Microgestin Fe
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Questions & Answers
Side Effects & Adverse Reactions
| Cigarette smoking increases the risk of serious cardiovascular side effects from oral contraceptive use. This risk increases with age and with heavy smoking (15 or more cigarettes per day) and is quite marked in women over 35 years of age. Women who use oral contraceptives should be strongly advised not to smoke. | |
The use of oral contraceptives is associated with increased risks of several serious conditions including myocardial infarction, thromboembolism, stroke, hepatic neoplasia, and gallbladder disease, although the risk of serious morbidity or mortality is very small in healthy women without underlying risk factors. The risk of morbidity and mortality increases significantly in the presence of other underlying risk factors such as hypertension, hyperlipidemias, obesity, and diabetes.
Practitioners prescribing oral contraceptives should be familiar with the following information relating to these risks.
The information contained in this package insert is principally based on studies carried out in patients who used oral contraceptives with higher formulations of estrogens and progestogens than those in common use today. The effect of long-term use of the oral contraceptives with lower formulations of both estrogens and progestogens remains to be determined.
Throughout this labeling, epidemiological studies reported are of two types: retrospective or case control studies and prospective or cohort studies. Case control studies provide a measure of the relative risk of a disease, namely, a ratio of the incidence of a disease among oral contraceptive users to that among non-users. The relative risk does not provide information on the actual clinical occurrence of a disease. Cohort studies provide a measure of attributable risk, which is the difference in the incidence of disease between oral contraceptive users and non-users. The attributable risk does not provide information about the actual occurrence of a disease in the population (adapted from References 8 and 9 with the author’s permission). For further information, the reader is referred to a text on epidemiological methods.
An increased risk of myocardial infarction has been attributed to oral contraceptive use. This risk is primarily in smokers or women with other underlying risk factors for coronary artery disease such as hypertension, hypercholesterolemia, morbid obesity, and diabetes. The relative risk of heart attack for current oral contraceptive users has been estimated to be two to six (10-16). The risk is very low under the age of 30.
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 (17). 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 (Table II) among women who use oral contraceptives.
Oral contraceptives may compound the effects of well-known risk factors, such as hypertension, diabetes, hyperlipidemias, age and obesity (19). In particular, some progestogens are known to decrease HDL cholesterol and cause glucose intolerance, while estrogens may create a state of hyperinsulinism (20-24). Oral contraceptives have been shown to increase blood pressure among users (see section 9 in WARNINGS). Similar effects on risk factors have been associated with an increased risk of heart disease. Oral contraceptives must be used with caution in women with cardiovascular disease risk factors.
An increased risk of thromboembolic and thrombotic disease associated with the use of oral contraceptives is well established. Case control studies have found the relative risk of users compared to non-users to be 3 for the first episode of superficial venous thrombosis, 4 to 11 for deep vein thrombosis or pulmonary embolism, and 1.5 to 6 for women with predisposing conditions for venous thromboembolic disease (9, 10, 25-30). Cohort studies have shown the relative risk to be somewhat lower, about 3 for new cases and about 4.5 for new cases requiring hospitalization (31). The risk of thromboembolic disease due to oral contraceptives is not related to length of use and disappears after pill use is stopped (8).
A two- to four-fold increase in relative risk of postoperative thromboembolic complications has been reported with the use of oral contraceptives (15,32). The relative risk of venous thrombosis in women who have predisposing conditions is twice that of women without such medical conditions (15,32). If feasible, oral contraceptives should be discontinued at least four weeks prior to and for two weeks after elective surgery of a type associated with an increase in risk of thromboembolism and during and following prolonged immobilization. Since the immediate post-partum period is also associated with an increased risk of thromboembolism, oral contraceptives should be started no earlier than four to six weeks after delivery in women who elect not to breast feed.
Oral contraceptives have been shown to increase both the relative and attributable risks of cerebrovascular events (thrombotic and hemorrhagic strokes), although, in general, the risk is greatest among older (>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 (33-35).
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 (36). The relative risk of hemorrhagic stroke 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 (36). The attributable risk is also greater in older women (9).
A positive association has been observed between the amount of estrogen and progestogen in oral contraceptives and the risk of vascular disease (37-39). A decline in serum high-density lipoproteins (HDL) has been reported with many progestational agents (20-22). A decline in serum high-density lipoproteins has been associated with an increased incidence of ischemic heart disease. Because estrogens increase HDL cholesterol, the net effect of an oral contraceptive depends on a balance achieved between doses of estrogen and progestin and the nature of the progestin used in the contraceptives. The amount and activity of both hormones should be considered in the choice of an oral contraceptive.
Minimizing exposure to estrogen and progestogen is in keeping with good principles of therapeutics. For any particular oral contraceptive, the dosage regimen prescribed should be one which contains the least amount of estrogen and progestogen that is compatible with the needs of the individual patient. New acceptors of oral contraceptive agents should be started on preparations containing the lowest dose of estrogen which produces satisfactory results for the patient.
There are two studies which have shown persistence of risk of vascular disease for ever-users of oral contraceptives. In a study in the United States, the risk of developing myocardial infarction after discontinuing oral contraceptives persists for at least 9 years for women 40 to 49 years who had used oral contraceptives for 5 or more years, but this increased risk was not demonstrated in other age groups (14). In another study in Great Britain, the risk of developing cerebrovascular disease persisted for at least 6 years after discontinuation of oral contraceptives, although excess risk was very small (40). However, both studies were performed with oral contraceptive formulations containing 50 mcg or higher of estrogens.
One study gathered data from a variety of sources which have estimated the mortality rate associated with different methods of contraception at different ages (Table III). These estimates include the combined risk of death associated with contraceptive methods plus the risk attributable to pregnancy in the event of method failure. Each method of contraception has its specific benefits and risks. The study concluded that with the exception of oral contraceptive users 35 and older who smoke and 40 and older who do not smoke, mortality associated with all methods of birth control is low and below that associated with childbirth. The observation of a possible increase in risk of mortality with age for oral contraceptive users is based on data gathered in the 1970’s but not reported until 1983 (41). However, current clinical practice involves the use of lower estrogen dose formulations combined with careful restriction of oral contraceptive use to women who do not have the various risk factors listed in this labeling.
Because of these changes in practice and, also, because of some limited new data which suggest that the risk of cardiovascular disease with the use of oral contraceptives may now be less than previously observed (Porter JB, Hunter J, Jick H, et al. Oral contraceptives and nonfatal vascular disease. Obstet Gynecol 1985;66:1-4 and Porter JB, Hershel J, Walker AM. Mortality among oral contraceptive users. Obstet Gynecol 1987;70:29-32), the Fertility and Maternal Health Drugs Advisory Committee was asked to review the topic in 1989. The Committee concluded that although cardiovascular disease risks may be increased with oral contraceptive use after age 40 in healthy non-smoking women (even with the newer low-dose formulations), there are greater potential health risks associated with pregnancy in older women and with the alternative surgical and medical procedures which may be necessary if such women do not have access to effective and acceptable means of contraception.
Therefore, the Committee recommended that the benefits of oral contraceptive use by healthy non-smoking women over 40 may outweigh the possible risks. Of course, older women, as all women who take oral contraceptives, should take the lowest possible dose formulation that is effective.
| Method of control | ||||||
| and outcome | 15-19 | 20-24 | 25-29 | 30-34 | 35-39 | 40-44 |
| *Deaths are birth related. | ||||||
| **Deaths are method related. | ||||||
| Adapted from H.W. Ory, Reference 41. | ||||||
| No fertility | ||||||
| control methods* | 7.0 | 7.4 | 9.1 | 14.8 | 25.7 | 28.2 |
| Oral contraceptives | ||||||
| non-smoker** | 0.3 | 0.5 | 0.9 | 1.9 | 13.8 | 31.6 |
| Oral contraceptives | ||||||
| smoker** | 2.2 | 3.4 | 6.6 | 13.5 | 51.1 | 117.2 |
| IUD** | 0.8 | 0.8 | 1.0 | 1.0 | 1.4 | 1.4 |
| Condom* | 1.1 | 1.6 | 0.7 | 0.2 | 0.3 | 0.4 |
| Diaphragm/ | ||||||
| spermicide* | 1.9 | 1.2 | 1.2 | 1.3 | 2.2 | 2.8 |
| Periodic | ||||||
| abstinence* | 2.5 | 1.6 | 1.6 | 1.7 | 2.9 | 3.6 |
Numerous epidemiological studies have been performed on the incidence of breast, endometrial, ovarian, and cervical cancer in women using oral contraceptives. Most of the studies on breast cancer and oral contraceptive use report that the use of oral contraceptives is not associated with an increase in the risk of developing breast cancer (42,44,89). Some studies have reported an increased risk of developing breast cancer in certain subgroups of oral contraceptive users, but the findings reported in these studies are not consistent (43,45-49,85-88).
Some studies suggest that oral contraceptive use has been associated with an increase in the risk of cervical intraepithelial neoplasia in some populations of women (51-54). However, there continues to be controversy about the extent to which such findings may be due to differences in sexual behavior and other factors.
In spite of many studies of the relationship between oral contraceptive use and breast and cervical cancers, a cause and effect relationship has not been established.
Benign hepatic adenomas are associated with oral contraceptive use, although the incidence of benign tumors is rare in the United States. Indirect calculations have estimated the attributable risk to be in the range of 3.3 cases/100,000 for users, a risk that increases after four or more years of use (55). Rupture of rare, benign, hepatic adenomas may cause death through intra-abdominal hemorrhage (56,57).
Studies from Britain have shown an increased risk of developing hepatocellular carcinoma (58-60) in long-term (>8 years) oral contraceptive users. However, these cancers are extremely rare in the U.S., and the attributable risk (the excess incidence) of liver cancers in oral contraceptive users approaches less than one per million users.
There have been clinical case reports of retinal thrombosis associated with the use of oral contraceptives. Oral contraceptives should be discontinued if there is unexplained 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.
Extensive epidemiological studies have revealed no increased risk of birth defects in women who have used oral contraceptives prior to pregnancy (61-63). Studies also do not suggest a teratogenic effect, particularly insofar as cardiac anomalies and limb reduction defects are concerned (61,62,64,65), when taken inadvertently during early pregnancy.
The administration of oral contraceptives to induce withdrawal bleeding should not be used as a test for pregnancy. Oral contraceptives should not be used during pregnancy to treat threatened or habitual abortion.
It is recommended that for any patient who has missed two consecutive periods, pregnancy should be ruled out before continuing oral contraceptive use. If the patient has not adhered to the prescribed schedule, the possibility of pregnancy should be considered at the time of the first missed period. Oral contraceptive use should be discontinued if pregnancy is confirmed.
Earlier studies have reported an increased lifetime relative risk of gallbladder surgery in users of oral contraceptives and estrogens (66,67). More recent studies, however, have shown that the relative risk of developing gallbladder disease among oral contraceptive users may be minimal (68-70). The recent findings of minimal risk may be related to the use of oral contraceptive formulations containing lower hormonal doses of estrogens and progestogens.
Oral contraceptives have been shown to cause glucose intolerance in a significant percentage of users (23). Oral contraceptives containing greater than 75 mcg of estrogens cause hyperinsulinism, while lower doses of estrogen cause less glucose intolerance (71). Progestogens increase insulin secretion and create insulin resistance, this effect varying with different progestational agents (23,72). However, in the non-diabetic woman, oral contraceptives appear to have no effect on fasting blood glucose (73). Because of these demonstrated effects, prediabetic and diabetic women should be carefully observed while taking oral contraceptives.
A small proportion of women will have persistent hypertriglyceridemia while on the pill. As discussed earlier (see WARNINGS 1a. and 1d.), changes in serum triglycerides and lipoprotein levels have been reported in oral contraceptive users.
An increase in blood pressure has been reported in women taking oral contraceptives (74) and this increase is more likely in older oral contraceptive users (75) and with continued use (74). Data from the Royal College of General Practitioners (18) and subsequent randomized trials have shown that the incidence of hypertension increases with increasing concentrations of progestogens.
Women with a history of hypertension or hypertension-related diseases, or renal disease (76) should be encouraged to use another method of contraception. If women elect to use oral contraceptives, they should be monitored closely and if significant elevation of blood pressure occurs, oral contraceptives should be discontinued. For most women, elevated blood pressure will return to normal after stopping oral contraceptives (75), and there is no difference in the occurrence of hypertension among ever and never users (74,76,77).
The onset or exacerbation of migraine or development of headache with a new pattern which is recurrent, persistent, or severe requires discontinuation of oral contraceptives and evaluation of the cause.
Breakthrough bleeding and spotting are sometimes encountered in patients on oral contraceptives, especially during the first three months of use. Non-hormonal causes should be considered, and adequate diagnostic measures taken to rule out malignancy or pregnancy in the event of breakthrough bleeding, as in the case of any abnormal vaginal bleeding. If pathology has been excluded, time or a change to another formulation may solve the problem. In the event of amenorrhea, pregnancy should be ruled out.
Some women may encounter post-pill amenorrhea or oligomenorrhea, especially when such a condition was pre-existent.
Legal Issues
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FDA Safety Alerts
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Manufacturer Warnings
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FDA Labeling Changes
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Uses
MICROGESTIN® 1/20, MICROGESTIN® Fe 1/20, MICROGESTIN® 1.5/30, and MICROGESTIN® Fe 1.5/30 are indicated for the prevention of pregnancy in women who elect to use oral contraceptives as a method of contraception.
Oral contraceptives are highly effective. Table I lists the typical accidental pregnancy rates for users of combination oral contraceptives and other methods of contraception. The efficacy of these contraceptive methods, except sterilization, depends upon the reliability with which they are used. Correct and consistent use of methods can result in lower failure rates.
| % of Women Experiencing an Unintended Pregnancy in the First Year of Continuous Use | ||
| Lowest | ||
| Method | Expected* | Typical** |
| Adapted from RA Hatcher et al, Reference 7. | ||
| *The authors’ best guess of the percentage of women expected to experience an accidental pregnancy among couples who initiate a method (not necessarily for the first time) and who use it consistently and correctly during the first year if they do not stop for any other reason. | ||
| **This term represents “typical” couples who initiate use of a method (not necessarily for the first time), who experience an accidental pregnancy during the first year if they do not stop use for any other reason. | ||
| ***N/A - Data not available. | ||
| (No contraception) ...................... | (85) | (85) |
| Oral contraceptives .................... | - | 3 |
| combined ................................ | 0.1 | N/A*** |
| progestin only ........................ | 0.5 | N/A*** |
| Diaphragm with spermicidal | ||
| cream or jelly .............................. | 6 | 20 |
| Spermicides alone (foam, creams, gels, vaginal suppositories, and vaginal film) ................................ | 6 | 26 |
| Vaginal Sponge | ||
| nulliparous .............................. | 9 | 20 |
| parous .................................... | 20 | 40 |
| Implant........................................ | 0.05 | 0.05 |
| Injection: | ||
| depot medroxyprogesterone acetate .................................... | 0.3 | 0.3 |
| IUD | ||
| progesterone T ........................ | 1.5 | 2.0 |
| copper T 380A ........................ | 0.6 | 0.8 |
| LNg 20 .................................... | 0.1 | 0.1 |
| Condom without spermicides | ||
| female...................................... | 5 | 21 |
| male ........................................ | 3 | 14 |
| Cervical Cap with spermicidal | ||
| cream or jelly | ||
| nulliparous .............................. | 9 | 20 |
| parous .................................... | 26 | 40 |
| Periodic abstinence | ||
| (all methods) .............................. | 1-9 | 25 |
| Withdrawal.................................. | 4 | 19 |
| Female sterilization...................... | 0.5 | 0.5 |
| Male sterilization ........................ | 0.10 | 0.15 |
History
There is currently no drug history available for this drug.
Other Information
MICROGESTIN® 1/20, MICROGESTIN® Fe 1/20, MICROGESTIN® 1.5/30, and MICROGESTIN® Fe 1.5/30 are progestogen-estrogen combinations.
The structural formula of norethindrone acetate (17 alpha-ethinyl-19-nortestosterone acetate) and ethinyl estradiol (17 alpha-ethinyl-1, 3, 5(10)-estratriene-3, 17 beta-diol) are as follows:
Microgestin Fe 1/20 provides a continuous dosage regimen consisting of 21 white oral contraceptive tablets and 7 brown ferrous fumarate tablets. The ferrous fumarate tablets are present to facilitate ease of drug administration via a 28-day regimen, are non-hormonal, and do not serve any therapeutic purpose.
Each white tablet, for oral administration, contains 1 mg norethindrone acetate and 20 mcg ethinyl estradiol. It also contains the following inactive ingredients: anhydrous lactose, ethyl alcohol, magnesium stearate, microcrystalline cellulose, polacrilin potassium, and povidone.
Each brown tablet for oral administration contains 75 mg ferrous fumarate, USP, magnesium stearate, NF, microcrystalline cellulose, NF, sodium starch glycolate, NF.
Microgestin Fe 1.5/30 provides a continuous dosage regimen consisting of 21 green oral contraceptive tablets and 7 brown ferrous fumarate tablets. The ferrous fumarate tablets are present to facilitate ease of drug administration via a 28-day regimen, are non-hormonal, and do not serve any therapeutic purpose.
Each green tablet, for oral administration, contains 1.5 mg norethindrone acetate and 30 mcg ethinyl estradiol. It also contains the following inactive ingredients: anhydrous lactose, ethyl alcohol, FD&C green (a composite of D&C yellow No. 10 and FD&C blue No. 1), magnesium stearate, microcrystalline cellulose, polacrilin potassium, and povidone.
Each brown tablet for oral administration contains 75 mg ferrous fumarate, USP, magnesium stearate, NF, microcrystalline cellulose, NF, sodium starch glycolate, NF.
Sources
Microgestin Fe Manufacturers
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Physicians Total Care, Inc.
![Microgestin Fe (Norethindrone Acetate And Ethinyl Estradiol And Ferrous Fumarate) Kit Microgestin (Norethindrone Acetate And Ethinyl Estradiol) Tablet [Physicians Total Care, Inc.]](/wp-content/themes/bootstrap/assets/img/loading2.gif)
Microgestin Fe | Physicians Total Care, Inc.
The tablet dispenser has been designed to make oral contraceptive dosing as easy and as convenient as possible. The tablets are arranged in three or four rows of seven tablets each, with the days of the week appearing on the tablet dispenser above the first row of tablets.
Important: The patient should be instructed to use an additional method of protection until after the first week of administration in the initial cycle when utilizing the Sunday-Start Regimen.
The possibility of ovulation and conception prior to initiation of use should be considered.
Dosage and Administration for 21-Day Dosage RegimenTo achieve maximum contraceptive effectiveness, MICROGESTIN 1/20 and MICROGESTIN 1.5/30 should be taken exactly as directed and at intervals not exceeding 24 hours.
MICROGESTIN 1/20 and MICROGESTIN 1.5/30 provide a convenient tablet schedule of “3 weeks on-1 week off.” Two dosage regimens are described, one of which may be more convenient or suitable than the other for an individual patient. For the initial cycle of therapy, the patient begins her tablets according to the Day-1 or Sunday-Start regimen. With either regimen, the patient takes one tablet daily for 21 consecutive days followed by one week of no tablets.
A. Sunday-Start Regimen:
The patient begins taking the first white or green tablet from the top row of the dispenser (labeled Sunday) on the first Sunday after menstrual flow begins. When menstrual flow begins on Sunday, the first white or green tablet is taken on the same day. The patient takes one white or green tablet daily for 21 days. The last white or green tablet will be taken on a Saturday, followed by no tablets for a week (7 days). For all subsequent cycles, the patient begins a new 21-tablet regimen on the eighth day, Sunday, after taking her last tablet. Following this regimen of 21 days on-7 days off, the patient will start all subsequent cycles on a Sunday.
B. Day-1 Start Regimen:
The first day of menstrual flow is Day 1. The patient starts taking one white or green tablet daily, beginning with the first white or green tablet in the top row. After the last white or green tablet (Saturday) has been taken, if any white or green tablets remain in the top row, the patient takes the remaining white or green tablets starting with the Sunday white or green tablets in the top row until all of the tablets have been taken. She will then take no tablets for a week (7 days). For all subsequent cycles, the patient begins a new 21- tablet regimen on the eighth day after taking her last white or green tablet, again starting with the first tablet in the top row. Following this regimen of 21 days on–7 days off, the patient will start all subsequent cycles on the same day of the week as the first course. Likewise, the interval of no tablets will always start on the same day of the week.
Tablets should be taken regularly with a meal or at bedtime. It should be stressed that efficacy of medication depends on strict adherence to the dosage schedule.
Dosage and Administration for 28-Day Dosage RegimenTo achieve maximum contraceptive effectiveness, MICROGESTIN Fe 1/20 and MICROGESTIN Fe 1.5/30 should be taken exactly as directed and at intervals not exceeding 24 hours.
MICROGESTIN Fe 1/20 and MICROGESTIN Fe 1.5/30 provide a continuous administration regimen consisting of 21 white or green tablets of Microgestin and 7 brown non-hormone containing tablets of ferrous fumarate. The ferrous fumarate tablets are present to facilitate ease of drug administration via a 28-day regimen and do not serve any therapeutic purpose. There is no need for the patient to count days between cycles because there are no “off-tablet days.”
A. Sunday-Start Regimen:
The patient begins taking the first white or green tablet from the top row of the dispenser (labeled Sunday) on the first Sunday after menstrual flow begins. When menstrual flow begins on Sunday, the first white or green tablet is taken on the same day. The patient takes one white or green tablet daily for 21 days. The last white or green tablet will be taken on a Saturday. Upon completion of all 21 white or green tablets, and without interruption, the patient takes one brown tablet daily for 7 days. Upon completion of this first course of tablets, the patient begins a second course of 28-day tablets, without interruption, the next day, Sunday, starting with the Sunday white or green tablet in the top row. Adhering to this regimen of one white or green tablet daily for 21 days, followed without interruption by one brown tablet daily for 7 days, the patient will start all subsequent cycles on a Sunday.
B. Day-1 Start Regimen:
The first day of menstrual flow is Day 1. The patient starts taking one white or green tablet daily, beginning with the first white or green tablet in the top row. After the last white or green tablet (Saturday) has been taken, if any white or green tablets remain in the top row, the patient takes the remaining white or green tablets starting with the Sunday white or green tablets in the top row, followed by the brown tablets for a week (7 days). For all subsequent cycles, the patient begins a new 28 tablet regimen on the eighth day after taking her last white or green tablet, again starting with the first tablet in the top row. Following this regimen of 21 white or green tablets and 7 brown tablets, the patient will start all subsequent cycles on the same day of the week as the first course.
Tablets should be taken regularly with a meal or at bedtime. It should be stressed that efficacy of medication depends on strict adherence to the dosage schedule.
Special Notes on AdministrationMenstruation usually begins two or three days, but may begin as late as the fourth or fifth day, after the patient has taken the last white or green tablet. In any event, the next course of tablets should be started without interruption. If spotting occurs while the patient is taking white or green tablets, continue medication without interruption.
If the patient forgets to take one or more white or green tablets, the following is suggested:
One tablet is missed
take tablet as soon as remembered
take next tablet at the regular time
Two consecutive tablets are missed (week 1 or week 2)
take two tablets as soon as remembered
take two tablets the next day
use another birth control method for seven days following the missed tablets
Two consecutive tablets are missed (week 3)
Sunday-Start Regimen:take one tablet daily until Sunday
discard remaining tablets
start new pack of tablets immediately (Sunday)
use another birth control method for seven days following the missed tablets
Day-1 Start Regimen:
discard remaining tablets
start new pack of tablets that same day
use another birth control method for seven days following the missed tablets
Three (or more) consecutive tablets are missed
Sunday-Start Regimen:
take one tablet daily until Sunday
discard remaining tablets
start new pack of tablets immediately (Sunday)
use another birth control method for seven days following the missed tablets
Day-1 Start Regimen:
discard remaining tablets
start new pack of tablets that same day
use another birth control method for seven days following the missed tablets
The possibility of ovulation occurring increases with each successive day that scheduled white or green tablets are missed. While there is little likelihood of ovulation occurring if only one white or green tablet is missed, the possibility of spotting or bleeding is increased. This is particularly likely to occur if two or more consecutive white or green tablets are missed.
If the patient is taking MICROGESTIN Fe (28-Day Dosage Regimen) and forgets to take any of the seven brown tablets in week four, those brown tablets that were missed are discarded and one brown tablet is taken each day until the pack is empty. A back up birth control method is not required during this time. A new pack of tablets should be started no later than the eighth day after the last white or green tablet was taken.
In the rare case of bleeding which resembles menstruation, the patient should be advised to discontinue medication and then begin taking tablets from a new tablet dispenser on the next Sunday or the first day (Day-1), depending on her regimen. Persistent bleeding which is not controlled by this method indicates the need for re-examination of the patient, at which time nonfunctional causes should be considered.
Use of Oral Contraceptives in the Event of a Missed Menstrual PeriodIf the patient has not adhered to the prescribed dosage regimen, the possibility of pregnancy should be considered after the first missed period and oral contraceptives should be withheld until pregnancy has been ruled out.
If the patient has adhered to the prescribed regimen and misses two consecutive periods, pregnancy should be ruled out before continuing the contraceptive regimen.
After several months on treatment, bleeding may be reduced to a point of virtual absence. This reduced flow may occur as a result of medication, in which event it is not indicative of pregnancy.
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