ADVERSE REACTIONS SECTION.

ADVERSE REACTIONS. Adverse reactions reported with the use of POPs include:Menstrual irregularity is the most frequently reported side effect.Frequent and irregular bleeding are common, while long duration of bleeding episodes and amenorrhea are less likely. Headache, breast tenderness, nausea, and dizziness are increased among progestin-only oral contraceptive users in some studies. Androgenic side effects such as acne, hirsutism, and weight gain occur rarely. The following adverse reactions were also reported in clinical trials or during post-marketing experience: Gastrointestinal Disorders: vomiting, abdominal pain; General Disorders and Administration Site Conditions: fatigue, edema; Psychiatric Disorders: depression, nervousness; Musculoskeletal and Connective Tissue Disorders: pain in extremity; Reproductive System and Breast Disorders: genital discharge; breast pain, menstruation delayed, suppressed lactation, vaginal hemorrhage, menorrhagia, withdrawal bleed when product is stopped; Immune System Disorders: anaphylactic/anaphylactoid reaction, hypersensitivity; Hepatobiliary Disorders: hepatitis, jaundice cholestatic; Skin and Subcutaneous Tissue Disorders: alopecia, rash, rash pruritic.. Menstrual irregularity is the most frequently reported side effect.. Frequent and irregular bleeding are common, while long duration of bleeding episodes and amenorrhea are less likely. Headache, breast tenderness, nausea, and dizziness are increased among progestin-only oral contraceptive users in some studies. Androgenic side effects such as acne, hirsutism, and weight gain occur rarely.

CARCINOGENESIS & MUTAGENESIS & IMPAIRMENT OF FERTILITY SECTION.

6. Carcinogenesis. See WARNINGS.

CLINICAL PHARMACOLOGY SECTION.

CLINICAL PHARMACOLOGY. 1. Mode of Action Emzahh(TM)progestin-only oral contraceptives prevent conception by suppressing ovulation in approximately half of users, thickening the cervical mucus to inhibit sperm penetration, lowering the midcycle LH and FSH peaks, slowing the movement of the ovum through the fallopian tubes, and altering the endometrium. 2. Pharmacokinetics Serum progestin levels peak about two hours after oral administration, followed by rapid distribution and elimination. By 24 hours after drug ingestion, serum levels are near baseline, making efficacy dependent upon rigid adherence to the dosing schedule. There are large variations in serum levels among individual users. Progestin-only administration results in lower steady-state serum progestin levels and shorter elimination half-life than concomitant administration with estrogens.

CONTRAINDICATIONS SECTION.

CONTRAINDICATIONS. Progestin-only oral contraceptives (POPs) should not be used by women who currently have the following conditions:Known or suspected pregnancyKnown or suspected carcinoma of the breastUndiagnosed abnormal genital bleedingHypersensitivity to any component of this productBenign or malignant liver tumorsAcute liver disease Known or suspected pregnancy. Known or suspected carcinoma of the breast. Undiagnosed abnormal genital bleeding. Hypersensitivity to any component of this product. Benign or malignant liver tumors. Acute liver disease.

DESCRIPTION SECTION.

DESCRIPTION. Emzahh(TM) TabletsEach tablet contains 0.35 mg norethindrone USP. Inactive ingredients include anhydrous lactose, corn starch, D&C Yellow No. 10 aluminum lake, ethylcellulose, magnesium stearate, microcrystalline cellulose, povidone, sodium starch glycolate, and talc. Chemical Structure.

DOSAGE & ADMINISTRATION SECTION.

DOSAGE AND ADMINISTRATION. To achieve maximum contraceptive effectiveness, Emzahh(TM)tablets must be taken exactly as directed. One tablet is taken every day, at the same time. Administration is continuous, with no interruption between pill packs. See Detailed Patient Labeling for detailed instruction.

DRUG & OR LABORATORY TEST INTERACTIONS SECTION.

5. Interactions with Laboratory Tests. The following endocrine tests may be affected by progestin-only oral contraceptive use:Sex hormone-binding globulin (SHBG) concentrations may be decreased. Thyroxine concentrations may be decreased, due to decrease in thyroid binding globulin (TBG).. Sex hormone-binding globulin (SHBG) concentrations may be decreased.. Thyroxine concentrations may be decreased, due to decrease in thyroid binding globulin (TBG).

PREGNANCY SECTION.

7. Pregnancy. Many studies have found no effects on fetal development associated with long-term use of contraceptive doses of oral progestins. The few studies of infant growth and development that have been conducted have not demonstrated significant adverse effects. It is nonetheless prudent to rule out suspected pregnancy before initiating any hormonal contraceptive use.

DRUG INTERACTIONS SECTION.

4. Drug Interactions. Consult the labeling of concurrently-used drugs to obtain further information about interactions with hormonal contraceptives or the potential for enzyme alterations.Effects of Other Drugs on Hormonal ContraceptivesSubstances decreasing the systemic concentrations of hormonal contraceptives (HCs) and potentially diminishing the efficacy of HCs:Drugs or herbal products that induce certain enzymes, including cytochrome P450 3A4 (CYP3A4), may decrease the systemic concentrations of HCs and potentially diminish the effectiveness of HCs or increase breakthrough bleeding.Some drugs or herbal products that may decrease the effectiveness of HCs include efavirenz, phenytoin, barbiturates, carbamazepine, bosentan, felbamate, griseofulvin, oxcarbazepine, rifampicin, rifabutin, rufinamide, aprepitant, and products containing St. Johns wort. Interactions between HCs and other drugs may lead to breakthrough bleeding and/or contraceptive failure. Counsel women to use an alternative non-hormonal method of contraception or back-up method when enzyme inducers are used with HCs, and to continue back-up non-hormonal contraception for 28 days after discontinuing the enzyme inducer to ensure contraceptive reliability.Substances increasing the systemic concentrations of HCs: Co-administration of certain HCs and strong or moderate CYP3A4 inhibitors such as itraconazole, voriconazole, fluconazole, grapefruit juice, or ketoconazole may increase the systemic concentrations of progestins, including norethindrone.Human Immunodeficiency Virus (HIV)/Hepatitis Virus (HCV) protease inhibitors and nonnucleoside reverse transcriptase inhibitors: Significant decreases in systemic concentrations of progestin have been noted in cases of co-administration with some HIV protease inhibitors (e.g., nelfinavir, ritonavir, darunavir/ritonavir, (fos)amprenavir/ritonavir, lopinavir/ritonavir, and tipranavir/ritonavir), some HCV protease inhibitors (e.g., boceprevir and telaprevir), and some non-nucleoside reverse transcriptase inhibitors (e.g., nevirapine, efavirenz). In contrast, significant increases in systemic exposure of the progestin have been noted in cases of co-administration with certain other HIV protease inhibitors (e.g., indinavir and atazanavir/ritonavir) and with other non-nucleoside reverse transcriptase inhibitors (e.g., etravirine). These changes may be clinically relevant in some cases. Consult the prescribing information of anti-viral and anti-retroviral concomitant medications to identify potential interactions.Effects of Hormonal Contraceptives on Other DrugsHormonal contraceptives may affect the metabolism of other drugs. Consequently, systemic concentrations may either increase (for example, cyclosporine) or decrease. Consult the labeling of all concurrently-used drugs to obtain further information about interactions with hormonal contraceptives or the potential for enzyme alterations.Interactions between ulipristal and hormonal contraceptives Effectiveness of progestin-containing hormonal contraceptives and emergency contraceptive ulipristal acetate may be decreased if progestin-containing hormonal contraceptives are used within five days after ulipristal acetate dosing. Therefore, if woman wishes to use norethindrone after using ulipristal acetate, she should do so no sooner than days after the intake of ulipristal acetate and she should use reliable barrier method for subsequent acts of intercourse until her next menstrual period.. Effects of Other Drugs on Hormonal Contraceptives. Effects of Hormonal Contraceptives on Other Drugs. Interactions between ulipristal and hormonal contraceptives.

GENERAL PRECAUTIONS SECTION.

1. General. Patients should be counseled that this product does not protect against HIV infection (AIDS) and other sexually transmitted diseases. 2. Physical Examination and Follow-up It is considered good medical practice for sexually active women using oral contraceptives to have annual history and physical examinations. The physical examination may be deferred until after initiation of oral contraceptives if requested by the woman and judged appropriate by the healthcare professional. 3. Carbohydrate and Lipid Metabolism Some users may experience slight deterioration in glucose tolerance, with increases in plasma insulin but women with diabetes mellitus who use progestin-only oral contraceptives do not generally experience changes in their insulin requirements. Nonetheless, prediabetic and diabetic women in particular should be carefully monitored while taking POPs. Lipid metabolism is occasionally affected in that HDL, HDL2, and apolipoprotein A-I and A-II may be decreased; hepatic lipase may be increased. There is usually no effect on total cholesterol, HDL3, LDL, or VLDL.

HOW SUPPLIED SECTION.

HOW SUPPLIED. EmzahhTM (Norethindrone Tablets USP, 0.35 mg) are light yellow to yellow, round, flat faced beveled edged uncoated tablets, debossed with on one side and 13 on other side of the tablet. It is supplied as 28 tablets in blister pack.The blister packs are available in the following packages:o The blister packs are packed in pouches and the pouches are packaged in carton Carton of Pouches NDC 59651-136-92Carton of Pouches NDC 59651-136-88o The blister pack is packed in carton Carton of Blister Pack NDC 59651-136-28 STORAGE: Store at 20 to 25C (68 to 77F); excursions permitted to 15o to 30oC (59o to 86oF) [See USP Controlled Room Temperature]. Keep out of reach of children.

INDICATIONS & USAGE SECTION.

INDICATIONS AND USAGE. 1. Indications Progestin-only oral contraceptives are indicated for the prevention of pregnancy. 2. EfficacyIf used perfectly, the first-year failure rate for progestin-only oral contraceptives is 0.3%. However, the typical failure rate is estimated to be closer to 9%, due to late or omitted pills. Table lists the pregnancy rates for users of all major methods of contraception.Table 1: Percentage of Women Experiencing an Unintended Pregnancy During the First Year of Typical Use and the First Year of Perfect Use of Contraception and the Percentage Continuing Use at the End of the First Year. United States. Method(1) of Women Experiencing an Unintended Pregnancy within the First Year of Use of Women Continuing Use at One Year3 Typical Use1 (2) Perfect Use2 (3) (4) No method4 85 85 Spermicides5 28 18 42 Fertility awareness-based methods 24 47 Standard Days method6 TwoDay method6 Ovulation method6 Symptothermal method6 0.4 Withdrawal 22 46 Sponge 36 Parous Women 24 20 Nulliparous Women 12 Condom7 Female (fc) 21 41 Male 18 43 Diaphragm8 12 57 Combined pill and progestin-only pill 0.3 67 Norelgestromin and ethinyl estradiol patch 0.3 67 NuvaRing 0.3 67 Depo-Provera 0.2 56 Intrauterine contraceptives ParaGard (copper T) 0.8 0.6 78 Mirena (LNg) 0.2 0.2 80 Implanon 0.05 0.05 84 Female Sterilization 0.5 0.5 100 Male Sterilization 0.15 0.10 100 Emergency Contraception: Emergency contraceptive pills or insertion of copper intrauterine contraceptive after unprotected intercourse substantially reduces the risk of pregnancy.9 (See Chapter 6.).Lactational Amenorrhea Method: LAM is highly effective, temporary method of contraception.10 (See Chapter 18.) Source: Trussell J. Contraceptive Efficacy. In Hatcher RA, Trussell J, Nelson AL, Cates W, Kowal D, Policar M. Contraceptive Techology: Twentieth Revised Edition. New York NY: Ardent Media, 2011.--------------------------------------------------------------------------------------------------------------------------------------Notes:1 Among typical couples who initiate use of method (not necessarily for the first time), the percentage who experience an accidental pregnancy during the first year if they do not stop use for any other reason. Estimates of the probability of pregnancy during the first year of typical use for spermicides, withdrawal, fertility awareness-based methods, the diaphragm, the male condom, the oral contraceptive pill, and Depo-Provera are taken from the 1995 National Survey of Family Growth corrected for underreporting of abortion; see the text for the derivation of estimates for the other methods. Among couples who initiate use of method (not necessarily for the first time) and who use it perfectly (both consistently and correctly), the percentage who experience an accidental pregnancy during the first year if they do not stop use for any other reason. See the text for the derivation of the estimate for each method.3 Among couples attempting to avoid pregnancy, the percentage who continue to use method for year.4 The percentages becoming pregnant in columns (2) and (3) are based on data from populations where contraception is not used and from women who cease using contraception in order to become pregnant. Among such populations, about 89% become pregnant within year. This estimate was lowered slightly (to 85%) to represent the percentage who would become pregnant within year among women now relying on reversible methods of contraception if they abandoned contraception altogether.5 Foams, creams, gels, vaginal suppositories, and vaginal film.6 The Ovulation and TwoDay methods are based on evaluation of cervical mucus. The Standard Days method avoids intercourse on cycle days through 19. The Symptothermal method is double-check method based on evaluation of cervical mucus to determine the first fertile day and evaluation of cervical mucus and temperature to determine the last fertile day.7 Without spermicides.8 With spermicidal cream or jelly.9 ella, Plan One-Step and Next Choice are the only dedicated products specifically marketed for emergency contraception. The label for Plan One-Step (one dose is white pill) says to take the pill within 72 hours after unprotected intercourse. Research has shown that all of the brands listed here are effective when used within 120 hours after unprotected sex. The label for Next Choice (one dose is peach pill) says to take pill within 72 hours after unprotected intercourse and another pill 12 hours later. Research has shown that both pills can be taken at the same time with no decrease in efficacy or increase in side effects and that they are effective when used within 120 hours after unprotected sex. The FDA has in addition declared the following 19 brands of oral contraceptives to be safe and effective for emergency contraception: Ogestrel (1 dose is white pills), Nordette (1 dose is light-orange pills), Cryselle, Levora, Low-Ogestrel, Lo/Ovral, or Quasence (1 dose is white pills), Jolessa, Portia, Seasonale or Trivora (1 dose is pink pills), Seasonique (1 dose is light-blue-green pills), Enpresse (one dose is orange pills), Lessina (1 dose is pink pills), Aviane or LoSeasonique (one dose is orange pills), Lutera or Sronyx (one dose is white pills), and Lybrel (one dose is yellow pills).10 However, to maintain effective protection against pregnancy, another method of contraception must be used as soon as menstruation resumes, the frequency or duration of breastfeeds is reduced, bottle feeds are introduced, or the baby reaches months of age. Emzahh(TM) Tablets have not been studied for and are not indicated for use in emergency contraception.

INFORMATION FOR PATIENTS SECTION.

INFORMATION FOR THE PATIENT. 1. See Detailed Patient Labeling for detailed information. 2. Counseling issues The following points should be discussed with prospective users before prescribing progestin-only oral contraceptives:The necessity of taking pills at the same time every day, including throughout all bleeding episodes.The need to use backup method such as condom and spermicide for the next 48 hours whenever progestin-only oral contraceptive is taken or more hours late. The potential side effects of progestin-only oral contraceptives, particularly menstrual irregularities.The need to inform the healthcare professional of prolonged episodes of bleeding, amenorrhea or severe abdominal pain.The importance of using barrier method in addition to progestin-only oral contraceptives if woman is at risk of contracting or transmitting STDs/HIV.. The necessity of taking pills at the same time every day, including throughout all bleeding episodes.. The need to use backup method such as condom and spermicide for the next 48 hours whenever progestin-only oral contraceptive is taken or more hours late. The potential side effects of progestin-only oral contraceptives, particularly menstrual irregularities.. The need to inform the healthcare professional of prolonged episodes of bleeding, amenorrhea or severe abdominal pain.. The importance of using barrier method in addition to progestin-only oral contraceptives if woman is at risk of contracting or transmitting STDs/HIV.

NURSING MOTHERS SECTION.

8. Nursing Mothers. In general, no adverse effects have been found on breastfeeding performance or on the health, growth, or development of the infant. However, isolated post-marketing cases of decreased milk production have been reported. Small amounts of progestins pass into the breast milk of nursing mothers, resulting in detectable steroid levels in infant plasma.

OVERDOSAGE SECTION.

OVERDOSAGE. There have been no reports of serious ill effects from overdosage, including ingestion by children.

PACKAGE LABEL.PRINCIPAL DISPLAY PANEL.

PACKAGE LABEL-PRINCIPAL DISPLAY PANEL 0.35 mg Pouch Label. NDC 59651-136-87 28 day Emzahh(TM) (Norethindrone Tablets, USP) 0.35 mg Each light yellow to yellow tablet contains 0.35 mgnorethindrone USP. This product (like all oral contraceptives) is intended to prevent pregnancy. It does not protect against HIV infection (AIDS) and other sexually transmitted diseases. Rx only Pouch of 28 Tablets AUROBINDO PACKAGE LABEL-PRINCIPAL DISPLAY PANEL 0.35 mg Pouch Label.

PEDIATRIC USE SECTION.

9. Pediatric Use. Safety and efficacy of norethindrone tablets have been established in women of reproductive age. Safety and efficacy are expected to be the same for postpubertal adolescents under the age of 16 and for users 16 years and older. Use of this product before menarche is not indicated. 10. Fertility Following Discontinuation The limited available data indicate rapid return of normal ovulation and fertility following discontinuation of progestin-only oral contraceptives. 11. Headache The onset or exacerbation of migraine or development of severe headache with focal neurological symptoms which is recurrent or persistent requires discontinuation of progestin-only contraceptives and evaluation of the cause.

PRECAUTIONS SECTION.

PRECAUTIONS. 1. General. Patients should be counseled that this product does not protect against HIV infection (AIDS) and other sexually transmitted diseases. 2. Physical Examination and Follow-up It is considered good medical practice for sexually active women using oral contraceptives to have annual history and physical examinations. The physical examination may be deferred until after initiation of oral contraceptives if requested by the woman and judged appropriate by the healthcare professional. 3. Carbohydrate and Lipid Metabolism Some users may experience slight deterioration in glucose tolerance, with increases in plasma insulin but women with diabetes mellitus who use progestin-only oral contraceptives do not generally experience changes in their insulin requirements. Nonetheless, prediabetic and diabetic women in particular should be carefully monitored while taking POPs. Lipid metabolism is occasionally affected in that HDL, HDL2, and apolipoprotein A-I and A-II may be decreased; hepatic lipase may be increased. There is usually no effect on total cholesterol, HDL3, LDL, or VLDL.. 4. Drug Interactions. Consult the labeling of concurrently-used drugs to obtain further information about interactions with hormonal contraceptives or the potential for enzyme alterations.Effects of Other Drugs on Hormonal ContraceptivesSubstances decreasing the systemic concentrations of hormonal contraceptives (HCs) and potentially diminishing the efficacy of HCs:Drugs or herbal products that induce certain enzymes, including cytochrome P450 3A4 (CYP3A4), may decrease the systemic concentrations of HCs and potentially diminish the effectiveness of HCs or increase breakthrough bleeding.Some drugs or herbal products that may decrease the effectiveness of HCs include efavirenz, phenytoin, barbiturates, carbamazepine, bosentan, felbamate, griseofulvin, oxcarbazepine, rifampicin, rifabutin, rufinamide, aprepitant, and products containing St. Johns wort. Interactions between HCs and other drugs may lead to breakthrough bleeding and/or contraceptive failure. Counsel women to use an alternative non-hormonal method of contraception or back-up method when enzyme inducers are used with HCs, and to continue back-up non-hormonal contraception for 28 days after discontinuing the enzyme inducer to ensure contraceptive reliability.Substances increasing the systemic concentrations of HCs: Co-administration of certain HCs and strong or moderate CYP3A4 inhibitors such as itraconazole, voriconazole, fluconazole, grapefruit juice, or ketoconazole may increase the systemic concentrations of progestins, including norethindrone.Human Immunodeficiency Virus (HIV)/Hepatitis Virus (HCV) protease inhibitors and nonnucleoside reverse transcriptase inhibitors: Significant decreases in systemic concentrations of progestin have been noted in cases of co-administration with some HIV protease inhibitors (e.g., nelfinavir, ritonavir, darunavir/ritonavir, (fos)amprenavir/ritonavir, lopinavir/ritonavir, and tipranavir/ritonavir), some HCV protease inhibitors (e.g., boceprevir and telaprevir), and some non-nucleoside reverse transcriptase inhibitors (e.g., nevirapine, efavirenz). In contrast, significant increases in systemic exposure of the progestin have been noted in cases of co-administration with certain other HIV protease inhibitors (e.g., indinavir and atazanavir/ritonavir) and with other non-nucleoside reverse transcriptase inhibitors (e.g., etravirine). These changes may be clinically relevant in some cases. Consult the prescribing information of anti-viral and anti-retroviral concomitant medications to identify potential interactions.Effects of Hormonal Contraceptives on Other DrugsHormonal contraceptives may affect the metabolism of other drugs. Consequently, systemic concentrations may either increase (for example, cyclosporine) or decrease. Consult the labeling of all concurrently-used drugs to obtain further information about interactions with hormonal contraceptives or the potential for enzyme alterations.Interactions between ulipristal and hormonal contraceptives Effectiveness of progestin-containing hormonal contraceptives and emergency contraceptive ulipristal acetate may be decreased if progestin-containing hormonal contraceptives are used within five days after ulipristal acetate dosing. Therefore, if woman wishes to use norethindrone after using ulipristal acetate, she should do so no sooner than days after the intake of ulipristal acetate and she should use reliable barrier method for subsequent acts of intercourse until her next menstrual period.. Effects of Other Drugs on Hormonal Contraceptives. Effects of Hormonal Contraceptives on Other Drugs. Interactions between ulipristal and hormonal contraceptives. 5. Interactions with Laboratory Tests. The following endocrine tests may be affected by progestin-only oral contraceptive use:Sex hormone-binding globulin (SHBG) concentrations may be decreased. Thyroxine concentrations may be decreased, due to decrease in thyroid binding globulin (TBG).. Sex hormone-binding globulin (SHBG) concentrations may be decreased.. Thyroxine concentrations may be decreased, due to decrease in thyroid binding globulin (TBG).. 6. Carcinogenesis. See WARNINGS. 7. Pregnancy. Many studies have found no effects on fetal development associated with long-term use of contraceptive doses of oral progestins. The few studies of infant growth and development that have been conducted have not demonstrated significant adverse effects. It is nonetheless prudent to rule out suspected pregnancy before initiating any hormonal contraceptive use.. 8. Nursing Mothers. In general, no adverse effects have been found on breastfeeding performance or on the health, growth, or development of the infant. However, isolated post-marketing cases of decreased milk production have been reported. Small amounts of progestins pass into the breast milk of nursing mothers, resulting in detectable steroid levels in infant plasma.. 9. Pediatric Use. Safety and efficacy of norethindrone tablets have been established in women of reproductive age. Safety and efficacy are expected to be the same for postpubertal adolescents under the age of 16 and for users 16 years and older. Use of this product before menarche is not indicated. 10. Fertility Following Discontinuation The limited available data indicate rapid return of normal ovulation and fertility following discontinuation of progestin-only oral contraceptives. 11. Headache The onset or exacerbation of migraine or development of severe headache with focal neurological symptoms which is recurrent or persistent requires discontinuation of progestin-only contraceptives and evaluation of the cause.. INFORMATION FOR THE PATIENT. 1. See Detailed Patient Labeling for detailed information. 2. Counseling issues The following points should be discussed with prospective users before prescribing progestin-only oral contraceptives:The necessity of taking pills at the same time every day, including throughout all bleeding episodes.The need to use backup method such as condom and spermicide for the next 48 hours whenever progestin-only oral contraceptive is taken or more hours late. The potential side effects of progestin-only oral contraceptives, particularly menstrual irregularities.The need to inform the healthcare professional of prolonged episodes of bleeding, amenorrhea or severe abdominal pain.The importance of using barrier method in addition to progestin-only oral contraceptives if woman is at risk of contracting or transmitting STDs/HIV.. The necessity of taking pills at the same time every day, including throughout all bleeding episodes.. The need to use backup method such as condom and spermicide for the next 48 hours whenever progestin-only oral contraceptive is taken or more hours late. The potential side effects of progestin-only oral contraceptives, particularly menstrual irregularities.. The need to inform the healthcare professional of prolonged episodes of bleeding, amenorrhea or severe abdominal pain.. The importance of using barrier method in addition to progestin-only oral contraceptives if woman is at risk of contracting or transmitting STDs/HIV.

REFERENCES SECTION.

REFERENCE. McCann M, and Potter L. Progestin-Only Oral Contraceptives: Comprehensive Review. Contraception, 50:60 (Suppl. 1), December 1994. Van Giersbergen PLM, Halabi A, Dingemanse J. Pharmacokinetic interaction between bosentan and the oral contraceptives norethisterone and ethinyl estradiol. Int Clin Pharmacol Ther 2006;44(3):113-118. Truitt ST, Fraser A, Gallo ME, Lopez LM, Grimes DA and Schulz KF. Combined hormonal versus nonhormonal versus progestin-only contraception in lactation (Review). The Cochrane Collaboration. 2007, Issue 3. Halderman, LD and Nelson AL. Impact of early postpartum administration of progestin-only hormonal contraceptives compared with nonhormonal contraceptives on short-term breast-feeding patterns. Am Obstet Gynecol.; 186 (6):1250-1258. Ostrea EM, Mantaring III JB, Silvestre MA. Drugs that affect the fetus and newborn infant via the placenta or breast milk. Pediatr Clin Am; 51(2004): 539-579. Cooke ID, Back DJ, Shroff NE: Norethisterone concentration in breast milk and infant and maternal plasma during ethynodiol diactetate administration. Contraception 1985; 31:611-21. 2008 USPC Official:12/1/08-4/30/09, USP Monographs: Norethindrone Tablets (page of 5). McCann M, and Potter L. Progestin-Only Oral Contraceptives: Comprehensive Review. Contraception, 50:60 (Suppl. 1), December 1994. Van Giersbergen PLM, Halabi A, Dingemanse J. Pharmacokinetic interaction between bosentan and the oral contraceptives norethisterone and ethinyl estradiol. Int Clin Pharmacol Ther 2006;44(3):113-118. Truitt ST, Fraser A, Gallo ME, Lopez LM, Grimes DA and Schulz KF. Combined hormonal versus nonhormonal versus progestin-only contraception in lactation (Review). The Cochrane Collaboration. 2007, Issue 3. Halderman, LD and Nelson AL. Impact of early postpartum administration of progestin-only hormonal contraceptives compared with nonhormonal contraceptives on short-term breast-feeding patterns. Am Obstet Gynecol.; 186 (6):1250-1258. Ostrea EM, Mantaring III JB, Silvestre MA. Drugs that affect the fetus and newborn infant via the placenta or breast milk. Pediatr Clin Am; 51(2004): 539-579. Cooke ID, Back DJ, Shroff NE: Norethisterone concentration in breast milk and infant and maternal plasma during ethynodiol diactetate administration. Contraception 1985; 31:611-21. 2008 USPC Official:12/1/08-4/30/09, USP Monographs: Norethindrone Tablets (page of 5).

SPL PATIENT PACKAGE INSERT SECTION.

DETAILED PATIENT LABELING. Emzahh(TM) (Norethindrone Tablets, USP)This product (like all oral contraceptives) is used to prevent pregnancy. It does not protect against HIV infection (AIDS) or other sexually transmitted diseases. DESCRIPTION Emzahh(TM) TabletsEach tablet contains 0.35 mg norethindrone USP. Inactive ingredients include anhydrous lactose, corn starch, D&C Yellow No. 10 aluminum lake, ethylcellulose, magnesium stearate, microcrystalline cellulose, povidone, sodium starch glycolate, and talc.INTRODUCTIONThis leaflet is about birth control pills that contain one hormone, progestin. Please read this leaflet before you begin to take your pills. It is meant to be used along with talking with your healthcare professional.Progestin-only pills are often called POPs or the minipill. POPs have less progestin than the combined birth control pill (or the pill) which contains both an estrogen and progestin.HOW EFFECTIVE ARE POPsAbout in 200 POP users will get pregnant in the first year if they all take POPs perfectly (that is, on time, every day). About in 20 typical POP users (including women who are late taking pills or miss pills) gets pregnant in the first year of use. Table will help you compare the efficacy of different methods.Table 2: Percentage of Women Experiencing an Unintended Pregnancy During the First Year of Typical Use and the First Year of Perfect Use of Contraception and the Percentage Continuing Use at the End of the First Year. United States. Method(1) of Women Experiencing an Unintended Pregnancy within the First Year of Use of Women Continuing Use at One Year3 Typical Use1 (2) Perfect Use2 (3) (4) No method4 85 85 Spermicides5 28 18 42 Fertility awareness-based methods 24 47 Standard Days method6 TwoDay method6 Ovulation method6 Symptothermal method6 0.4 Withdrawal 22 46 Sponge 36 Parous Women 24 20 Nulliparous Women 12 Condom7 Female (fc) 21 41 Male 18 43 Diaphragm8 12 57 Combined pill and progestin-only pill 0.3 67 Norelgestromin and ethinyl estradiol patch 0.3 67 NuvaRing 0.3 67 Depo-Provera 0.2 56 Intrauterine contraceptives ParaGard (copper T) 0.8 0.6 78 Mirena (LNg) 0.2 0.2 80 Implanon 0.05 0.05 84 Female Sterilization 0.5 0.5 100 Male Sterilization 0.15 0.10 100 Emergency Contraception: Emergency contraceptive pills or insertion of copper intrauterine contraceptive after unprotected intercourse substantially reduces the risk of pregnancy.9 (See Chapter 6.). Lactational Amenorrhea Method: LAM is highly effective, temporary method of contraception.10 (See Chapter 18.) Source: Trussell J. Contraceptive Efficacy. In Hatcher RA, Trussell J, Nelson AL, Cates W, Kowal D, Policar M. Contraceptive Techology: Twentieth Revised Edition. New York NY: Ardent Media, 2011.Notes: Among typical couples who initiate use of method (not necessarily for the first time), the percentage who experience an accidental pregnancy during the first year if they do not stop use for any other reason. Estimates of the probability of pregnancy during the first year of typical use for spermicides, withdrawal, fertility awareness-based methods, the diaphragm, the male condom, the oral contraceptive pill, and Depo-Provera are taken from the 1995 National Survey of Family Growth corrected for underreporting of abortion; see the text for the derivation of estimates for the other methods. Among couples who initiate use of method (not necessarily for the first time) and who use it perfectly (both consistently and correctly), the percentage who experience an accidental pregnancy during the first year if they do not stop use for any other reason. See the text for the derivation of the estimate for each method.3 Among couples attempting to avoid pregnancy, the percentage who continue to use method for year.4 The percentages becoming pregnant in columns (2) and (3) are based on data from populations where contraception is not used and from women who cease using contraception in order to become pregnant. Among such populations, about 89% become pregnant within year. This estimate was lowered slightly (to 85%) to represent the percentage who would become pregnant within year among women now relying on reversible methods of contraception if they abandoned contraception altogether.5 Foams, creams, gels, vaginal suppositories, and vaginal film.6 The Ovulation and TwoDay methods are based on evaluation of cervical mucus. The Standard Days method avoids intercourse on cycle days through 19. The Symptothermal method is double-check method based on evaluation of cervical mucus to determine the first fertile day and evaluation of cervical mucus and temperature to determine the last fertile day.7 Without spermicides.8 With spermicidal cream or jelly.9 ella, Plan One-Step and Next Choice are the only dedicated products specifically marketed for emergency contraception. The label for Plan One-Step (one dose is white pill) says to take the pill within 72 hours after unprotected intercourse. Research has shown that all of the brands listed here are effective when used within 120 hours after unprotected sex. The label for Next Choice (one dose is peach pill) says to take pill within 72 hours after unprotected intercourse and another pill 12 hours later. Research has shown that both pills can be taken at the same time with no decrease in efficacy or increase in side effects and that they are effective when used within 120 hours after unprotected sex. The FDA has in addition declared the following 19 brands of oral contraceptives to be safe and effective for emergency contraception: Ogestrel (1 dose is white pills), Nordette (1 dose is light-orange pills), Cryselle, Levora, Low-Ogestrel, Lo/Ovral, or Quasence (1 dose is white pills), Jolessa, Portia, Seasonale or Trivora (1 dose is pink pills), Seasonique (1 dose is light-blue-green pills), Enpresse (one dose is orange pills), Lessina (1 dose is pink pills), Aviane or LoSeasonique (one dose is orange pills), Lutera or Sronyx (one dose is white pills), and Lybrel (one dose is yellow pills).10 However, to maintain effective protection against pregnancy, another method of contraception must be used as soon as menstruation resumes, the frequency or duration of breastfeeds is reduced, bottle feeds are introduced, or the baby reaches months of age.Emzahh(TM) Tablets have not been studied for and are not indicated for use in emergency contraception.HOW DO POPs WORK POPs can prevent pregnancy in different ways including:They make the cervical mucus at the entrance to the womb (the uterus) too thick for the sperm to get through to the egg. They prevent ovulation (release of the egg from the ovary) in about half of the cycles. They also affect other hormones, the fallopian tubes and the lining of the uterus. YOU SHOULD NOT TAKE POPsIf there is any chance you may be pregnant.If you have breast cancer.If you have bleeding between your periods that has not been diagnosed.If you are hypersensitive, or allergic, to any component of this product.If you have liver tumors, either benign or cancerous.If you have acute liver disease.RISKS OF TAKING POPsCigarette smoking greatly increases the possibility of suffering heart attacks and strokes. Women who use oral contraceptives are strongly advised not to smoke.WARNING: If you have sudden or severe pain in your lower abdomen or stomach area, you may have an ectopic pregnancy or an ovarian cyst. If this happens, you should contact your healthcare professional immediately.Ectopic Pregnancy An ectopic pregnancy is pregnancy outside the womb. Because POPs protect against pregnancy, the chance of having pregnancy outside the womb is very low. If you do get pregnant while taking POPs, you have slightly higher chance that the pregnancy will be ectopic than do users of some other birth control methods.Ovarian Cysts These cysts are small sacs of fluid in the ovary. They are more common among POP users than among users of most other birth control methods. They usually disappear without treatment and rarely cause problems. Cancer of the Reproductive Organs and Breasts Some studies in women who use combined oral contraceptives that contain both estrogen and progestin have reported an increase in the risk of developing breast cancer, particularly at younger age and apparently related to duration of use. There is insufficient data to determine whether the use of POPs similarly increases this risk.A meta-analysis of 54 studies found small increase in the frequency of having breast cancer diagnosed for women who were currently using combined oral contraceptives or had used them within the past ten years. This increase in the frequency of breast cancer diagnosis, within ten years of stopping use, was generally accounted for by cancers localized to the breast. There was no increase in the frequency of having breast cancer diagnosed ten or more years after cessation of use.Some studies have found an increase in the incidence of cancer of the cervix in women who use oral contraceptives. However, this finding may be related to factors other than the use of oral contraceptives and there is insufficient data to determine whether the use of POPs increases the risk of developing cancer of the cervix.Liver Tumors In rare cases, combined oral contraceptives can cause benign but dangerous liver tumors. These benign liver tumors can rupture and cause fatal internal bleeding. In addition, some studies report an increased risk of developing liver cancer among women who use combined oral contraceptives. However, liver cancers are rare. There is insufficient data to determine whether POPs increase the risk of liver tumors.Diabetic Women Diabetic women taking POPs do not generally require changes in the amount of insulin they are taking. However, your healthcare professional may monitor you more closely under these conditions. SEXUALLY TRANSMITTED DISEASES (STDs) WARNING: POPs do not protect against getting or giving someone HIV (AIDS) or any other STD, such as chlamydia, gonorrhea, genital warts or herpes. SIDE EFFECTS Irregular Bleeding: The most common side effect of POPs is change in menstrual bleeding. Your periods may be either early or late, and you may have some spotting between periods. Taking pills late or missing pills can result in some spotting or bleeding.Other Side Effects: Less common side effects include headaches, tender breasts, nausea, vomiting, dizziness, and fatigue. Depression, nervousness, leg pain, vaginal discharge, fluid retention, allergic reactions, jaundice or yellowing of the skin or eyeballs, loss of scalp hair, rash/itchy rash, weight gain, acne and extra hair on your face and body have been reported, but are rare.If you are concerned about any of these side effects, check with your healthcare professional.USING POPs WITH OTHER MEDICINES Before taking POP, inform your healthcare professional of any other medication, including over-the-counter medicine, that you may be taking.These medicines can make POPs less effective:Medicines for seizures such as:Phenytoin Carbamazepine PhenobarbitalFelbamateOxcarbazepineRufinamideMedicine for nausea and vomiting caused by certain anti-cancer (chemotherapy) medicines: (Fos)aprepitantMedicines for tuberculosis (TB):Rifampin and rifabutinMedicine for fungal infections such as: GriseofulvinMedicine for pulmonary hypertension such as:Bosentan Medicines used for the treatment of HIV infections or AIDS and infections due to Hepatitis such as: Efavirenz, nevirapine, nelfinavir, and some ritonavir-containing drugsHerbal products such as:St. Johns wortThese medicines and substances can increase your exposure to POPs: Grapefruit juice Medicines for fungal infections such as:ItraconazoleVoriconazoleFluconazoleKetoconazoleBefore you begin taking any new medicines be sure your healthcare professional knows you are taking progestin-only birth control pill. HOW TO TAKE POPs IMPORTANT POINTS TO REMEMBER POPs must be taken at the same time every day, so choose time and then take the pill at that same time every day. Every time you take pill late, and especially if you miss pill, you are more likely to get pregnant.Start the next pack the day after the last pack is finished. There is no break between packs. Always have your next pack of pills ready.You may have some menstrual spotting between periods. Do not stop taking your pills if this happens.If you vomit soon after taking pill, use backup method (such as condom and/or spermicide) for 48 hours.If you want to stop taking POPs, you can do so at any time, but, if you remain sexually active and dont wish to become pregnant, be certain to use another birth control method.If you are not sure about how to take POPs, ask your healthcare professional. STARTING POPs Its best to take your first POP on the first day of your menstrual period.If you decide to take your first POP on another day, use backup method (such as condom and/or spermicide) every time you have sex during the next 48 hours.If you have had miscarriage or an abortion, you can start POPs the next day. IF YOU ARE LATE OR MISS TAKING YOUR POPs If you are more than hours late or you miss one or more POPs:1) TAKE missed pill as soon as you remember that you missed it,2) THEN go back to taking POPs at your regular time,3) BUT be sure to use backup method (such as condom and/or spermicide) every time you have sex for the next 48 hours.If you are not sure what to do about the pills you have missed, keep taking POPs and use backup method until you can talk to your healthcare professional. IF YOU ARE BREASTFEEDING If you are fully breastfeeding (not giving your baby any food or formula), you may start your pills weeks after delivery.If you are partially breastfeeding (giving your baby some food or formula), you should start taking pills by weeks after delivery. IF YOU ARE SWITCHING PILLS If you are switching from the combined pills to POPs, take the first POP the day after you finish the last active combined pill. Do not take any of the inactive pills from the combined pill pack. You should know that many women have irregular periods after switching to POPs, but this is normal and to be expected.If you are switching from POPs to the combined pills, take the first active combined pill on the first day of your period, even if your POPs pack is not finished.If you switch to another brand of POPs, start the new brand anytime.If you are breastfeeding, you can switch to another method of birth control at any time, except do not switch to the combined pills until you stop breastfeeding or at least until months after delivery.PREGNANCY WHILE ON THE PILL If you think you are pregnant, contact your healthcare professional. Even though research has shown that POPs do not cause harm to the unborn baby, it is always best not to take any drugs or medicines that you dont need when you are pregnant.You should get pregnancy test:If your period is late and you took one or more pills late or missed taking them and had sex without backup method.Anytime it has been more than 45 days since the beginning of your last period. WILL POPs AFFECT YOUR ABILITY TO GET PREGNANT LATER If you want to become pregnant, simply stop taking POPs. POPs will not delay your ability to get pregnant.BREASTFEEDINGIf you are breastfeeding, POPs will not affect the quality or amount of your breast milk or the health of your nursing baby. However, isolated cases of decreased milk production have been reported.OVERDOSE No serious problems have been reported when many pills were taken by accident, even by small child, so there is usually no reason to treat an overdose. OTHER QUESTIONS OR CONCERNS If you have any questions or concerns, check with your healthcare professional. You can also ask for the more detailed Professional Labeling written for doctors and other healthcare professionals. HOW TO STORE YOUR POPs Store at 20 to 25C (68 to 77F); excursions permitted to 15o to 30oC (59o to 86oF) [See USP Controlled Room Temperature]. Keep out of reach of children. INSTRUCTIONS FOR USING YOUR BLISTER PACK FOR THE 28 TABLETS Please Read Me Save these Instructions. Its best to take your first POP on the first day of your menstrual period (Day Start). If you use Day Start, you are protected from becoming pregnant as soon as you take your first pill.If you decide to take your first POP on another day, use backup method (such as condom and/or spermicide) every time you have sex during the next 48 hours.SET THE DAY:Pick the day label strip that starts with the first day of your period.Place this day label strip on the tablet blister pack over the area that has the days of the week (starting with Sunday) pre-printed on the tablet blister pack.Note: If the first day of your period is Sunday, you can skip steps and 2If you decide to take your first POP on another day, use backup method (such as condom and/or spermicide) every time you have sex during the next 48 hours.Swallow the pill. You will take one pill each day. POPs must be taken at the same time every day, so choose time and then take the pill at that same time every day. Every time you take pill late, and especially if you miss pill, you are more likely to get pregnant.Wait 24 hours to take your next pill. POPs must be taken at the same time every day, so choose time and then take the pill at that same time every day. Every time you take pill late, and especially if you miss pill, you are more likely to get pregnant. Continue to take one pill each day whether bleeding or not until all the pills have been taken.Take your pill at the same time every day. It is important to take the correct pill each day and not miss any pills. To help you remember, take your pill at the same time as another daily activity, like turning off your alarm clock or brushing your teeth.You will start new blister pack on the day after last pillTHE FIRST PILL IN EVERY BLISTER PACK WILL ALWAYS BE TAKEN ON THE SAME DAY OF THE WEEK, NO MATTER WHEN YOUR NEXT PERIOD STARTS.If you are late or you miss taking your POPs: If you are more than hours late or you miss one or more POPs: 1) TAKE missed pill as soon as you remember that you missed it, 2) THEN go back to taking POPs at your regular time, 3) BUT be sure to use backup method (such as condom and/or spermicide) every time you have sex for the next 48 hours. If you are not sure what to do about the pills you have missed, keep taking POPs and use backup method until you can talk to your healthcare professional. Important points to remember: POPs must be taken at the same time every day, so choose time and then take the pill at that same time every day. Every time you take pill late, and especially if you miss pill, you are more likely to get pregnant. Start the next pack the day after the last pack is finished. There is no break between packs. Always have your next pack of pills ready. You may have some menstrual spotting between periods. Do not stop taking your pills if this happens. If you vomit soon after taking pill, use backup method (such as condom and/or spermicide) for 48 hours. If you want to stop taking POPs, you can do so at any time, but, if you remain sexually active and dont wish to become pregnant, be certain to use another birth control method. If you are not sure about how to take POPs, ask your healthcare professional. Distributed by: Aurobindo Pharma USA, Inc. 279 Princeton-Hightstown RoadEast Windsor, NJ 08520 Manufactured by: Aurobindo Pharma Limited Hyderabad-500 032, India Revised: 03/2023. They make the cervical mucus at the entrance to the womb (the uterus) too thick for the sperm to get through to the egg. They prevent ovulation (release of the egg from the ovary) in about half of the cycles. They also affect other hormones, the fallopian tubes and the lining of the uterus. If there is any chance you may be pregnant.. If you have breast cancer.. If you have bleeding between your periods that has not been diagnosed.. If you are hypersensitive, or allergic, to any component of this product.. If you have liver tumors, either benign or cancerous.. If you have acute liver disease.. Phenytoin Carbamazepine Phenobarbital. Felbamate. Oxcarbazepine. Rufinamide. (Fos)aprepitant. Rifampin and rifabutin. Griseofulvin. Bosentan Efavirenz, nevirapine, nelfinavir, and some ritonavir-containing drugs. St. Johns wort. Itraconazole. Voriconazole. Fluconazole. Ketoconazole. POPs must be taken at the same time every day, so choose time and then take the pill at that same time every day. Every time you take pill late, and especially if you miss pill, you are more likely to get pregnant.. Start the next pack the day after the last pack is finished. There is no break between packs. Always have your next pack of pills ready.. You may have some menstrual spotting between periods. Do not stop taking your pills if this happens.. If you vomit soon after taking pill, use backup method (such as condom and/or spermicide) for 48 hours.. If you want to stop taking POPs, you can do so at any time, but, if you remain sexually active and dont wish to become pregnant, be certain to use another birth control method.. If you are not sure about how to take POPs, ask your healthcare professional.. Its best to take your first POP on the first day of your menstrual period.. If you decide to take your first POP on another day, use backup method (such as condom and/or spermicide) every time you have sex during the next 48 hours.. If you have had miscarriage or an abortion, you can start POPs the next day.. If you are more than hours late or you miss one or more POPs:. If you are not sure what to do about the pills you have missed, keep taking POPs and use backup method until you can talk to your healthcare professional.. If you are fully breastfeeding (not giving your baby any food or formula), you may start your pills weeks after delivery.. If you are partially breastfeeding (giving your baby some food or formula), you should start taking pills by weeks after delivery.. If you are switching from the combined pills to POPs, take the first POP the day after you finish the last active combined pill. Do not take any of the inactive pills from the combined pill pack. You should know that many women have irregular periods after switching to POPs, but this is normal and to be expected.. If you are switching from POPs to the combined pills, take the first active combined pill on the first day of your period, even if your POPs pack is not finished.. If you switch to another brand of POPs, start the new brand anytime.. If you are breastfeeding, you can switch to another method of birth control at any time, except do not switch to the combined pills until you stop breastfeeding or at least until months after delivery.. If your period is late and you took one or more pills late or missed taking them and had sex without backup method.. Anytime it has been more than 45 days since the beginning of your last period.. Its best to take your first POP on the first day of your menstrual period (Day Start). If you use Day Start, you are protected from becoming pregnant as soon as you take your first pill.. If you decide to take your first POP on another day, use backup method (such as condom and/or spermicide) every time you have sex during the next 48 hours.. Pick the day label strip that starts with the first day of your period.. Place this day label strip on the tablet blister pack over the area that has the days of the week (starting with Sunday) pre-printed on the tablet blister pack.. If you decide to take your first POP on another day, use backup method (such as condom and/or spermicide) every time you have sex during the next 48 hours.. Swallow the pill. You will take one pill each day. POPs must be taken at the same time every day, so choose time and then take the pill at that same time every day. Every time you take pill late, and especially if you miss pill, you are more likely to get pregnant.. Wait 24 hours to take your next pill. POPs must be taken at the same time every day, so choose time and then take the pill at that same time every day. Every time you take pill late, and especially if you miss pill, you are more likely to get pregnant. Continue to take one pill each day whether bleeding or not until all the pills have been taken.. Take your pill at the same time every day. It is important to take the correct pill each day and not miss any pills. To help you remember, take your pill at the same time as another daily activity, like turning off your alarm clock or brushing your teeth.. You will start new blister pack on the day after last pill. THE FIRST PILL IN EVERY BLISTER PACK WILL ALWAYS BE TAKEN ON THE SAME DAY OF THE WEEK, NO MATTER WHEN YOUR NEXT PERIOD STARTS.. If you are more than hours late or you miss one or more POPs: If you are not sure what to do about the pills you have missed, keep taking POPs and use backup method until you can talk to your healthcare professional. POPs must be taken at the same time every day, so choose time and then take the pill at that same time every day. Every time you take pill late, and especially if you miss pill, you are more likely to get pregnant. Start the next pack the day after the last pack is finished. There is no break between packs. Always have your next pack of pills ready. You may have some menstrual spotting between periods. Do not stop taking your pills if this happens. If you vomit soon after taking pill, use backup method (such as condom and/or spermicide) for 48 hours. If you want to stop taking POPs, you can do so at any time, but, if you remain sexually active and dont wish to become pregnant, be certain to use another birth control method. If you are not sure about how to take POPs, ask your healthcare professional. Figure 1.

WARNINGS SECTION.

WARNINGS. Cigarette smoking increases the risk of serious cardiovascular disease. Women who use oral contraceptives should be strongly advised not to smoke. Norethindrone does not contain estrogen and, therefore, this insert does not discuss the serious health risks that have been associated with the estrogen component of combined oral contraceptives (COCs). The healthcare professional is referred to the prescribing information of combined oral contraceptives for discussion of those risks. The relationship between progestin-only oral contraceptives and these risks is not fully defined. The healthcare professional should remain alert to the earliest manifestation of symptoms of any serious disease and discontinue oral contraceptive therapy when appropriate. 1. Ectopic Pregnancy The incidence of ectopic pregnancies for progestin-only oral contraceptive users is per 1000 woman-years. Up to 10% of pregnancies reported in clinical studies of progestin-only oral contraceptive users are extrauterine. Although symptoms of ectopic pregnancy should be watched for, history of ectopic pregnancy need not be considered contraindication to use of this contraceptive method. Healthcare professionals should be alert to the possibility of an ectopic pregnancy in women who become pregnant or complain of lower abdominal pain while on progestin-only oral contraceptives. 2. Delayed Follicular Atresia/Ovarian Cysts If follicular development occurs, atresia of the follicle is sometimes delayed and the follicle may continue to grow beyond the size it would attain in normal cycle. Generally these enlarged follicles disappear spontaneously. Often they are asymptomatic; in some cases they are associated with mild abdominal pain. Rarely they may twist or rupture, requiring surgical intervention. 3. Irregular Genital Bleeding Irregular menstrual patterns are common among women using progestin-only oral contraceptives. If genital bleeding is suggestive of infection, malignancy or other abnormal conditions, such nonpharmacologic causes should be ruled out. If prolonged amenorrhea occurs, the possibility of pregnancy should be evaluated. 4. Carcinoma of the Breast and Reproductive Organs Some epidemiological studies of oral contraceptive users have reported an increased relative risk of developing breast cancer, particularly at younger age and apparently related to duration of use. These studies have predominantly involved combined oral contraceptives and there is insufficient data to determine whether the use of POPs similarly increases the risk. meta-analysis of 54 studies found small increase in the frequency of having breast cancer diagnosed for women who were currently using combined oral contraceptives or had used them within the past ten years. This increase in the frequency of breast cancer diagnosis, within ten years of stopping use, was generally accounted for by cancers localized to the breast. There was no increase in the frequency of having breast cancer diagnosed ten or more years after cessation of use. Women with breast cancer should not use oral contraceptives because the role of female hormones in breast cancer has not been fully determined. 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. However, there continues to be controversy about the extent to which such findings may be due to differences in sexual behavior and other factors. There is insufficient data to determine whether the use of POPs increases the risk of developing cervical intraepithelial neoplasia. 5. Hepatic Neoplasia Benign hepatic adenomas are associated with combined oral contraceptive use, although the incidence of benign tumors is rare in the United States. Rupture of benign, hepatic adenomas may cause death through intra-abdominal hemorrhage. Studies have shown an increased risk of developing hepatocellular carcinoma in combined oral contraceptive users. However, these cancers are rare in the U.S. There is insufficient data to determine whether POPs increase the risk of developing hepatic neoplasia.