and methylated metabolites undergo glucuronide and sulfate conjugation. Estrogen conjugates can be hydrolyzed back to the active drug in the GI tract and then undergo entero-hepatic recycling. The progestin desogestrel is rapidly and completely metabolized by hydroxylation and first-pass through the liver to 3-keto-desogestrel, the active metabolite responsible for the pharmacologic actions. Some minor, non-active metabolites have been identified. These occur via conjugation to the sulfate and glucuronate salts. Excretion of the oral contraceptive steroids as inactive metabolites occurs via the urine and feces. Elimination half-life is approximately 38 hours for 3-keto-desogestrel and about 26 hours for ethinyl estradiol at steady state. It is the prolonged biologic effects of the hormones that allows for once-daily administration.
Affected cytochrome P450 (CYP450) isoenzymes and drug transporters: CYP3A4, CYP2B6, CYP2C19, CYP2C9, P-glycoprotein (P-gp)
Ethinyl Estradiol: In vitro and in vivo studies indicate that estrogens are partially metabolized by CYP3A4. Interactions with drugs that are inhibitors or inducers of CYP3A4 are possible.[47343][57085] Ethinyl estradiol is a substrate of the drug transporter P-gp.[60859] While ethinyl estradiol is an in vitro inhibitor of CYP2B6, 2C19, and 3A4 and an in vitro substrate of 2C9, clinically significant drug interactions are not expected through these pathways.
Following oral administration in the third cycle of use, roughly 84% of desogestrel and 83% of ethinyl estradiol survive absorption and first pass through the liver.
Discontinue desogestrel; ethinyl estradiol if pregnancy is detected as there is no reason to continue combined hormonal contraceptives (CHCs) 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 CHCs before conception or during early pregnancy. The administration of CHCs to induce withdrawal bleeding should not be used as a test for pregnancy. CHCs should not be used during pregnancy to treat threatened or habitual abortion. For any CHC user who has missed 2 consecutive periods, pregnancy should be ruled out before continuing CHC use. If the CHC user has not adhered to the prescribed schedule, consider the possibility of pregnancy at the first missed period; discontinue the CHC until pregnancy is ruled out.[30858] [43312] [50744] [62071]
Manufacturers recommend avoidance of combined hormonal contraceptives (CHCs) during breast-feeding until the lactating individual has completely weaned their child. Small amounts of hormonal contraceptive steroids (estrogens and progestins) have been identified in human milk and a few reports of effects on the infant exist, including jaundice and breast enlargement.[43312] [50744] [62071] The U.S. Medical Eligibility Criteria state that postpartum breast-feeding individuals should not use CHCs during the first 3 weeks after obstetric delivery because of the increased risk for venous thromboembolism, and generally should not use CHCs through the fourth week postpartum because of concerns about potential effects of estrogen on breast-feeding performance during the establishment of lactation. Postpartum individuals with other risk factors for venous thromboembolism generally should not use CHCs until 4 to 6 weeks after delivery. CHCs may be used after 6 weeks postpartum without restriction as thromboembolism risk returns to baseline; if breast-feeding and taking a CHC, general monitoring of the breastfed infant for appetite changes, breast changes, and proper weight gain/growth should occur.[48201] One study found that low-dose CHCs (e.g., 10 mcg per day ethinyl estradiol) may not adversely affect lactation.[48200] However, a systematic review concluded that the available evidence, even from randomized controlled trials, is limited and of low quality; proper trials are needed.[48202] The World Health Organization (WHO) has published contraceptive criteria recommendations that are more restrictive than U.S. recommendations; the WHO criteria state CHCs should not be used in an individual who is breast-feeding before 42 days postpartum and that the disadvantages of using CHCs generally outweigh the advantages between 6 weeks and 6 months postpartum in this group.[48204] Alternate contraceptive agents to consider for the breast-feeding individual include non-hormonal contraceptive methods (e.g., copper IUD, barrier methods) and progestin-only contraceptives (e.g., medroxyprogesterone contraceptive injections, norgestrel oral contraceptive, levonorgestrel IUDs).[48201]
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