Dr.

Saiful Batubara
Pharmacology
Department

A 15-year-old female comes to your office

by herself. She asked if you can prescribed
oral contraceptives, because she will soon
become sexually active. Her medical
history is unremarkable. What should you
do next?
a)
b)
c)
d)
e)

Obtain parental permission.

Prescribe oral contraceptives.
Refuse treating the patient.
Counsel her on safe sex practices.
Order a pregnancy test.

Contraceptive Agents

Specific agents
Oral contraceptives are available as either a
combination of an estrogen and a progestin, or
as progestin only ("mini-pill").
The combination products may be biphasic or
triphasic.
In which the dose of progestin increases during
the later days of the month to mimic the natural
menstrual cycle.

Specific agents
Progestin implants consist of
levonorgestrel capsules.
Which are implanted under the skin of the
upper arm, providing a slow release of
progestin.
Progestin implants are considered an
effective and reversible contraception for
up to 5 years.

Specific agents

Medroxyprogesterone acetate.
Intramuscular depot injection.
Provides contraception for 3 months.

Mechanism Action
Estrogen component inhibits ovulation
By negative feed-back to inhibit the release of
FSH and LH.
Progestin component may, but does not
always, inhibit ovulation.
Reduces the possibility of fertilization and
implantation.
By effecting changes in fallopian tube motility,
cervical mucus, and endometrium.

Clinical Uses

Contraceptive.
Pregnancy rate 0.5-1 per 100 woman.
Rate increases with missed doses.

Side Effects
Nausea and vomiting.
Breast tenderness, increased skin
pigmentation, hypertension
Breakthrough bleeding correlate with the
amount of estrogen given.
Weight gain, depression, and hirsutism
correlate with progestin content.

Side Effects
Headaches may occur but are often
transient;
Migraine headaches may occur for the
first time or be exacerbated and
associated with stroke.
Oral contraceptives are contraindicated in
patients with a history of migraine
headaches.

Side Effects
May be withdrawal bleeding.
Excessive spotting and late cycle
spotting may improve by decreasing
estrogen and increasing progestin.
Vaginal infections may occur.

Side Effects
Changes in serum proteins.
Specifically, increased fibrinogen may
increase the erythrocyte sedimentation
rate.
Cholestatic jaundice has been reported
in patients taking progestins.

Side Effects
Cardiovascular effects
Thromboembolic disease.
The risks of superficial and deep venous
thrombosis and pulmonary embolism are
related to estrogen content.

Side Effects
There is an increased risk of myocardial
infarction.
Related to estrogen content, usually after
prolonged use.
The risk is increased by cigarette
smoking, hyperlipoproteinemia, diabetes,
hypertension, and a history of
preeclampsia.

Side Effects
Stroke may occur.
There is an increased incidence of
thrombolytic and hemorrhagic strokes.
Predominantly in women over 35 years
old.
Sodium and water retention may occur.

Contraceptives vs.
Cancer
Cancer risk
DES use during pregnancy has been
associated with vaginal and uterine
carcinoma in female offspring.
Because progestins oppose estrogeninduced cell growth, oral contraceptives
do not increase the incidence of
endometrial cancer.

Contraceptives vs.
Cancer
They actually decrease the incidence by 50%.
Lasts 15 years after the pills are stopped.
Similar data exists for the incidence of ovarian
cancer.
The use of oral contraceptives is not
associated with a significant increase in breast
cancer.
The only cancer risk is that of liver adenoma.

Postcoital
Contraceptives
Morning after
72 hrs after unprotected intercourse.
Effective 99% times.
40% have nausea, vomiting, headache,
breast tenderness and abdominal
cramps.
Mifepristone w/prostaglandins.

Postcoital
Contraceptives
Schedules for emergency contraception
Conjugated strogens

10mg tid for 5 days

Ethinyl estradiol

2.5mg bid for 5 days

DES

50mg daily for 5 days

L-Norgestrel

0.75mg bid for 1 day

Norgestrel/ethinyl estradiol
Mifepristone/Misoprostol

0.5mg/0.05mg 4 tab bid

600mg/400mcg once

Well be starting in 10min sharply

Infertility

Infertility
A couple's inability to become pregnant after 1
year of sex without using birth control.
Of all couples who have not conceived after 1
year, about 50% will go on to conceive
naturally in the following year.
Primary: never been pregnant.
Secondary: had been pregnant for 2 years.

Infertility
Woman's fertility declines from her mid30s into her 40s, as her egg supply ages.
At the same time, her risk of miscarriage
increases.
Although a man's sperm count
decreases with age, male fertility is not
known to be greatly affected by age

Causes

High-Yield Slides.
Dr. Rosas Blum

Oral Contraceptives
Combination
Estrogen and progesterone.

Progesterone only.

Combination
Decreased the incidence of

breakthrough menstrual bleeding

compared to progesterone-only.

Contraindications
Presence or history:
Thromboembolitic disease.
Inherited clotting disorders.
Cerebral vascular disease.
Myocardical infarction.
Coronary artery disease.
Congenital hyperlipidemia.

Contraindications
Cigarettes smoking
Carcinoma of the breast.
Carcinoma of the female reproductive

tract.
Abnormal undiagnosed vaginal bleeding.
Known or suspected pregnancy.
Liver tumor or impaired liver function.

Progesterone-only
Safer that combination contraceptives.
Cause irregular, breakthrough
menstrual bleeding.
Options.
Depot injection of
medroxyprogesterone (depo-provera).
Implants of levonorgestrel.

Postcoital
Contraceptives
Schedules for emergency
contraception
Conjugated strogens
10mg tid for 5 days
Ethinyl estradiol
2.5mg bid for 5 days
DES
50mg daily for 5 days
L-Norgestrel
0.75mg bid for 1 day
Norgestrel/ethinyl
0.5mg/0.05mg 4 tab
estradiol
bid
Mifepristone/Misoprostol
600mg/400mcg once

A 15-year-old female comes to your office

by herself. She asked if you can prescribed
oral contraceptives, because she will soon
become sexually active. Her medical
history is unremarkable. What should you
do next?
a) Obtain parental permission.
b) Prescribe oral contraceptives.
c) Refuse treating the patient.
d) Counsel her on safe sex practices.

e) Order a pregnancy test.

laloblum_md@yahoo.com