Counselling on Oral Contraception Kanadi Sumapraja Department of Obstetrics and Gynecology.

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Transcript presentasi:

Counselling on Oral Contraception Kanadi Sumapraja Department of Obstetrics and Gynecology

Outline Overview of OCPs Overview of counselling Latest OCP development Case study

Too many, too close, too early, too late

210 million pregnancies each year 38% are unplanned 22% end in abortion Developed countries 28 million pregnancies each year 49% are unplanned 36% end in abortion Developing countries 182 million pregnancies each year 36% are unplanned 22% end in abortion

Failure rates in Perfect use vs. Typical use % of unintended pregnancies within first year MethodTypical usePerfect use Withdrawal274 Condom152 COC80.3 Patch80.3 Ring month injectable30.3 Copper IUD LNG-IUS0.2 3-years implant0.05 Perfect use measures the effectiveness when a contraceptive is used exactly according to clinical guidelines. Typical use measures how effective a method is for the average person who does not always use the method correctly or consistently. Trussell J. Best Pract Res Clin Obstet Gynaecol. 2009;23:199

Pil kontrasepsi dianggap sebagai salah satu metode kontrasepsi yang cukup efektif

Rates of discontinuation due to dissatisfaction Ever users of reversible contraception (%) Rate of discontinuation of method due to dissatisfaction (%) Diaphragm Injectable Implant IUD Pill Patch Condom All reversible methods Moreau C., et al. Contraception. 2007;76:267

What happens when women discontinue a contraceptive method? 42%19%69% Discontinue without consulting their healthcare provider Discontinue without selecting another contra- ceptive method Choose a less effective contraceptive method Rosenberg MJ., Waugh MS. Am J Obstet Gynecol. 1998;179:577

Attributes wanted by women, n=1117 (US women) Thompson. Sexual, reproduction and menopause. 2006;4:74

Many factors are associated with initiation and adherence to particular contr. method Factors associated with contraceptive use Individual factorsMedical conditionsSocio-demographic factors Barrier factors Personal goalsDeppresionLevel of educationAbility to get to the clinic Fear/misconceptionsCardiovascular disease EthnicityAbility to pick up prescription Ambivalence about avoiding pregnancy Family history of cancer AgeTime limitations Satisfaction with contraception Sexually transmitted diseases Relationship status Prior contraceptive experience Mansour D. Lecture at 3rd APCOC meeting, 2010

Critical components of contraceptive success Siraj HH. Lecture at 3rd APCOC meeting, 2010

How important is counselling?

Patient’s may not directly express their wishes and concerns because : They feel embarressed and insecure The medical professional gives verbal and non-verbal signals that she/he is in a hurry Active listen by : Giving patients time to talk Being attentive to non-verbal cues Active listening provides : Assurance that the patient is understood and respected A good basis for adherence with medical treatment

Siraj HH. Lecture at 3rd APCOC meeting, 2010

Health concerns and side effects

No restriction Advantage > theoritical/proven risk Theoritical/proven risk > advantage High risk

Kinds of oral contraceptive pills

Mechanism of actions GnRH FSH LH Estrogen Progesterone

3 spectacular evolutions of OC pills Estradiol dose reduction Kaunitz AM Am. J. Obstet. Gynecol. ;190:S23-9

3 spectacular evolutions of OC pills Antiestrogenic Anti-androgenic Anti-glucocorticoid Anti-mineralocorticoid

3 spectacular evolutions of OC pills Ethynil Estradiol 30  g Progestin Ethynil Estradiol 20  g Progestin Shorter pill free interval

What to do when pills are missed ? 1 pill missed3 pill missed2 pill missed Take missed pill as soon as possible Resume scheduled Back-up not necessary Take 2 pills daily for 2 days then finish pack Unlikely back-up needed but advised for 7 days Start new pack During week 1 or 2 Use back-up immediately and for 7 days Start new pack Use back-up immediately and for 7 days During week 3

Beyond contraceptive effect GnRH FSH LH Estrogen Progesterone Penekanan kadar GnRH Pengaturan siklus haid Mengurangi jumlah perdarahan Mengurangi nyeri haid Mengatasi gejala PMS Mengatasi hiperandrogenisme

Take home messages Counseling for contraceptive choice is necessary and appropriate Structured and/or motivational counseling can be successful for both appropriate contraceptive choice and adherence The effect of counseling appears short-lived, therefore counseling should occur on a regular/periodic basis to re- assess apprpriate choice and acceptability

Diskusi kasus

Kasus 1 Seorang wanita rumah tangga berusia 43 tahun datang untuk mendapatkan pelayanan kontrasepsi. Ia telah memiliki 3 anak yang sehat. Ia sebelumnya telah menggunakan IUD namun mengalami keluhan nyeri setiap haid dan pernah mengalami ekspulsi. Saat ini ia memiliki IMT sebesar 26 dan sedang dalam pengobatan DM (late onset) Ia ingin tahu apakah boleh menggunakan pil KB ?

Pilihan A.Penggunaan pil KB pada wanita usia > 35 tahun dan DM cukup berisiko untuk itu sebaiknya pasien dianjurkan untuk steril saja B.Sangat cocok untuk menggunakan kontrasepsi hormonal jangka panjang, mengingat usia menopause tidak lama lagi C.Dapat menggunakan pil KB dosis rendah, karena dianggap cukup aman D.Kesuburan alami dianggap cukup rendah oleh karena itu cukup aman hanya menggunakan alat kontrasepsi barrier

Kasus 2 Seorang wanita berusia 20 tahun datang untuk mendapatkan pelayanan kontrasepsi. Ia bekerja sebagai pelayan toko, namun ia mengakui memiliki gaya hidup seksual yang bebas, dan memiliki banyak pasangan seks. Ia juga mengaku kadangkala memiliki siklus haid yang tidak teratur. Ia juga mengaku pernah melakukan aborsi sebanyak satu kali. Oleh karena itu ia ingin menggunakan cara kontrasepsi yang sesuai dengan kebutuhannya.

Pilihan A.Gunakan saja kontrasepsi barrier untuk mencegah STD dengan back up menggunakan kontrasepsi darurat B.Gunakan saja IUD C.Dapat menggunakan pil KB, sambil mengingatkan kembali pentingnya melakukan safer sex D.Konseling pentingnya untuk melakukan abstinensi

Kasus 3 Seorang wanita berusia 36 tahun datang untuk mendapatkan pelayanan kontrasepsi. Ia telah menikah selama 10 tahun dan telah memiliki 2 anak yang sehat. Namun ia mengaku setiap haid seringkali mengalami nyeri yang amat mengganggu aktivitas sehari-hari. Namun ia amat takut dengan cancer, karena ibunya meninggal karena Ca ovarium, dan tantenya juga meninggal karena Ca payudara.

Pilihan A.Gunakan saja kontrasepsi barrier (kondom atau diafragma) untuk menghindari risiko terjadinya kanker B.Gunakan saja IUD C.Pertimbangan risiko dan manfaat yang terkait dengan pil KB memperlihatkan risiko yang rendah untuk terjadinya kanker D.Mengingat adanya keluhan nyeri haid yang dapat mengganggu aktivitas sebaiknya dianjurkan saja untuk melakukan histeektomi dan salfingooforektomi bilateral

Kasus 4 Seorang wanita berusia 24 tahun datang untuk mendapatkan pelayanan kontrasepsi. Ia baru saja menikah. Namun saat ini ia ingin menunda kehamilannya karena saat ini ia baru saja menandatangani kontrak ikatan dinas bahwa ia tidak boleh hamil dulu dalam waktu 2 tahun. Selain itu ia juga sering mengalami perubahan mood setiap akan datang bulan, dan ada pula keluhan seperti payudara tegang dan perut kembung.

Pilihan A.Karena telah memiliki gejala PMS, maka sebaiknya menggunakan obat-obatan SSRI untuk mengurangi gejala PMS dan dapat dikombinasi dengan kondom B.Dapat digunakan kontrasepsi jangka panjang Progestin saja, dan dapat dikombinasi dengan SSRI C.Dapat menggunakan extended regiment. Pasien dapat hanya haid sebanyak 3-6 bulan sekali D.Gunakan pil kombinasi dengan menggunakan komponen drospirenone, dengan menggunakan rejimen 24/4

Department of Obstetrics and Gynecology