Instructions for Leveret mini tablets 0.1mg/0.02mg No. 21
Composition
active ingredients: levonorgestrel, ethinyl estradiol;
1 tablet contains 0.1 mg of levonorgestrel and 0.02 mg of ethinyl estradiol;
excipients: anhydrous lactose, povidone K-30, magnesium stearate;
The film coating contains: polyvinyl alcohol, talc (E 553b), titanium dioxide (E 171), macrogol/PEG 3350, red aluminum dye (E 129), lecithin (E 322), red iron oxide (E 172), blue aluminum dye (E 132).
Dosage form
Film-coated tablets.
Main physicochemical properties: round, pink film-coated tablets.
Pharmacotherapeutic group
Hormonal contraceptives for systemic use.
ATX code G03A A07.
Pharmacological properties
Pharmacodynamics.
The contraceptive effect of a combined oral contraceptive (COC) is based on the interaction of various factors, the most important of which are inhibition of ovulation and changes in cervical mucus.
Pharmacokinetics.
Ethinylestradiol
Absorption. Ethinylestradiol is absorbed rapidly and almost completely, with peak serum concentrations (Cmax) occurring within 1.5 hours. After presystemic conjugation and first-pass metabolism, absolute bioavailability is 60%. The area under the curve (AUC) and Cmax may increase slightly over time.
Distribution: Ethinylestradiol is 98% bound to plasma proteins, mainly albumin.
Metabolism. Ethinylestradiol is broken down by presystemic conjugation. It passes through the intestinal wall (first phase of metabolism) and enters the liver, where conjugation occurs (second phase of metabolism). The most important metabolites of the first phase of metabolism are 2-OH-ethinylestradiol and 2-methoxyethinylestradiol. Both ethinylestradiol and the first phase metabolites are excreted as conjugates (sulfates and glucuronides) in the bile and enter the enterohepatic circulation.
Elimination: Ethinylestradiol is eliminated from plasma with a mean half-life of 29 hours (range 26-33 hours); plasma clearance ranges from 10 to 30 l/hour. Ethinylestradiol conjugates and metabolites are excreted in urine and feces in a 1:1 ratio.
Levonorgestrel
Absorption: After oral administration, levonorgestrel is rapidly and completely absorbed from the gastrointestinal tract. Bioavailability is almost 100% due to the lack of first-pass metabolism.
Distribution: Most of levonorgestrel binds to plasma proteins, mainly albumin and sex hormone binding globulin.
Metabolism. Metabolism mainly involves cleavage of the δ4-3-oxo group and hydroxylation at positions 2α, 1β and 16β, followed by conjugation. The majority of circulating metabolites are sulfates of 3α, 5β-tetrahydrolevonorgestrel. Excretion of the drug occurs mainly in the form of glucuronides. Some parent levonorgestrel also circulates in the form of 17β-sulfate. Metabolic clearance is marked by individual variability, which may partly explain the large differences in levonorgestrel concentrations observed between patients.
Elimination: The half-life of levonorgestrel shows individual variability and is approximately 36 hours at steady-state plasma concentrations. Levonorgestrel is excreted in the urine (40-68%) and feces (16-48%) in the form of metabolites (sulfate and glucuronide conjugates).
Indication
Oral contraception.
Contraindication
presence or history of venous thrombosis (e.g., deep vein thrombosis, pulmonary embolism);
presence or history of arterial thrombosis (e.g. myocardial infarction) or prodromal condition (e.g. angina pectoris or transient ischemic attack);
acute cerebrovascular accident currently or in history;
hereditary or acquired predisposition to the development of venous or arterial thrombosis, for example, resistance to activated protein C, antithrombin III deficiency, protein C deficiency, protein S deficiency, hyperhomocysteinemia, presence of antiphospholipid antibodies (anticardiolipin antibodies, lupus anticoagulant);
the presence of serious and multiple risk factors for arterial thrombosis (see section "Special precautions for use");
heart valve pathology, thrombogenic heart rhythm disturbances;
diabetes mellitus with manifestations of micro- or macroangiopathies;
severe arterial hypertension;
severe dyslipoproteinemia;
history of migraine with focal neurological symptoms;
Current or history of pancreatitis associated with severe hypertriglyceridemia;
severe liver disease, present or in history, until liver function tests return to normal;
presence or history of liver tumors (benign or malignant);
diagnosed or suspected hormone-dependent malignant tumors (for example, of the genital organs);
current or history of breast cancer, which may be hormone-sensitive (see section "Special warnings and precautions for use", subsection "Malignant neoplasms");
hypersensitivity to the active substances (levonorgestrel, ethinyl estradiol) or to any excipient of the drug;
The use of Leveret mini in combination with St. John's wort (Hypericum perforatum) is contraindicated (see section "Interaction with other medicinal products and other types of interactions").
The drug Leveret mini is contraindicated when used simultaneously with medicinal products containing ombitasvir/paritaprevir/ritonavir and dasabuvir or medicinal products containing glecaprevir/pibrentasvir or sofosbuvir/velpatasvir/voxilaprevir (see section “Interaction with other medicinal products and other types of interactions”).
Interaction with other medicinal products and other types of interactions
The information for the concomitant medicinal product should be consulted to identify potential interactions.
Pharmacodynamic interactions
In clinical trials in patients treated with hepatitis C virus (HCV) medicinal products containing ombitasvir/paritaprevir/ritonavir and dasabuvir with or without ribavirin, transaminase (ALT) elevations greater than 5 times the upper limit of normal (ULN) have been observed. This occurred at a significantly higher frequency in women taking ethinylestradiol-containing medicinal products, including combined hormonal contraceptives (CHCs). In addition, ALT elevations have been observed in women taking ethinylestradiol-containing medicinal products, such as CHCs, in patients treated with glecaprevir/pibrentasvir or sofosbuvir/velpatasvir/voxilaprevir (see section 4.3).
Therefore, women using Leveret mini should use an alternative method of contraception (e.g. progestogen-only contraceptives or non-hormonal methods) before starting therapy with this combination of drugs. Leveret mini can be restarted 2 weeks after completing therapy with this combination.
Pharmacokinetic interactions
Effects of other medicines on Leveret mini
Interaction with drugs that induce microsomal enzymes is possible, as a result of which the clearance of sex hormones may increase, which, in turn, causes changes in the pattern of menstrual bleeding and/or loss of contraceptive effectiveness.
Therapy
Enzyme induction may be detected within a few days of treatment. Maximum enzyme induction is generally observed after a few weeks. After drug withdrawal, enzyme induction may persist for up to 4 weeks.
Short-term treatment
Women taking enzyme-inducing drugs should temporarily use a barrier method or another method of contraception in addition to the COC. If therapy with an inducer is started during the last COC tablet period of the current package, the active tablets from the next COC package should be started immediately after the end of the active tablets in the previous package, skipping the placebo tablets.
Long-term treatment
Women on long-term therapy with active substances that induce liver enzymes are recommended to use another non-hormonal method of contraception.
The following interactions have been reported based on published data.
Active substances that increase the clearance of COCs (reduced COC efficacy due to enzyme induction), such as barbiturates, bosentan, carbamazepine, phenytoin, primidone, rifampicin, and drugs used to treat HIV infection: ritonavir, nevirapine and efavirenz; also possibly felbamate, griseofulvin, oxcarbazepine, topiramate and drugs containing St. John's wort extract (Hypericum perforatum).
Active substances with inconsistent effects on PDA clearance
When used concomitantly with COCs, a large number of combinations of HIV protease inhibitors and non-nucleoside reverse transcriptase inhibitors, including combinations with hepatitis C virus inhibitors, may increase or decrease plasma concentrations of estrogen or progestins. The cumulative effect of such changes may be clinically significant in some cases.
Therefore, the prescribing information for the concomitant HIV/HCV medicinal product should be consulted for potential interactions and any other recommendations. In case of any doubt, women should additionally use a barrier method of contraception during treatment with protease inhibitors or non-nucleoside reverse transcriptase inhibitors.
Influence of Leveret mini on other medicines
COCs can affect the metabolism of other drugs. Therefore, they can change the concentration of active substances in blood plasma and tissues - both increasing (e.g., cyclosporine) and decreasing (e.g., lamotrigine).
Troleandomycin
May increase the risk of intrahepatic cholestasis when used concomitantly with COCs.
Modafinil
There is a risk of reduced contraceptive effect during and in the next cycle after stopping modafinil, as it is an inducer of liver microsomal enzymes.
Regular oral contraceptives (not low-dose) or other methods of contraception should be used.
There is a risk of decreased estrogen and progestogen concentrations with a subsequent risk of lack of efficacy.
Perampanel
When using perampanel at a dose equal to or exceeding 12 mg per day, there is a risk of reduced contraceptive effect. It is recommended to use other methods of contraception, preferably barrier methods.
Rufinamide
Causes a moderate decrease in ethinylestradiol concentrations. It is recommended to use other methods of contraception, preferably barrier methods.
Etoricoxib
When used simultaneously with etoricoxib, an increase in ethinylestradiol concentrations is observed.
Laboratory studies
The use of contraceptive steroids may affect the results of certain laboratory tests, including biochemical indicators of liver function, thyroid function, adrenal and renal function, as well as the level of plasma transport proteins, such as corticosteroid-binding globulin and lipid/lipoprotein fractions; indicators of carbohydrate metabolism, coagulation and fibrinolysis. Changes usually occur within the normal range of laboratory values.
Application features
Special warnings
If any of the diseases/risk factors listed below are present, the benefits of COCs and the possible risks of their use should be assessed for the individual woman and the respective benefits and risks should be discussed with her before she decides to use such drugs. In the event of the first appearance, worsening or exacerbation of any of these diseases or risk factors, the woman should consult her doctor. The doctor should decide whether to stop taking COCs.
Circulatory disorders
The use of all combined contraceptives increases the risk of venous thromboembolic complications (deep vein thrombosis, pulmonary embolism) in women compared with those who do not use them. The risk of these diseases reaches its maximum in the first year of COC use. In women using oral contraceptives with a low estrogen content (<0.05 mg ethinylestradiol) and who do not have established risk factors for venous thromboembolism, the incidence of venous thromboembolic complications is approximately 20 cases per 100,000 woman-years (in women who used COCs containing levonorgestrel) and 40 cases per 100,000 woman-years (in women who used COCs containing desogestrel or gestodene). In women who do not use COCs, this risk is 5-10 cases per 100,000 woman-years and 60 cases per 100,000 pregnancies. Venous thromboembolism is fatal in 1-2% of cases.
In 1-2% of cases, venous thromboembolism can lead to death.
Some epidemiological studies have established an association between COC use and an increased risk of arterial thromboembolic diseases (myocardial infarction, transient ischemic attack).
Thrombosis in other blood vessels, such as hepatic, mesenteric, renal, cerebral, retinal veins and arteries, has been reported very rarely in women using oral contraceptives. There is no consensus on whether these events are related to the use of hormonal contraceptives.
Symptoms of venous or arterial thrombotic/thromboembolic events or stroke may include:
unusual leg pain and/or swelling in one leg;
sudden severe chest pain that may or may not spread to the left arm;
sudden shortness of breath;
any unusual, severe, prolonged headache;
sudden partial or complete loss of vision;
double vision;
slurred speech or aphasia;
vertigo;
loss of consciousness with or without focal epileptic seizure;
weakness or very severe numbness that suddenly affects one side or one part of the body;
motor disorders;
"acute stomach".
The risk of venous thromboembolic complications in women using COCs increases:
with age;
if there is a family history (venous thromboembolism in a brother, sister or parent at a relatively early age); if a hereditary predisposition is suspected, it is necessary to consult a specialist before using any COC;
in case of prolonged immobilization, major surgery, any surgery on the legs or serious trauma; in these situations it is advisable to stop using COCs (in the case of elective surgery - at least 4 weeks before it) and not to resume taking them earlier than 2 weeks after full recovery;
with obesity (body mass index above 30 kg/m2);
There is no consensus regarding the possible role of varicose veins and superficial thrombophlebitis in the development or progression of venous thrombosis.
The risk of arterial thromboembolic complications or stroke in women using COCs is increased by:
with age;
when smoking (women over 35 years of age are strongly advised not to smoke if they wish to use COCs);
in the presence of dyslipoproteinemia;
with arterial hypertension;
for migraine;
with obesity (body mass index above 30 kg/m2);
if there is a family history of arterial thromboembolism (arterial thromboembolism in a brother, sister or parent at a relatively early age); if a hereditary predisposition is suspected, a woman should consult a specialist before using an oral contraceptive;
with atrial fibrillation (atrial fibrillation).
The presence of one or more serious risk factors for venous or arterial thromboembolism may also be a contraindication. The possibility of anticoagulant therapy should also be taken into account. Women using COCs should consult a doctor if they experience symptoms of thrombosis. In the event of suspected or confirmed thrombosis, COCs should be discontinued. Adequate alternative contraception should also be initiated due to the teratogenicity of anticoagulant therapy (coumarins).
In the postpartum period, the increased risk of venous thromboembolism should be taken into account (see section "Use during pregnancy or breastfeeding").
Other diseases associated with adverse circulatory system reactions include: diabetes mellitus, systemic lupus erythematosus, hemolytic uremic syndrome, chronic inflammatory bowel disease (Crohn's disease or ulcerative colitis), and sickle cell anemia.
An increase in the frequency or severity of migraine during COC use (which may be a prodromal or cerebrovascular event) may be a reason for immediate discontinuation of COC use.
Tumors
Some epidemiological studies have reported an increased risk of cervical cancer in women who have used COCs for a long time (> 5 years), but this statement is still controversial, as it is not yet clear to what extent the results of the studies take into account concomitant risk factors, such as sexual behavior and human papillomavirus (HPV) infection.
A meta-analysis of 54 epidemiological studies has shown a slightly increased relative risk (RR = 1.24) of developing breast cancer in women who use COCs. This increased risk gradually decreases within 10 years after stopping COC use. Since breast cancer is rare in women under 40 years of age, the increase in the number of breast cancer diagnoses in women who use or have recently used COCs is small compared with the overall risk of breast cancer. Evidence of a causal relationship has not been provided in these studies.
The increased risk may be due to the early diagnosis of breast cancer in women who used COCs, the biological effects of COCs, or a combination of both factors.
In women who use oral contraceptives, breast cancer is diagnosed at a slightly earlier stage compared to women who have not used COCs.
In rare cases, benign (adenoma, focal nodular hyperplasia) and even more rarely malignant liver tumors have been observed in women taking COCs. In some cases, these tumors can lead to life-threatening intra-abdominal hemorrhage. Liver tumors should be considered in the differential diagnosis when women taking COCs develop severe upper abdominal pain, liver enlargement, or signs of intra-abdominal hemorrhage.
Malignant neoplasms (warnings issued by the FDA's Center for Drug Evaluation and Research (CDER)).
Breast cancer
Leveret mini is contraindicated in women who currently have or have had breast cancer in the past, as breast cancer may be hormone-sensitive (see Contraindications).
Epidemiological studies have not found a consistent association between the use of combined oral contraceptives (COCs) and the risk of breast cancer. Studies have not shown an association between current or past use of COCs and the risk of breast cancer. However, some studies have reported a small increased risk of breast cancer among current or recent users (less than 6 months since last use) and among current users of COCs (see section 4.8, subsection Post-marketing data).
Other states
Hypertriglyceridemia
Women with hypertriglyceridemia or a family history of this condition are at increased risk of pancreatitis when using COCs.
Arterial hypertension
A slight increase in blood pressure has been reported in many women using COCs, but clinically significant increases have been rare. Only in these rare cases has immediate discontinuation of COC use been justified. If, during COC use in pre-existing hypertension, a persistent increase in blood pressure occurs or if the significant increase in blood pressure does not respond adequately to treatment of hypertension, COC use should be discontinued. In some cases, COC use can be resumed if normal blood pressure values can be achieved with antihypertensive therapy.
Angioedema
In women with hereditary angioedema, exogenous estrogens may induce or exacerbate symptoms of angioedema.
Liver disease
In case of acute or chronic liver dysfunction, the question of discontinuing COCs may arise until liver function tests return to normal.
Although COCs may affect peripheral insulin resistance and glucose tolerance, there is no evidence to suggest that the therapeutic dosage regimen should be altered in diabetic women taking low-dose COCs (containing < 0.05 mg ethinylestradiol). However, diabetic women should be closely monitored throughout the entire period of COC use.
Other states
Depressed mood and depression are common adverse reactions with hormonal contraceptives (see section 4.8). Depression can be severe and is a known risk factor for suicidal behaviour and suicide. Women should be advised to seek medical advice if they experience mood swings and symptoms of depression, even if they occur soon after starting treatment.
In case of recurrence of cholestatic jaundice, which first occurred during pregnancy or previous use of sex steroid hormones, COC use should be discontinued.
The following conditions have been reported to develop or worsen during pregnancy and COC use (the relationship to COC use is unclear): jaundice and/or pruritus associated with cholestasis; gallstones; porphyria; systemic lupus erythematosus; hemolytic uremic syndrome; Sydenham's chorea; herpes gestationis; hearing loss associated with otosclerosis.
Worsening of endogenous depression, epilepsy, Crohn's disease and ulcerative colitis has been observed during COC use.
Chloasma may occasionally occur, especially in women with a history of chloasma during pregnancy. Women with a tendency to chloasma should avoid direct sunlight or ultraviolet radiation when using COCs.
Particular attention should be paid to patients with hyperprolactinemia.
Medical examination/consultation
Before starting or resuming the use of Leveret mini, the patient's medical history, including family history, should be carefully examined and pregnancy should be excluded. Blood pressure should also be measured and a general examination should be performed, taking into account the contraindications (see section "Contraindications") and special precautions (see section "Special warnings and precautions for use"). The instructions for medical use should be carefully read and the recommendations given in it should be followed. The frequency and nature of the examinations should be based on current standards of medical practice, taking into account the individual characteristics of each woman.
The patient should also be warned that oral contraceptives do not protect against HIV infection (AIDS) and other sexually transmitted diseases.
Decreased efficiency
The effectiveness of COCs may be reduced, for example, in the event of missed tablets (see section "Method of administration and dosage"), vomiting, diarrhea (see section "Method of administration and dosage") or when other medicines are used simultaneously (see section "Interaction with other medicines and other types of interactions").
Decreased cycle control
As with all COCs, irregular bleeding (spotting or breakthrough bleeding) may occur, especially during the first months of use, so any irregular bleeding should only be assessed after the adaptation period of approximately three cycles.
If irregular bleeding persists or occurs after several regular cycles, non-hormonal causes should be considered and appropriate diagnostic measures should be taken to exclude malignancy or pregnancy. These measures may include curettage.
Some women may not have a menstrual period during the usual COC break. If the COC has been used according to the instructions in the section "Method of administration and dosage", pregnancy is unlikely. However, if the instructions in the section "Method of administration and dosage" were not followed before the first absence of withdrawal bleeding or if menstrual bleeding is absent for two cycles, pregnancy should be excluded before COC use is continued.
Exogenous estrogens may induce or exacerbate symptoms of hereditary and acquired angioedema.
Excipients
Leveret mini contains anhydrous lactose. Women with rare hereditary problems of galactose intolerance, the Lapp lactase deficiency or glucose-galactose malabsorption should not take this medicine.
Use during pregnancy or breastfeeding
Pregnancy. The drug Leveret mini is contraindicated for use during pregnancy.
If a woman becomes pregnant while taking the pills, further use should be discontinued immediately.
Breastfeeding Oral hormonal contraceptives may affect lactation as they may reduce the quantity and change the composition of breast milk. Therefore, the use of COCs is not recommended until breastfeeding is stopped. Small amounts of contraceptive steroids and/or their metabolites may pass into breast milk. These amounts may affect the child. If a woman wishes to breastfeed, she should be offered other methods of contraception.
Ability to influence reaction speed when driving vehicles or other mechanisms
No studies on the effects on the ability to drive and use machines have been performed. No effects on the ability to drive and use machines have been observed in women using COCs.
Method of administration and doses
Method of administration. Take orally in the order indicated on the package, at approximately the same time, one tablet per day, washed down with a small amount of liquid.
If the woman did not use a contraceptive in the previous cycle, the first tablet is started on the 1st day of the onset of menstruation and is taken 1 tablet per day for 21 days (preferably at the same time of day). Starting on days 2-7 is also possible, but during the first cycle it is recommended to additionally use a non-hormonal method of contraception (such as condoms or spermicides) for the first 7 days of tablet-taking.
After the 21-day course of taking the drug, a 7-day break is taken, during which menstrual-like bleeding usually occurs (usually on the 2nd or 3rd day). Taking the tablets from the next pack should be started after the 7-day break, even if the bleeding has not stopped.
This method of use can be continued as long as pregnancy prevention is desired. With regular use of Leveret mini, the contraceptive effect is maintained even during the 7-day break.
Switching from another combined hormonal contraceptive (pill, vaginal ring or transdermal patch). Use of Leveret mini should be started on the day after taking the last tablet of the previous contraceptive (removal of the vaginal ring, transdermal patch), but at the latest on the day after the tablet-free interval (placebo pill, removal of the vaginal ring, transdermal patch) of the previous contraceptive.
Switching to Leveret mini from a progestogen-only pill (low-dose oral contraceptive, injection, implant or intrauterine device). Switching from a low-dose oral contraceptive can be done on any day of the menstrual cycle (from an implant and an intrauterine device – on the day of their removal, from an injection – on the day when the next injection would be due). In this case, it is recommended to additionally use a barrier method of contraception during the first 7 days of tablet-taking.
After abortion in the first trimester of pregnancy, the drug should be started immediately on the same day after the operation. In this case, there is no need to use additional contraceptive methods.
After childbirth or after abortion in the second trimester of pregnancy, the use of the drug should be started on the 21st-28th day after childbirth or abortion in the second trimester of pregnancy, since there is a risk of thromboembolic disorders during the postpartum period. If a woman starts taking the pills later, barrier methods of contraception should be used additionally during the first 7 days of taking the drug. However, if sexual intercourse has already taken place, then before starting the use of a combined contraceptive, a possible pregnancy should be excluded or wait for the first menstruation.
Lactation. Information on the use of the drug during lactation is presented in the section "Use during pregnancy or breastfeeding".
Missed pill
If less than 12 hours have passed since the time when the next tablet should have been taken, contraceptive protection is not reduced. Women should take the missed tablet as soon as she remembers, and the next tablet should be taken at the usual time.
If more than 12 hours have passed since the time when the next tablet should have been taken, contraceptive protection may be reduced. In this case, two basic rules must be followed:
1. The break in taking pills should never exceed 7 days.
2. To achieve adequate suppression of the hypothalamic-pituitary-ovarian system, continuous tablet intake for 7 days is necessary.
Accordingly, the following recommendations should be followed in everyday life.
The last missed tablet should be taken as soon as the woman remembers, even if this means taking 2 tablets at the same time. Then the tablet-taking routine continues as usual. In addition, barrier methods of contraception (e.g. condoms) should be used for the next 7 days. If sexual intercourse has taken place in the previous 7 days, the possibility of pregnancy should be considered. The more tablets are missed and the closer the missed tablet is to the 7-day tablet-free interval, the higher the risk of pregnancy.
2nd week
The last missed tablet should be taken as soon as the woman remembers, even if she has to take 2 tablets at the same time. Then the tablet-taking continues as usual. If the woman has taken the tablets correctly for the 7 days before the missed tablet, there is no need to use additional contraceptive measures. Otherwise, if more than one tablet is missed, it is recommended to additionally use a barrier method of contraception for 7 days.
3rd week
The risk of a critical reduction in contraceptive protection is unavoidable due to the upcoming 7-day break in taking the drug. However, by adhering to the tablet-taking schedule, a reduction in contraceptive protection can be avoided. If you follow one of the options below, you will not need to use additional contraceptive measures, provided that you have taken the tablets correctly for the 7 days before the missed tablet. Otherwise, it is recommended to follow the first of the options below and use additional contraceptive methods for the next 7 days.
1. The last missed tablet should be taken as soon as the woman remembers, even if it means taking 2 tablets at the same time. Then the tablet-taking continues as usual. The patient should start taking the tablets from the next pack the day after taking the last tablet from the current pack, i.e. there should be no break between taking the tablets from different packs. It is unlikely that the woman will start menstrual-like bleeding before finishing the tablets from the second pack, although spotting or breakthrough bleeding may occur.
2. The woman may also be advised to stop taking the tablets from the current pack. In this case, the patient should take a break in taking the drug for up to 7 days, including the days on which she forgot to take the tablets, and then start taking the tablets from the next pack of the drug.
If a woman misses a tablet and then has no menstrual-like bleeding during the first usual tablet-free interval, the possibility of pregnancy should be considered.
Gastrointestinal diseases
In the presence of vomiting or diarrhea, the effectiveness of the drug is reduced due to incomplete absorption of the active ingredients.
If vomiting occurs within 3-4 hours after taking the pill, the woman should follow the recommendations described in the section "Missed pills".
If a woman with diarrhea does not want to change her usual pill-taking regimen, she should take an additional pill every day from a different pack for as many days as necessary.
Delay or acceleration of the menstrual cycle
To delay menstrual bleeding, taking Leveret mini tablets from a new package should be started the day after the end of the current package without a break in between. The duration of the delay in menstrual bleeding depends on the number of tablets taken from the second package. During this period, breakthrough bleeding or spotting may occur. Regular use of Leveret mini can be resumed after the usual 7-day break.
In order to accelerate the onset of menstrual bleeding, the 7-day break in taking the drug is shortened by the desired number of days. The shorter the break in taking the drug, the more likely it is that menstrual-like bleeding will not occur, and breakthrough or spotting bleeding will occur while taking the tablets from the next package. It is important to emphasize that the break in taking the drug cannot be extended.
