TRANSFORM HOW YOU USE DRUG INFORMATION

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 oral contraceptive 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 four weeks or more.[41608] 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 greater 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.

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).[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] [41608] [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 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.[43312] [50744] [62071]

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.[43312] [50744] [62071]

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.[43312] [50744] [62071]

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.[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]

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. benefit of COC use in these patients. Avoid COC use in SLE patients with a history of venous or arterial thrombosis or the presence of a hypercoagulable state. If COCs 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. Combined hormonal oral contraceptive (COC) use has also been reported to induce, unmask, or exacerbate SLE; more data are needed.[31435] [48201]

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.[43312] [50744] [62071]

Manufacturers recommend avoidance of combined hormonal oral contraceptives (COCs) if possible during breast-feeding until a mother has completely weaned her child.[43312] [50744] [62071] 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.[48201] 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.[48204] One study found that lower dose oral combined contraceptives (e.g., 10 mcg per day EE) may not affect lactation.[48200] However, a systematic review concluded that the available evidence, even from randomized controlled trials, is limited and of poor quality; proper trials are needed.[48202] 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.g., medroxyprogesterone injection).[48201]

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.g., uncompensated cirrhosis). Do not use hormonal contraceptives in patients with a history of cholestatic jaundice/pruritus of pregnancy or jaundice from prior hormonal contraceptives; these conditions can recur with subsequent COC use. Discontinue the COC if jaundice develops during COC use. 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. Patients with hepatitis C who are being treated with ombitasvir/paritaprevir/ritonavir, with or without dasabuvir are also contraindicated to receive COCs. 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 women using ethinyl estradiol-containing medications. Discontinue combined oral contraceptives prior to starting hepatitis C therapy with the combination drug regimen ombitasvir/paritaprevir/ritonavir, with or without dasabuvir; COCs can be restarted approximately 2 weeks following completion of treatment with the hepatitis C combination drug regimen. Hepatic adenomas are associated with COC use. An estimate of the attributable risk is 3.3 cases/100,000 COC users. 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.[43312] [50744] [62071] [48201]

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.[43312] [50744] [62071]

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. 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] Several large, well-designed observational studies have provided data regarding the risk of breast cancer with combined oral contraceptive (COC) 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 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.[48201]

Desogestrel; ethinyl estradiol is 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 COCs, studies have found a slightly increased risk of cervical cancer compared with never-users. The risk appears to increase with duration of use and appears to decline when COCs are discontinued. Clinical surveillance of all women using COCs is important; all women receiving COC treatment should have a 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]

In those women with known endometrial cancer or other estrogen-dependent tumors (e.g., vaginal cancer, uterine cancer, ovarian cancer), combined hormonal contraceptives are contraindicated, as such tumors are hormonally sensitive. Hormonal contraceptives are contraindicated in women with undiagnosed vaginal bleeding; evaluate such patients before combined hormonal contraceptive use to determine if a contraindication to use exists.[48201] [43312] [50744] [62071] The use of combined oral contraceptives (COCs) appears to have a protective effect against some cancers. In women using COCs, a meta-analysis of 10 studies indicates a significant trend in decreasing endometrial and ovarian cancer risk with increasing duration of COC use. The beneficial effects of COCs in this regard may persist for 15 years or more after COC use ceases.[25198] [48201] [62647]

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] 

Chloasma may occur with combined oral hormonal contraceptive (COC) use, especially in women with a history of chloasma gravidarum (melasma). Advise females who tend to develop chloasma to avoid exposure to the sun or ultraviolet (UV) exposure while taking desogestrel; ethinyl estradiol.[43312] [50744] [62071]

Preexisting morbid obesity is one factor that may increase cardiovascular or thromboembolic risks associated with combination hormonal contraceptive use. Consider the presence of obesity and other underlying risk factors that may increase the risk of cardiovascular disease or thromboembolism, particularly for women over 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 combined hormonal contraceptive products (with a few known exceptions) does not seem to be compromised in women who are overweight.[48201] [66895]

The safety and efficacy of hormonal contraceptive products, like desogestrel; ethinyl estradiol, have only been established in females of reproductive age. Safety and efficacy of hormonal birth control is expected to be the same for postpubertal children under the age of 16 and for users 16 years of age and older. Use of hormonal contraceptive products in female children before menarche is not indicated.[43312] [50744] [62071]