Contraception

Teoh Huey Ching

Pegawai Farmasi UF41
Klinik Kesihatan Durian Tunggal
What is
contraception?
Contraception

• Methods or techniques used to prevent pregnancy.

• By preventing unwanted pregnancies to:
• Reduces the need for abortions
• Helps prevent pregnancy-related health risks in women
Types of Contraception
Natural Methods Hormonal methods Mechanical or barrier Sterilization
methods
• Symptoms-based • Combined contraceptives • IUDs/ IUS • Tubal ligation
methods • Progestin-only • Condoms • Vasectomy
• Calendar-based • Injectables • Diaphragm
methods • Implant • Cervical Cap
• Withdrawal • Contraceptive patch • Spermicides
• Emergency contraception • Vaginal ring
Oral Contraceptives
Two main hormones found in oral contraceptives:
• Estrogen: Ethinylestradiol (dose: 20mcg, 30mcg and 35 mcg)
• Progestogen:
 First generation: Norethindrone, Ethynediol diacetate
 Second generation: Levonorgestrel, Norethisterone
 Third generation: Desogestrel, Gestodene
 Fourth generation: Cyproterone acetate, Drospirenone
Comparison of progestin generations

Structurally related to testosterone Structurally related to

spironolactone

1 2 3 4
Has anti-
mineralcorticosteroid
activity

Androgenic Pregestational

Acne/ Oily skin Headache

More pregestational Weight gain Breast pain/
Increased risk of VTE Hirsutism tenderness
Fatigue Hypertension
Less Androgenic Depression
Before initiate
oral
contraceptives…

Medical Eligibility criteria

for Contraceptive use App
WHO-Medical Eligibility Criteria
Categories
1 A condition for which there is no restriction for the use of contraceptive method.
2 A condition where the advantages of using the method generally outweigh the theoretical of proven risks.
3 A condition where the theoretical or proven risks usually outweigh the advantages of using the method
3 A condition which represents an unacceptable health risk if the contraception method is used.

Category With Clinical Judgement With Limited Clinical Judgement

1 Use method in any circumstances Yes
(Use the method)
2 Generally, use the method
3 Use of method not usually recommended No
unless other more appropriate methods are (Do not use the method)
not available or not acceptable
4 Method not to be used
 Screening
(to exclude personal or family history of
contraindication/ precautions)

Contraindication/ No Contraindication
Precaution

Breastfeeding No Breastfeeding
Refer to doctor for
further medical
evaluation No specific medical
Specific medical
condition
condition
Prescribe a low dose COC
Progestin only Pills (eg: Acne/ Hirsutism)
(≤ 35mcg ethinylestradiol
and
Counselling ≤ 150mcg Levonorgestrel)
Gestodene-; Desogestrel-;
OR Cyproterone-; Drospirenone-
containing OCs
1mg Norethisterone

Response to the request for Counselling Counselling

OCs
Mechanism of OCPs
How do oral contraceptive work?
Without oral With oral
contraceptives contraceptives

1. Estrogen and progestins

Ovary will inhibit ovulation.
release ovum

2. Progestins cause endometrial

thinning which reduces odds of
successful implantation.

3. Progestins thicken cervical mucus,

hampering the transport of sperm.
Combined Oral
Contraceptives
• Contains both synthetic estrogen (usually ethinylestradiol) and 21 days active pills with 7 placebo
a progestin – either in a fixed amount or varying amount in
each tablet
• Usually taken once a day
 21 days followed by a seven-day break
 28 days without a pill-free day
• Rationale:
 To mimic the natural menstrual cycle 28 days active pills
 Low incidence of breakthrough bleeding
A woman can start using her COC any time she wants as long as she isn’t pregnant

If no preceding hormonal contraception: If changing from a progestin-only pill:

 Start active pills within the first 5 days of  Can start taking the active pills without any
menstruation starting for immediate interval
contraception (can protect right away)  Require additional contraceptive methods until
 Otherwise, use additional contraceptive methods active pills have been taken 7 days
until active pills have been taken 7 days

If switching from another COC:

After taking EC:
 For continued contraception, start taking new
 Can start or restart COC immediately after EC
active pills the day after old COC is stopped
 No need to wait for the next monthly bleeding
 No additional contraception required
 Initiation of COCs in specific situation

Postpartum: After a miscarriage or abortion

 Non-breastfeeding mother: can start 21-28 days  Can take the first pill on the next day (will be
postpartum (no additional contraceptive) protected immediately)

Breastfeeding: After diarrhea or vomiting:

 From 6 weeks to <6 months postpartum: cannot  Occurs within 4 hours, tablet absorption may be
initiate COC incomplete
 ≥ 6 months postpartum: can start COC  Follow steps in missed pills
 Miss Pills
One pill Two or more pills
or if you have started the new pack one or if you have started the new pack two
day late or more day late
>24 hours & up > 48 hours late
to 48 hours late

• Take the last pill you missed • Take the last pill you missed
• Continue taking the rest as usual • Continue taking the rest as usual
• Emergency contraception is not • Leave earlier missed pills
required and additional • Use additional contraception for
protection (maybe considered if the next seven days
pills have been missed earlier in • May need emergency pills if
the pack or in the last week of you have unprotected sex in the
the previous pack. ) past seven days, seek advice.
Progestin-only pills
• Minipills
• It has been developed to avoid long term risk of
Estrogen.
• A low dose progestin (alternative therapy for
women in whom estrogen is contraindicated)
• Take once daily with no breaks or placebos
• Not affecting breast milk volume.
 Initiation of POPs in specific situation

Postpartum:
After a miscarriage or abortion
 The first pill should be taken on 21st day after
 Can take the first pill on the next day (will be
childbirth. (no additional contraception required)
protected immediately)
 If there is a delay of first pills, extra
contraception needed (protection established
after 7 days of pills)

After diarrhea or vomiting:

Breastfeeding:  May reduce pills’ effectiveness, additional
 < 6 weeks postpartum: can start POP (but not contraceptive is required for 14 days after
injectables type) symptoms have subsided.
 ≥ 6 months postpartum: can start POP
 Miss Pills

More than 3 hours late

Less than 3 hours
• Take the last pilled you missed
• Continue taking the rest as usual
• Take the last pilled you missed
• Need extra precautions needed
immediately
until 2 further pills are taken in
• No extra precautions needed.
a row.
• No emergency contraception
• Emergency contraception
protection needed
needed if there is unprotected
sexual intercourse
COCs vs POPs
COCs POPs
• Reversible • Reversible
• More effective • Can be used for lactating women
Advantages • Can be used for other indications (eg: • Safer for women with higher risk
acne) of cardiovascular disease
• Help to regulate menstruation

• Precaution required in lactating • Less effective

women • High incidence of irregular menses
Disadvantages • Can only start using > 21 days • Spotting and breakthrough
postpartum bleeding
• > side effects • Higher risk of ectopic pregnancy
• Not recommended for women with
higher risk of cardiovascular disease
and history of thromboembolism
Emergency Contraception
• Morning after pill
• Mechanism of action:
Prevent ovulation/ fertilization and implantation of the embryo
• Used to reduce the risk of pregnancy after:
Unprotected sexual intercourse
Contraceptive failure (E.g., missed pill, condom breakage)
Sexual assault
 Emergency Postinor-2 Escapelle Ella
contraception
Content Levonorgestrel 0.75mg x 2 Levonorgestrel 1.5mg Ulipristal acetate 30mg

When to take Within 72 hours (3 days) Within 72 hours (3 days) Within 120 hours (5 days)

How to use 1 tab to be taken immediately & Take 1 tab immediately. Take 1 tab immediately.
1 tab 12 hours after taking the
1st tab.
Who can use All women (unless
All women. Less effective for breastfeeding). Less
women with BMI >25. May not work for effective for women with
women with BMI>30. BMI >35.
Benefits of OCP

• Prevent unwanted pregnancy.

• Reduced menstrual blood loss and associated anemia.
• Premenstrual tension, dysmenorrhea and menorrhagia are better.
• Improve endometriosis and pelvic inflammatory disease.
• Reduce incidence of ovarian cysts.
Side Effects
• Breast fullness
• Fluid retention
• Headache
• Nausea
• Cervical cancer
• Increased blood pressure, myocardial infarction, stroke (rarely)
• Depression, changes in libido, hirsutism, acne (Progestins)
• Venous thromboembolism (>common in COCs)
Contraindications
Combined contraceptive pills Progestin-only pills Emergency Pills
• Venous thrombosis • Known, suspected or a past • Acute porphyria
• Coronary and cerebrovascular history of breast history of
disease breast, genital or hormone
• Presence of severe or multiple dependent cancer
risk factors (eg: diabetes • Active liver disease
mellitus with vascular • Undiagnosed abnormal
symptoms, severe vaginal bleeding
hypertension, • Disorders of lipid metabolism
dyslipoproteinaemia)
• Active liver disease
• Suspected/ over malignancy
of genitals/ breast
Drug Interaction
• Rifampicin
• Isoniazid
• Carbamazepine
• Phenytoin
• Griseofulvin
• Antibiotics (eg: Ampicillin, Cephalosporin, Erythromycin)
• Corticosteroids
• St. John’s Wart
 Contraceptive patch
• Applied once weekly for 3 consecutive weeks (week 4
is a patch-free week, withdrawal bleeding is expected)
• Location: upper outer arm, abdomen, buttock, back

• Less effective in patients >90kg

• If avoid menses are desired, skip the patch-free week
and apply a new patch in week 4.
• Advantages:
 Easy to use
 Only changes once a week
 Compliance issue can be minimized
Delaying menstruation
• Possible to use a progestogen-only pill containing norethisterone.
• It is a progestogen hormone that sustains the lining of the uterus.
• Normally, before the start of menstruation, the progesterone level in the body will
drop. Once the level drops below a certain level, the uterus lining will shed as
menstruation.
• This tablet helps to sustain the lining of the uterus until it is stopped.

For women take the fixed dose COPs, the same effect can be achieved by
starting the next pack of the pill immediately without normal seven-day
break.
Delaying
menstruation
• Norethisterone 5mg
• 1 tablet 3 times a day (for max 10-14 days),
starting 3 days before the expected onset of
menstruation.
• Keep taking it until you wish your period to
resume. (A normal period should occur 2-3
days after you stop taking the tablets)
• Available products: Norcolut, Sunolut
References
1. https://www.who.int/news-room/fact-sheets/detail/family-planning-contraception

2. Davtyan C. Four Generations of Progestins in Oral Contraceptives. N Engl J Med. 2012;16.

3. Plu-Bureau G. Combined oral contraceptives and risk of venous thromboembolism: there is higher risk in new generations compared to
second generations, but paradoxically not in norgestimate-containing-pills. Evidence Based Medicine. 2015;20(5):189-189.

4. Oslakovic S, Zadro R. Comparison of the Impact of Four Generations of Progestins on Hemostatic Variables. Clinical and Applied
Thrombosis/Hemostasis. 2012;20(4):448-455.

5. FRSH Guideline on Missed Pill Recommendations, 2012.

6. https://apps.who.int/iris/bitstream/handle/10665/173585/9789241549257_eng.pdf;jsessionid=F2FC6997E2F8AF0A6F95AB7946501AD
7?sequence=1

7. Sweet B. Handbook of Applied Therapeutics Ninth Edition. Pg: 365-374

8. MIMS Pharmacy Patient Counselling Guide. Pg: 93-99

9. Product leaflets
Thank you