4.1. Therapeutic indications

Contraception.

The decision to prescribe Millinette should take into consideration the individual woman's current risk factors, particularly those for venous thromboembolism (VTE), and how the risk of VTE with Millinette compares with other combined hormonal contraceptives (CHCs) (see sections 4.3 and 4.4).

4.2. Posology and method of administration

Do not start or continue with Millinette in case of known or suspected pregnancy.

Posology

How is Millinette taken?

To patients who use a package with 21 active tablets:

The tablets 1-21 contain active substances (active tablets).

The tablets must be taken in the order given on the blister pack, every day at approximately the same time point. One active tablet is taken daily for 21 consecutive days followed by a 7 day tablet-free interval. Every subsequent blister pack is started after a tablet-free interval during which time a withdrawal bleeding occurs. This bleeding will usually start on the 2nd or 3rd day after the last tablet has been taken and it may not have stopped, before the next blister pack is started.

How to start Millinette

No preceding hormonal contraceptive use in the past month

The tablets should be started on day 1 in the woman's normal cycle (i.e. on the first day of the woman has a menstrual bleeding). It is acceptable to start the tablets on day 2-5, but during the first cycle the concomitant use of non-hormonal contraception (e.g. condom or spermicide) for the first 7 days is recommended.

Changing from another combined oral pill

The woman should start with Millinette on the day following the usual tablet-free or placebo tablet interval of her previous COC.

Changing from a progestogen-only method (mini pills, injection, implant, intrauterine system)

The woman may switch from progestogen-only pills on any day (from an implant or intrauterine system on the day the implant or the progestogen-containing intrauterine system is removed, from injection, when the next injection should have been given). In all these cases, the woman should be advised to use a concomitant barrier method for the first 7 days of the tablet intake.

After an abortion in 1st trimester

The woman may start the tablet intake immediately. In this case, it is not necessary to take further contraceptive precautions.

After delivery or abortion in 2nd trimester

For breastfeeding women - see section 4.6.

The woman should be advised to start on day 21- 28 after delivery in non-lactating women or abortion in the 2nd trimester. She should also be advised to use a concomitant contraception method during the first 7 days of tablet intake. However, if she already has had intercourse, pregnancy must be excluded, before she starts the tablets, or she should wait for her first menstrual bleeding.

Missed tablets

The contraceptive effect may be reduced in case of forgotten tablet intake, especially if the forgotten tablets prolong the tablet-free interval.

If the woman has forgotten tablet intake for less than 12 hours, the woman should take the tablet as soon as she remembers this, and the remaining tablets should be taken at the usual time.

If the delay exceeds 12 hours, the contraceptive protection may be reduced.

The woman should take the last missed tablet as soon as she remembers this, even if this means that she has to take 2 tablets at the same time. Hereafter, she continues taking the tablets at the usual time point. She should also use a barrier method concomitantly for the next 7 days.

If there are less than 7 days back in the actual package the woman should continue taking the pills in the package until the actual package is empty, there will be no tablet-free interval. This will prevent a prolonged tablet-free interval, which increases the risk of premature ovulation. A withdrawal bleeding is unlikely until the end of the second blister pack, but she may experience spotting or break through bleeding on the days she is taking tablets.

If no bleeding occurs after finishing the second package the possibility of pregnancy must be eliminated before the woman continues with the tablets in the next package.

Advice in the case of vomiting/diarrhoea

If vomiting occurs within 3-4 hours after tablet taking, absorption may not be complete. In this case the advice concerning missed tablets, described in the section “Missed tablets” should be followed. The woman should take the required extra tablet(s) from another blister pack.

In case of longer lasting or severe gastrointestinal symptoms, the woman should be advised to use another contraceptive method and/or to contact her physician.

How to delay or shift a withdrawal bleeding

In order to delay a withdrawal bleeding, the woman should continue the next blister pack of Millinette without a tablet-free interval. The extension can be carried on for as long as is desired until the end of the second blister pack. During the extension the woman may experience break through bleeding or spotting. Regular intake of Millinette is resumed after the usual 7 days tablet-free interval.

To move menstruation to a weekday other than that on which the woman is used to having it under the current tablet schedule, she can be advised to shorten the next tablet-free period by as many days as she wishes. The shorter the pause, the higher the risk that she will not get her menstruation and will have withdrawal bleeding or spotting while she is taking the next pack (which is also true when menstruation is being delayed).

Special population

Elderly

Not applicable. Millinette is not indicated for use in postmenopausal women.

Hepatic impairment

Millinette is contraindicated in women with hepatic impairment (see section 4.3).

Renal impairment

There are no data available in patients with renal impairment.

Paediatric population

Millinette is indicated only after first menstrual bleeding.

Method of administration

For oral use.

4.3. Contraindications

Combined oral contraceptives (COCs) must not be used in the presence of the conditions listed below. Should any of the conditions appear for the first time during COC use, the product must be stopped immediately:

- Presence or risk of venous thromboembolism (VTE)

- Venous thromboembolism – current VTE (on anticoagulants) or history of (e.g. deep venous thrombosis [DVT] or pulmonary embolism [PE]).

- Known hereditary or acquired predisposition for venous thromboembolism, such as APC-resistance, (including Factor V Leiden), antithrombin-III-deficiency, protein C deficiency, protein S deficiency

- Major surgery with prolonged immobilisation (see section 4.4)

- A high risk of venous thromboembolism due to the presence of multiple risk factors (see section 4.4)

- Presence or risk of arterial thromboembolism (ATE)

- Arterial thromboembolism – current arterial thromboembolism, history of arterial thromboembolism (e.g. myocardial infarction) or prodromal condition (e.g. angina pectoris)

- Cerebrovascular disease – current stroke, history of stroke or prodromal condition (e.g. transient ischaemic attack, TIA)

- Known hereditary or acquired predisposition for arterial thromboembolism, such as hyperhomocysteinaemia and antiphospholipid-antibodies (anticardiolipin-antibodies, lupus anticoagulant).

- History of migraine with focal neurological symptoms.

- A high risk of arterial thromboembolism due to multiple risk factors (see section 4.4) or to the presence of one serious risk factor such as:

- diabetes mellitus with vascular symptoms

- severe hypertension

- severe dyslipoproteinaemia

- Present or previous pancreatitis if associated with serious hypertriglyceridaemia;

- Precent or previous serious hepatic disorders, as long as liver function tests are not normalised;

- Known or suspected sex-steroid influenced malignant conditions of e.g. the breasts or genital organs;

- Present or previous benign or malignant liver tumours;

- Undiagnosed vaginal bleeding;

- Hypersensitivity to the active substances or to any of the excipients listed in section 6.1.

Millinette is contraindicated for concomitant use with the medicinal products containing ombitasvir/paritaprevir/ritonavir and dasabuvir, medicinal products containing glecaprevir/pibrentasvir or sofosbuvir/velpatasvir/voxilaprevir (see section 4.5).

4.4. Special warnings and precautions for use

Medical examination/Consultation

Prior to the initiation or reinstitution of Millinette a complete medical history (including family history) should be taken and pregnancy must be ruled out. Blood pressure should be measured and a physical examination should be performed, guided by the contra-indications (see section 4.3) and warnings (see section 4.4). It is important to draw a woman's attention to the information on venous and arterial thrombosis, including the risk of Millinette compared with other CHCs, the symptoms of VTE and ATE, the known risk factors and what to do in the event of a suspected thrombosis.

The woman should also be instructed to carefully read the user leaflet and to adhere to the advice given. The frequency and nature of examinations should be based on established practice guidelines and be adapted to the individual woman.

Women should be advised that hormonal contraceptives do not protect against HIV infections (AIDS) and other sexually transmitted diseases.

Warnings

If any of the conditions or risk factors mentioned below is present, the suitability of Millinette should be discussed with the woman.

In the event of aggravation, or first appearance of any of these conditions or risk factors, the woman should be advised to contact her doctor to determine whether the use of Millinette should be discontinued.

Circulatory disorders

Risk of venous thromboembolism (VTE)

The use of any combined hormonal contraceptive (CHC) increases the risk of venous thromboembolism (VTE) compared with no use. Products that contain levonorgestrel, norgestimate or norethisterone are associated with the lowest risk of VTE. Other products such as Millinette may have up to twice this level of risk. The decision to use any product other than one known to have the lowest VTE risk should be taken only after a discussion with the woman to ensure she understands the risk of VTE with Millinette, how her current risk factors influence this risk, and that her VTE risk is highest in the first ever year of use. There is also some evidence that the risk is increased when a CHC is re-started after a break in use of 4 weeks or more.

In women who do not use a CHC and are not pregnant about 2 out of 10,000 will develop a VTE over the period of one year. However, in any individual woman the risk may be far higher, depending on her underlying risk factors (see below).

It is estimated1 that out of 10,000 women who use a CHC containing gestodene between 9 and 12 women will develop a VTE in one year; this compares with about 62 in women who use a levonorgestrel-containing CHC.

In both cases, the number of VTEs per year is fewer than the number expected during pregnancy or in the postpartum period.

VTE may be fatal in 1-2% of cases.

Number of VTE events per 10,000 women in one year

Extremely rarely, thrombosis has been reported to occur in CHC users in other blood vessels, e.g. hepatic, mesenteric, renal, cerebral or retinal veins and arteries.

Risk factors for VTE

The risk for venous thromboembolic complications in CHC users may increase substantially in a woman with additional risk factors, particularly if there are multiple risk factors (see table).

Millinette is contraindicated if a woman has multiple risk factors that put her at high risk of venous thrombosis (see section 4.3). If a woman has more than one risk factor, it is possible that the increase in risk is greater than the sum of the individual factors – in this case her total risk of VTE should be considered. If the balance of benefits and risks is considered to be negative a CHC should not be prescribed (see section 4.3).

Table: Risk factors for VTE

Risk factor

Comment

Obesity (body mass index over 30 kg/m²)

Risk increases substantially as BMI rises.

Particularly important to consider if other risk factors also present.

Prolonged immobilisation, major surgery, any surgery to the legs or pelvis, neurosurgery, or major trauma.

Note: temporary immobilisation including air travel >4 hours can also be a risk factor for VTE, particularly in women with other risk factors.

In these situations it is advisable to discontinue use of the pill (in the case of elective surgery at least four weeks in advance) and not resume until two weeks after complete remobilisation. Another method of contraception should be used to avoid unintentional pregnancy.

Antithrombotic treatment should be considered if Millinette has not been discontinued in advance.

Positive family history (venous thromboembolism ever in a sibling or parent especially at a relatively early age e.g. before 50).

If a hereditary predisposition is suspected, the woman should be referred to a specialist for advice before deciding about any CHC use.

Other medical conditions associated with VTE

Cancer, systemic lupus erythematosus, haemolytic uraemic syndrome, chronic inflammatory bowel disease (Crohn's disease or ulcerative colitis) and sickle cell disease.

Increasing age

Particularly above 35 years.

There is no consensus about the possible role of varicose veins and superficial thrombophlebitis in the onset or progression of venous thrombosis.

The increased risk of thromboembolism in pregnancy, and particularly the 6 week period of the puerperium, must be considered (for information on “Fertility, pregnancy and lactation” see section 4.6).

Symptoms of VTE (deep vein thrombosis and pulmonary embolism)

In the event of symptoms women should be advised to seek urgent medical attention and to inform the healthcare professional that she is taking a CHC.

Symptoms of deep vein thrombosis (DVT) can include:

- unilateral swelling of the leg and/or foot or along a vein in the leg;

- pain or tenderness in the leg which may be felt only when standing or walking,

- increased warmth in the affected leg; red or discoloured skin on the leg.

Symptoms of pulmonary embolism (PE) can include:

- sudden onset of unexplained shortness of breath or rapid breathing;

- sudden coughing which may be associated with haemoptysis;

- sharp chest pain;

- severe light headedness or dizziness;

- rapid or irregular heartbeat.

Some of these symptoms (e.g. “shortness of breath”, “coughing”) are non-specific and might be misinterpreted as more common or less severe events (e.g. respiratory tract infections).

Other signs of vascular occlusion can include: sudden pain, swelling and slight blue discoloration of an extremity.

If the occlusion occurs in the eye symptoms can range from painless blurring of vision which can progress to loss of vision. Sometimes loss of vision can occur almost immediately.

Risk of arterial thromboembolism (ATE)

Epidemiological studies have associated the use of CHCs with an increased risk for arterial thromboembolism (myocardial infarction) or for cerebrovascular accident (e.g. transient ischaemic attack, stroke). Arterial thromboembolic events may be fatal.

Risk factors for ATE

The risk of arterial thromboembolic complications or of a cerebrovascular accident in CHC users increases in women with risk factors (see table). Millinette is contraindicated if a woman has one serious or multiple risk factors for ATE that puts her at high risk of arterial thrombosis (see section 4.3). If a woman has more than one risk factor, it is possible that the increase in risk is greater than the sum of the individual factors - in this case her total risk should be considered. If the balance of benefits and risks is considered to be negative a CHC should not be prescribed (see section 4.3).

Table: Risk factors for ATE

Risk factor

Comment

Increasing age

Particularly above 35 years

Smoking

Women should be advised not to smoke if they wish to use a CHC. Women over 35 who continue to smoke should be strongly advised to use a different method of contraception.

Hypertension

Obesity (body mass index over 30 kg/m2)

Risk increases substantially as BMI increases.

Particularly important in women with additional risk factors.

Positive family history (arterial thromboembolism ever in a sibling or parent especially at relatively early age e.g. below 50).

If a hereditary predisposition is suspected, the woman should be referred to a specialist for advice before deciding about any CHC use.

Migraine

An increase in frequency or severity of migraine during CHC use (which may be prodromal of a cerebrovascular event) may be a reason for immediate discontinuation.

Other medical conditions associated with adverse vascular events

Diabetes mellitus, hyperhomocysteinaemia, valvular heart disease and atrial fibrillation, dyslipoproteinaemia, systemic lupus erythematosus.

Symptoms of ATE

In the event of symptoms women should be advised to seek urgent medical attention and to inform the healthcare professional that she is taking a CHC.

Symptoms of a cerebrovascular accident can include:

- sudden numbness or weakness of the face, arm or leg, especially on one side of the body;

- sudden trouble walking, dizziness, loss of balance or coordination;

- sudden confusion, trouble speaking or understanding;

- sudden trouble seeing in one or both eyes;

- sudden, severe or prolonged headache with no known cause;

- loss of consciousness or fainting with or without seizure.

Temporary symptoms suggest the event is a transient ischaemic attack (TIA).

Symptoms of myocardial infarction can include:

- pain, discomfort, pressure, heaviness, sensation of squeezing or fullness in the chest, arm, or below the breastbone;

- discomfort radiating to the back, jaw, throat, arm, stomach;

- feeling of being full, having indigestion or choking;

- sweating, nausea, vomiting or dizziness;

- extreme weakness, anxiety, or shortness of breath;

- rapid or irregular heartbeats.

Biochemical factors indicating hereditary or acquired predisposition for venous or arterial thrombosis, include activated protein C (APC) resistance, hyperhomocysteinaemia, antithrombin III deficiency, protein C deficiency, protein S deficiency, antiphospholipid antibodies (anticardiolipin antibodies, lupus anticoagulant).

When weighing the advantages/disadvantages the physician should take into consideration that adequate treatment of a given condition may reduce the risk associated with thrombosis and that the risk of developing thrombosis during pregnancy is higher than with low-dose COCs (<50 microgram ethinylestradiol).

Tumours:

Cervical cancer

The most important risk factor for cervical cancer is persistent HPV infection. Some epidemiological studies have indicated that long-term use of COCs may further contribute to this increased risk but there continues to be controversy about the extent to which this finding is attributable to confounding effects, e.g., cervical screening and sexual behavior including use of barrier contraceptives.

Breast cancer

A meta-analysis from 54 epidemiological studies reported that there is a slightly increased relative risk (RR=1.24) of having breast cancer diagnosed in women who are currently using combined oral contraceptives (COCs). The excess risk gradually disappears during the course of the 10 years after stopping COC. As breast cancer is rare among women under 40 years the excess number of breast cancer diagnoses in current and recent COC users is small in relation to the overall risk of breast cancer in their complete life time. The observed pattern of increased risk may be due to an earlier diagnosis of breast cancer in COC users, the biological effects of COCs or a combination of both. The additional breast cancers diagnosed in current users of COCs or in women who have used COCs in the last ten years are more likely to be localised to the breast than those in women who never used COCs.

With the use of the higher-dosed COCs (0.05 mg ethinylestradiol) the risk of endometrial and ovarian cancer is reduced. Whether this also applies to lower-dosed COCs remains to be confirmed.

Hepatic neoplasia/ liver disease

In rare cases benign and, in even rarer cases, malignant liver tumours have been reported. In isolated cases these tumours have led to life-threatening intra-abdominal haemorrhage. If severe upper abdominal complaints, liver enlargement or signs of intra-abdominal haemorrhage occur, the possibility of a liver tumour should be included in the differential diagnosis in women taking COCs.

Acute or chronic disturbances of liver function may necessitate the discontinuation of COC use until markers of liver function return to normal.

Other conditions

Depressed mood and depression are well-known undesirable effects of hormonal contraceptive use (see section 4.8). Depression can be serious and is a well-known risk factor for suicidal behaviour and suicide. Women should be advised to contact their physician in case of mood changes and depressive symptoms, including shortly after initiating the treatment.

Women with hypertriglyceridaemia, or a family history thereof, may be at increased risk of pancreatitis when taking COCs.

Even though slight increases in blood pressure have been reported in many women taking COCs, clinically important increases in blood pressure are rare. If persistent clinical hypertension develops during COC use, intake should be discontinued and the hypertension treated. Use of COCs may be resumed, if appropriate, when normotensive values are reached with antihypertensive therapy.

It has been reported that the following conditions may occur, or worsen both during pregnancy and during use of COCs, but the evidence of a relationship is inconclusive: Jaundice and/or pruritus in connection with cholestasis; development of gallstones; porphyria; systemic lupus erythematosus; haemolytic uraemic syndrome; Sydenham's chorea; herpes gestationis; loss of hearing due to otosclerosis.

Acute or chronic disturbances of liver function may necessitate the discontinuation of COC use until markers of liver function return to normal. Re-emergence of cholestatic jaundice which first occurred during pregnancy or previous use of sex hormones requires withdrawal of the use of COCs.

There are reports about liver damage when using CHCs. Early identification of drug related liver damage may reduce the severity of liver toxicity upon withdrawal of the drug. If liver damage is diagnosed the patient must stop using oral contraceptives, use non-hormonal contraception and contact her physician.

Although COCs may have an effect on peripheral insulin resistance and glucose tolerance, there is no evidence for a need to alter the therapeutic regimen in diabetics using low-dose COCs (containing <50 microgram ethinylestradiol). However, diabetic women should be carefully monitored, particularly in the early stage of COC use.

Crohn's disease and colitis ulcerosa have been associated with the use of combined oral contraceptives.

Chloasma may occur, in particular in women with a medical history of chloasma gravidarum. Women with a tendency to chloasma should avoid exposure to sunlight or ultraviolet radiation while taking COCs.

Migraine/headache

Women with migraine (especially migraine with aura) using CHCs may have an increased risk of having a stroke.

The immune system

Angioedema

Exogenous estrogens may induce or exacerbate symptoms of hereditary and acquired angioedema.

Herbal preparations containing St John's wort (Hypericum perforatum) should not be used while taking Millinette due to the risk of decreased plasma concentrations and reduced clinical effects of Millinette (see section 4.5).

Reduced efficacy

The efficacy of oral contraceptives may be reduced in the case of missed tablets or gastrointestinal disease (see section 4.2) or concomitant use of other medicinal product (see section 4.5).

Reduced cycle control

With all combined oral contraceptives, irregular bleeding (spotting or break through bleeding) may occur, especially during the first months. Hence, the evaluation of any irregular bleeding should be considered after a period of adaptation of approximately 3 cycles.

If bleeding irregularities occur after previously regular cycles, then non-hormonal causes should be considered, and adequate diagnostic measures are indicated to exclude malignancy or pregnancy. These may include curettage. If non-hormonal causes are ruled out recommending COC with a higher hormone content may be considered.

In some woman withdrawal bleeding may not occur during the tablet-free interval. If the tablets have been taken according to the instructions described in section 4.2, it is unlikely that the woman is pregnant. However, if the tablets have not been taken according to the instructions, before the first absent withdrawal bleeding, or if two withdrawal bleedings are missed, pregnancy must be ruled out before COC use is continued

Excipients

This medicinal product contains lactose and sucrose.

Patients with rare hereditary problems of galactose intolerance, total lactase deficiency, glucose-galactose malabsorption, fructose intolerance or sucrase-isomaltase insufficiency should not take this medicine.

This medicinal product contains less than 1 mmol sodium (23 mg) per tablet, that is to say essentially 'sodium-free'.

1These incidences were estimated from the totality of the epidemiological study data, using relative risks for the different products compared with1 levonorgestrel-containing CHCs.

2 Mid-point of range of 5-7 per 10,000 WY, based on a relative risk for CHCs containing levonorgestrel versus non-use of approximately 2.3 to 3.6.

4.5. Interaction with other medicinal products and other forms of interaction

Note: The prescribing information of concomitant medications should be consulted to identify potential interactions.

Pharmacodynamic interactions

During clinical trials with patients treated for hepatitis C virus infections (HCV) with medicinal products containing ombitasvir/paritaprevir/ritonavir and dasabuvir with or without ribavirin, transaminase (ALT) elevations higher than 5 times the upper limit of normal (ULN) occurred significantly more frequently in women using ethinylestradiol-containing medications such as combined hormonal contraceptives (CHCs). Additionally, also in patients treated with glecaprevir/pibrentasvir or sofosbuvir/velpatasvir/voxilaprevir, ALT elevations were observed in women using ethinylestradiol-containing medications such as CHCs (see section 4.3). Therefore, Millinette users must switch to an alternative method of contraception (e.g., progestagen-only contraception or non-hormonal methods) prior to starting therapy with these combination drug regimens. Millinette can be restarted 2 weeks following completion of treatment with these combination drug regimens.

Pharmacokinetic interactions

Effects of other medicinal products on Millinette

Interactions can occur with drugs that induce microsomal enzymes which can result in increased clearance of sex hormones and which may lead to breakthrough bleeding and/or contraceptive failure.

Management

Enzyme induction can already be observed after a few days of treatment. Maximal enzyme induction is generally seen within a few weeks. After the cessation of drug therapy enzyme induction may be sustained for about 4 weeks.

Short-term treatment

Women on treatment with enzyme inducing drugs should temporarily use a barrier method or another method of contraception in addition to the COC. The barrier method must be used during the whole time of the concomitant drug therapy and for 28 days after its discontinuation. If the drug therapy runs beyond the end of the tablets in the COC pack, the next COC pack should be started right after the previous one without the usual tablet-free interval.

Long-term treatment

In women on long-term treatment with enzyme-inducing active substances, another reliable, non-hormonal, method of contraception is recommended.

The following interactions have been reported in the literature.

Substances increasing the clearance of COCs (diminished efficacy of COCs by enzyme-induction), e.g

Barbiturates, bosentan, carbamazepine, phenytoin, primidone, rifampicin and HIV medication ritonavir, nevirapine and efavirenz and possibly also felbamate, griseofulvin, oxcarbazepine, topiramate and products containing the herbal remedy St. John's Wort (Hypericum perforatum).

Substances with variable effects on the clearance of COCs

When co-administered with COCs, many combinations of HIV protease inhibitors and non-nucleoside, reverse transcriptase inhibitors, including combinations with HCV inhibitors can increase or decrease, plasma concentrations of estrogen or progestins. The net effect of these changes may be clinically, relevant in some cases.

Therefore, the prescribing information of concomitant HIV/HCV medications should be consulted to identify potential interactions and any related recommendations. In case of any doubt, an additional barrier contraceptive method should be used by women on protease inhibitor or non-nucleoside reverse transcriptase inhibitor therapy.

Substances decreasing the clearance of COCs (enzyme inhibitors):

The clinical relevance of potential interactions with enzyme inhibitors remains unknown.

Concomitant administration of strong CYP3A4 inhibitors can increase plasma concentrations of the estrogen or the progestin or both.

Etoricoxib doses of 60 to 120 mg/day have been shown to increase plasma concentrations of ethinylestradiol 1.4 to 1.6-fold, respectively when taken concomitantly with a combined hormonal contraceptive containing 0.035 mg ethinylestradiol.

Effects of Millinette on other medicinal products

COCs may affect the metabolism of certain other active substances. Accordingly, plasma, and tissue concentrations may either increase (e.g. ciclosporin) or decrease (e.g. lamotrigine).

Clinical data suggests that ethinylestradiol is inhibiting the clearance of CYP1A2 substrates leading to a weak (e.g. theophylline) or moderate (e.g. tizanidine) increase in their plasma concentration.

Laboratory tests

The use of contraceptive steroids may influence the results of certain laboratory tests, including the biochemical parameters of liver, thyroid, adrenal, and renal function; plasma levels of (carrier) proteins, e.g. corticosteroid-binding globulin and lipid/lipoprotein fractions; parameters of carbohydrate metabolism and parameters of coagulation and fibrinolysis. Changes generally remain within the normal laboratory range.

4.6. Fertility, pregnancy and lactation

Pregnancy

Millinette is not indicated during pregnancy. If pregnancy occurs during medication with Millinette, treatment should be withdrawn immediately.

There is no conclusive evidence that the oestrogen and gestagen adversely affects the foetus if conception inadvertently happens during the use of COCs.

The increased risk of VTE during the postpartum period should be considered when re-starting Millinette (see section 4.2 and 4.4).

Breast-feeding

Should not be used.

Lactation may be influenced by COCs as they reduce the amount and change the composition of human milk. Hence, the use of oral contraceptives cannot generally be recommended until the lacting mother has completely weaned off the child. Small amounts of contraceptive steroids and/or their metabolites can be excreted in the milk, but there is no evidence that this adversely affects infant health.

4.7. Effects on ability to drive and use machines

Millinette has no or negligible influence on the ability to drive and use machines.

4.8. Undesirable effects

Description of selected adverse reactions

An increased risk of arterial and venous thrombotic and thrombo-embolic events, including myocardial infarction, stroke, transient ischemic attacks, venous thrombosis and pulmonary embolism has been observed in women using CHCs, which are discussed in more detail in section 4.4.

The following serious adverse events have been reported in women using COCs, see sections 4.3 and 4.4.

- Benign liver tumours (e.g. focal nodular hyperplasia, hepatic adenomas).

- Cervical intraepithelial neoplasia and cervical cancer.

- Breast cancer.

In the beginning of the treatment period a large part (10-13%) of women may expect adverse events such as headache, breast tenderness, malaise and spot bleeding. These adverse events are usually temporary and disappear after 2-4 months.

The following adverse events were reported by users of COCs but the connection with the use of COCs is neither confirmed or ruled out:

Infections and infestations

Common (≥1/100 to <1/10)

Vaginitis, including candidiasis

Neoplasms benign, malignant and unspecified (including cysts and polyps)

Very rare (<1/10,000, including isolated cases)

Hepatocellular carcinomas

Blood and lymphatic system disorders

Very rare (<1/10,000, including isolated cases)

Exacerbation of varicose veins

Immune system disorders

Rare (≥1/10,000 to <1/1,000)

Rare – very rare (<1/1,000)

Not known (frequency cannot be estimated from the available data)

Anaphylactic/ anaphylactoid reactions including very rare cases of urticaria, angiooedema and serious reactions with circulatory and respiratory symptoms

General disease in the immune system, hypersensitivity. Exacerbation of systemic lupus erythematosus

Exacerbation of symptoms of hereditary and acquired angioedema

Metabolism and nutrition disorders

Uncommon (≥1/1,000 to <1/100)

Rare (≥1/10,000 to <1/1,000)

Very rare (<1/10,000, including isolated cases)

Fluid retention.

Changed appetite (increased or reduced)

Reduced glucose-tolerance

Exacerbation of porphyria

Psychiatric disorders

Common (≥1/100 to <1/10)

Uncommon (≥1/1,000 to <1/100)

Rare – very rare (<1/1,000)

Depression/ mood swings

Reduced libido

Increased libido

Nervous system disorders

Very common (≥1/10)

Uncommon (≥1/1,000 to <1/100)

Common (≥1/100 to <1/10)

Very rare (<1/10,000, including isolated cases)

Headache

Migraine

Nervousness, dizziness

Exacerbation of chorea

Eye disorders

Rare – very rare (<1/1,000)

Very rare (<1/10,000, including isolated cases)

Ocular irritation when wearing contact lenses

Optical neuritis, retinal vascular thrombosis

Ear and labyrinth disorders

Rare – very rare (<1/1,000)

General disease in ear and labyrinth

Vascular disorders

Uncommon (>1/1,000 to <1/100)

Rare (≥1/10,000 and <1/1,000)

Hypertension

Venous or arterial thromboembolism

Gastrointestinal disorders

Common (≥1/100 to <1/10)

Uncommon (≥1/1,000 to <1/100)

Rare – very rare (<1/1,000)

Very rare (<1/10,000, including isolated cases)

Nausea, abdominal pain

Vomiting, diarrhoea

Other disease in the gastrointestinal tract

Pancreatitis, ischaemic colitis

Inflammatory intestinal disorder (Crohn's disease, ulcerative colitis)

Hepatobiliary disorders

Rare (≥1/10,000 to <1/1,000)

Very rare (<1/10,000, including isolated cases)

Not known (frequency cannot be estimated from the available data)

Jaundice

Gall bladder disease including gall stones

Liver damage (such as hepatitis, abnormal liver function)

Skin and subcutaneous tissue disorders

Common (≥1/100 to <1/10)

Uncommon (≥1/1,000 to <1/100)

Rare – very rare (<1/1,000)

Acne

Rash, urticaria, chloasma (melasma) which may be permanent, hirsutism, alopecia

Various skin diseases (such as erythema multiforme, erythema nodosum)

Renal and urinary disorders

Very rare (<1/10.000, including isolated cases)

Haemolytic uraemic syndrome

Reproductive system and breast disorders

Very common (≥1/10)

Common (≥1/100 to <1/10)

Spot bleeding/ break-through bleeding.

Breast tenderness, pain, swelling, secretion. Dysmenorrhoea, changes in vaginal secretion, amennorrhea

Investigations

Common (≥1/100 to <1/10)

Uncommon (≥1/1.000 to <1/100)

Rare (≥1/10,000 to <1/1,000)

Rare – very rare (<1/1,000)

Weight increase

Changes in plasma-lipid values including hyper-triglyceridaemia

Reduction of folate level in plasma

Weight decrease

The following serious adverse events have been reported in women using COCs, see sections 4.3 and 4.4.

- Venous thromboembolism, i.e. deep leg or pelvic venous thrombosis and pulmonary embolism.

- Arterial thromboembolic disorders

- Cervical cancer

- Liver tumours

- Skin and subcutaneous disorders: chloasma; erythema nodosum.

The frequency of diagnosis of breast cancer is very slightly increased among COC-users. As breast cancer is rare in women under 40 years of age the excess number is small in relation to the overall risk of breast cancer. Causation with COC use is unknown. For further information, see sections 4.3 and 4.4.

Interactions

Breakthrough bleeding and/or contraceptive failure may result from interactions of other drugs (enzyme inducers) with oral contraceptives (see section 4.5).

Reporting of suspected adverse reactions

Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via the Yellow Card Scheme, website: www.mhra.gov.uk/yellowcard.

4.9. Overdose

No serious, harmful effects after overdose have been reported.

Symptoms:

Nausea, vomiting and in young girls a slight vaginal bleeding.

Treatment:

There is no antidote, and further treatment should be symptomatic.