PENGGUNAAN KONTRASEPSI ORAL YANG RASIONAL

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SEMINAR NASIONAL

THE 2

ND

_{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

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Pilihan Kontrasepsi



Oral kontrasepsi



Postcoital (morning after) pills/emergency contraceptive

Pills



Patch &ring kontrasepsi



Long acting injections



Intrauterine device (IUD)



Diaphragm



Cervical Cap



Condoms

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Kontrasepsi oral



Sejak 1960



Bekerja : mencegah konsepsi sebelum fertilisasi



Progestin:

 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

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Estrogen, kerja fisiologis

((1) Promotion of tissue growth associated with

1) Promotion of tissue growth associated with

puberty

puberty----vagina, uterus,

vagina, uterus, Fallopian tubes,

Fallopian tubes,

mammary glands (stromal and ductal growth).

(2) Proliferation of uterine

(2) Proliferation of uterine endometrium

endometrium

((3) Increase in

3) Increase in myometrial

myometrial and Fallopian tube

and Fallopian tube

peristalsis

peristalsis to promote ovum

to promote ovum transport.

transport.

((4) Decrease in viscosity of cervical mucus.

4) Decrease in viscosity of cervical mucus.

((55)) Biphasic

Biphasic inhibition

inhibition on

on pituitary

pituitary gonadotropin

gonadotropin

secretion

secretion..

((66)) Promotion

Promotion of

of epiphyseal

epiphyseal closure

closure..

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Estrogen, kerja fisiologis ..lanjutan

77)) Ovum

Ovum implantation

implantation facilitated

facilitated via

via endometrial

endometrial

"conditioning"

"conditioning"..

((88)) Promotion

Promotion of

of salt

salt and

and water

water retention

retention via

via decrease

decrease

in

in plasma

plasma volume

volume

((99)) Lipid

Lipid metabolism

metabolism ((

↑HDL, ↓LDL; ↓LDL/HDL

ratio)

..

((10

10)) Enhancement

Enhancement of

of blood

blood coagulability

coagulability..

((11

11)) Inhibition

Inhibition of

of PTH

PTH--induced

induced bone

bone resorption

resorption..

((12

12)) Reduction

Reduction of

of intestinal

intestinal motility

motility..

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Progestin , Kerja fisiologis

(1) Development of

(1) Development of secretory

secretory endometrium

endometrium. .

(2) Decrease in

(2) Decrease in myometrial

myometrial contractility

contractility

(3) Decrease in fallopian tube peristalsis

(4) Increase in viscosity of cervical mucus

(5) Mammary gland development

-- promotion of development of lobules and

promotion of development of lobules and alveoli

alveoli

(6) Feedback inhibition on pituitary

(6) Feedback inhibition on pituitary gonadotropins

gonadotropins

-- not as potent as the

not as potent as the estrogens.

estrogens.

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7)

7) Thermogenic

Thermogenic effects

effects

-- appears to be a direct effect on

appears to be a direct effect on

thermoregulatory

thermoregulatory centers in the hypothalamus.

centers in the hypothalamus.

(8) Increase in basal insulin levels and insulin response

to glucose.

(9) Respiratory effects

(9) Respiratory effects -- increased response to CO2.

increased response to CO2.

(10) Lipid metabolism (

↓

HDL, ↑ LDL; ↑ LDL/HDL

ratio)

. .

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↑

Na+ and H2O

Na+ and H2O elimanation

elimanation

(12) Weight gain

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Siklus Menstruasi Siklus Menstruasi

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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

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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,

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WHO : Peringatan penggunaan Kontrasepsi oral

kombinasi

Category 4: Refrain from providing CHCs for women with the following diagnoses

 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

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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

 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,

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

 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) •

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Category 2



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

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Category 1: Do not restrict use of combined oral

contraceptives for the following conditions



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

 

•

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Category 1

 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 •

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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

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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

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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

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Efek Samping



Mual, kembung, perdarahan pd pengguna awal (3 -6

siklus)



Monitor



Stop bila:



Abdominal pain



Chest pain



Headaches



Eye problems



Severe leg pain

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Interaksi



Rifampisin menginduksi metabolisme estrogen



Antikejang; Barbiturat, fenitoin, karbamazepim

Menginduksi metabolisme estrogen dan progestin

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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

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Informasi untuk pasien



Kerja Kontrasepsi Oral



Cara penggunaan



Bila lupa



Kepatuhan



ROTD yang Umum



Manfaat dan risiko

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Daftar bacaan

 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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