Norgestrel And Ethinyl Estradiol

WARNINGS 1. Thromboembolic Disorders and Other Vascular Problems Stop Turqoz if an arterial thrombotic event or venous thromboembolic (VTE) event occurs. Stop Turqoz if there is unexplained loss of vision, proptosis, diplopia, papilledema, or retinal vascular lesions. Evaluate for retinal vein thrombosis immediately. If feasible, stop Turqoz at least 4 weeks before and through 2 weeks after major surgery or other surgeries known to have an elevated risk of VTE as well as during and following prolonged immobilization. Start Turqoz no earlier than 4 weeks after delivery, in women who are not breastfeeding. The risk of postpartum VTE decreases after the third postpartum week, whereas the risk of ovulation increases after the third postpartum week. The use of COCs increases the risk of VTE. However, pregnancy increases the risk of VTE as much or more than the use of COCs. The risk of VTE in women using COCs is 3 to 9 cases per 10,000 woman-years. The risk of VTE is highest during the first year of use of COCs and when restarting hormonal contraception after a break of 4 weeks or longer. The risk of thromboembolic disease due to COCs gradually disappears after use is discontinued. Use of COCs also increases the risk of arterial thromboses such as strokes and myocardial infarctions, especially in women with other risk factors for these events. COCs have been shown to increase both the relative and attributable risks of cerebrovascular events (thrombotic and hemorrhagic strokes). This risk increases with age, particularly in women over 35 years of age who smoke. Use COCs with caution in women with cardiovascular disease risk factors. 2. Liver Disease Impaired Liver Function Do not use Turqoz in women with liver disease, such as acute viral hepatitis or severe (decompensated) cirrhosis of the liver [see Contraindications ] . 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. Discontinue Turqoz if jaundice develops. Liver Tumors Turqoz is contraindicated in women with benign and malignant liver tumors [see Contraindications ] . Hepatic adenomas are associated with COC use. An estimate of the attributable risk is 3.3 cases/100,000 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 (>8 years) COC users. However the risk of liver cancers in COC users approaches less than one case per million users. Risk of Liver Enzyme Elevations with Concomitant Hepatitis C Treatment 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 such as COCs. Discontinue Turqoz prior to starting therapy with the combination drug regimen ombitasvir/paritaprevir/ritonavir, with or without dasabuvir [ see Contraindications ]. Turqoz can be restarted approximately 2 weeks following completion of treatment with the combination drug regimen. 3. High Blood Pressure Turqoz is contraindicated in women with uncontrolled hypertension or hypertension with vascular disease [see Contraindications ] . For women with well-controlled hypertension, monitor blood pressure and stop Turqoz if blood pressure rises significantly. An increase in blood pressure has been reported in women taking COCs, and this increase is more likely in older women with extended duration of use. The incidence of hypertension increases with increasing quantities of progestin. 4. Gallbladder Disease Studies suggest a small increased relative risk of developing gallbladder disease among COC users. Use of COCs may worsen existing gallbladder disease. A past history of COC-related cholestasis predicts an increased risk with subsequent COC use. Women with a history of pregnancy-related cholestasis may be at an increased risk for COC related cholestasis. 5. Carbohydrate and Lipid Metabolic Effects Carefully monitor prediabetic and diabetic women who take Turqoz. COCs may decrease glucose tolerance. Consider alternative contraception for women with uncontrolled dyslipidemia. A small proportion of women will have adverse lipid changes while on COCs. Women with hypertriglyceridemia, or a family history thereof, may be at an increased risk of pancreatitis when using COCs. 6. Headache If a woman taking Turqoz develops new headaches that are recurrent, persistent, or severe, evaluate the cause and discontinue Turqoz if indicated. Consider discontinuation of Turqoz in the case of increased frequency or severity of migraine during COC use (which may be prodromal of a cerebrovascular event). 7. Bleeding Irregularities and Amenorrhea Unscheduled Bleeding and Spotting Unscheduled (breakthrough or intracyclic) bleeding and spotting sometimes occur in patients on COCs, especially during the first three months of use. If bleeding persists or occurs after previously regular cycles, check for causes such as pregnancy or malignancy. If pathology and pregnancy are excluded, bleeding irregularities may resolve over time or with a change to a different contraceptive product. In 1,287 patients (pooled data from a number of studies), unscheduled bleeding was recorded in 15 % of first cycles and by Cycle 12 was 5 %. In total, 23 % of subjects reported spotting, 20 % reported unscheduled bleeding, and 2 % reported change in menstrual flow at some point in the studies. In the studies, 1.2 % discontinued use of the product due to breakthrough bleeding and 1 % discontinued due to spotting. Amenorrhea and Oligomenorrhea Women who use Turqoz may experience amenorrhea. A total of 9 % of subjects in the studies reported amenorrhea in one or more cycles. Some women may experience amenorrhea or oligomenorrhea after discontinuation of COCs, especially when such a condition was pre-existent. If scheduled (withdrawal) bleeding does not occur, consider the possibility of pregnancy. If the patient has not adhered to the prescribed dosing schedule (missed one or more active tablets or started taking them on a day later than she should have), consider the possibility of pregnancy at the time of the first missed period and take appropriate diagnostic measures. If the patient has adhered to the prescribed regimen and misses two consecutive periods, rule out pregnancy. 8. Depression Carefully observe women with a history of depression and discontinue Turqoz if depression recurs to a serious degree. 9. Malignant Neoplasms Breast Cancer Turqoz is contraindicated in females who currently have or have had breast cancer because breast cancer may be hormonally sensitive [ see Contraindications ] . Epidemiology studies have not found a consistent association between use of combined oral contraceptives (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 (<6 months since last use) and also among current users with longer duration of COC use [see Adverse Reactions ]. Cervical Cancer Some studies suggest that COC use has been associated with an increase in the risk of cervical cancer or intraepithelial neoplasia. However, there continues to be controversy about the extent to which such findings may be due to differences in sexual behavior and other factors.