Annie 21

A combined hormonal tablet, 21 tablets per box. Each tablet holds two active substances.

• Cyproterone acetate 2 mg: an anti-androgen hormone. It blocks androgen receptors and lowers androgen production in the body.
• Ethinylestradiol 0.035 mg: an oestrogen that raises SHBG, the protein that carries sex hormones in the blood.

The combination stops ovulation, so it also prevents pregnancy. The medical facts here come from the UK SmPC of Dianette (same actives and strengths), not from a leaflet for Annie itself.

The UK SmPC lists moderate to severe acne related to androgen sensitivity (with or without oily skin) and/or excess hair growth in women of reproductive age. For acne, it is used only after topical treatment or antibiotics by mouth have failed.

• It is also a hormonal contraceptive, so it must not be combined with another hormonal contraceptive.
• It is not recommended for contraception alone. It is kept for women who need treatment for androgen-related skin conditions.
• It is for use after the first period, not in men and not after menopause.
• In 2013 the EMA limited this formula to androgen-related acne and excess hair growth.

First course: one tablet a day for 21 days in a row, starting on day 1 of the menstrual cycle (the first day of bleeding counts as day 1). Then take 7 days off without tablets and start the next pack after the 7 days.

• When relying on it for contraception: follow this schedule strictly.
• No bleed in the tablet-free days: rule out pregnancy before starting the next pack.
• Changing from a 21-day pill: take the first tablet the day after the old course ends, with no extra precautions.
• Changing from a 28-day pill: start after the last hormone tablet, with the first tablet the next day.

Before starting, a doctor or pharmacist should check your personal and family history, measure blood pressure and rule out pregnancy (UK SmPC). For a missed tablet, see the questions below.

Common side effects (1 in 100 to fewer than 1 in 10 users) according to the UK SmPC:

• nausea and abdominal pain
• weight gain and headache
• depressed or altered mood
• breast pain and tenderness

Others listed include vomiting, diarrhoea, rash, hives, migraine, fluid retention, spotting, reduced or missed periods and chloasma. The text read here does not split them by frequency.

Irregular bleeding is common in the first months. If it continues after about 3 cycles, a doctor must assess it. Severe depression has been reported, but a causal link has not been established, so tell a doctor about any mood change. Serious effects of combined hormonal pills include blood clots in veins and arteries, high blood pressure and liver tumours.

Do not use if (UK SmPC)

• you already use another hormonal contraceptive
• you have or had a blood clot in a vein or artery, including heart attack and stroke
• you have severe or several clot risk factors, such as diabetes with vessel damage, severe high blood pressure, severe lipid disorders, or an inherited or acquired tendency to clot
• you have migraine with focal neurological symptoms
• you have severe liver disease with abnormal liver tests, or a past or present liver tumour
• you have or had breast cancer
• you have or had a meningioma
• you are or may be pregnant, are breastfeeding, or are allergic to an ingredient

Precautions: clot risk rises with age, smoking, family history, long immobility, major surgery and a BMI over 30. Stop at least 4 weeks before planned major surgery. In 2020 the EMA said the data do not point to a meningioma risk at 2 mg with ethinylestradiol, but as a precaution it must not be used by anyone who has or had one.

All three share the same formula: cyproterone acetate 2 mg with ethinylestradiol 0.035 mg. The EMA calls this formula Diane 35 and its generics, so the indication, the contraindications and the clot risk are the same set.

• Diane-35: the Bayer brand, the original name of this formula
• Sucee: another brand with the same actives
• Annie 21: made by JSP in Thailand and distributed by Pharmahof

No document was found that compares efficacy or side effects between these three brands directly.

In short: choose by the brand or maker you prefer, not by the active ingredient. Never take Diane-35 or Sucee together with Annie 21, because that doubles the oestrogen dose.

These are the medicines to avoid or to watch. Always tell your doctor or pharmacist that you take this medicine.

• Other hormonal contraceptives: not allowed together, because the hormone dose is excessive and clot risk rises substantially (MHRA).
• CYP3A4 enzyme inducers: can cause breakthrough bleeding and contraceptive failure. Examples are phenobarbitone, phenytoin, carbamazepine, topiramate, rifampicin, St John's wort and the antivirals ritonavir, nelfinavir and nevirapine. For short courses add a barrier method during use and for 28 days after; for long-term use choose another method.
• Some hepatitis C regimens: ombitasvir/paritaprevir/ritonavir + dasabuvir, glecaprevir/pibrentasvir and sofosbuvir/velpatasvir/voxilaprevir must not be combined.
• Levels that change: combined pills can raise ciclosporin and lower lamotrigine levels.

Some blood tests can be affected, so tell the laboratory that you take this medicine.

The Dianette label says relief of symptoms takes at least three months, and the treating doctor must review from time to time whether to continue.

For blood levels, cyproterone acetate is fully absorbed, peaks about 1.6 hours after a dose and builds up to a steady level at about 16 days. Ethinylestradiol peaks at about 1.7 hours and reaches a steady level in 3 to 4 days.

Spotting can occur in the first months and does not mean that the medicine is failing.

Where to buy Annie 21?

Order online at Intimo Life. Delivery across Thailand takes 1-3 working days, packed discreetly for privacy, with no product name on the parcel.