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LOESTRIN PATIENT INFORMATION LEAFLET INSTRUCTIONS FOR USE OF 21-TABLET PACKS
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This leaflet is designed to help you use correctly Parke-Davis 21-tablet combined oral contraceptive (combination of two hormones) and to answer many of the questions that you may have about the pill. It cannot tell you everything about the pill because this requires explanation by your doctor as much of it may not apply to your particular circumstances.
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The pill has been extensively researched, and vast experience has confirmed that it can be safely used by the majority of women. Nevertheless, it is important to recognise that, however wide medical experience of a product becomes, its complete safety in all users can never be guaranteed, since every person is unique, and that with the pill, or with any other medicinal product, some risk must be accepted. The pill is available to you only on prescription because your doctor’s professional knowledge and judgment are required to supervise its use. Therefore, the leaflet is not intended to take the place of his information and instructions to you, but to reinforce them. Ask him to explain anything that you do not understand, and do not hesitate to consult him if you have any doubts or anxieties about your use of the pill or the effect it may be having on you.
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THE BENEFITS OF COMBINED ORAL CONTRACEPTIVES
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Pills of this type are highly effective reversible forms of contraception. In addition, they have advantages not provided by other methods. Generally, irregular periods are replaced by regular bleeding, and heavy periods by lighter bleeding. Painful periods are in most cases abolished. The symptoms that often make the last few days before a period so unpleasant a part of every month (known as the premenstnual syndrome) are commonly eliminated. Finally, because of the combined pill’s outstanding reliability, all the risks that result from failure of contraception - in other words from pregnancy - are much less than with other methods.
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HOW PREGNANCY IS PREVENTED
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From the beginning of sexual maturity until the change of life, the ovaries normally release an egg cell (ovulate) every month. If it is fertilized by a man’s sperm, it becomes embedded in the womb and begins to grow. From then on, the ovaries produce increased amounts of hormone to maintain the pregnancy and to prevent further egg cells from developing. Thus, in pregnancy, development of egg cells is inhibited by the body’s own hormones.
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Combined oral contraceptives contain similar hormones, and therefore ad in a similar way, so that normally when an oral contraceptive is taken no egg cells are released for fertilization. In addition, the fluid present in the neck of the womb remains thick, so that it is more difficult for sperms to enter the womb. Also, the lining of the womb is not prepared sufficiently for a fertilised egg to grow in it. A combined oral contraceptive thus offers protection against pregnancy in several ways.
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BEFORE STARTING THE PILL
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There are certain medical conditions that nub out the use of this type of pill, which are listed later under ‘Contra-indications’. There are certain other conditions that, while not ruling out the pill, indicate the need for careful consideration before a decision is taken to use the pill, and which require supervision during its use. These conditions are referred to under ‘Warnings and Precautions’. Your doctor will have considered whether or not any of the conditions referred to under those headings apply to you, but before you start taking the pill, d you are in any doubt, discuss the matter with him again.
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HOW TO TAKE THE PILL About the pack
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This memo-pack has been specially designed to help your memory; in fact, it does the counting for you. Each pill is placed in a section marked with the day of the week on which it should be taken. If, at any time, you are in doubt whether you have taken your pill, a glance at the appropriate day on the memo-pack will tell you.
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Taking your first course
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If you are having as usual, count the first day of bleeding of your next period as day 1, and take your first pill on that day. Choose a pill marked with the correct day of the week. One Loestrin tablet should be taken daily for three weeks. Following the direction of the arrows, take a pill each day until the pack is empty.
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2
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If you have just had a baby, it is usual to wait until your first period before starting the pill, but you should realise that it is possible to get pregnant before the first period, and use some other form of contraception in the meantime. If you are breastfeeding, or want to start the pill earlier, you should get your doctor’s advice.
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After a miscarriage or abortion within the first twelve weeks of pregnancy, oral contraceptives can normally be started at once.
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If you are changing from another oral contraceptive, leave whatever break is appropriate between courses of that contraceptive before starting the new one.
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If the starting day was not the first day of menstrual bleeding, you should use an additional contraceptive for the first 7 days of the first pack in addition to taking the tablets. Suitable methods are sheaths. cap plus spermicide, and intra-uterine devices. The rhythm, temperature and cervical-mucus methods cannot be used.
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Additional precautions are not needed subsequently. except when special circumstances reduce the reliability of the pill, as described under ‘Reduced protection’. Except in those circumstances, the protection provided by the pill is continuous, and this includes the weeks between the courses of pill when you are taking no tablets.
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Subsequent courses
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Allow an interval of one tablet-free week before commencing the second and subsequent courses of tablets. Each new course of tablets is always started on the same day of the week.
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IRREGULAR BLEEDING  If bleeding is missed
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If, as may occasionally happen, you should have no bleeding at all in the seven days after a course of pills, and you have taken the tablets correctly, it is very unlikely that you are pregnant, but the possibility should be ruled out by your doctor before you start a new course of pills.
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If bleeding starts while you are taking tablets
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If bleeding occurs during the three weeks in which you are taking the pills do not stop taking them. The bleeding should stop in a day or two. However, if the bleeding is troublesome, very heavy, prolonged or recurrent, you should consult your doctor. Bleeding while the pills are being taken does not mean that the pill does not suit you, nor does it necessarily mean that contraceptive protection is lost (but see ‘Interaction with other medicines’). If bleeding does occur during pill-taking, it is usually only in the first two or three months, while your body is adjusting itself to the pill.
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REDUCED PROTECTION If you forget to take your pill
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If you forget to take a pill at the usual time, it must be taken as soon as possible and the next tablet taken at the normal time. If the delay exceeds twelve hours, additional contraception (which must be a sheath, or cap and spermicide) should be used for the next seven days, while the next seven tablets are being taken; then continue as usual according to instructions. If your period fails to occur, consult your doctor immediately before starting your next course. If pills have been missed during the last seven days of the pack, there should be no break before the next pack is started.
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If you have a stomach upset
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Vomiting and diarrhoea may interfere with absorption of the pill and reduce its contraceptive effect. If you do get such a stomach upset, continue to take the pills, but you should use another method of contraception, which must be a sheath or cap plus spermicide, during and for seven days after the upset. If those seven days overrun the end of the pack, the next pack should be started without a break.
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Interaction with other medicines
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Some medicines may reduce the effectiveness of oral contraceptives when taken at the same time. They include certain sedatives, antibiotics and anti-epileptic drugs. Suspicion that the reliability of an oral contraceptive is reduced in this way is sometimes raised by occurrence of irregular bleeding. If you are taking any medicines at all while you are also taking an oral contraceptive, be sure to tell your doctor, who can advise you whether or not you should take additional contraceptive precautions.
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By law, certain information must appear in any leaflet of this kind, and must be kept separate from the rest of the contents. That information comprises the remainder of this leaflet.
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3 CONTRA-INDICATIONS
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You should not take a combined oral contraceptive if you have any of the following: clots in the blood vessels (thrombotic disorders), or a history of these conditions: abnormal red blood cells (sickle-cell anaemia); high blood fats (disorders of lipid metabolism) and other conditions in which there is known or suspected to be a much increased risk of thrombosis (eg severe forms of the condition referred to in paragraph 2 of ‘Warnings’ or the presence of a number of these conditions); a possible pregnancy; cancer of the breasts or of the lining of the womb (mammary or endometrial carcinoma) or a history of these conditions; abnormal vaginal bleeding of unknown cause; a history during pregnancy of (1) itching of the whole body (pruritus of pregnancy), (2) shingles (herpes) of pregnancy, (3) inherited deafness (otosclerosis), or (4) jaundice not explained by infections, poisons or obstruction of the flow of bile (idiopathic jaundice of pregnancy); certain other types of jaundice (Dubin-Johnson or Rotor syndromes); any short-term or severe long-term liver disease.
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WARNINGS
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There is a general opinion, based on statistical evidence, that users of combined oral contraceptives experience more often than non-users various disorders of the circulation of blood, including strokes (blood clots in and haemorrhages from the blood-vessels of the brain), heart attacks (coronary thromboses), and blood clots obstructing the arteries of the lungs (pulmonary emboli). There may not be a full recovery from such disorders and it should be realized that in a few cases they are fatal. How often these disorders occur in users of modem contraceptives is not known, but there are reasons for suggesting that they may occur less often than with older pills containing more oestrogen.
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Certain conditions carry some risk of thrombosis. They include smoking, obesity, varicose veins, some diseases of the heart and blood vessels, diabetes and migraine. If any of these conditions apply to you, the advisability of your taking a combined oral contraceptive should be discussed with your doctor before you decide to take the pill. The risk of arterial thrombosis (eg heart attack and stroke) associated with combined oral contraceptives increases with age, and this risk is aggravated by cigarette smoking. For this reason, the use of combined oral contraceptives by women in the older age group, especially those who are cigarette smokers, is to be discouraged.
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The possibility cannot be ruled out that certain chronic diseases may occasionally deteriorate during the use of combined oral contraceptives. The diseases are those listed as requiring careful observation under ‘Precautions’.
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Very rarely, tumours of the liver have been reported in users of combined oral contraceptives, especially it they have been taken for a long time.
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Many studies have been reported on the risks of ovarian, endometrial, cervical and breast cancer in women using combined oral contraceptives. The evidence is clear that combined oral contraceptives other substantial protection against both ovarian and endometrial cancer.
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An increased risk of cervical cancer in long term users of combined oral contraceptives has been reported in some studies, but this may also be attributable to other factors, such as sexual behaviour.
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The evidence linking combined oral contraceptive use and breast cancer remains inconclusive. The results of some studies suggest an increased risk of breast cancer in those under about 35, the risk rising with duration of use. Any possible increased risk of breast cancer with combined oral contraceptives is however likely to be small. This possible risk should be weighed against the many benefits of combined oral contraceptives, including their protective effects against ovarian and endometrial cancers.
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Reasons for stopping oral contraceptives immediately.
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You should take no further oral contraceptive tablets and should consult your doctor immediately if you experience any of the following: the very first attack of migraine (typically a throbbing headache and nausea, preceded by visual disturbances) that you have ever experienced; worsening of pre-existing migraine; any unusually frequent or unusually severe headaches; dizziness or fainting; sudden disturbance of vision; disturbance of speech; inflamed veins (phlebitis); pains in the chest or abdomen; swelling in the limbs; pain, tingling or numbness in any part of the body; unexplained cough; breathlessness; pain on breathing. Any of these symptoms might indicate the beginning of immediate risk of a serious thrombosis.
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The risk of thrombosis is increased after many injuries, especially fractures, during and after many surgical operations, and during immobilisation, eg after accidents. Combined oral contraceptives should be stopped immediately when immobilisation (i.e. inability to move freely) is necessary.
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4
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Your doctor will probably stop the pill at once if you become jaundiced, or if he finds your blood pressure to be significantly raised, or if any of the conditions known to be capable of deteriorating during oral contraception or pregnancy (referred to under 'Precautions') should show clear signs of deteriorating.
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You should stop the pill immediately if pregnancy is diagnosed, or if there are reasonable grounds for suspecting that you may be pregnant, since it has been suggested that combined oral contraceptives, in common with many other substances, might be capable of affecting the normal development of the child in the early stages of pregnancy. It can be definitely concluded, however, that, if a risk of abnormality (foetal &amp; malformation) exists at all, it is very small. q
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PRECAUTIONS
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Examination of the pelvic organs, breasts and blood pressure should precede the prescribing of any oral contraceptive, and should be repeated regularly. The possibility of existing pregnancy should be ruled out.
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The following conditions require careful observation while you are taking the pill: a history of severe depressive states, varicose veins, diabetes, high blood pressure (hypertension), fits (epilepsy), the inherited form of deafness known as otosclerosis, the disease of the nervous system called multiple sclerosis, the inherited metabolic disease called porphyria, calcium deficiency with cramps (tetany), disturbed liver function, gallstones, diseases of the heart and blood vessels (cardiovascular diseases), kidney diseases, brown patches on the face and body such as occur during pregnancy (chloasma), fibroids of the womb, asthma, the wearing of contact lenses, or any disease that is prone to worsen during  pregnancy (your doctor can explain any of these terms you do not understand). The worsening or first appearance of any of these conditions may indicate that the oral contraceptive should be stopped.
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The risk of the deterioration of chloasma, which is often not fully reversible, is reduced by the avoidance of excessive exposure to sunlight.
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SIDE EFFECTS
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Occasional side effects may include nausea, vomiting, headaches, breast tension, changes in body weight or interest in sex (libido) and depressive moods; and possible deterioration or recurrence of the conditions mentioned in paragraph 2 of 'Precautions'.
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It is not easy to decide whether or not something that you notice Is the result of your taking the pill, since among millions of women during long periods of treatment many symptoms are bound to appear that are quite unconnected with the use of the pill. Studies comparing oral contraceptives with dummy tablets have suggested that true side effects experienced by the users are few, and are mainly short-lasting However, such studies may not detect rare or long term side effects. Most known or suspected side effects are of a minor nature and are reversible, but not all. Ask your doctor about any change in your health or general sense of well being that you notice while taking an oral contraceptive.
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Store below 30°C In a dry place.
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Keep out of the reach of children
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Each tablet of LOESTRIN 20 contains 1 mg Norethisterone acetate PhEur and 20 micrograms Ethinyloestradiol PhEur.
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Each tablet of LOESTRIN 30 contains 1.5 mg Norethisterone acetate PhEur and 30 micrograms Ethinyloestradiol PhEur.
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Product Licence Number LOESTRIN 200018/0086 LOESTRIN 300018/0087 
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Parke, Davis &amp; Company, Pontypool, Gwent, U.K.
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November 1993 Loestrin is a trade mark
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