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Marvelon contraceptive pill – background information

Contraceptive pill consultation process

Please read in full the medical information before completing an online consultation for Marvelon on prescription.

Who qualifies for Marvelon

Eligible women can obtain a 3-month supply of Marvelon contraceptive pill. Women qualify if:

• They have been taking Marvelon for the last year.
• They have had no problems with Marvelon in the last year.
• They have had a face-to-face pill check-up for their contraceptive pill in the last year.

Brands of contraceptive similar to Marvelon

Gederel 30/150 contains the same hormones as Marvelon.

Mercilon contraceptive pills are similar to Marvelon. They contain the same hormones, Marvelon having slightly less oestrogen, 20 micrograms of the oestrogen ethinylestradiol compared to 30 micrograms for Marvelon.

Alternative contraceptive pills

Please note: Dr Fox can only issue the same pill you are already taking. Women cannot change their regular oral contraceptive pill to a new type without seeing a doctor or nurse face-to-face.

In addition to Marvelon Dr Fox supplies all other brands of contraceptive pills including other combined pills and mini pills. Combined pills contain two types of hormone: oestrogens and progestogens. Mini pills contain progestogens only.

What is Marvelon?

Marvelon is a combined oral contraceptive pill manufactured by Organon pharmaceutical company containing the following active ingredients:

• 150 micrograms of the progestogen desogestrel
• 30 micrograms of the oestrogen ethinylestradiol

Product characteristics of Marvelon from eMC.

Further details can be found in the Patient Information Leaflet for Marvelon.

Patient information leaflet – Marvelon contraceptive pill

The 'Patient Information Leaflet' supplied with medication must be read before use.
Marvelon Patient Leaflet

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Marvelon patient information summary

Below is a brief summary of information in the patient leaflet supplied with Marvelon.

Marvelon is a combined hormonal contraceptive (CHC).

Important things to know about combined hormonal contraceptives (CHCs)

• CHCs are a highly reliable method of contraception to prevent pregnancy when used correctly.
• CHCs slightly increase the risk of having a blood clot in the veins and arteries, especially in the first year or when restarting a combined hormonal contraceptive following a break of 4 or more weeks.
• Please see your doctor if you think you may have symptoms of a blood clot (see section Blood clots below).
• Some women should not take certain contraceptive pills because of medical problems, or illnesses, age, or if they smoke.
• To prevent pregnancy it is important to take Marvelon as instructed and to start each pack on the correct day and time. Please make sure that you understand what to do if you miss a pill or if you think you may be pregnant.

• If you need more advice, ask your doctor, family planning nurse, or local pharmacist.
• Marvelon will be prescribed for you. Do not pass it on to others as it may cause them harm.
• If any side effects (listed below) get severe, or if you notice any not listed in the patient leaflet, please tell your doctor, family planning nurse, or a pharmacist.

How reliable is it?

Typical reliability of combined oral contraceptive pills is 91%, but if used absolutely correctly ('perfect' use) it can give reliability of 99%. Mobile phone apps or alarms can give reminders to take tablets and so improve user reliability.

For further details on the reliability of different forms on contraception see Can I trust my contraceptive?

About Marvelon

Active ingredients:

• Desogestrel (150 micrograms)
• Ethinyl estradiol (30 micrograms)

This low-dose contraceptive contains two types of female sex hormones, oestrogen and progestogen. These hormones prevent an egg being released from your ovaries so you cannot get pregnant. Marvelon also makes the fluid (mucus) in women's cervix thicker which makes it more difficult for sperm to enter the womb.

Marvelon contains 21 pills – you take one pill each day for 21 consecutive days, followed by 7 days when you take no pills.

Benefits of taking the Pill also include:

• No interruption to sex
• Usually makes women's periods regular, lighter, and less painful
• May help with pre-menstrual symptoms.

Marvelon will not protect you against sexually transmitted infections, such as Chlamydia or HIV. Only condoms can help to do this.

What you need to know

Tell your doctor if you have any of the illnesses or risk factors mentioned below or in the patient leaflet before requesting combined oral contraceptive pills. Your doctor will ask about you and your family's medical problems and check your blood pressure. You may also need other checks, such as a breast examination.

When taking the Pill:

• Will need regular check-ups with your doctor or family planning nurse, usually when you need another prescription of the Pill.
• You must also go for regular cervical smear tests.
• Check your breasts and nipples every month for changes – tell your doctor if you can see or feel anything unusual, such as lumps, or dimpling of the skin.
• If you need a blood test tell your doctor that you are taking the Pill, because the Pill can affect the results of some tests.
• If you're going to have an operation, make sure your doctor knows about it. You may need to stop taking the Pill 4-6 weeks before any operation. This is to reduce the risk of a blood clot. Your doctor will tell you when you can start taking the Pill again.

When you should not use Marvelon

You should not use Marvelon if you have any of the conditions listed below. Other forms of birth control may be more appropriate (discuss with your doctor).

• If you have ever had a blood clot in a blood vessel of your legs (deep vein thrombosis, DVT), your lungs (pulmonary embolus, PE), or any other organs.
• If you know you have a disorder affecting blood clotting – eg: protein C deficiency, protein S deficiency, antithrombin-III deficiency, Factor V Leiden or antiphospholipid antibodies.
• If you need an operation or if you are off your feet for a long time (see section Blood clots).
• If you have ever had a heart attack or stroke.
• If you have (or have ever had) angina pectoris (a condition that causes severe chest pain and may be a first sign of a heart attack), or transient ischaemic attack (TIA) - temporary stroke symptoms.
• If you have any of the following diseases that may increase your risk of a clot in the arteries:
  • severe diabetes with blood vessel damage,
  • very high blood pressure,
  • a very high level of fat in the blood (cholesterol or triglycerides),
  • a condition known as hyperhomocysteinaemia.
• If you have (or have ever had) a type of migraine called 'migraine with aura'. (The aura of migraine includes a wide range of neurological symptoms. This stage can last for between 5 and 30 minutes, and usually happens before the headache. Only 15% of migraine sufferers have aura.)
• If you have or have recently had a severe liver disease.
• If you have ever had a liver tumour.
• If you have cancer affected by sex hormones – such as some cancers of the breast, womb lining, or ovary.
• If you have vaginal bleeding that has not been explained by your doctor.
• If you are allergic (hypersensitive) to any of the ingredients in Marvelon.

• If you suffer from any of these, or get them for the first time while taking Marvelon, contact your doctor as soon as possible. Do not take Marvelon.

When to take special care with Marvelon

When should you contact your doctor?

IMPORTANT

Seek urgent medical attention

• if you notice possible signs of a blood clot that may mean you are suffering from a blood clot in the leg (i.e. deep vein thrombosis), a blood clot in the lung (i.e. pulmonary embolism), a heart attack or a stroke (see Blood clots section below).

For a description of the symptoms of these serious side effects please go to 'How to recognise a blood clot'.

Tell your doctor if any of the following conditions apply to you.

If the condition develops, or gets worse while you are using Marvelon, you should also tell your doctor.

• If you have ever had problems with your heart, circulation or blood clotting.
• If you have diabetes.
• If you have ever had kidney or liver problems.
• If you have ever had severe depression.
• If you have ever had migraines.
• If you have had problems while pregnant or while using the pill, like:
  • itching of the whole body (pruritus)
  • jaundice which was not caused by infection
  • gall stones
  • systemic lupus erythematosus (SLE)
  • a blister-like rash, called herpes gestationis
  • a hearing problem called otosclerosis
  • other rare conditions called porphyria and hereditary angioedema.
• If you have brown patches on your face or body (chloasma) – if so avoid too much exposure to the sun or ultraviolet light.
• If you have Crohn's disease or ulcerative colitis (chronic inflammatory bowel disease).
• If you have systemic lupus erythematosus (SLE – a disease affecting your natural defence system).
• If you have haemolytic uraemic syndrome (HUS – a disorder of blood clotting causing failure of the kidneys).
• If you have sickle cell anaemia (an inherited disease of the red blood cells).
• If you have elevated levels of fat in the blood (hypertriglyceridaemia) or a positive family history for this condition. Hypertriglyceridaemia has been associated with an increased risk of developing pancreatitis (inflammation of the pancreas).
• If you need an operation, or you are off your feet for a long time (see in section Blood clots).
• If you have just given birth you are at an increased risk of blood clots. You should ask your doctor how soon after delivery you can start taking Marvelon.
• If you have an inflammation in the veins under the skin (superficial thrombophlebitis).
• If you have varicose veins.

The Pill and Thrombosis

BLOOD CLOTS

Using a combined hormonal contraceptive such as Marvelon, increases your risk of developing a blood clot compared with not using one. In rare cases a blood clot can block blood vessels and cause serious problems.

Blood clots can develop:

• in veins (referred to as a 'venous thrombosis', 'venous thromboembolism' or VTE)
• in the arteries (referred to as an 'arterial thrombosis', 'arterial thromboembolism' or ATE).

Recovery from blood clots is not always complete. Rarely, there may be serious lasting effects or, very rarely, they may be fatal.

It is important to remember that the overall risk of a harmful blood clot due to Marvelon is small.

HOW TO RECOGNISE A BLOOD CLOT

Seek urgent medical attention if you notice any of the following signs or symptoms.

Symptoms of deep vein thrombosis:

• swelling of one leg or along a vein in the leg or foot especially when accompanied by:
  • pain or tenderness in the leg which may be felt only when standing or walking
  • increased warmth in the affected leg
  • change in colour of the skin on the leg e.g. turning pale, red or blue

Symptoms of pulmonary embolism:

• sudden unexplained breathlessness or rapid breathing
• sudden cough without an obvious cause, which may bring up blood
• sharp chest pain which may increase with deep breathing
• severe light headedness or dizziness
• rapid or irregular heartbeat
• severe pain in your stomach

If you are unsure, talk to a doctor as some of these symptoms such as coughing or being short of breath may be mistaken for a milder condition such as a respiratory tract infection (e.g. a 'common cold').

Symptoms of retinal vein thrombosis (most commonly occur in one eye):

• immediate loss of vision or
• painless blurring of vision which can progress to loss of vision.

Symptoms of a heart attack:

• chest pain, discomfort, pressure, heaviness
• sensation of squeezing or fullness in the chest, arm or below the breastbone
• fullness, indigestion or choking feeling
• upper body discomfort radiating to the back, jaw, throat, arm and stomach
• sweating, nausea, vomiting or dizziness
• extreme weakness, anxiety, or shortness of breath
• rapid or irregular heartbeats

Symptoms of a stroke:

• sudden weakness or numbness of the face, arm or leg, especially on one side of the body
• sudden confusion, trouble speaking or understanding
• sudden trouble seeing in one or both eyes
• sudden trouble walking, dizziness, loss of balance or coordination
• sudden, severe or prolonged headache with no known cause
• loss of consciousness or fainting with or without seizure

Sometimes the symptoms of stroke can be brief with an almost immediate and full recovery, but you should still seek urgent medical attention as you may be at risk of another stroke.

Symptoms of blood clots blocking other blood vessels:

• swelling and slight blue discolouration of an extremity
• severe pain in your stomach (acute abdomen)

When is the risk of developing a blood clot in a vein highest?

The risk of developing a blood clot is highest during the first year of taking a combined hormonal contraceptive for the first time. The risk may also be higher if you restart taking a combined hormonal contraceptive (the same product or a different product) after a break of 4 weeks or more.

After the first year, the risk gets smaller but is always slightly higher than if you were not using a combined hormonal contraceptive.

When you stop Marvelon your risk of a blood clot returns to normal within a few weeks.

What is the risk of developing a blood clot?

The risk depends on your natural risk of VTE and the type of combined hormonal contraceptive you are taking.

The overall risk of a blood clot in the leg or lung (DVT or PE) with Marvelon is small.

• Out of 10,000 women who are not using any combined hormonal contraceptive and are not pregnant, about 2 will develop a blood clot in a year.
• Out of 10,000 women who are using a combined hormonal contraceptive that contains levonorgestrel, norethisterone, or norgestimate about 5-7 will develop a blood clot in a year.
• Out of 10,000 women who are using a combined hormonal contraceptive that contains desogestrel such as Marvelon between about 9 and 12 women will develop a blood clot in a year.
• The risk of having a blood clot will vary according to your personal medical history.

Factors that increase your risk of a blood clot in a vein

The risk of a blood clot with Marvelon is small but some conditions will increase the risk. Your risk is higher:

• if you are very overweight (body mass index or BMI over 30kg/m²);
• if one of your immediate family has had a blood clot in the leg, lung or other organ at a young age (e.g. below the age of about 50 years old). In this case you could have a hereditary blood clotting disorder;
• if you need to have an operation, or if you are off your feet for a long time because of an injury or illness, or you have your leg in a cast. The use of Marvelon may need to be stopped several weeks before surgery or while you are less mobile. If you need to stop Marvelon ask your doctor when you can start using it again.
• as you get older (particularly above about 35 years);
• if you gave birth less than a few weeks ago.

The risk of developing a blood clot increases the more conditions you have.

Air travel (over 4 hours) may temporarily increase your risk of a blood clot, particularly if you have some of the other factors listed.

If any of the above conditions change while you are using Marvelon, for example a close family member experiences a thrombosis for no known reason; or you gain a lot of weight, tell your doctor.

BLOOD CLOTS IN AN ARTERY

What can happen if a blood clot forms in an artery?

Like a blood clot in a vein, a clot in an artery can cause serious problems. For example, it can cause a heart attack or a stroke.

Factors that increase your risk of a blood clot in an artery

It is important to note that the risk of a heart attack or stroke from using Marvelon is very small but can increase:

• with increasing age (beyond about 35 years);
• if you smoke. When using a combined hormonal contraceptive like Marvelon you are advised to stop smoking. If you are unable to stop smoking and are older than 35 your doctor may advise you to use a different type of contraceptive;
• if you are overweight;
• if you have high blood pressure;
• if a member of your immediate family has had a heart attack or stroke at a young age (less than about 50 years old). In this case you could also have a higher risk of having a heart attack or stroke;
• if you, or someone in your immediate family, have a high level of fat in the blood (cholesterol or triglycerides);
• if you get migraines, especially migraines with aura;
• if you have a problem with your heart (valve disorder, disturbance of the rhythm called atrial fibrillation);
• if you have diabetes.

If you have more than one of these conditions or if any of them are particularly severe the risk of developing a blood clot may be increased even more.

If any of the above conditions change while you are using Marvelon, for example you start smoking, a close family member experiences a thrombosis for no known reason; or you gain a lot of weight, tell your doctor.

The Pill and cancer

The Pill reduces your risk of cancer of the ovary and womb if used in the long term. However, it also seems to slightly increase your risk of cancer of the cervix – although this may be due to having sex without a condom rather than the Pill itself. All women should have regular smear tests.

If you have breast cancer, or have had it in the past, you should not take the Pill. The Pill slightly increases your risk of breast cancer. This risk goes up the longer you're on the Pill, but returns to normal within about 10 years of stopping it. Because breast cancer is rare in women under the age of 40 the extra number of cases of breast cancer in current and recent users of the Pill is small.

For example:

• Of 10,000 women who have never taken the Pill, about 16 will have breast cancer by the time they are 35 years.
• Of 10,000 women who take the Pill for 5 years in their early twenties, about 17-18 will have breast cancer by the time they are 35 years old.
• Of 10,000 women who have never taken the Pill, about 100 will have breast cancer by the time they are 45 years old.
• Of 10,000 women who take the Pill for 5 years in their early thirties, about 110 will have breast cancer by the time they are 45 years old.

Your risk of breast cancer is higher:

• if you have a close relative (mother, sister, or grandmother) who had breast cancer
• if you are seriously overweight

• See a doctor as soon as possible if you notice any changes in your breasts, such as dimpling of the skin, changes in the nipple, or any lumps you can see or feel.

Taking the Pill has also been linked to liver diseases, such as jaundice and non-cancer liver tumours, but this is rare. Very rarely, the Pill has also been linked with some forms of liver cancer in women who have taken it for a long time.

• See a doctor as soon as possible if you get severe pain in your stomach, or yellow skin or eyes (jaundice). You may need to stop taking Marvelon.

Taking other medicines

If you ever need to take another medicine at the same time as being on the Pill, always tell your doctor, pharmacist, or dentist that you're taking Marvelon. Also check the leaflets that come with all your medicines to see if they can be taken with hormonal contraceptives.

Some medicines can stop Marvelon from working properly – for example:

• some medicines used to treat epilepsy (primidone, phenytoins, barbiturates, carbamazepine, oxcarbazepine, topiramate, felbamate);
• medicine to treat tuberculosis (rifampicin);
• certain HIV medicines (ritonavir);
• certain antibiotics (penicillins, tetracyclines);
• St John's Wort (a herbal remedy);
• Griseofulvin (an antifungal drug).

If you do need to take one of these medicines, Marvelon may not be suitable for you, or you may be able to take Marvelon and use extra contraception for a while. Your doctor, pharmacist or dentist can tell you if this is necessary and for how long.

Marvelon can also affect how well other medicines work. For example ciclosporin and lamotrigine. Remind your doctor if you are taking these in case your treatment needs to be adjusted.

Taking Marvelon with food and drink

There are no special instructions about food and drink while on Marvelon.

Pregnancy and breast-feeding

Do not use Marvelon if you are pregnant. If you think you might be pregnant, do a pregnancy test to confirm that you are before you stop taking Marvelon.

Marvelon is not recommended for use during breast-feeding. Ask your doctor or family planning nurse about alternative contraception. Breast-feeding may not stop you getting pregnant.

Taking Marvelon

To prevent pregnancy, always take Marvelon exactly as described below. Check with your doctor or family planning nurse if you are not sure.

Take Marvelon every day for 21 days

Marvelon comes in strips of 21 pills, each marked with a day of the week.

• Take your pill at the same time every day.
• Start by taking a pill marked with the correct day of the week.
• Follow the direction of the arrows on the strip. Take one pill each day, until you have finished all 21 pills.
• Swallow each pill whole, with water if necessary. Do not chew the pill.

Then have seven pill-free days

After you have taken all 21 pills in the strip, you have seven days when you take no pills. So if you take the last pill of one pack on a Friday, you will take the first pill of your next pack on the Saturday of the following week.

Within a few days of taking the last pill from the strip, you should have a withdrawal bleed like a period. This bleed may not have finished when it is time to start your next strip of pills. You don't need to use extra contraception during these seven pill-free days – as long as you have taken your pills correctly and start the next strip of pills on time.

Then start your next strip

Start taking your next strip of Marvelon after the seven pill-free days – even if you are still bleeding. Always start the new strip on time.

As long as you take Marvelon correctly, you will always start each new strip on the same day of the week.

Starting Marvelon

As a new user or starting the Pill again after a break

Either take your first Marvelon pill on the first day of your next period. By starting in this way, you will have contraceptive protection with your first pill.

Or if your period has already begun start taking Marvelon on day 5 (counting the first day of your period as day 1) whether or not your bleeding has stopped. You must also use extra contraception, such as condoms, until you have taken the first seven pills correctly.

Changing to Marvelon from another contraceptive Pill

• If you are currently on a 21-day Pill: start taking Marvelon the next day after the end of the previous strip. You will have contraceptive protection with your first pill but you will not have a bleed until after you finish your first strip of Marvelon.
• If you are currently on a 28-day Pill: start taking Marvelon the day after your last active pill. You will have contraceptive protection with your first pill. You will not have a bleed until after you finish your first strip of Marvelon.
• Or if you are taking a progestogen-only Pill (mini-Pill or POP): start Marvelon on the first day of bleeding, even if you have already taken the POP for that day. You will have contraceptive cover straight away. If you don't usually have any bleeding while you are taking a progestogen-only Pill, you can stop taking it any day and start Marvelon the next day. You will need to use extra contraception, such as a condom, for seven days.

Serious side effects – see a doctor straight away

Signs of deep vein thrombosis include;

• swelling of one leg or along a vein in the leg or foot especially when accompanied by:
• pain or tenderness in the leg which may be felt only when standing or walking;
• increased warmth in the affected leg;
• change in colour of the skin on the leg e.g. turning pale, red, or blue.

Signs of a pulmonary embolism:

• sudden unexplained breathlessness or rapid breathing;
• sudden cough without an obvious cause, which may bring up blood;
• sharp chest pain which may increase with deep breathing;
• severe light headedness or dizziness;
• rapid or irregular heartbeat;
• severe pain in your stomach.

If you are unsure, talk to a doctor as some of these symptoms such as coughing or being short of breath may be mistaken for a milder condition such as a respiratory tract infection (e.g. a 'common cold').

Signs of retinal vein thrombosis (blood clot in the eye):

• Symptoms most commonly occur in one eye:
• immediate loss of vision or
• painless blurring of vision which can progress to loss of vision.

Signs of heart attack:

• chest pain, discomfort, pressure, heaviness;
• sensation of squeezing or fullness in the chest, arm or below the breastbone;
• fullness, indigestion or choking feeling;
• upper body discomfort radiating to the back, jaw, throat, arm and stomach;
• sweating, nausea, vomiting or dizziness;
• extreme weakness, anxiety, or shortness of breath;
• rapid or irregular heartbeats.

Signs of a stroke:

• sudden weakness or numbness of the face, arm or leg, especially on one side of the body;
• sudden confusion, trouble speaking or understanding;
• sudden trouble seeing in one or both eyes;
• sudden trouble walking, dizziness, loss of balance or coordination;
• sudden, severe or prolonged headache with no known cause;
• loss of consciousness or fainting with or without seizure.

Sometimes the symptoms of stroke can be brief with an almost immediate and full recovery, but you should still seek urgent medical attention as you may be at risk of another stroke.

Signs of blood clots blocking other blood vessels:

• swelling and slight blue discolouration of an extremity;
• severe pain in your stomach (acute abdomen).

Signs of a severe allergic reaction to Marvelon

• swelling of the face, lips, mouth, tongue or throat.

Signs of breast cancer include:

• dimpling of the skin;
• changes in the nipple;
• any lumps you can see or feel.

Signs of cancer of the cervix include:

• vaginal discharge that smells and contains blood;
• Unusual vaginal bleeding;
• pelvic pain;
• painful sex.

Signs of severe liver problems include:

• severe pain in your upper abdomen;
• yellow skin or eyes(jaundice).

• If you think you may have any of these, see a doctor straight away. You may need to stop taking Marvelon.

Possible side effects

Common (more than 1 in 100 people who take Marvelon are affected)

• Migraine or headache (see a doctor as soon as possible if this is your first migraine or it's worse than usual, or if the headache is severe, unusual or long lasting)
• Putting on weight or losing weight
• Breast problems, such as painful or tender breasts; producing a milky fluid from the nipples
• Depression or mood changes
• Changes in sexual desire
• Heart or circulation problems, such as increased blood pressure, swollen hands, ankles or feet - a sign of fluid retention
• Changes in vaginal secretions
• Irregular vaginal bleeding - see section Bleeding between periods should not last long
• Skin problems, such as rash; bruise-like swelling to the shins (erythema nodosom)
• Stomach problems, such as nausea; vomiting
• Discomfort of the eyes if you wear contact lenses

Rare (less than 1 in 1000 people who take Marvelon are affected)

• Harmful blood clots in a vein or artery for example:
  • in a leg or foot (i.e. DVT)
  • in a lung (i.e. PE)
  • heart attack
  • stroke
  • mini-stroke or temporary stroke-like symptoms, known as a transient ischaemic attack (TIA)
  • blood clots in the liver, stomach/intestine, kidneys or eye.

  The chance of having a blood clot may be higher if you have any other conditions that increase this risk. (See section 2 for more information on the conditions that increase risk for blood clots and the symptoms of a blood clot.)

• Severe allergic reaction to Marvelon
• Breast cancer
• Cancer of the cervix
• Severe liver problems
• High blood pressure
• Gall stones
• Chorea (a problem with the nervous system causing jerky movements that you can't control)
• Worsening of systemic lupus erythematosus (SLE - when your immune system attacks your body causing, for example, joint ache and tiredness)
• Stomach and intestine problems such as pancreatitis; Crohn's disease; ulcerative colitis
• Worsening of otosclerosis (a hearing problem)
• Problems with blood sugar
• Worsening of a rare condition called porphyria
• Worsening of skin problems, such as brown patches on your face or body (chloasma) blister-like rash, (herpes gestationis)

• Tell your doctor, pharmacist or family planning nurse if you are worried about any side effects which you think may be due to Marvelon. Also tell them if any existing conditions get worse while you are taking Marvelon.

Bleeding between periods should not last long

A few women have a little unexpected bleeding or spotting while they are taking Marvelon, especially during the first few months. Normally, this bleeding is nothing to worry about and will stop after a day or two. Keep taking Marvelon as usual; the problem should disappear after the first few strips.

You may also have unexpected bleeding if you are not taking your pills regularly, so try to take your pill at the same time every day. Also, unexpected bleeding can sometimes be caused by other medicines.

• Make an appointment to see your doctor if you get breakthrough bleeding or spotting that:
  • carries on for more than the first few months
  • starts after you've been taking Marvelon for a while
  • carries on even after you've stopped taking Marvelon.

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