Aurobindo Pharma Limited Aurobindo Pharma Limited

Simpesse Levonorgestrel and Ethinyl Estradiol and Ethinyl Estradiol Simpesse Levonorgestrel/Ethinyl Estradiol LEVONORGESTREL LEVONORGESTREL ETHINYL ESTRADIOL ETHINYL ESTRADIOL CROSCARMELLOSE SODIUM LACTOSE MONOHYDRATE MAGNESIUM STEARATE MICROCRYSTALLINE CELLULOSE POVIDONE K30 Biconvex S;27 Ethinyl Estradiol Ethinyl Estradiol ETHINYL ESTRADIOL ETHINYL ESTRADIOL SILICON DIOXIDE FD&C BLUE NO. 1 LACTOSE MONOHYDRATE POVIDONE K30 STARCH, CORN STEARIC ACID .ALPHA.-TOCOPHEROL, DL- Light Blue Biconvex S;45

Contraindications, Pregnancy (4)                              Removed 01/2023 Warnings and Precautions, Malignant Neoplasms (5.11)          04/2022


Cigarette smoking increases the risk of serious cardiovascular events from combination oral contraceptives (COC) use. This risk increases with age, particularly in women over 35 years of age, and with the number of cigarettes smoked. For this reason, COCs, including Simpesse, are contraindicated in women who are over 35 years of age and smoke. [See Contraindications (4) and Warnings and Precautions (5.1).].
WARNING: CIGARETTE SMOKING AND SERIOUS CARDIOVASCULAR EVENTS See full prescribing information for complete boxed warning. Simpesse is contraindicated in women over 35 years old who smoke. Cigarette smoking increases the risk of serious cardiovascular events from combination oral contraceptive (COC) use.

Simpesse® (levonorgestrel and ethinyl estradiol tablets and ethinyl estradiol tablets) is indicated for use by females of reproductive potential to prevent pregnancy. Simpesse is a combination of levonorgestrel, a progestin, and ethinyl estradiol, an estrogen, indicated for use by females of reproductive potential to prevent pregnancy. (1)

Take one tablet daily by mouth at the same time every day for 91 days in the order directed on the blister pack. (2)

Begin Simpesse on the first Sunday after the onset of menstruation. If menstruation begins on a Sunday, take the first white tablet that day.
For each 91-day course, take in the following order:
1.  Start the first white tablet on the first Sunday after onset of menstruation. Then take one white tablet daily for 84 consecutive days. Use a non-hormonal back-up method of contraception (such as condoms and spermicide) until a white tablet has been taken daily for 7 consecutive days.
2. Then take one light blue tablet for 7 consecutive days. Bleeding should occur during the 7 days that the light blue tablets are taken.
Begin the next and all subsequent 91-day cycles without interruption on the same day of the week (Sunday) on which the patient began her first dose of Simpesse, following the same schedule: 84 days taking a white tablet followed by 7 days taking a light blue tablet. If the patient does not immediately start her next pill pack, instruct her to protect herself from pregnancy by using a non-hormonal back-up method of contraception until she has taken a white tablet daily for 7 consecutive days.
Switching to Simpesse from another oral hormonal contraceptive or from another contraceptive method (transdermal patch, vaginal ring, injection, intrauterine contraceptive, implant)
Start on the Sunday after the patient’s next period starts. Use additional non-hormonal contraceptive (such as condoms and spermicide) until the patient has taken a white tablet for 7 consecutive days.
Starting Simpesse after Abortion or Miscarriage
First-trimester
Simpesse may be started on the Sunday after an abortion or miscarriage. The patient must use additional non-hormonal contraception (such as condoms and spermicide) until the patient has taken a white tablet for 7 consecutive days.
Second-trimester
Do not start until 4 weeks after a second-trimester abortion or miscarriage, due to the increased risk of thromboembolic disease. Start contraceptive therapy with Simpesse following the instructions for women not currently using hormonal contraception. Use additional non-hormonal contraception (such as condoms and spermicide) until the patient has taken a white tablet for 7 consecutive days [see Contraindications (4) and Warnings and Precautions (5.1)].
Starting Simpesse after Childbirth
Do not start until 4 weeks after delivery, due to the increased risk of thromboembolic disease. Start contraceptive therapy with Simpesse following the instructions for women not currently using hormonal contraception. Use additional non-hormonal contraception (such as condoms and spermicide) until the patient has taken a white tablet for 7 consecutive days [see Contraindications (4) and Warnings and Precautions (5.1)].
If the woman has not yet had a period postpartum, consider the possibility of ovulation and conception occurring prior to use of Simpesse [see Warnings and Precautions (5.1), Use in Specific Populations (8.1)].

Take one tablet by mouth at the same time every day. The dosage of Simpesse is one white tablet daily for 84 consecutive days, followed by one light blue tablet daily for 7 days. To achieve maximum contraceptive effectiveness, Simpesse must be taken exactly as directed, in the order directed, and at intervals not exceeding 24 hours. The failure rate may increase when pills are missed or taken incorrectly.

Table 1. Instructions for Missed Simpesse Tablets

If one white  tablet is missed	Take the missed tablet as soon as possible. Take the next tablet at the regular time. Continue taking one tablet a day until the pack is finished. A back-up birth control method is not required if the patient has sex.
If two white tablets in a row are missed	Take the two missed tablets as soon as possible, and the next two tablets the next day. Continue taking one tablet a day until the pack is finished. Use additional nonhormonal contraception (such as condoms and spermicide) until tablets have been taken for 7 days after missing tablets.
If three or more white pills in a row are missed	Throw away the missed pills. Continue taking one tablet every day as indicated on the pack until the pack is finished. Bleeding may occur during the week following the missed tablets. Use additional nonhormonal contraception (such as condoms and spermicide) until tablets have been taken for 7 days after missing tablets.
If any of the seven light blue  tablets are missed	Throw away the missed tablets. Continue taking the remaining tablets until the pack is finished. A backup birth control method is not needed.

In case of prolonged vomiting or diarrhea, absorption may not be complete and additional contraceptive measures should be taken.

Simpesse tablets (levonorgestrel and ethinyl estradiol tablets, USP and ethinyl estradiol tablets, USP) are available in Extended-Cycle Wallets, each containing a 13-week supply of tablets: 84 white tablets, each containing 0.15 mg of levonorgestrel and 0.03 mg ethinyl estradiol, and 7 light blue tablets each containing 0.01 mg of ethinyl estradiol. The white tablets are round, biconvex, beveled-edge, debossed with “S” on one side and “27” on other side. The light blue tablets are mottled, round, biconvex, beveled-edge, debossed with “S” on one side and “45” on other side. Simpesse consists of 84 white tablets containing 0.15 mg levonorgestrel and 0.03 mg ethinyl estradiol, and 7 light blue tablets containing 0.01 mg ethinyl estradiol. (3)

Simpesse is contraindicated in females who are known to have or develop the following conditions:
A high risk of arterial or venous thrombotic diseases. Examples include females who are known to:         –   Smoke, if over age 35 [see Boxed Warning and Warnings and Precautions (5.1)].         –   Have current or history of deep vein thrombosis or pulmonary embolism [see Warnings and Precautions (5.1)].         –   Have cerebrovascular disease [see Warnings and Precautions (5.1)]         –   Have coronary artery disease [see Warnings and Precautions (5.1)].         –   Have thrombogenic valvular or thrombogenic rhythm diseases of the heart (for example, subacute bacterial endocarditis with valvular disease, or atrial fibrillation) [see Warnings and Precautions (5.1)].         –   Have inherited or acquired hypercoagulopathies [see Warnings and Precautions (5.1)].         –   Have uncontrolled hypertension or hypertension with vascular disease [see Warnings and Precautions (5.3)].         –   Have diabetes mellitus and are over age 35, diabetes mellitus with hypertension or with vascular disease or other end-organ damage, or diabetes mellitus of > 20 years duration [see Warnings and Precautions (5.7)].         –   Have headaches with focal neurological symptoms, migraine headaches with aura, or over age 35 with any migraine headaches [see Warnings and Precautions (5.8)]. Current diagnosis of, or history of, breast cancer, which may be hormone sensitive [see Warnings and Precautions (5.11)].   Liver tumors, acute viral hepatitis, or severe (decompensated) cirrhosis [see Warnings and Precautions (5.2)  and Use in Specific Populations (8.6)]. Undiagnosed abnormal uterine bleeding [see Warnings and Precautions (5.9)]. Use of Hepatitis C drug combinations containing ombitasvir/paritaprevir/ritonavir, with or without dasabuvir, due to the potential for ALT elevations [see Warnings and Precautions (5.4)]. A high risk of arterial or venous thrombotic diseases (4) Undiagnosed abnormal uterine bleeding (4) Breast cancer (4) Liver tumors or liver disease, acute viral hepatitis or decompensated cirrhosis (4) Co-administration with Hepatitis C drug combinations containing ombitasvir/paritaprevir/ritonavir, with or without dasabuvir. (4)

Vascular risks: Stop if a thrombotic or thromboembolic event occurs. Stop at least 4 weeks before and through 2 weeks after major surgery. Start no earlier than 4 weeks after delivery, in women who are not breastfeeding. Consider cardiovascular risk factors before initiating in all females, particularly those over 35 years. (5.1, 5.5) Liver disease: Discontinue if jaundice occurs. (5.2) Hypertension: If used in females with well-controlled hypertension, monitor blood pressure and stop if blood pressure rises significantly. (5.3) Gallbladder disease: May cause or worsen gallbladder disease. (5.6) Adverse carbohydrate and lipid metabolic effects: Monitor glucose in prediabetic and diabetic women taking Simpesse. Consider an alternate contraceptive method for women with uncontrolled dyslipidemias. (5.7) Headache: Evaluate significant change in headaches and discontinue if indicated. (5.8) Uterine bleeding: May cause irregular bleeding or amenorrhea. Evaluate for other causes if symptoms persist. (5.9)

Stop Simpesse if an arterial or deep venous thrombotic/thrombembolic event occurs. Stop Simpesse if there is unexplained loss of vision, proptosis, diplopia, papilledema, or retinal vascular lesions and evaluate for retinal vein thrombosis immediately. Discontinue Simpesse during prolonged immobilization. If feasible, stop Simpesse at least 4 weeks before and through 2 weeks after major surgery, or other surgeries known to have an elevated risk of thromboembolism. Start Simpesse no earlier than 4 weeks after delivery, in women who are not breastfeeding. The risk of postpartum thromboembolism decreases after the third postpartum week, whereas the risk of ovulation increases after the third postpartum week. Before starting Simpesse evaluate any past medical history or family history of thrombotic or thromboembolic disorders and consider whether the history suggests an inherited or acquired hypercoagulopathy. Simpesse is contraindicated in women with a high risk of arterial or venous/thromboembolic diseases [see Contraindications (4)].  
Arterial Events
COCs increase the risk of cardiovascular events and cerebrovascular events, such as myocardial infarction and stroke. The risk is greater among older women (> 35 years of age), smokers, and females with hypertension, dyslipidemia, diabetes, or obesity.
Simpesse is contraindicated in women over 35 years of age who smoke [see Contraindications (4)]. Cigarette smoking increases the risk of serious cardiovascular events from COC use. This risk increases with age, particularly in women over 35 years of age, and with the number of cigarettes smoked.
Venous Events
Use of COCs increases the risk of venous thromboembolic events (VTEs), such as deep vein thrombosis and pulmonary embolism. Risk factors for VTEs include smoking, obesity, and family history of VTE, in addition to other factors that contraindicate use of CHCs [see Contraindications (4)]. While the increased risk of VTE associated with use of COCs is well-established, the rates of VTE are even greater during pregnancy, and especially during the postpartum period (see Figure 1). The rate of VTE in females using COCs has been estimated to be 3 to 9 cases per 10,000 woman years.  
The risk of VTE is highest during the first year of use of a COC and when restarting hormonal contraception after a break of four weeks or longer. The risk of thromboembolic disease due to COCs gradually disappears after COC use is discontinued.  
Figure 1 shows the risk of developing a VTE for women who are not pregnant and do not use oral contraceptives, for women who use oral contraceptives, and for women in the postpartum period. To put the risk of developing a VTE into perspective: If 10,000 women who are not pregnant and do not use oral contraceptives are followed for one year, between 1 and 5 of these women will develop a VTE.



Use of Simpesse provides women with more hormonal exposure on a yearly basis than conventional monthly oral contraceptives containing the same strength synthetic estrogens and progestins (an additional 9 and 13 weeks of exposure to progestin and estrogen, respectively, per year). Figure 1

Elevated Liver Enzymes
Simpesse is contraindicated in women with acute viral hepatitis or severe (decompensated) cirrhosis of the liver [see Contraindications (4)]. Acute liver test abnormalities may necessitate the discontinuation of Simpesse until the liver tests return to normal and Simpesse causation has been excluded.  Discontinue Simpesse if jaundice develops.
Liver Tumors
Simpesse is contraindicated in women with benign or malignant liver tumors [see Contraindications (4)]. COCs increase the risk of hepatic adenomas. An estimate of the attributable risk is 3.3 cases/100,000 COC users. Rupture of hepatic adenomas may cause death from abdominal hemorrhage.  Studies have shown an increased risk of developing hepatocellular carcinoma in long-term (> 8 years) COC users. The attributable risk of liver cancers in COC users is less than one case per million users.

Simpesse is contraindicated in women with uncontrolled hypertension or hypertension with vascular disease [see Contraindications (4)] . For all women, including those with well-controlled hypertension, monitor blood pressure at routine visits and stop Simpesse if blood pressure rises significantly.
An increase in blood pressure has been reported in women taking COCs, and this increase is more likely in older women and with extended duration of use. The effect of COCs on blood pressure may vary according to the progestin in the COC.


During clinical trials with the Hepatitis C combination drug regimen that contains obmitasvir/paritaprevir/ritonavir, with or without dasabuvir, ALT elevations greater than 5 times the upper limit of normal (ULN), including some cases greater than 20 times the ULN, were significantly more frequent in women using ethinyl estradiol-containing medications, such as Simpesse. Discontinue Simpesse prior to starting therapy with the combination drug regimen ombitasvir/paritaprevir/ritonavir, with or without dasabuvir [see Contraindications (4)]. Simpesse can be restarted approximately 2 weeks following completion of treatment with the Hepatitis C combination drug regimen.

The risk for cardiovascular disease and prevalence of risk factors for cardiovascular disease increases with age. Certain conditions, such as smoking and migraine headache without aura, that do not contraindicate COC use in younger females, are contraindications to use in women over 35 years of age [see Contraindications (4) and Warnings and Precautions (5.1)]. Consider the presence of underlying risk factors that may increase the risk of cardiovascular disease or VTE, particularly before initiating a COC for women over 35 years, such as: Hypertension Diabetes Dyslipidemia Obesity

Studies suggest a small increased relative risk of developing gallbladder disease among COC users. Use of COCs, including Simpesse, may also worsen existing gallbladder disease.
A past history of COC-related cholestasis predicts an increased risk with subsequent COC use. Females with a history of pregnancy-related cholestasis may be at an increased risk for COC-related cholestasis.

Hyperglycemia
Simpesse is contraindicated in diabetic women over age 35, or females who have diabetes with hypertension, nephropathy, retinopathy, neuropathy, other vascular disease, or females with diabetes of > 20 years duration [see Contraindications (4)]. Simpesse may decrease glucose tolerance. Carefully monitor prediabetic and diabetic women who are taking Simpesse. 
Dyslipidemia
Consider alternative contraception for women with uncontrolled dyslipidemia. Simpesse may cause adverse lipid changes.
Women with hypertriglyceridemia, or a family history thereof, may have an increase in serum triglyceride concentrations when using Simpesse, which may increase the risk of pancreatitis.

Simpesse is contraindicated in females who have headaches with focal neurological symptoms or have migraine headaches with aura, and in women over 35 years of age who have migraine headaches with or without aura [see Contraindications (4)].
If a woman taking Simpesse develops new headaches that are recurrent, persistent, or severe, evaluate the cause and discontinue Simpesse if indicated. Consider discontinuation of Simpesse if there is an increased frequency or severity of migraine during COC use (which may be prodromal of a cerebrovascular event).

Unscheduled Bleeding and Spotting

Women using Simpesse may experience unscheduled (breakthrough or intracyclic) bleeding and spotting, especially during the first 3 months of use. Bleeding irregularities may resolve over time or by changing to a different contraceptive product. If unscheduled bleeding persists or occurs after previously regular cycles, evaluate for causes such as pregnancy or malignancy.

When prescribing Simpesse, the occurrence of fewer planned menses (4 per year instead of 13 per year) should be weighed against the occurrence of increased unscheduled bleeding and/or spotting. The primary clinical trial (PSE-301) that evaluated the efficacy of Simpesse also assessed unscheduled bleeding. The participants in the 12-month clinical trial  (N=1,006) completed the equivalent of 8,681 28-day cycles of exposure and were composed primarily of women who had used oral contraceptives previously (89%) as opposed to new users (11%). A total of 82 (8.2%) of the women discontinued Simpesse, at least in part, due to bleeding or spotting.

Scheduled (withdrawal) bleeding and/or spotting remained fairly constant over time, with an average of 3 days of bleeding and/or spotting per each 91-day cycle. Unscheduled bleeding and unscheduled spotting decreased over successive 91-day cycles. Table 1 below presents the number of days with unscheduled bleeding in treatment cycles 1 and 4. Table 2 presents the number of days with unscheduled spotting in treatment cycles 1 and 4. 

Table 2: Total Number of Days with Unscheduled Bleeding

Q1=Quartile 1: 25% of women had this number of days of unscheduled bleeding Median: 50% of women had ≤ this number of days of unscheduled bleeding Q3=Quartile 3: 75% of women had ≤ this number of days of unscheduled bleeding
91-Day Treatment Cycle	Days per 84-Day Interval				Days per 28-Day Interval
	Q1	Median	Q3	Mean	Mean
1st	1	4	10	6.9	1.7
4th	0	1	4	3.2	0.8

Table 3: Total Number of Days with Unscheduled Spotting

Q1=Quartile 1: 25% of women had ≤ this number of days of unscheduled spotting Median: 50% of women had ≤ this number of days of unscheduled spotting Q3=Quartile 3: 75% of women had ≤ this number of days of unscheduled spotting
91-Day Treatment Cycle		Days per 84-Day Interval			Days per 28­-Day Interval
	Q1	Median	Q3	Mean	Mean
1st	1	4	11	7.4	1.9
4th	0	2	7	4.4	1.1

Figure 2 shows the percentage of Simpesse subjects participating in trial PSE-301 with ≥ 7 days or ≥ 20 days of unscheduled bleeding and/or spotting, or only unscheduled bleeding, during each 91-day treatment cycle.


If unscheduled spotting or bleeding occurs, instruct the patient to continue on the same regimen. If the bleeding is persistent or prolonged, advise the patient to consult her healthcare provider.

Amenorrhea and Oligomenorrhea

Women who use Simpesse may experience absence of scheduled (withdrawal) bleeding, even if they are not pregnant.

If scheduled bleeding does not occur, consider the possibility of pregnancy.

After discontinuation of Simpesse, amenorrhea or oligomenorrhea may occur, especially if these conditions were pre-existent.
fIGURE 2

Carefully observe women with a history of depression and discontinue Simpesse if depression recurs to a serious degree. Data on the association of COCs with the onset of depression or exacerbation of existing depression are limited.

Breast Cancer

Simpesse is contraindicated in females who currently have or have had breast cancer because breast cancer may be hormonally sensitive [see Contraindications (4)].

Epidemiology studies have not found a consistent association between use of combined oral contraceptives (COCs) and breast cancer risk. Studies do not show an association between ever (current or past) use of COCs and risk of breast cancer. However, some studies report a small increase in the risk of breast cancer among current or recent users (<6 months since last use) and current users with longer duration of COC use [see Postmarketing Experience (6.2)].
Cervical Cancer
Some studies suggest that COCs are associated with an increase in the risk of cervical cancer or intraepithelial neoplasia. However, there is controversy about the extent to which these findings are due to differences in sexual behavior and other factors.

The estrogen component of Simpesse may raise the serum concentrations of thyroxine-binding globulin, sex hormone-binding globulin, and cortisol-binding globulin. The dose of replacement thyroid hormone or cortisol therapy may need to be increased.


In females with hereditary angioedema, exogenous estrogens, including Simpesse, may induce or exacerbate symptoms of hereditary angioedema.

Chloasma may occur with Simpesse use, especially in women with a history of chloasma gravidarum. Advise women with a history of chloasma to avoid exposure to the sun or ultraviolet radiation while using Simpesse.

The following serious adverse reactions with the use of COCs are discussed elsewhere in the labeling:
Serious cardiovascular events and stroke [see Boxed Warning and Warnings and Precautions (5.1)] Vascular events [see Warnings and Precautions (5.1)] Liver disease [see Warnings and Precautions (5.2)] The most common adverse reactions (≥5%) in clinical trials for Simpesse are irregular and/or heavy uterine bleeding, weight gain, and acne. (6)

To report SUSPECTED ADVERSE REACTIONS, contact Aurobindo Pharma USA, Inc. at 1-866-850-2876 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch.

Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to the rates in the clinical trials of another drug and may not reflect the rates observed in practice.

The clinical trial that evaluated the safety and efficacy of Simpesse was a 12-month, randomized, multicenter, open-label study, which enrolled women aged 18 to 40, of whom 1,006 took at least one dose of Simpesse.

Adverse Reactions Leading to Study Discontinuation: 16.3% of the women discontinued from the clinical trial due to an adverse reaction; the most common adverse reactions (≥ 1% of women) leading to discontinuation were irregular and/or heavy uterine bleeding (5.9%), weight gain (2.4%), mood changes (1.5%), and acne (1.0%).

Common Treatment-Emergent Adverse Reactions (≥ 5% of women): irregular and/or heavy uterine bleeding (17%), weight gain (5%), acne (5%).

Serious Adverse Reactions: migraine, cholecystitis, cholelithiasis, pancreatitis, abdominal pain, and major depressive disorder.

Five studies that compared breast cancer risk between ever-users (current or past use) of COCs and never-users of COCs reported no association between ever use of COCs and breast cancer risk, with effect estimates ranging from 0.90 to 1.12 (Figure 3).
Three studies compared breast cancer risk between current or recent COC users (<6 months since last use) and never users of COCs (Figure 3). One of these studies reported no association between breast cancer risk and COC use. The other two studies found an increased relative risk of 1.19 to 1.33 with current or recent use. Both of these studies found an increased risk of breast cancer with current use of longer duration, with relative risks ranging from 1.03 with less than one year of COC use to approximately 1.4 with more than 8 to 10 years of COC use.
Figure 3: Relevant Studies of Risk of Breast Cancer with Combined Oral Contraceptives


RR = relative risk; OR = odds ratio; HR = hazard ratio. “ever COC” are females with current or past COC use; “never COC use” are females that never used COCs.
The following adverse reactions have been identified during post-approval use of Simpesse. Because these reactions are reported voluntarily from a population of uncertain size, it is not possible to reliably estimate their frequency of establish a causal relationship to drug exposure.
Gastrointestinal disorders: abdominal distension, vomiting
General disorders and administration site conditions: chest pain, fatigue, malaise, edema peripheral, pain
Immune system disorders: hypersensitivity reaction
Investigations: blood pressure increased
Musculoskeletal and connective tissue disorders: muscle spasms, pain in extremity
Nervous system disorders: dizziness, loss of consciousness
Psychiatric disorders: insomnia
Reproductive and breast disorders: dysmenorrhea
Respiratory, thoracic and mediastinal disorders: pulmonary embolism, pulmonary thrombosis
Skin and subcutaneous tissue disorders: alopecia
Vascular disorders: thrombosis Figure 3

The sections below provide information on substances for which data on drug interactions with COCs are available. There is little information available about the clinical effect of most drug interactions that may affect COCs. However, based on the known pharmacokinetic effects of these drugs, clinical strategies to minimize any potential adverse effect on contraceptive effectiveness or safety are suggested.
Consult the approved product labeling of all concurrently used drugs to obtain further information about interactions with COCs or the potential for metabolic enzyme or transporter system alterations.
No drug-drug interaction studies were conducted with Simpesse. Enzyme inducers (e.g., CYP3A4): May decrease the effectiveness of Simpesse or increase breakthrough bleeding. Counsel patients to use a back-up method or alternative method of contraception when enzyme inducers are used with Simpesse. (7.1)

Substances Decreasing the Plasma Concentrations of COCs and Potentially Diminishing the Efficacy of COCs: 
Table 4 includes substances that demonstrated an important drug interaction with Simpesse.  Table 4: Significant Drug Interactions Involving Substances That Affect COCs

Metabolic Enzyme Inducers
Clinical effect	Concomitant use of COCs with metabolic enzyme inducers may decrease the plasma concentrations of the estrogen and/or progestin component of COCs.   Decreased exposure of the estrogen and/or progestin component of COCs may potentially diminish the effectiveness of COCs and may lead to contraceptive failure or an increase in breakthrough bleeding.
Prevention or management	Counsel females to use an alternative method of contraception or a backup method when enzyme inducers are used with COCs.   Continue backup contraception for 28 days after discontinuing the enzyme inducer to maintain contraceptive reliability.
Examples	Aprepitant, barbiturates, bosentan, carbamazepine, efavirenz, felbamate, griseofulvin, oxcarbazepine, phenytoin, rifampin, rifabutin, rufinamide, topiramate, products containing St. John’s worta, and certain protease  inhibitors (see separate section on protease inhibitors below).
Colesevelam
Clinical effect	Concomitant use of COCs with colesevelam significantly decreases systemic exposure of ethinyl estradiol.   Decreased exposure of the estrogen component of COCs may potentially reduce contraceptive efficacy or result in an increase in breakthrough bleeding, depending on the strength of ethinyl estradiol in the CHC.
Prevention or management	Administer 4 or more hours apart to attenuate this drug interaction.

^a  Induction potency of St. John’s wort may vary widely based on preparation.
Substances increasing the systemic exposure of COCs:
Co-administration of atorvastatin or rosuvastatin and COCs containing ethinyl estradiol increase systemic exposure of ethinyl estradiol by approximately 20 to 25 percent. Ascorbic acid and acetaminophen may increase systemic exposure of ethinyl estradiol, possibly by inhibition of conjugation. CYP3A inhibitors such as itraconazole, voriconazole, fluconazole, grapefruit juice, or ketoconazole may increase systemic exposure of the estrogen and/or progestin component of COCs.
Human immunodeficiency virus (HIV)/hepatitis C virus (HCV) protease inhibitors and nonnucleoside reverse transcriptase inhibitors:
Significant decreases in systemic exposure of the estrogen and/or progestin have been noted when COCs are co-administered 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).
In contrast, significant increases in systemic exposure of the estrogen and/or progestin have been noted when COCs are co-administered with certain other HIV protease inhibitors (e.g., indinavir and atazanavir/ritonavir) and with other non-nucleoside reverse transcriptase inhibitors (e.g., etravirine).

Table 5 provides significant drug interaction information for drugs co-administered with Simpesse. Table 5: Significant Drug Interaction Information for Drugs Co-Administered With COCs

Lamotrigine
Clinical effect	Concomitant use of COCs with lamotrigine may significantly decrease systemic exposure of lamotrigine due to induction of lamotrigine glucuronidation.   Decreased systemic exposure of lamotrigine may reduce seizure control.
Prevention or management	Dose adjustment may be necessary. Consult the approved product labeling for lamotrigine.
Thyroid Hormone Replacement Therapy or Corticosteroid Replacement Therapy
Clinical effect	Concomitant use of COCs with thyroid hormone replacement therapy or corticosteroid replacement therapy may increase systemic exposure of thyroid-binding and cortisol-binding globulin [see Warnings and Precautions (5.12)].
Prevention or management	The dose of replacement thyroid hormone or cortisol therapy may need to be increased. Consult the approved product labeling for the therapy in use [see Warnings and Precautions (5.12)].
Other Drugs
Clinical effect	Concomitant use of COCs may decrease systemic exposure of acetaminophen, morphine, salicylic acid, and temazepam. Concomitant use with ethinyl estradiol-containing COCs may increase systemic exposure of other drugs (e.g., cyclosporine, prednisolone, theophylline, tizanidine, and voriconazole).
Prevention or management	The dosage of drugs that can be affected by this interaction may need to be increased. Consult the approved product labeling for the concomitantly used drug.

Co-administration of Simpesse with HCV drug combinations containing ombitasvir/paritaprevir/ritonavir, with or without dasabuvir is contraindicated due to potential for ALT elevations [see Warning and Precautions (5.4)]. Co-administration of Simpesse and glecaprevir/pibrentasvir is not recommended due to potential for ALT elevations.

The use of COCs may influence the results of certain laboratory tests, such as coagulation factors, lipids, glucose tolerance, and binding proteins.

Pregnancy: Discontinue if pregnancy occurs. (8.1) Lactation: Advise use of another method; Simpesse is not recommended for nursing mothers; may decrease milk production. (8.2)

Risk Summary
There is no use for contraception in pregnancy; therefore, Simpesse should be discontinued during pregnancy. Epidemiologic studies and meta-analyses have not found an increased risk of genital or non-genital birth defects (including cardiac anomalies and limb- reduction defects) following exposure to COCs before conception or during early pregnancy. 
In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2 to 4 percent and 15 to 20 percent, respectively.

Risk Summary
Contraceptive hormones and/or metabolites are present in human milk. COCs can reduce milk production in breastfeeding females. This reduction can occur at any time but is less likely to occur once breastfeeding is well-established. When possible, advise the nursing woman to use other methods of contraception until she discontinues breastfeeding [See Dosage and Administration (2.1)]. The developmental and health benefits of breastfeeding should be considered along with the mother’s clinical need for Simpesse and any potential adverse effects on the breastfed child from Simpesse or the underlying maternal condition.

Safety and efficacy of Simpesse have been established in women of reproductive age. Safety and efficacy are expected to be the same for postpubertal adolescents under the age of 18 as for users 18 years and older. Use of Simpesse before menarche is not indicated.

Simpesse has not been studied in postmenopausal women and is not indicated in this population.

No studies have been conducted to evaluate the effect of hepatic disease on the disposition of Simpesse. However, steroid hormones may be poorly metabolized in patients with impaired liver function. Simpesse is contraindicated in females with acute hepatitis or severe decompensated cirrhosis [see Contraindications (4) and Warnings and Precautions (5.2)].

There have been no reports of serious ill effects from overdose of oral contraceptives, including ingestion by children. Overdosage may cause uterine bleeding in females and nausea.

Simpesse (levonorgestrel and ethinyl estradiol tablets USP and ethinyl estradiol tablets USP) is an extended-cycle oral contraceptive consisting of 84 white tablets each containing 0.15 mg of levonorgestrel USP, a synthetic progestogen and 0.03 mg of ethinyl estradiol USP, and 7 light blue tablets containing 0.01 mg of ethinyl estradiol USP.

The structural formulas for the active components are:

Levonorgestrel is chemically 18,19-Dinorpregn-4-en-20-yn-3-one, 13-ethyl-­17-hydroxy-, (17α)-, (-)-.
Ethinyl Estradiol is 19-Norpregna-1,3,5(10)-trien-20-yne-3,17-diol, (17α)-.

Each white tablet contains the following inactive ingredients: croscarmellose sodium, lactose monohydrate, magnesium stearate, microcrystalline cellulose, and povidone.

Each light blue tablet contains the following inactive ingredients: colloidal silicon dioxide,  FD&C Blue No. 1, lactose monohydrate, povidone, pregelatinized starch (maize), stearic acid, and vitamin E.  Levonorgestrel Chemical Structure Ethinyl Estradiol Chemical Structure

COCs prevent pregnancy primarily by suppressing ovulation.  

Absorption Ethinyl estradiol and levonorgestrel are absorbed with maximum plasma concentrations occurring within 2 hours after Simpesse administration. Levonorgestrel is completely absorbed after oral administration (bioavailability nearly 100%) and is not subject to first-pass metabolism. Ethinyl estradiol is absorbed from the gastrointestinal tract but, due to first-pass metabolism in gut mucosa and liver, the bioavailability of ethinyl estradiol is approximately 43%.
The daily exposure to levonorgestrel and ethinyl estradiol on Day 21, corresponding to the end of a typical 3-week contraceptive regimen, and on Day 84, at the end of an extended cycle regimen, were similar. There was no additional accumulation of ethinyl estradiol after dosing a 0.03 mg ethinyl estradiol tablet during Days 84 to 91. The mean plasma pharmacokinetic parameters of Simpesse following a single dose of one levonorgestrel/ethinyl estradiol combination tablet, for 84 days, in normal healthy women are reported in Table 6.

Table 6: Mean Pharmacokinetic Parameters for Simpesse during Daily One Tablet Dosing for 84 Days 

	AUC0-24 hr  (mean ± SD)	Cmax (mean ± SD)	Tmax (mean ± SD)
	Levonorgestrel
Day 1	18.2 ± 6.1 ng•hr/mL	3.0 ± 1.0 ng/mL	1.3 ± 0.4 hours
Day 21	64.4 ± 25.1 ng•hr/mL	6.2 ± 1.6 ng/mL	1.3 ± 0.4 hours
Day 84	60.2 ± 24.6 ng•hr/mL	5.5 ± 1.6 ng/mL	1.3 ± 0.3 hours
	Ethinyl Estradiol
Day 1	509.3 ± 172.0 pg•hr/mL	69.8 ± 26 pg/mL	1.5 ± 0.3 hours
Day 21	837.1 ± 271.2 pg•hr/mL	99.6 ± 31 pg/mL	1.5 ± 0.3 hours
Day 84	791.5 ± 215.0 pg•hr/mL	91.3 ± 32 pg/mL	1.6 ± 0.3 hours

The effect of food on the rate and the extent of levonorgestrel and ethinyl estradiol absorption following oral administration of Simpesse has not been evaluated.
Distribution The apparent volume of distribution of levonorgestrel and ethinyl estradiol are reported to be approximately 1.8 L/kg and 4.3 L/kg, respectively. Levonorgestrel is about 97.5 to 99% protein-bound, principally to sex hormone binding globulin (SHBG) and, to a lesser extent, serum albumin. Ethinyl estradiol is about 95 to 97% bound to serum albumin. Ethinyl estradiol does not bind to SHBG, but induces SHBG synthesis, which leads to decreased levonorgestrel clearance. Following repeated daily dosing of levonorgestrel/ethinyl estradiol oral contraceptives, levonorgestrel plasma concentrations accumulate more than predicted based on single-dose pharmacokinetics, due in part, to increased SHBG levels that are induced by ethinyl estradiol, and a possible reduction in hepatic metabolic capacity. Metabolism Following absorption, levonorgestrel is conjugated at the 17β-OH position to form sulfate and to a lesser extent, glucuronide conjugates in plasma. Significant amounts of conjugated and unconjugated 3α,5β-tetrahydrolevonorgestrel are also present in plasma, along with much smaller amounts of 3α,5α-tetrahydrolevonorgestrel and 16β-hydroxylevonorgestrel. Levonorgestrel and its phase I metabolites are excreted primarily as glucuronide conjugates. Metabolic clearance rates may differ among individuals by several-fold, and this may account in part for the wide variation observed in levonorgestrel concentrations among users.
First-pass metabolism of ethinyl estradiol involves formation of ethinyl estradiol-3-sulfate in the gut wall, followed by 2-hydroxylation of a portion of the remaining untransformed ethinyl estradiol by hepatic cytochrome P-­450 3A4 (CYP3A4). Levels of CYP3A4 vary widely among individuals and can explain the variation in rates of ethinyl estradiol hydroxylation. Hydroxylation at the 4-, 6-, and 16- positions may also occur, although to a much lesser extent than 2-hydroxylation. The various hydroxylated metabolites are subject to further methylation and/or conjugation.
Excretion About 45% of levonorgestrel and its metabolites are excreted in the urine and about 32% are excreted in feces, mostly as glucuronide conjugates. The terminal elimination half-life for levonorgestrel after a single dose of Simpesse was about 34 hours.
Ethinyl estradiol is excreted in the urine and feces as glucuronide and sulfate conjugates, and it undergoes enterohepatic recirculation. The terminal elimination half-life of ethinyl estradiol after a single dose of Simpesse was found to be about 18 hours.
Race The effect of race on the pharmacokinetics of Simpesse has not been evaluated.

[See Warnings and Precautions (5.2, 5.11)].

In a 12-month, multicenter, randomized, open-label clinical trial, 1,006 women aged 18 to 40 were studied to assess the safety and efficacy of Simpesse, completing the equivalent of 8,681 28-day cycles of exposure. The racial demographic of those enrolled was: Caucasian (80%), African-American (11%), Hispanic (5%), Asian (2%), and Other (2%). There were no exclusions for body mass index (BMI) or weight. The weight range of those women treated was 91 to 360 lbs., with a mean weight of 156 lbs. Among the women in the trial, 63% were current or recent hormonal contraceptive users, 26% were prior users (who had used hormonal contraceptives in the past but not in the 6 months prior to enrollment), and 11% were new starts. Of treated women, 14.8% were lost to follow-up, 16.3% discontinued due to an adverse event, and 12.9% discontinued by withdrawing their consent.

The pregnancy rate (Pearl Index [PI]) in women aged 18 to 35 years was 1.34 pregnancies per 100 women-years of use (95% confidence interval 0.54 to 2.75), based on 7 pregnancies that occurred after the onset of treatment and within 14 days after the last combination pill.  Cycles in which conception did not occur, but which included the use of backup contraception, were not included in the calculation of the PI. The PI includes patients who did not take the drug correctly.

How Supplied
Simpesse tablets (levonorgestrel and ethinyl estradiol tablets USP 0.15 mg/0.03 mg and ethinyl estradiol tablets USP  0.01 mg) are available in Extended-Cycle Wallets, each containing a 13-week supply of tablets: 84 white tablets, each containing 0.15 mg of levonorgestrel and 0.03 mg ethinyl estradiol, and 7 light blue tablets each containing 0.01 mg of ethinyl estradiol. The white tablets are round, biconvex, beveled-edge, debossed with “S” on one side and “27” on other side. The light blue tablets are mottled, round, biconvex, beveled-edge, debossed with “S” on one side and “45” on other side.
            Pouch of 1 Extended-Cycle Wallet                  NDC 65862-864-94
            Carton of 2 Pouches                                         NDC 65862-864-95

Storage and Handling
Store at 20° to 25°C (68° to 77°F) [see USP Controlled Room Temperature].

Advise the patient to read the FDA-approved Patient Labeling (Patient Information and Instructions for Use).
Counsel patients about the following information:
Cigarette Smoking
Cigarette smoking increases the risk of serious cardiovascular events from COC use. Women who are over 35 years old and smoke should not use Simpesse [see Boxed Warning and Warnings and Precautions (5.1)].
Venous Thromboembolism
Increased risk of VTE compared to non-users of COCs is greatest after initially starting a COC or restarting (following a 4-week or greater interruption in intake) the same or a different COC [see Warnings and Precautions (5.1)].
Use during Pregnancy
Instruct females to stop further intake of Simpesse if pregnancy is confirmed during treatment.
Sexually Transmitted Infections
Simpesse does not protect against HIV-infection (AIDS) and other sexually transmitted infections.
Dosing and Missed Pill Instructions
Patients should take one tablet daily by mouth at the same time every day.  
Instruct patients what to do in the event pills are missed. See, “What to do if you miss pills” section of FDA-Approved Instructions for Use [see Dosage and Administration (2.3)].
Need for Additional Contraception
Postpartum females who have not yet had a period when they start Simpesse need to use an additional method of contraception until they have taken a white tablet for 7 consecutive days [see Dosage and Administration (2.1)].
There is a need to use a back-up or alternative method of contraception when enzyme inducers are used with Simpesse [see Drug Interactions (7.1)].
Lactation
Simpesse may reduce breast milk production. This is less likely to occur if breastfeeding is well established. When possible, nursing women should use other methods of contraception until they have discontinued breastfeeding [see Use in Specific Populations (8.2)].
Amenorrhea and Possible Symptoms of Pregnancy
Amenorrhea may occur. Advise patients to contact a healthcare provider in the event of amenorrhea with symptoms of pregnancy, such as morning sickness or unusual breast tenderness [see Warnings and Precautions (5.9)]. Fertility Following Discontinuation of Simpesse
Resumption of pre-treatment ovarian function is expected, generally within 8 weeks after discontinuation of Simpesse.
Depression
Depressed mood and depression may occur. Women should contact their healthcare provider if mood changes and depressive symptoms occur, including shortly after initiating the treatment [see Warnings and Precautions (5.10)].

PATIENT INFORMATION
Simpesse^®
(sim pe' see)
(levonorgestrel and ethinyl estradiol tablets USP 0.15 mg/0.03 mg
and ethinyl estradiol tablets USP 0.01 mg)

WARNING TO WOMEN WHO SMOKE Do not use S impesse if you smoke cigarettes and are over 35 years old. Smoking increases your risk of serious cardiovascular side effects from birth control pills, including death from heart attack, blood clots or stroke. This risk increases with age and the number of cigarettes you smoke.

What is the most important information I should know about Simpesse?
Do not use Simpesse if you smoke cigarettes and are over 35 years old. Smoking increases your risk of serious cardiovascular side effects from birth control pills, including death from heart attack, blood clots or stroke. This risk increases with age and the number of cigarettes you smoke.
What is Simpesse?
Simpesse is a birth control pill (hormonal contraceptive) used by women to prevent pregnancy. It contains two female hormones, an estrogen called ethinyl estradiol, and a progestin called levonorgestrel.

Simpesse does not protect against HIV infection (AIDS) and other sexually transmitted infections.
How Does Simpesse Work for contraception? Your chance of getting pregnant depends on how well you follow the directions for taking your birth control pills. The more carefully you follow the directions, the less chance you have of getting pregnant.
Based on the results of a single clinical study lasting 12 months, 1 to 3 women, out of 100 women, may get pregnant during the first year they use Simpesse.
The following chart shows the chance of getting pregnant for women who use different methods of birth control. Each box on the chart contains a list of birth control methods that are similar in effectiveness. The most effective methods are at the top of the chart. The box on the bottom of the chart shows the chance of getting pregnant for women who do not use birth control and are trying to get pregnant.
Who Should Not Take Simpesse? Do not take Simpesse if you:
smoke and are over 35 years of age have or had blood clots in your arms, legs, eyes or lungs   had a stroke had a heart attack have certain heart valve problems or heart rhythm abnormalities that can cause blood clots to form in the heart have or had a problem with your blood that makes it clot more than normal have high blood pressure that cannot be controlled by medicine or have high blood pressure with blood vessel problems have diabetes and are over the age of 35; have diabetes with high blood pressure; kidney, eye, nerve, or blood vessel damage; or for more than 20 years have certain kinds of severe migraine headaches with aura, numbness, weakness or changes in vision, or any migraine headaches if you are over the age of 35 have or had breast cancer have liver disease, including liver tumors have unexplained vaginal bleeding take any Hepatitis C drug combination containing ombitasvir/paritaprevir/ritonavir, with or without dasabuvir. This may increase levels of the liver enzyme “alanine aminotransferase” (ALT) in the blood.
Birth control pills may not be a good choice for you if you have ever had jaundice (yellowing of the skin or eyes) caused by pregnancy.
If any of these conditions happen to you while you are taking Simpesse, stop taking Simpesse right away and talk to your healthcare provider. Use non-hormonal contraception when you stop taking Simpesse.
What should I tell my healthcare provider before taking Simpesse? Tell your healthcare provider if you:
are pregnant or think you may be pregnant are scheduled for surgery. Simpesse may increase your risk of blood clots after surgery. You should stop taking Simpesse at least 4 weeks before you have surgery and not restart Simpesse until at least 2 weeks after your surgery. are depressed now or have been depressed in the past had yellowing of your skin or eyes (jaundice) caused by pregnancy (cholestasis of pregnancy) are breastfeeding or plan to breastfeed. Simpesse may decrease the amount of breast milk you make. A small amount of the hormones in Simpesse may pass into your breast milk. Talk to your healthcare provider about the best birth control method for you while breastfeeding.
Tell your healthcare provider if you have ever had any of the conditions listed in, “Who should not take Simpesse” above. Your healthcare provider may recommend another method of birth control.
Tell your healthcare provider about all medicines and herbal products that you take. Some medicines and herbal products may make birth control pills less effective, including:
barbiturates bosentan carbamazepine  felbamate  griseofulvin oxcarbazepine phenytoin rifampin St. John’s wort topiramate
Use a back-up or alternative birth control method when you take medicines that may make birth control pills less effective.
Birth control pills may interact with lamotrigine, an anticonvulsant used for epilepsy. This may increase the risk of seizures, so your physician may need to adjust the dose of lamotrigine.
Women on thyroid hormone replacement therapy may need increased doses of thyroid hormone.
Know the medicines you take. Keep a list of them to show your healthcare provider and pharmacist when you get a new medicine.
How should I take Simpesse?
Read the Instructions for Use at the end of this Patient Information.
What are the most serious risks of taking birth control pills? Like pregnancy, birth control pills increase the risk of serious blood clots, especially in women who have other risk factors, such as smoking, obesity, or age over 35 years old. It is possible to die from a problem caused by a blood clot, such as a heart attack or a stroke. Some examples of serious blood clots are blood clots in the:
Legs (thrombophlebitis) Lungs (pulmonary embolus) Eyes (loss of eyesight) Heart (heart attack) Brain (stroke)
Women who take birth control pills may get:
High blood pressure. You should see your healthcare provider to check your blood pressure regularly. Gallbladder problems Rare cancerous or noncancerous liver tumors
All of these events are uncommon in healthy women.
Call your healthcare provider right away if you have: Persistent leg pain Sudden shortness of breath  Sudden blindness, partial or complete  Severe pain in your chest Sudden, severe headache unlike your usual headaches Weakness or numbness in an arm or leg, or trouble speaking Yellowing of the skin or eyeballs
What are common side effects of birth control pills? The most common side effects of birth control pills are:
Spotting or bleeding between menstrual periods Nausea Breast tenderness Headache
These side effects are usually mild and usually disappear with time.
Less common side effects are:
Acne Less sexual desire Bloating or fluid retention  Blotchy darkening of the skin, especially on the face  High blood sugar, especially in women who already have diabetes High fat levels in the blood Depression, especially if you have had depression in the past. Call your healthcare provider immediately if you have any thoughts of harming yourself. Problems tolerating contact lenses Weight changes
This is not a complete list of possible side effects. Talk to your healthcare provider if you develop any side effects that concern you. You may report side effects to the FDA at 1-800-FDA-1088.
No serious problems have been reported from a birth control pill overdose, even when accidentally taken by children.
What else should I know about taking Simpesse?
If you are scheduled for any lab tests, tell your healthcare provider you are taking Simpesse. Certain blood tests may be affected by Simpesse. Do not skip any pills, even if you do not have sex often. Birth control pills should not be taken during pregnancy. However, birth control pills taken by accident during pregnancy are not known to cause birth defects. You should stop Simpesse at least four weeks before you have major surgery and not restart it for at least two weeks after the surgery, due to an increased risk of blood clots. If you are breastfeeding, consider another birth control method until you are ready to stop breastfeeding. Birth control pills that contain estrogen, like Simpesse, may decrease the amount of milk you make. A small amount of the pill's hormones pass into breast milk. If you have vomiting or diarrhea, your birth control pills may not work as well. Use another birth control method, like condoms or a spermicide, until you check with your healthcare provider.
How should I store Simpesse?
Store Simpesse at room temperature between 68°F to 77°F (20°C to 25°C). Keep Simpesse and all medicines out of the reach of children.
General information about Simpesse
Medicines are sometimes prescribed for purposes other than those listed in a Patient Information leaflet. Do not use Simpesse for a condition for which it was not prescribed. Do not give Simpesse to anyone else.
This Patient Information summarizes the most important information about Simpesse. If you have concerns or questions, ask your healthcare provider. You may also ask your healthcare providers for a more detailed label written for medical professionals.
Do birth control pills cause cancer? It is not known if hormonal birth control pills cause breast cancer. Some studies, but not all, suggest that there could be a slight increase in the risk of breast cancer among current users with longer duration of use.
If you have breast cancer now, or have had it in the past, do not use hormonal birth control because some breast cancers are sensitive to hormones. Women who use birth control pills may have a slightly higher chance of getting cervical cancer. However, this may be due to other reasons such as having more sexual partners.
What if I want to become pregnant? You may stop taking the pill whenever you wish. Consider a visit with your healthcare provider for a pre-pregnancy checkup before you stop taking the pill.
What should I know about my period when taking Simpesse? When you take Simpesse, which has a 91-day extended dosing cycle, you should expect to have 4 scheduled periods per year (bleeding when you are taking the 7 light blue pills). Each period is likely to last about 3 days. However, you will probably have more bleeding or spotting between your scheduled periods than if you were using a birth control pill with a 28 -day dosing cycle. During the first Simpesse 91-day treatment cycle, about 3 in 10 women may have 20 or more days of unplanned bleeding or spotting. This bleeding or spotting tends to decrease with time. Do not stop taking Simpesse because of this bleeding or spotting. If the spotting continues for more than 7 consecutive days or if the bleeding is heavy, call your healthcare provider.
What if I miss my scheduled period when taking Simpesse? You should consider the possibility that you are pregnant if you miss your scheduled period (no bleeding on the days that you are taking light blue tablets). Since scheduled periods are less frequent when you are taking Simpesse, notify your healthcare provider that you have missed your period and that you are taking Simpesse. Also notify your healthcare provider if you have symptoms of pregnancy such as morning sickness or unusual breast tenderness. It is important that your healthcare provider evaluates you to determine if you are pregnant. Stop taking Simpesse if it is determined that you are pregnant.
What are the ingredients in Simpesse? Active ingredients:
White tablets: levonorgestrel and ethinyl estradiol                                                                                       Light blue tablets: ethinyl estradiol
Inactive ingredients:
White tablets: croscarmellose sodium, lactose monohydrate, magnesium stearate, microcrystalline cellulose, and povidone
Light blue tablets: colloidal silicon dioxide, FD&C Blue No. 1, lactose monohydrate, povidone, pregelatinized starch (maize), stearic acid, and vitamin E.
Distributed by:
Aurobindo Pharma USA, Inc.
279 Princeton-Hightstown Road
East Windsor, NJ 08520

Manufactured by:
Aurobindo Pharma Limited
Hyderabad-500 032, India

Revised: 04/2023 Figure 4

Simpesse®
(sim pe' see)  (levonorgestrel and ethinyl estradiol tablets USP 0.15 mg/0.03 mg and ethinyl estradiol tablets USP 0.01 mg)
How do I take Simpesse?
Take one pill every day at the same time. If you miss pills you could get pregnant. This includes starting the pack late. The more pills you miss, the more likely you are to get pregnant. Many women have spotting or light bleeding or may feel sick to their stomach during the first few months of taking Simpesse. If you feel sick to your stomach, do not stop taking the pill. The problem will usually go away. If it doesn't go away, check with your healthcare provider. Missing pills can also cause spotting or light bleeding, even when you take the missed pills later. On the days you take 2 pills to make up for missed pills, you could also feel a little sick to your stomach. If you have trouble remembering to take Simpesse, talk to your healthcare provider about how to make pill-taking easier or about using another method of birth control.
Before you start taking Simpesse Decide what time of day you want to take your pill. It is important to take it at about the same time every day. Look at your Extended-Cycle Wallet. Your Wallet consists of 3 blister strips that hold 91 individually sealed pills (a 13-week or 91-day cycle). The 91 pills consist of 84 white and 7 light blue pills. Blister strips 1 and 2 each contain 28 white pills (4 rows of 7 pills). Blister strip 3 contains 35 pills consisting of 28 white pills (4 rows of 7 pills) and 7 light blue pills (1 row of 7 pills).  3. Also find:
Where on the first blister strip in the pack to start taking pills (upper left corner at the start arrow) and In what order to take the pills (follow the weeks and arrow). 
4. Be sure you have ready at all times another kind of birth control (such as condoms or spermicides), to use as a back-up in case you miss pills.
If you are switching from another birth control method:
If you have been using a different hormonal method of birth control (such as a different pill, the “patch,” or the “vaginal ring”), you need to use another method of birth control (such as condoms or spermicides) each time you have sex after stopping your old method of birth control until you have taken Simpesse for 7 days.
If you have recently given birth and have not yet had a period, use another method of birth control if you have sex (such as condoms and spermicides) as a back-up method until you have taken Simpesse for 7 days.
When to start Simpesse? Take the first white pill on the Sunday after your period starts, even if you are still bleeding. If your period begins on Sunday, start the first white pill that same day. Use another method of birth control (such as condoms or spermicides) as a back-up method if you have sex anytime from the Sunday you start your first white pill until the next Sunday (first 7 days). If you have been using a different hormonal method of birth control (such as a different pill, the “patch,” or the “vaginal ring”), you need to use another method of birth control (such as condoms or spermicides) each time you have sex after stopping your old method of birth control until you have taken Simpesse for 7 days.
How to take Simpesse? 1. Take one pill at the same time every day until you have taken the last pill in the wallet. Do not skip pills even if you are experiencing spotting or bleeding or feel sick to your stomach (nausea). Do not skip pills even if you do not have sex very often.  2. When you finish a wallet After taking the last light blue pill, start taking the first white pill from a new Extended-Cycle Wallet the very next day (this should be on a Sunday) regardless of when your period started. 3. If you miss your scheduled period when you are taking the light blue pills, contact your healthcare provider because you may be pregnant. If you are pregnant, you should stop taking Simpesse.
What to do if you miss pills If you MISS 1 white pill:
Take it as soon as you remember. Take the next pill at your regular time. This means you may take 2 pills in 1 day. You do not need to use a back-up birth control method if you have sex.
If you MISS 2 white pills in a row:
Take 2 pills on the day you remember, and 2 pills the next day. Then take 1 pill a day until you finish the pack.  You could become pregnant if you have sex in the 7 days after you miss two pills. You MUST use another birth control method (such as condoms or spermicide) as a back up for the 7 days after you restart your pills.
If you MISS 3 OR MORE white pills in a row:
Do not take the missed pills. Keep taking 1 pill every day as indicated on the pack until you have completed all of the remaining pills in the pack. For example: If you resume taking the pill on Thursday, take the pill under “Thursday” and do not take the missed pills. You may experience bleeding during the week following the missed pills. You could become pregnant if you have sex during the days of missed pills or during the first 7 days after restarting your pills. You MUST use a non-hormonal birth control method (such as condoms or spermicide) as a back-up when you miss pills and for the first 7 days after you restart your pills. If you do not have your period when you are taking the light blue pills, call your healthcare provider because you may be pregnant.
If you MISS ANY of the 7 light blue pills:
Throw away the missed pills. Keep taking the scheduled pills until the pack is finished. You do not need a back-up method of birth control.
Finally, if you are still not sure what to do about the pills you have missed Use a back-up method anytime you have sex. Keep taking one pill each day until you contact your healthcare provider.
This Patient Information and Instructions for Use has been approved by the U.S. Food and Drug Administration.  
Distributed by:
Aurobindo Pharma USA, Inc.
279 Princeton-Hightstown Road
East Windsor, NJ 08520

Manufactured by:
Aurobindo Pharma Limited
Hyderabad-500 032, India

Revised: 04/2023 Figure 5

NDC 65862-864-94

Simpesse®
(levonorgestrel and ethinyl estradiol
tablets USP, 0.15 mg/0.03 mg and ethinyl estradiol tablets USP, 0.01 mg)

Rx only                                                    1 Extended-Cycle Wallet,
                                                                 Containing 91 Tablets

Contains 1 Extended-Cycle Wallet containing 91 tablets: 84 white tablets, each
containing 0.15 mg levonorgestrel USP and 0.03 mg ethinyl estradiol USP, and
7 light blue tablets, each containing 0.01 mg ethinyl estradiol USP.

PACKAGE LABEL-PRINCIPAL DISPLAY PANEL - 0.15 mg/0.03 mg and 0.01 mg (91 Tablets Pouch)

NDC 65862-864-95 Simpesse® (levonorgestrel and ethinyl estradiol tablets USP, 0.15 mg/0.03 mg and ethinyl estradiol tablets USP, 0.01 mg) Rx only                                                    2 Extended-Cycle Wallets,                                                                                 91 Tablets Each
Contains 2 Extended-Cycle Wallets, each containing 91 tablets: 84 white tablets, each containing 0.15 mg levonorgestrel USP and 0.03 mg ethinyl estradiol USP, and 7 light blue tablets, each containing 0.01 mg ethinyl estradiol USP.
PACKAGE LABEL-PRINCIPAL DISPLAY PANEL - 0.15 mg/0.03 mg and 0.01 mg (2 x 91 Tablets Carton)