PENGGUNAAN KONTRASEPSI ORAL YANG RASIONAL

SEMINAR NASIONAL THE 2ND INDONESIAN PHARMACIST UPDATE” DOKTER & APOTEKER PARTNERSHIP DALAM KUALITAS PELAYANAN OBAT

PENGGUNAAN KONTRASEPSI ORAL YANG RASIONAL

Dra. Retnosari Andrajati , PhD., Apt. Fakultas Farmasi Universitas Indonesia

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pilihan kontrasepsi Kontrasepsi oral Siklus menstruasi Kerja Estrogen dan progesteron Pemilihan kontrasepsi oral Regimen Keamanan Informasi untuk pasien

Pilihan Kontrasepsi  

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Oral kontrasepsi Postcoital (morning after) pills/emergency contraceptive Pills Patch &ring kontrasepsi Long acting injections Intrauterine device (IUD) Diaphragm Cervical Cap Condoms Vaginal spermicides

Kontrasepsi oral 

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Sejak 1960 Bekerja : mencegah konsepsi sebelum fertilisasi Progestin:   

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mukus serviks> kental penetrasi sperma < Motilitas tuba falopii  pergerakan sperma Menekan sekresi LH dari hipofisa menghambat ovulasi

Estrogen   

Menekan sekresi FSH dari hipofisa  menghambat pematangan ovum Dapat ikut menekan sekresi LH menghambat ovulasi Menstabilkan endometrium

Estrogen, kerja fisiologis (1) Promotion of tissue growth associated with puberty---vagina, uterus, Fallopian tubes, puberty mammary glands (stromal and ductal growth). (2) Proliferation of uterine endometrium (3) Increase in myometrial and Fallopian tube peristalsis to promote ovum transport. (4) Decrease in viscosity of cervical mucus. (5) Biphasic inhibition on pituitary gonadotropin secretion.. secretion (6) Promotion of epiphyseal closure closure..

Estrogen, kerja fisiologis ..lanjutan 7) Ovum implantation facilitated via endometrial "conditioning".. "conditioning" (8) Promotion of salt and water retention via decrease in plasma volume (9) Lipid metabolism (↑HDL, ↓LDL; ↓LDL/HDL ratio).. (10 10)) Enhancement of blood coagulability coagulability.. (11 11)) Inhibition of PTH PTH--induced bone resorption resorption.. (12 12)) Reduction of intestinal motility motility..

Progestin , Kerja fisiologis (1) Development of secretory endometrium endometrium.. (2) Decrease in myometrial contractility (3) Decrease in fallopian tube peristalsis (4) Increase in viscosity of cervical mucus (5) Mammary gland development - promotion of development of lobules and alveoli (6) Feedback inhibition on pituitary gonadotropins - not as potent as the estrogens.

7) Thermogenic effects - appears to be a direct effect on thermoregulatory centers in the hypothalamus. (8) Increase in basal insulin levels and insulin response to glucose. (9) Respiratory effects - increased response to CO2. (10) Lipid metabolism (↓ ( HDL, ↑ LDL; ↑ LDL/HDL ratio).. (11) ↑ Na+ and H2O elimanation (12) Weight gain

Siklus Menstruasi

Pemilihan Kontrasepsi Oral Apakah mempunyai masalah:  Merokok dan usia ≥35 thn  Hipertensi sedang/berat (>160/100  Perdarahan vagina yg tdk terdiagnosis  Diabetes dgn komplikasi vaskuler>20 thn  Deep vein thrombosis (DVT) atau unless anticoagulated(PE) atau mempunyai riwayat penyakit jantung iskemik  Sakit kepala dgn gejala neurologi fokal atau riwayat stroke  Riwayat keluarga : trombosis,  Riwayat keluarga/mengalami Ca payudara  Hepatitis virus aktif dan sirosis berat/ringan  Menyusui  Bedah mayor dgn imobilisasi dlm 1 bulan  Riwayat pribadi kolestasis dgn penggunaan COC  Hamil

Pemilihan kontrasepsi Oral Masalah

Ya: riwayat + utk 1/>

Mungkin tdk dapat menggunakan KO

Pertimbangkan metode Kontrasepsi lain, Pertimbangkan kontrasepsi hanya Progestin

Tidak ada riwayat untuk semua masalah

Dapat menggunakan KO Pilih sesuai keinginan, ketersediaan, ROTD, biaya, pengalaman , klinisi

WHO : Peringatan penggunaan Kontrasepsi oral kombinasi Category 4: Refrain from providing CHCs for women with the following diagnoses   

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Thrombophlebitis or thromboembolic disorder, or a history of these conditions Cerebrovascular disease, coronary artery disease, peripheral vascular disease Valvular heart disease with thrombogenic complications (e.g., pulmonary 
hypertension, atrial fibrillation, history of endocarditis) Diabetes with vascular involvement (e.g., nephropathy, retinopathy, neuropathy, 
other vascular disease or diabetes >20 years’ duration) Migraine headaches with focal aura Migraine headaches without aura in women ³35 years old should discontinue CHC Uncontrolled hypertension (≥160 mm Hg systolic or ³90 mm Hg diastolic) Major surgery with prolonged immobilization Thrombogenic mutations (e.g., factor V Leiden, protein C or S deficiency, Breast Ca Acute chronic hepatocelular diseases Age>35 years and currently smoking>15 cigarettes perday

Category 3: Conditions may be adversely impacted by CHCs, and the risksgenerally outweigh the benefits; providers should exercise caution ifcombined CHCs are used in these situations and carefully monitor foradverse effects

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Multiple risk factors for arterial cardiovascular disease • Known hyperlipidemia • Migraine headache without aura in women ≥35 years old • • History of hypertension (systolic 140–159 mm Hg or diastolic 90–99 mm Hg) • • History of cancer, but no evidence of current disease for 5 years • • Cirrhosis, mild and compensated • • Symptomatic gallbladder disease • • Cholestatic jaundice with prior pill use • Age >35 years and currently smoking <15 cigarettes per day • • Postpartum < 21 days, not breast-feeding • • Breast-feeding women 6 weeks to 6 months postpartum • • Commonly used drugs that induce liver enzymes (rifampin, phenytoin, carbamazepine, barbiturates, primidone, topiramate) and reduce efficacy of CHC

Category 2: Some conditions may trigger potential concerns with CHCs, but benefits usually outweigh risks

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Family history of thromboembolism • Superficial thrombophlebitis • Uncomplicated valvular heart disease • Diabetes without vascular disease Sickle cell disease
 Migraine headaches without aura in women <35 years old
• Nonmigrainous headaches at any age should discontinue CHC
 Hypertension during pregnancy, resolved postpartum
• Major surgery without prolonged immobilization
• Gallbladder disease (symptomatic and treated by cholecystectomy or asymptomatic) •

Category 2 

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Cholestatic jaundice of pregnancy
• Undiagnosed breast mass
• Undiagnosed abnormal genital bleeding
• Cervical intraepithelial neoplasia or cervical cancer
• Obesity (body mass index ³30 kg/m2)
• Age <35 years and currently smoking
• Breastfeeding women ³6 months postpartum
• Age ³40 years and currently smoking>15 cigarettes perday Drugs that may induce metabolism of CHC and reduce efficacy (griseofulvin, antiretroviral therapy)

Category 1: Do not restrict use of combined oral contraceptives for the following conditions 

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Varicose veins
• History of gestational diabetes
• Nonmigrainous headaches
• Thyroid disease
• Thalassemia
• Iron deficiency anemia
• Depression
• Epilepsy
• Infectious diseases (HIV, schistosomiasis, tuberculosis, malaria)
• Minor surgery without immobilization
• Benign ovarian tumors
• Endometriosis
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Category 1         

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Irregular or heavy vaginal bleeding, severe dysmenorrhea
• Sexually transmitted diseases
• Uterine fibroids
• Pelvic inflammatory disease
• Endometrial cancer
• Ovarian cancer
• History of pelvic surgery
• Trophoblast disease
• History of ectopic pregnancy
• Postabortion
• Postpartum women >21 weeks, not breast-feeding
• Menarche to 40 years of age
• Drug interactions with antibiotics other than rifampin and griseofulvin

Memulai Kontrasepsi Oral   

Sesudah periode menstruasi Beberapa minggu sesudah persalinan Sesudah tidak menyusui  Metode

Cepat: segera sesudah test urin kehamilan negatif  Metode hari pertama (First day method): mulai hari pertama siklus menstruasi berikutnya.  Metode hari Minggu (Sunday Method): mulai pada hari Minggu pertama sesudah siklus mentruasi

Regimen 

Konvensional : 21 berisi zat aktif, & plasebo  Menstruasi

terprediksi  Mudah digunakan  Mudah mengidentifikasi dana menangani ES  Mudah melakukan perubahan untuk mengubah siklus menstruasi 

Bifasik/trifasik  OCs.3–5

ExtendedcycleOCs either eliminate the menstrual cycle or result in only four

Kontrasepsi Oral di Indonesia Levonorgestel 0,15 mg, ethynilestradiol 0,03 mg Desogestrel 150 mcg, etinilestradiol 30 mcg Desogestrel 150 mcg , etinilestradiol 20 mcg

Drospirenon 3 mg, etinil estradiol 0,03 mg

Trifasik: levonorgestrel 0,05 mg etinilestradiol 0,03 mg/ 6 tablet, levonorgestrel 0,075 mg etinilestradiol 0,04 mg tiap 5 tablet levonorgestrel 0,125 mg etinilestradiol 0,03 mg tiap 10 tablet 7 plasebo 28 tablet Post coital: levonorgestrel 0,75 mg

Efek Samping 

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Mual, kembung, perdarahan pd pengguna awal (3 -6 siklus)  Monitor Stop bila:  Abdominal  Chest

pain

pain  Headaches  Eye problems  Severe leg pain

Interaksi Rifampisin menginduksi metabolisme estrogen

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Antikejang; Barbiturat, fenitoin, karbamazepim

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Menginduksi metabolisme estrogen dan progestin

Kegagalan , perdarahan

Fertilitas stlhPenghentian pengunaan 

Fertillitas  Ovulasi 

: 1-2 minggu setelah penghentian

> panjang pada riwayat menstruasi tdk teratur

 Amenorhae

jarang berakhir 6 bulan  Studi kohort dan kasus kontrol: yang langsung hamil tdk kecacatan bayi tdk lebih besar dari populasi umum

Informasi untuk pasien       

Kerja Kontrasepsi Oral Cara penggunaan Bila lupa Kepatuhan ROTD yang Umum Manfaat dan risiko Tanda-tanda bahaya

Daftar bacaan 

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Koda Kimble MA., Young LY., Kradjan WA., Guglielmo BJ., Alldredge BK., Corelli RL., Handbbook of Applied Therapeutics 8th ed., 2007:44.1-44.20 Lippincott Williams & Wilkins , Baltimore, USA Dipiro JT., Talbert RL., Yee GC., Matzke GR., Wells BG, Posey LM. Patophysiology a patophysiology Approach. 7th 2008. McGraw Hill Medical , Newyork, USA Egarter C, Tirri BF, Bitzer J., Kaminskyy V., JOddens B., Prilepskaya V., Yeshaya A., Marintcheva-Petrova M., Weyers S Women’s perceptions and reasons for choosingthe pill, patch, or ring in the CHOICE study: across-sectional survey of contraceptive methodselection after counseling. BMC Women's Healt 2013,13:9 2 of 14 http://www.biomedcentral.com/1472-6874/13/9

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