Symonette: composition and presentation
Symonette comes as film-coated tablets; each contains 75 µg of desogestrel. There is no oestrogen in it, and that is the main thing to know about the medicine: this is a progestogen-only contraceptive, not a combined pill.
From that follows the area of use, which the description names plainly: the medicine may be taken while breastfeeding and by women who cannot or do not wish to use oestrogens. The excipients contain lactose, so in the rare hereditary galactose intolerance, Lapp lactase deficiency or glucose-galactose malabsorption it is not suitable.
How Symonette works
Desogestrel is one of the progestogens, and it works differently from traditional tablets containing progestogen alone. In the classic "mini-pills" the main mechanism is thickening of the cervical mucus, and ovulation is by no means always suppressed. With desogestrel the contraceptive effect is achieved chiefly by inhibiting ovulation; increased viscosity of the cervical mucus remains an additional effect rather than the principal one.
That difference explains both the strength of the medicine and its peculiarity. The strength is plain: suppression of ovulation is close to 100%, so reliability compares with combined pills but without an oestrogen component. The peculiarity springs from the same mechanism: the woman's own cycle is switched off entirely and the bleeding pattern becomes unpredictable — more on that in the section on adverse reactions. One further consequence: the serum concentration of oestradiol falls to the level of the early follicular phase.
Indications
The indications section of the description consists of a single word — contraception. The medicine has neither therapeutic aims nor secondary indications such as regulating the cycle or treating acne, and that is worth bearing in mind: everything else that happens to the cycle during treatment is not a therapeutic effect but a side consequence of suppressed ovulation.
Since there is only one indication, the medicine is chosen not "by symptoms" but by circumstances: breastfeeding, intolerance of oestrogens or unwillingness to take them, and the presence of risk factors that make a combined pill unsuitable.
Method of use and dosage
The tablets are taken daily with a little liquid, at roughly the same time, so that the interval between two consecutive tablets is always 24 hours. The first tablet is taken on the first day of menstrual bleeding. From then on one tablet is taken every day continuously, without regard to any bleeding that may occur.
The key word here is "continuously". Tablets from a new pack are started the very next day after the previous one runs out: the breaks between blisters familiar from combined contraception do not exist with this medicine. Keeping to the 24-hour interval is no formality either: it is what holds ovulation suppressed.
Contraindications
The medicine is not used in hypersensitivity to the active substance or any excipient, in pregnancy or its suspicion, in active venous thromboembolic disease, in serious liver disease — present now or in the past — for as long as liver function parameters have not returned to normal, in the presence or suspicion of malignancies dependent on sex hormones, and in vaginal bleeding of unknown origin.
The last entry is easy to underrate, yet in practice it weighs more than the others: bleeding of unknown origin is a symptom that has to be explained, and a hormonal contraceptive will alter its picture and make diagnosis harder. The liver proviso is carefully built: the ban holds until the parameters normalise, so liver disease that has been through and resolved does not close the door on the medicine.
Special warnings and precautions
The section is built as a list of risk factors: with each of them the benefit of the progestogen is weighed against the possible risk individually and discussed with the patient before starting, and if a condition appears for the first time or worsens, the woman consults her doctor, who decides whether to continue. Breast cancer comes first. Its risk rises with age by itself; with combined contraceptives the likelihood of a diagnosis increases slightly, that increase fades over ten years after stopping, and it is bound up not with the duration of use but with age. For progestogen-only preparations the degree of risk is probably similar, but the data are less conclusive, and against a lifetime risk the additional one is small. Then the liver: a biological effect of progestogens on liver cancer cannot be ruled out, so with that diagnosis benefit and risk are weighed individually, and in acute or chronic impairment of liver function the woman is referred to a specialist. The third block is thrombosis: epidemiological studies link combined contraceptives with an increased frequency of venous thromboembolic disease; the clinical significance of those data for desogestrel without an oestrogen component is not known, but if thrombosis occurs the medicine is withdrawn. Withdrawal is also considered during prolonged immobilisation because of surgery or illness, and women with past thromboembolic disorders are warned that it may recur.
The remaining situations are dealt with more briefly. In diabetes progestogens may affect peripheral insulin resistance and glucose tolerance, but the regimen need not be changed — patients are simply watched carefully in the first months. Where persistent hypertension develops during use, or blood pressure responds poorly to treatment, withdrawal is considered. The fall in oestradiol to early follicular phase levels is mentioned with an honest caveat: whether that has a clinically meaningful effect on bone mineral density is not yet known. On ectopic pregnancy it says this: traditional mini-pills protect against it less well than combined pills, because ovulation with them occurs often; this medicine suppresses ovulation consistently, but with absent menstruation or abdominal pain an ectopic pregnancy is still considered in the differential diagnosis. Chloasma is occasionally possible, especially in those who had it during pregnancy — women prone to it should avoid the sun. Follicle growth occurs with all low-dose hormonal contraceptives; occasionally a follicle grows larger than usual, such functional cysts generally disappear on their own and only rarely call for intervention. Finally, a number of conditions are named that have been reported in pregnancy and with medicines containing sex hormones but whose link with progestogens has not been established — from cholestasis and gallstones to porphyria, lupus and hereditary angioedema. The medicine has no or negligible influence on the ability to drive.
Interactions with other medicines
Interactions of hormonal contraceptives with other medicines have two consequences: intermenstrual bleeding and reduced reliability. They have been described mainly for combined preparations, occasionally for progestogen-only ones too. The mechanism is hepatic: medicines that induce microsomal enzymes speed up the clearance of sex hormones. The list includes hydantoins such as phenytoin, barbiturates such as phenobarbital, primidone, carbamazepine and rifampicin; the same may apply to oxcarbazepine, topiramate, rifabutin, felbamate, ritonavir, nelfinavir, griseofulvin and preparations containing St John's wort.
Induction also comes with timings that are easily forgotten. Its maximum arrives no sooner than two to three weeks, yet it persists for at least four weeks after the inducer is stopped. For that reason a barrier method is used in addition during such treatment and for a further 28 days after it, and with long-term use of inducers it is worth considering non-hormonal contraception altogether. Activated charcoal reduces absorption of the steroid from the tablet and with it the reliability. The influence works the other way as well: hormonal contraceptives can disturb the metabolism of other medicines, raising — as with ciclosporin — or lowering their concentrations in plasma and tissues. Finally, steroid contraceptives may alter laboratory results: biochemical tests of liver, thyroid, adrenal and kidney function, carrier proteins, lipid fractions, carbohydrate metabolism and coagulation. Usually the changes stay within the normal range, and how far this applies to progestogen-only preparations is unknown.
Pregnancy and breastfeeding
In pregnancy the medicine is contraindicated, but the data the description cites are rather reassuring: very high doses of progestogens in animal studies could cause masculinisation of female foetuses, yet extensive epidemiological studies found neither an increased risk of birth defects in women who had used combined contraceptives before pregnancy, nor a teratogenic effect from inadvertent use in early pregnancy. Pharmacovigilance data on contraceptives containing desogestrel likewise point to no increased risk.
Breastfeeding is the very ground on which this type of tablet is most often chosen. On the production and the quality of milk — its protein, lactose and fat content — the medicine has no effect. Small amounts of etonogestrel do pass into milk: a child may receive 0.01 to 0.05 µg per kilogram of body weight a day, taking an estimated milk intake of 150 ml per kilogram a day. There are also follow-up data on children whose mothers began desogestrel 4 to 8 weeks after delivery: the children were breastfed for seven months and followed up to the age of one and a half in 32 cases and to two and a half in 14, and assessment of growth and of physical and psychomotor development showed no differences from children whose mothers used copper intrauterine devices. On that basis the medicine may be used during lactation, though the child's growth and development should be watched attentively.
Adverse reactions
The commonest adverse effect is disturbance of the bleeding pattern, and it deserves separate treatment because with desogestrel it happens more often than with other progestogen-only pills. The reason is paradoxical: precisely because suppression of ovulation is close to 100%, the woman's own cycle disappears, and with it the predictability of bleeding.
| What happens to bleeding | How often |
| Bleeding irregularities of any kind | in almost half of those taking desogestrel |
| Bleeding becomes more frequent than usual | in 20–30% of women |
| Bleeding becomes less frequent or stops altogether | in a further 20% |
| Bleeding lasts longer than usual | possible in any user |
| After some months of use | bleeding occurs less often and the picture settles |
The description advises outright what leaflets rarely say: information, counselling and a bleeding diary improve acceptance of the new rhythm. Of the other effects, those occurring in more than 2.5% were acne, mood changes, breast pain, nausea and weight gain. Common effects are mood change, reduced sexual drive, headache, nausea, acne, breast pain, irregular menstruation, absent menstruation and weight gain; uncommon ones are vaginal infection, intolerance of contact lenses, vomiting, hair loss, painful menstruation, ovarian cyst and fatigue; rare ones are rash, hives and erythema nodosum. Galactorrhoea is possible, and ectopic pregnancy has occasionally been reported. Serious events recorded in users of oral contraceptives are mentioned separately: venous and arterial thromboembolic disease, hormone-dependent tumours including liver tumours and breast cancer, and chloasma.
Overdose
There are no reports of serious adverse effects after an overdose of the medicine. The symptoms that may occur are limited to nausea, vomiting and slight vaginal bleeding in young girls. No antidote is used, and symptomatic treatment is given if needed.
The practical sense of this section lies not in poisoning but in reassurance: two tablets taken by mistake instead of one call for no emergency measures. Far more important is the opposite situation — a missed tablet or a broken 24-hour interval — because that is what reduces reliability. It is worth finding out in advance what to do about a missed tablet, rather than on the day it happens.
How to get a Symonette prescription online
Contraception is an area where a consultation is needed not to make a diagnosis but to assess contraindications, and it therefore sits well with the remote format. At e-zdrowie.com you fill in a questionnaire, the doctor reviews the answers and, where there is nothing in the way, issues an electronic prescription: the code arrives by message, and any Polish pharmacy will dispense the tablets against it. Renewing contraception already settled on is particularly straightforward this way.
What counts in the questionnaire is not complaints but circumstances. State whether you are breastfeeding and how long it has been since delivery, whether there is a pregnancy or a suspicion of one, whether there have been venous thromboses or a long period of immobility after an operation, whether there is liver disease, diabetes or raised blood pressure, and whether there are hormone-dependent tumours in you or in the family. Be sure to report vaginal bleeding of unknown origin and list the medicines you take — anticonvulsants, rifampicin, rifabutin, griseofulvin, HIV medicines and St John's wort supplements above all: every one of them reduces contraceptive reliability.
