Contraception

Luciana
Kasus

• Seorang wanita usis 34 tahun dengan BB : 49 kg/ TB : 155 cm, memiliki riwayat penyakit
dahulu : TB paru on OAT, pengobatan sudah berjalan selama 2 bulan ( Rifampicin 450 mg;
Isoniazid 300 mg, Pyrazinamid 1000 mg dan Ethambutol 1x1000 mg ). dan riwayat
rheumatoid arthritis ( rutin mengkonsumsi methotrexate 2,5 mg tiap hari selasa, kamis dan
sabtu ). Saat ini ia mengeluh pusing, demam dan nyeri tenggorokan. Dokter umum
tempatnya berobat memberikan Bactrim forte 2x sehari 1 tablet selama 5 hari. Wanita
tersebut juga berencana membeli pil kontrasepsi , untuk mengganti metode kontrasepsi
sebelumnya yaitu injeksi kontrasepsi menjadi kontrasepsi hormonal peroral. Informasi apa
yang dapat anda sampaikan kepada wanita tersebut dan masalah apa yang dapat ditemukan
berkaitan dengan penggunaan obat-obatannya? ( Hasil lab terakhir yang dimiliki pasien
tersebut 1 bulan yang lalu adalah : Hb : 10,8; Leukosit : 5100; Trombosit : 178.000 ).
•
Introduction
• Contraception commonly prevents the pregnancy and secondary
uses :
Heavy or irregular menstruation
Endometriosis
Polycystic ovary syndrome
Dysfunctional uterine bleeding
Introduction

• Commonly used methods of reversible contraception, include :

 Oral
 Intrauterine devices ( IUDs)
 Barrier methods :
 Condoms
 Spermicides
 Diaphragms
 Cervical caps
The menstrual cycle

• The cycle of menstruation comprises three phases ( follicular,

ovulatory and luteal ( postovulatory )
• The first day of menses is referred to as day 1 of the
menstrual cycle ( the beginning of the follicular phase )
• The median menstrual cycle length is range from 21 to 40
days
• The menstrual cycle is influenced by the hormonal relationship,
among the hypothalamus, anterior pituitary and ovaries
• The hypothalamus secretes GnRH
• GnRH stimulates the anterior pituitary to secrete bursts of
gonadotropins, FSH,and LH
• The gonadotropins FSH and LH direct events in the ovarian
follicles that result in the production of a fertile ovum
Hormonal Contraception

• Hormonal contraceptives contain either a combination of estrogen

and progestin or progestin alone
• Combined hormonal contraceptives (CHCs) work before
fertilization to prevent conception
• Most combined OC s contain estrogen at doses 20 to 50 mcg of
Progestins ( synthetic progesterone ) used in OCs include
desogestrel, drospirenone, norgestrel, levonorgestrel, norethindrone,
norethindrone acetate, ethynodiol diacetate
Combined Hormonal Contraceptive

• Combined hormonal contraceptives ( CHCs ) contain both estrogen and

progestin and work primarily before fertilization to prevent conception
• Progestins - thickening cervical mucus to prevent sperm penetration, slowing
tubal motility, delaying sperm transport
• Progestins- block the LH surge - inhibiting ovulation
• Estrogens - suppress FSH release from the pituitary - inhibiting ovulation
Adverse effect of CHC

• Women older than 35 years old :

 The increased risk of VTE, MI
 The increase risk of ischemic stroke in women with migraine and breast
cancer in older women
• Smoking :
 50 mcg EE  increased MI
• Hypertension :
 An increased of MI and stroke ( sistolic > 160 mmHg and diastolic > 100
mmHg is contraindicated )
• Dyslipidemia :
 Progestins affect lipid metabolism by decreasing HDL and increasing LDL
 Estrogens increase triglycerides or total cholesterol
• Diabetes :
 Progestins alter carbohydrate metabolism
 The new progrestin ( desogestrel )are believed to have little effect on
carbohydrate
• Migrain headaches
 A higher risk of stroke in women experiencing migraine with aura
• Breast cancer :
 Women with current or past history of BC should not use CHCs
• Thromboemboli :
• Estrogens increase hepatic production of factor VII, X and fibrinogen in the
coagulation cascade- increase the risk of thromboembolism
• Newer progrestin, such as : desogestrel, norgestimate ( 3rd gen ); drospirenone( 4th
gen )
• Women who are at an increased risk of thromboembolism : older than 35 years old,
obesity, smoking, prolonged immbobilization )
Mechanism action of the pill
Mechanism of action of the pill

• Inhibition of ovulation
• Effects on the cervical mucus glands, uterine tubes. And
endometrium that decrease fertilization and implantation
Types of pill contraceptives
• Monophasic oral contraceptives :
 Contain the same amounts of estrogen and progestin for 21 days, followed by 7
days of placebo pills
• Multiphasic pills
 Contain variable amounts of estrogen and progestin for 21 days, followed by 7 days
of placebo pills
• Minipill
 Contain progestin only ( 28 days of active hormone per cycle )
 Minipills must be taken everyday of the menstrual cycle at approximately the same
time to maintain contraceptive efficacy
Oral Contraception pills

Komponen estrogen Komponen progestin Jumlah tablet Nama dagang

Monofasik
Etinilestradiol 20 mcg Desogestrel 150 mcg 28 Mercilon 28
Etinilestradiol 30 mcg Gestoden 75 mcg 28 Gynera
Desogestrel 150 mcg 28 Marvelon 28
Levonorgestrel 150 mcg 28 Microgynon
28 Nordette 28
28 Andalan
Etinilestradiol 35 mcg Siproteron 2 mg 21 Diane 35
Oral contraception pills

Komponen estrogen Komponen progestin Jumlah tablet Nama dagang

Trifasik
Etinilestradiol 50 mcg Linestrenol 2,5 mg 22 Lyndiol
Linestrenol 1 mg 28 Ovostat 28
Initiating an Oral Contraceptive

• Ocs were initiated after the next menstrual period occurred, several
weeks after childbirth, or after a breastfeeding infant was weaned
• In the first 21 days postpartum ( the risk of thrombosis is higher ) if
contraception is required, progestin only pills and IUDs are acceptable
choices
• The women who are breastfeeding avoid CHCs for the first 42 days
postpartum- risk VTE increased
Choice of Oral Contraceptive
Choice of Oral Contraceptive

• Adolescents, underweight women , women older than 35 years and those who are
perimenopausal may have fewer side effects with OCs containing 20-25 mcg EE
• Women with oily skin, acne, and hirsutism should be given low androgenic Ocs
• Women with migraine headaches, history of thromboembolic disease, heart disease,
cerebrovascular disease, SLE, and hypertriglyceridemia are candidates for progestin
only methods
• Women who are older than 35 years , smokers , or obese , have hypertension or
vascular disease should use progesterone only
Oral contraceptives side effects

• Nausea
• Bloating
• Headache
• Weight changes
• Spotting
• Breast tenderness
Symptoms of a Serious or Potentially of Combined
Hormonal Contraception
Symptoms of a Serious or Potentially of Combined
Hormonal Contraception
Monitoring Of Hormonal Contraceptives
Monitoring Of Hormonal Contraceptives
Monitoring Of Hormonal Contraceptives
Monitoring Of Hormonal Contraceptives
Oral contraceptives instruction

• 28 pill pack has 21 hormone pills. The seven pills are placebo to
help the user stay in the habit of taking a pill everyday
• Take a birth control pill at the same time everyday
Instruction for missed pills

• If one tablet is missed or late take the tablet as soon as remembered and
continue taking the rest of tablet as prescribed ( two tablets taken on the
same day )
• If two or more consecutive tablets are missed  take one missed as soon as
remembered and discard the remaining missed tablets. Continue taking the
OC tablets as scheduled ( two tablets may need to be taken on the same day :
one of the missed tablets and one of the regularly scheduled tablets ). Use
additional nonhormonal contraception until tablets have been taken for 7
days
Instruction for missed pills

• When two or more consecutive tablets are missed, consider counseling on

use EC if warranted
• If a woman forgets a tablet or is more than 3 hours late then additional
nonhormonal contraception should be used for 48 hours
Drug interactions with oral contraceptives
Emergency contraception ( postcoital contraceptives )

• Emergency contraception ( EC ) is used to prevent unwanted pregnancy after unprotected

sexual intercourse
• EC is taken within 72 hours after unprotected intercourse,
• Oral preparation containing a progrestin ( L-norgestrel ) alone, estrogen alone or a
combination of an estrogen and a progrestin are effective
• The progrestin only preparation causes fewer side effects than the estrogen-contaiming
preparation
• EC prevents the fertilized egg from implanting into the endometrium and impaired sperm
transport and corpus luteum function
• Oral EC will not disrupt the fertilized egg after implantation has
occured
• Common adverse effect include nausea, vomiting, and irregular
bleeding
• Appropriate counseling should be provided regarding : timing of
the dose, adverse effects and use of regular method
Injection Contraceptive

• Mechanism action : blocks the LH surge, thus preventing ovulation; thicken the
cervical mucus, producing a barrier to sperm penetration
• Depo-Provera ( medroxyprogesterone acetate ) is administered by deep IM injection
within 5 days of onset of menstrual bleeding and inhibit ovulation for more than 3
months
• These injection may inhibit ovulation for up to 14 weeks , the dose should be
repeated every 3 months
• Adverse effect : breast tenderness, weight gain, menstrual irregularities
Subdermal Progestin Implants

• Norplant implant
Vaginal ring

• Vaginal ring contain EE and etonogestrel ( NuvaRing )

• Over a 3 week period, the ring releases approximately 15 mcg/day of EE and 120
mcg/day of etonogestrel
• On the first cycle of use, the ring should be inserted on or before the fifth day of
the menstrual cycle
• The ring should be inserted vaginally
• Side effects, precaution and contraindications for use of hormonal ring are similar
for all CHC
Intrauterine device

Two IUDs currently marketed , are T shaped and one with

levonorgestrel ( mirena )
Disadvantage of Levonorgestrel IUD is increased spotting in the
first 6 months of use
Disadvantage of copper IUD is increased menstrual blood flow
and dysmenorrhea
Spermicide-Implanted Barrier Techniques

• The vaginal contraceptive sponge contains the spermicide

nonoxynol-9
• Prevents pregnancy blocks the egg and sperm from meeting
• Barrier methods have higher failure rates than hormonal methods due to
design and human error
Diapraghm

• Inserted up to 18 hours before intercourse and can be left in for a total of 24

hours
Cervical cap

• Latex barrier inserted in vagina before intercourse

• Must be left in place six hours after sexual intercourse
Pharmaceutical Care Plan

• Annual blood pressure monitoring

• Monitoring of blood glucose ( especially with a history of DM )
• Monitoring for the presence of adverse effects related to hormonal
• Women using DMPA should be followed up : weight gain, menstrual cycle
disturbances and fractures