A publication for members only to promote continuing education among the pharmacy profession • Vol 1, Issue 1

MALAYSIAN PHARMACEUTICAL SOCIETY

5B, Lorong Rahim Kajai 13, Taman Tun Dr. Ismail, 60000 Kuala Lumpur, Malaysia. Tel: 603- 7729 1409 Fax: 603- 7726 3749 E-mail: [email protected] www.mps.org.com Benefits beyond contraception with Oral Contraceptive Pill (OCP) Dr Wong Yat May Lecturer Obstetrics and Gynaecology Department, University Hospital

Although the OCP has been widely recognized and accepted as an effective form of contraception, many are still unaware of its non-contraceptive benefits. This article aims to highlight some of these benefits.

Menstrual problem The OCP is very useful in the management of the exact mechanism is unknown. The progestogen- Benefits beyond contraception 1 menstrual problems, be it heavy period, irregular cycle, dominant OCP had been shown to reduce the growth of 2 with Oral Contraceptive Pill prolonged period or a combination of these symptoms. fibroid by 30% . (OCP) In patients with menorrhagia (heavy flow), the OCP can reduce the menstrual flow by 50%, by suppressing Protection against ovarian and endometrial 1 the endometrium . In women with irregular cycle, the cancer Tips on Merchandising 2 anovulation may cause endometrial stimulation, hence Studies have quoted a definite reduction in both ovarian heavy and irregular shedding of the endometrium may and endometrial cancer in pill takers (40-50%)1-2. And Management of missed pill occur. With the OCP, the endometrial development this protective effect is greater when the pill has been (7 days rule) 2 will be kept thin and hence the menstrual cycle will be used for a longer time. When a woman is on the pill, more regular and less heavy. The other added there is reduced chromosomal activity in her ovaries Facts and myths of taking the advantage of the pill is to reduce dysmenorrhoea and endometrium, as compared to a woman who is oral contraceptive pill 3 especially when this is secondary to menorrhagia. In ovulating regularly, hence less chance of mutation addition, the pill may also reduce the symptoms of happening and thus less risk of cancer developing. Contraception for the premenstrual tension and ovulatory pain by abolishing perimenopausal woman 4 ovulation. With the OCP, the endometrial development will be kept thin and hence the Compliance with HRT 6 Pelvic inflammatory disease (PID) menstrual cycle will be more regular and It has been quoted that the OCP may reduce the Clinical usefulness of tissue- 1 incidence of PID by 50% . The progestogen component less heavy. specific approach in in the pill not only reduces the sperm penetrability of postmenopausal women 9 cervical mucus but also 'germ penetrability'. The Less ectopic pregnancy spermatozoa may act as 'a mean of transport' for the As the pill is so effective in inhibiting pregnancy per Current Choices In CPE Talks 10 organism to go up to the upper genital tract, hence by se, the incidence of ectopic pregnancy automatically reducing the penetrability of the sperm, the 'carriage decreases overall. Family planning: rate' of these organisms may be reduced too. from the islamic perspetives 11 Less benign breast disease Less functional ovarian cyst There is a definite reduction (50-75%) in the incidence 2 Menopause and sexuality 13 Functional ovarian cyst arises because of abnormalities of benign breast disease in pill takers . The underlying in the process of ovulation. Although benign, very mechanism is due to a reduction of activity in the Medications for men: often the presence of these cysts will lead to surgery. breast tissue due to the progestogen component of the Andropause 16 As the combined oral contraceptive pill abolishes pill and a decrease in hormone fluctuation. ovulation, this will explain why the incidence of these Continuing Education – 18 cysts is reduced in pill takers. Endometriosis As endometriosis may cause heavy painful period, the Mandatory or Voluntary? Reduces growth of fibroid OCP if taken continuously may help to reduce these Does it Really Protect Society from Fibroid is a growth in the womb muscle and its rate of symptoms by stopping the woman from having Incompetent Health Professionals? growth seems to be dependent on oestrogen although periods.

Reference: 1. Guillebaud J. Oral contraception-the combined oral contraceptive. In: Guillebaud J (ed), Contraception-your questions answered, 2nd edition, London: Churchill Livingstone, 1993: 95-221 This issue is sponsored by kind courtesy of 2. Szarewski A, Guillebaud J. The combined pill: weighing up the pros and cons. In: Szarewski A, Guillebaud J (eds), Contraception- a user's handbook, London: Oxford, 1994: 21-42

Disclaimer: The information and opinion expressed herein are not necessarily those of the MPS. In addition the inclusion of articles and advertisements does not mean that MPS advocates or rejects its use. Tips on Merchandising Tee Loong Tek Management of missed pill Senior Product Manager/Pharmacist

The arrangement of fixtures and fittings will be guided by (7 days rule) the type of merchandise sold. The merchandise is Dr Wong Yat May positioned in particular ways to aid customer selection Lecturer and therefore stimulate sales i.e merchandising is Obstetrics and Gynaecology Department, University Hospital anything you do that increases appeal, visibility and exposure of a product, influencing the customers to buy When a patient who is on the oral contraceptive pill (OCP) forgets to take a pill, it. The following are some points to be noted: this always poses a worrisome time to both the patient and her doctor or pharmacist alike. It is important for all medical health staff involved in prescribing a) Principal merchandise sections should be prominently the OCP to be able to counsel patients properly on the 'know-how' when she labeled by clear overhead signs. misses or forgets to take her pill. b) All merchandise sections should be accessible to customer. The '7 days rule' was derived from three simple analogies that was based on the c) All merchandise must be clearly and correctly priced pharmacology of contraceptive pill usage: (either on the merchandise or on the shelf edge).

d) The general rule on merchandise location is to use the 1. Once seven consecutive pills had been taken, 'the ovaries will be sent to best selling position for goods providing the greatest sleep', hence pill 8-21 in a packet is merely to ensure 'the ovaries remain in profit (i.e gross margin X rate of sale), not goods a sleeping state'. carrying the highest profit margins. Best selling positions 2. Ovulation will not occur even if seven pills have been omitted, as in the pill should include ends of gondolas and wall units . free week. e) "Everyday" purchases like skin care product, toiletries 3. But if more than 7 pills had been omitted in total, ovulation will then and etc should be placed near the entrance to start the become a real risk. customer buying.

f) Careful placing of basic demand lines helps to draw The flow chart below is a very simple plan for any missed pill management. customers to all parts of the shop. High profit margin, impulse purchase lines should be placed alongside them.

g) Promotional displays and/or point-of-sale should be controlled in size and number so that clutter is avoided, and neither should they be located immediately inside the store entrance nor immediately opposite a fast moving line. Customers tend to miss badly sited displays.

h) Displays (except for seasonal lines) should not be changed too often as it tends to annoy customers.

i) Maintain current inventory to minimize the risk of "run out of stock", expired & over ordering of stock situations. Inventory control can be done through stock cards or certain commercial software program designed for medical retail businesses. Optimal inventory control is one of the key factors for healthy cash flow.

An effective & successful in-store merchandising program will: Attract customers and build loyalty through more appealing surroundings Missed pills Stimulate impulse purchases. 8 out of 10 purchases by consumer are decided in the store. <12 hours late >12 hours late Optimize stock turns and minimize out of stocks on fast-moving items Just take the missed pill at once and the Take the most recently missed pill now. Reduce inventory and returns of slow-moving items rest at the usual time. Discard any of the other earlier missed pill. Use extra precaution for the next 7 All these benefits will lead to better profitability and days eg. condom that's business success through merchandising.

With this latest missed pill, how many more tablets are left in the packet? EDITORIAL BOARD

Chief Editor :Assoc Prof Dr Abas Hj Hussin Members :Prof Dr Abu Bakar Abdul Majeed ≥ 7 pills left ≤ 7 pills left Dr Noriati Ismail En Guna Sekaran Kanniah Finished this pack, have the usual 7 days Start new pack without a break when break, then restart new pack as planned this current pack has finished Community Pharmacy Self-Care Group Guest Members :Dr Syed Azhar Syed Sulaiman Mr Tee Loong Tek

2 Disclaimer: The information and opinion expressed herein are not necessarily those of the MPS. In addition the inclusion of articles and advertisements does not mean that MPS advocates or rejects its use. VOL 1 • ISSUE 1 • 2003

Myth: FACTS AND MYTHS OF "The Pill increases the risk of cancer" Fact: Although the effect on overall cancer risk is unknown, the Pill protects TAKING THE ORAL against endometrial and ovarian cancers. Avoiding the Pill may therefore even CONTRACEPTIVE PILL increase the overall risk of cancer. Continuing Use of the Pill Assoc. Prof Zaleha A. Mahdy Myth: Obstetrics and Gynaecology Department Faculty of Medicine, University Kebangsaan Malaysia "The Pill must be stopped after 35 years of age" Fact: There is no age limit to the use of the Pill by healthy non-smoking women. Even if cardiovascular risks increase with age, the non-contraceptive benefits of the Introduction Pill also increases, thereby increasing the risk-benefit ratio. Myths surrounding use of the Pill are influenced by the values, beliefs, Myth: concerns and lifestyle of the particular "There should be a break from Pill use every few years" community, and may therefore vary Fact: Taking a break from Pill use has no benefit on either preservation of fertility from one community to another. The list or circulatory disease. Metabolic risk markers show no apparent progression that follows is far from exhaustive but beyond 2 years' continuous use of the Pill. attempts to cover the main concerns in our Malaysian society.

Reference: Prescription of the Pill John Guillebaud. Contraception: Your Questions Answered. Myth: "Do not prescribe the Pill for patients who wish to optimize fertility" Fact: The Pill actually REDUCES the risk of infertility in several ways, i.e. by reducing: An update on • The incidence of pelvic infection • Fibroid growth Women's Health Initiative Trial • The occurrence of ectopic pregnancies • Ovarian cysts

• Endometriosis • Illegal abortion Professor Dr Nik Mohd Nasri Ismail (MB ChB (Alex), FRCOG (UK), FICS Professor & Senior Consultant of O&G , Deputy Dean (Training & Development) Faculty of Medicine, Universiti Kebangsaan Malaysia Myth: "Patients with uterine fibroids should not be given the Pill" Fact: The Pill REDUCES the need for additional hospital visits among patients with The Women's Health Initiative is a large study involving more than fibroids because the Pill can be prescribed to control menorrhagia in women with 160,000 women in the United States. It was set up to assess the health fibroids where surgery is not indicated. benefits and risks of strategies that could potentially reduce the incidence of heart disease, breast and colorectal cancer and bone fractures in Myth: postmenopausal women. This group of women were randomized to either "The Pill must not be given to women with secondary amenorrhoea" Premelle / Plentiva (CEE & MPA) or placebo. The study should have lasted Fact: The Pill can be used in these women after ruling out possible significant causes of 8.5 years but was halted after 5.2 years because the results showed that amenorrhoea by doing certain investigations such as urine pregnancy test, ultrasound the health risks of Premelle / Plentiva exceed the health benefits. However, scan, serum prolactin, thyroid function test, serum FSH/LH, progestogen challenge test. a parallel trial of estrogen alone in women who have had a hysterectomy In fact, the Pill may confer additional benefits when used in this condition. The is being continued and the trial will end in March 2005. oestrogen content of the Pill is beneficial in cases where the endogenous oestrogen level is low, in order to prevent long-term complications of oestrogen deficiency. On The main reason to halt this part of the trial was the observed increase in the other hand, the progestogen content is beneficial in women with relative oestrogen breast cancer risk that was found after an average of 5.2 years of use of excess, so as to prevent the occurrence of endometrial carcinoma. Premelle / Plentiva when compared to placebo.

The absolute excess risks per 10,000 person years were 7 more coronary Myth: artery disease (CHD) events, 8 more strokes, 8 more pulmonary embolism (PE) "Young post-pubertal girls should not be prescribed the Pill because it may lead to and 8 more invasive breast cancer as compared to the placebo group. stunted growth" Fact: The Pill can be safely prescribed after menarche. There is no evidence that the At the same time an absolute risk reduction were observed with colorectal Pill leads to premature closure of the epiphyses, and neither is there any increased risk cancer (6 fewer cancers per 10,000) and hip fracture (5 fewer hip fracture). of carcinoma of the breast. Sexual promiscuity may, however, be an issue in this age group when the girl feels secure in the contraceptive protection afforded by the Pill. However, it must be stressed that this trial tested only one drug regimen (CEE : 0.625 mg/d plus MPA 2.5 mg/d) in post menopausal women with an intact Myth: uterus. At the same time, the trial did not address the short term risk and "Women with varicose veins should refrain from taking the Pill" benefits of hormones given for the treatment of menopausal symptoms. Fact: Varicose veins may be a marker of previous venous thrombosis, in which case the Pill is contraindicated. However, without a history of thrombosis, the Pill Above all, these results do not necessarily apply to lower dosages of these may be safely used in women with varicose veins. drugs or other formulations of oral estrogen and progestin. However, conventional HRT should not be confused with Livial (tibolone). Side Effects of the Pill Livial is a single molecule compound which exerts its effects via a specific Myth: metabolism and enzyme regulation. "The Pill causes obesity / weight gain" Fact: Weight gain is variable among Pill users. Only 15 to 20% of Pill users As a result, Livial has a different effect on breast tissue (breast tenderness experiences weight gains in excess of 2kg. and mammographic density) and the haemostasis system when compared with conjugated equine estrogen (CEE) and medroxprogesterone acetate. Myth: "The Pill causes vaginal discharge" In essence, today's women should be offered the various options Fact: Vaginal discharge as a result of Pill use only occurs if the Pill causes significant available for the relief of menopausal symptoms. This would thus enable ectropion, and is less common with modern low-dose Pills. The Pill does not cause to make a difference in her life leading to a better quality of life. vaginal candidiasis (thrush) and may even protect against Trichomonas Vaginalis.

3 Disclaimer: The information and opinion expressed herein are not necessarily those of the MPS. In addition the inclusion of articles and advertisements does not mean that MPS advocates or rejects its use. Dr Hean-Choon Ong, MBBS, FRCOG, M.Med., FICS, FAMM Consultant Obstetrician & Gynaecologist, Taman Desa Medical Centre, Kuala Lumpur

Changing trends in socio-cultural norms & practices have influenced 20 to 40. About 50% of women over 40 are still actively engaged in greatly the role of the woman in society, and her fertility potential and coitus. About 30% of first marriages end in divorce, but with re-marriage management. Unwanted pregnancies over the age of 35 (even more over & new relationships, there is increase in coital frequency. 45) involve increased risks to both mother and fetus, and may well be catastrophic psychologically and socially. Getting pregnant at this older age is generally not acceptable. Thus, the question of family planning for We do not know at what age fertility in any the older woman must be seriously addressed. individual case is zero!

One of the most common problems facing GPs and gynaecologists today is the provision of contraception for the woman approaching the end of her Contraceptive efficacy in older women reproductive life. We have, in the past, been overly cautious on the role of Women over the age of 35 constitute 20% of candidates for contraception, particularly oral contraception, in these women. Current contraception. The problem is not the decision or necessity for thinking is that contraception should not stop at the age of 35, but should contraception, but choice of method! Nevertheless, because of the be extended beyond 35, even up to the age of menopause. decline in fertility & coital frequency, any simple or less effective method would suffice to offer 100% protection.

Contraception for the perimenopausal woman is Choice of method of contraception important! Whatever method chosen must be Combined Oral Contraception (COC ) No doubt COC is highly effective and reliable. not the method of first choice for these women, particularly if they are heavy smokers and/or they have associated medical problems. Women in the Social changes & need for perimenopausal years would, however, benefit contraception from being permitted to take some variety Many women are now postponing of estrogen/progestogen hormonal their first pregnancy for family, contraception. financial and career reasons. There are Besides the issue of fertility control, there are also the high divorce and re-marriage rates. desirable non-contraceptive benefits with this For these women, pregnancy would be approach, viz: undesirable. To many, pregnancy at this age would be a disaster, as late pregnancy poses considerable risks • it is effective in maintaining sexuality, by to the mother & child. Effective contraception is thus vital; reassuring good cycle control, slowing of skin aging, the problem lies in the choice of method! improved body image, improved libido, and prevention of vaginal dryness complaints, psychological and urethral Risk of pregnancy in older women disturbances There is evidence that pregnancy in older women is fraught with increased • it helps to control symptoms of the normal cycle, i.e. premenstrual maternal mortality, in some, a 4-fold rise from age 30 to 50. Perinatal mortality complaints and dysmenorrhoea is also higher, and doubles as the maternal age doubles. There is also increased • it helps to prevent bone loss, and thus protects against osteoporosis risk of spontaneous abortions. The legal abortion rate after the age of 40 has • it reduces the incidence of various gynaecological conditions, e.g. been recorded at 40-45%, very much higher than that for all ages below 40. In pelvic infections, ectopic pregnancy, dysfunctional uterine leeding addition, the risk of congenital abnormalities in the fetus is higher with (DUB), functional ovarian cysts, cancer of the uterus and ovary, benign advanced maternal age. breast disease.

In women with hypertension, diabetes mellitus, obesity, lipid disorders, For many couples, pregnancy at this age is a disaster! and who smoke heavily, one must be wary of possible increased cardiovascular risks.

Fertility/coital frequency in older women • it reduces the incidence of various gynaecological conditions, e.g. Fertility declines with age, and after 40, this decline is from 40 - 80%. pelvic infections, ectopic pregnancy, dysfunctional uterine leeding Nevertheless, pregnancy is still likely. Unwanted pregnancies occur most (DUB), functional ovarian cysts, cancer of the uterus and ovary, benign commonly in women over 40. A UK study noted that 1000 breast disease. pregnancies per year are seen in women aged 45-49 years. We do not know at what age fertility in any individual is zero. Studies show that fecundity in Nevertheless, with the advent of ultra-low dose estrogen/ progestogens women over 35 is about 54%, and in those aged 40-45, 95% of them still pills, and their low side-effects/risk profiles, the older woman can be safely ovulate every cycle! There is a 50% decline in coital frequency from age placed on combined oral contraceptives.

4 Disclaimer: The information and opinion expressed herein are not necessarily those of the MPS. In addition the inclusion of articles and advertisements does not mean that MPS advocates or rejects its use. VOL 1 • ISSUE 1 • 2003

each time, and so acceptability is vital. Older men using the condom may, however, experience difficulty with penile erection. Use of the diaphragm in older women may encounter problems when cervical abnormalities or vaginal laxity are present. Where vaginal dryness is a problem, addition of spermicides may help with its lubricating effect. There is of course, the additional advantage of protection against STDs and AIDs with barrier methods.

Female sterilization There is increasing popularity of sterilization in couples of all ages, who have completed their family. However, with the possibility of changes in social circumstances, e.g. divorce, re-marriage, change of partners, one should carefully consider this option. Recent studies do not support the impression that ligated women have a higher tendency to menorrhagia.

Oral contraceptives seem to be the best choice, There are problems with alternatives to the estrogen- especially for women who have climacteric symptoms progestogen approach, hence they are not always and who need contraception. acceptable.

Progestogen-only pill (POP) Conclusion Use of such pills allow freedom from estrogen-related side-effects. In the older age groups, contraceptive needs differ widely from couple to However, the cycle irregularities that may occur raise concern of uterine couple. Each must be counseled individually, taking into account their pathology, particularly cancer. Endometrial biopsies/diagnostic D&Cs may medical history and family circumstances. become necessary. POPs or estrogen-free OCs are relatively free of cardio-vascular side-effects, and can hence be prescribed up to Contraception for the older woman is highly desirable. The use of oral menopause. contraception provides, besides contraception, various non-contraceptive benefits in such women. Alternatives to oral contraception are not always Long-acting hormonal contraception acceptable. If they are not, they will not be used. Sometimes it is not what The long-term duration of use and high effectiveness of such options may the doctor thinks, but what the patient thinks that matters ! Some couples be attractive to this group of women. Such options include the injectables will be sure that they will never want another child, whatever the and implants. Again the cycle irregularities that occur, may raise concerns. circumstance, and for these, sterilization may be the best choice. For many others, however, effective reversible contra-ception is required. Intra-uterine contraceptive device (IUD) This would be the most attractive non-hormonal method. It is effective, long-acting, and with no systemic side-effects. In many countries, the IUD is very popular in women over 40. However, removals are more frequent in this age group because pelvic pain and uterine bleeding may occur, decreasing its acceptability. Increased menstrual blood loss may result in anemia, and if irregular, may necessitate diagnostic D&Cs/endometrial biopsy, laparoscopy, and even hysterectomy. This is a problem especially if the woman is suffering from dysfunctional uterine bleeding (DUB) that often occurs in this age group.

No doubt, there are fewer failures, and decreased incidence of pelvic inflammatory disease compared to younger women. The new progesterone-releasing LNG-IUD (Mirena) may prove better, with reduction in menorrhagia, and protection against endometrial hyperplasia and cancer. The IUD should be removed one year after the last menstrual period.

Barrier methods & spermicides With no significant side-effects, these are popular with older couples. The effectiveness of such intercourse- related methods depend on them being used correctly

5 Disclaimer: The information and opinion expressed herein are not necessarily those of the MPS. In addition the inclusion of articles and advertisements does not mean that MPS advocates or rejects its use. Dr Hean-Choon Ong MBBS, FRCOG, M.Med., FICS, FAMM Compliance with HRT Consultant Obstetrician & Gynaecologist, Taman Desa Medical Centre, Kuala Lumpur

Compliance refers to the extent to which a patient's behaviour coincides Reasons for Non-Compliance with the medical or health advice given. Basically, it refers to adherence A South Australian study in 1995 showed that the main reasons PMW to therapy. With HRT compliance, certain pre-requisites prevail: stopped or never started HRT were: 1. it presumes knowledge, both by the patient & physician, of an optimum length of time for treatment 2. it can only come from an understanding of the best scientific evidence available to date • side-effects 21.5% 3. it involves individualization of therapy to the particular woman's • no further need 17.5 needs, wishes and risk factors • not natural 16.5 4. it requires informed consent • fear of breast cancer 6.0 • fear of weight gain 2.5 Compliance statistics • dissuaded by others/media 1.5 It is clear that the long term benefits of HRT on the cardiovascular system, • other reasons 34.5 bone and central nervous system can only come about with its continued long-term use! However, long-term compliance remains low!!!

In US surveys, almost two- Another study of 179 PMW using the estradiol gel for 12 months, listed thirds of postmenopausal the main alleged reasons for non-compliance as: women (PMW) discontinue HRT before 5 years. Even in an educated population as in • conflicting recommendation by the Nurses' Health Study, another physician 14% only 17% continue HRT for • fear of recurrence of breast at least 5 years. pain episodes 12 • fear of weight gain 4 Hence, the actual benefits • unacceptable withdrawal bleed 1 with long-term therapy to • occurrence of skin irritation 0.5 have significant preventive • skin disease 0.5 effects, e.g. on osteoporosis prevention, fall below theoretical expectations. In the UK, the main reasons why women reject advice to take long-term HRT, despite being at risk of osteoporotic fractures, were controversy over benefits of The majority of HRT, concern over possible side-effects, fear of breast cancer. Of those who perimenopausal and PMW took HRT, the main reasons for stopping use were anxiety over unnecessary internationally, either do therapy or medication for life, return of regular bleeding or bleeding problems, not use HRT, or of those fear of breast cancer. who commence HRT, a high percentage discontinue it within 12 months. Reported use of HRT in various countries have been low, e.g. Overall, non-compliance with long-term HRT are related to either patient - Italy (3%), France (12%), Germany (25%), USA (<20%), UK (<10%). related or doctor/physician related factors. These can be summarized as Such uptakes of HRT are too low to have any major impact on public follows: health. Patient-related factors A recent US study on 2500 PMW who had been prescribed HRT Poor uptake showed that 30% never filled the prescription, 20% stopped therapy – lack of awareness within 9 months, and 10% used HRT only intermittently. – incomplete/inaccurate knowledge – women not consulting their health advisors What are the restricting factors ? – reluctance to take HRT because of fear of breast cancer, concerns Looking at the scenario of HRT use, some factors are relevant: about side effects, and its unnatural status 1. the concept of long-term HRT is relatively new. It is fine to accept HRT for vasomotor symptoms & uro-genital problems. However, in Discontinuation of therapy the absence of symptoms/disease, the PMW finds it difficult to – bleeding problems visualize late onset benefits on the heart, bone and brain! – other side-effects 2. even if the PMW is convinced of such late onset benefits, there may –HRT did not meet their expectations be uncertainty of the magnitude & duration of such benefits. – fear of weight gain 3. women and clinicians, no doubt, need new and more information – concern about long-term side-effects about the risks of long-term HRT, to reduce the anxiety of such – women who develop side-effects with HRT tend to discontinue therapy. rather than request for modification of regime 4. specifically, the possibility that long-term HRT may increase the risk of – majority use only for treatment of menopausal symptoms - once breast cancer, is a cause for concern. relieved, they stop HRT

6 Disclaimer: The information and opinion expressed herein are not necessarily those of the MPS. In addition the inclusion of articles and advertisements does not mean that MPS advocates or rejects its use. VOL 1 • ISSUE 1 • 2003

Doctor-related factors menopause nurse, and can then take on some of the training, teaching, and The prescribing rates & attitudes amongst GPs to HRT vary. The following are counseling within the team. She can also counsel and educate the patient, relevant : and this will greatly influence the woman's decision to take HRT. – there is variation of opinions amongst GPs about long-term benefits of HRT 6. Choice of hormonal preparations – there is need for more information Greater compliance is associated with discussions of therapy options with – there is genuine concern about breast cancer risks the patient, as well as individualizing treatment. It may be necessary – the increased time for supervision & monitoring involves increased to modify the type of estrogen or progestogen, as well as pattern and costs & proper time-budgeting. route of administration. Of course, new preparations like continuous combined HRT/alternative progestogens with decreased bleeding GPs used to be the main obstacle in some countries to women trying to obtain problems & side-effects do help to increase compliance. Easy-to-take HRT. With increasing knowledge and awareness, this has reduced! medications with reminder or calendar devices encourage long-term use of HRT. Methods to improve compliance Various avenues have been explored to make HRT more acceptable to women. 7. Resource locations Personalised care by informed doctors over 3-4 visits is associated with 1. Increase awareness of HRT increased and high rate of compliance. This allows precise titration of Specific health education campaigns, highlighting benefits of HRT, and using therapy and adequate counseling. consumer-friendly educational materials, can help. Media presentations should be based on cooperation between the medical profession and those media Future thoughts to facilitate compliance personnel responsible, so that correct & important messages ensue. Target Certainly, there are other aspects to consider in the future, in our attempt to groups should be the younger women, before they reach menopause, and improve compliance with HRT. PMW at increased risks of cardiovascular disease and osteoporosis. a. Menopause Societies 2. Education of health care professionals Such societies should give priority to both medical and lay education. Doctors should be made aware of their advisory roles about HRT. They should They should also act out independently of the pharmaceutical industry, be informed about the true benefits over risks of HRT. They should be alternative medical industry, and any other pressure groups. Opinion encouraged to disseminate accurate and up-to-date information and guidance. expressed should be evidence-based and independent, with only the The aim is to develop a doctor with increased interest and expertise in interest of PMW at heart ! menopause and HRT. b. Industry goals 3. Education and counseling The concept to follow for industries should be to increase product efficacy Improvement of patient compliance involves assessing patient's beliefs about and reduce costs. The pharmaceutical companies should work with HRT, dispelling their unrealistic expectations, and really explaining to them registering and authoritative bodies to ensure that accurate, balanced and about the problem of menopause and its therapy. Formal, as well as informal sensible patient information accompanies their products. counseling is useful, with involvement of the partner, and aid of the patient's family and friends. The availability of information booklets and a telephone- c. There should be policing and restriction of negative advertising answer line are useful. d. Reduction in HRT side-effects should be taken as a challenge by HRT Counseling should be truthful about the benefits vs risks of HRT. A recent manufacturers. cohort study of 422373 users over a 9-year period showed a 16% reduction in breast cancer fatalities in PMW ever users of HRT - such information will do e. Health professionals much to increase compliance. A family history of dementia may be an Adequate counseling skills and time must be available. Increased indication for longer compliance as new data on the role of HRT in relation to compliance is seen when supplementing verbal counseling with written Alzheimer's disease emerge. information. Investigations like bone scans predicting osteoporosis risk, and identification of risk factors for cardiovascular disease should be 4. Structured care considered, as these increase compliance. Doctors should also tailor HRT Increase in compliance has been found to be associated with planned follow- accordingly, up visits, in-depth discussions, and review sessions on compliance problems. e.g. – 50% of PMW require readjustment of therapy in the first year Planned 3-monthly scheduled visits help to identify problems, allows questions – early follow-up is important & answers, allows alteration of therapy as deemed appropriate, and encourages – easy telephone access is useful reading of literature prior to each visit. – yearly medical check-ups should be recommended.

Community-based menopause clinics achieve higher levels of satisfaction, as Conclusion hospital-based practice is usually unable to cope with the demand. Such clinics The issue of improving patient compliance with HRT needs to be tackled ! should complement GP/Specialist clinics. Establishment of menopause & While women value the quality of information from health care women's health clinics are associated with increased use of HRT by 20%, and a professionals, rather than that provided by the media and friends, the high rate of continued use. proportion obtaining it from the former source seems to be low. Greater emphasis needs to be made about cardiovascular benefits, and the need for A study in 1990 on postal invitations showed increased uptake of HRT from 15 long-term therapy for a greater public health impact. The increased HRT to 45%, and a long-term compliance of 84%. options with greater choice now available should improve compliance. However, it is crucial to tailor HRT to the individual woman's needs, and 5. The practice nurse allow her to participate in her own prescribing. Otherwise, she will be The GP/doctor's available time for the patient is limited. The role of the practice unaware of the preparations available, and not return for further treatment nurse then becomes important - she can be trained as a specialist if the initial drug is unsuitable.

7 Disclaimer: The information and opinion expressed herein are not necessarily those of the MPS. In addition the inclusion of articles and advertisements does not mean that MPS advocates or rejects its use. The IDEAL HRTHRT that meets the specific needs of a postmenopausal woman

Relieves the typical menopausal symptoms such as hot flushes and night sweats Improves mood and libido (sex drive)

Protects from heart disease

Does not stimulate the breast tissue nor induce tenderness (breast pain)

Does not proliferate the endometrium (no bleeding)

Relieves the urogenital symptoms like vaginal dryness, infection of vaginal and urethra, painful intercourse

Prevents osteoporosis

LADIES! This is the time to ENJOY everything you've worked hard for. So, don't deprive yourself of regaining your Quality of Life!

Ask your doctor for the Tissue specific HRT today. For further information, please contact:

Organon (M) Sdn Bhd (73127-H) Organon (S) Pte Ltd No. 29-1, 29-2, 29-3, Jalan USJ 9/5Q, Subang Business Centre, 19 Loyang Way, #06-22, Singapore 508724 47620 UEP Subang Jaya, Selangor, Malaysia. Tel: 02-65467727 Fax: 02-65467737 Tel: 03-80240532 Fax: 03-80240539 Email: [email protected] Email: [email protected] A04/02/322

8 Disclaimer: The information and opinion expressed herein are not necessarily those of the MPS. In addition the inclusion of articles and advertisements does not mean that MPS advocates or rejects its use. VOL 1 • ISSUE 1 • 2003

CLINICAL USEFULNESS OF TISSUE-SPECIFIC APPROACH IN POSTMENOPAUSAL WOMEN Professor Dr Nik Mohd Nasri Ismail (MB ChB (Alex), FRCOG (UK), FICS Professor & Senior Consultant of O&G , Deputy Dean (Training & Development) Faculty of Medicine, Universiti Kebangsaan Malaysia

With the increase of the life expectancy In the endometrium , clinical studies show that Livial is converted to its of the Malaysian women from 68.5 years isomer ∆4 which does not have oestrogenic properties and thus does not in 1978 to 74 years in 1994, the stimulate the endometrium. This further means if Livial is given to 3 management of the menopausal women postmenopausal women with intact uterus, no withdrawal bleeding occurs . is becoming more important and more In the breast , Livial and its metabolites have been shown to be potent demanding. Together with increased inhibitors of the local production of estradiol through the inhibition of 4 information about menopause, more responsible enzymes. Thus Livial inhibits breast cell proliferation . women are coming forward for hormone replacement therapy (HRT). Livial has the Livial is effective in treating climacteric symptoms like conventional HRT, 5 combination of oestrogenic, progesto- and also improves vaginal dryness, depressed mood and sexual dysfunction . genic and weak androgenic properties all The bone mineral density in early menopausal women increased by 4-5% 6 in one compound – Tibolone. It is an with Livial as compared to a decrease of 2.8% in placebo group . Even in oral therapeutic agent that exhibits women with established osteoporosis, Livial maintains bone mineral 7 unique specific sex steroid actions density . In these tissues, Livial shows its estrogenic properties. intended for the treatment of climacteric complaints in women who have been menopaused for at least a year and thus would not welcome In terms of its effects on the lipid profile, Livial produces significant reduction withdrawal bleeding which might be experienced with some regimens of in triglycerides and lipoprotein(a), which are two independent risk factors for 8 the conventional HRT. In an open non-comparative trial (unpublished), 30 cardiovascular diseases . The HDL level is however decreased, but this postmenopausal Malaysian women were recruited.They had been pharmacologically induced reduction may not be harmful. The overall menopaused for at least a year. They were offered Livial as their HRT and profile together with vasodilatation effects and increased capillary blood flow 9 were assesed before treatment commenced and after 1, 3 and 6 months of still contribute to cardioprotective effects for women on Livial . treatment. Livial seemed to be very acceptable and effective to overcome menopausal symptoms in 28 women causing no bleeding. One woman Another beneficial effect of Livial is the increased levels of ß-endorphins dropped out due to body aches after a few days on therapy while the in the plasma of postmenopausal women which produced immediate other was just not compliant and thus experienced some spotting. There improvement in mood . Livial is more effective than conventional HRT in 10 was no other adverse effects of the drug. There was definite improvement improving mood . This is important to improve the overall psychological in the psychological, somatic, vasomotor, anxiety, and depression of the symptoms of the menopausal women, which would further maintain or women as per Greene climacteric scale. Livial was useful for these improve the quality of life. postmenopausal women. In summary : Livial contains tibolone, a synthetic steroid which is metabolised into 3 1. Livial acts as an oestrogen at the brain , skeletal , vaginal tissues. active steroid metabolites. These molecules differ in their ability to bind to 2. It effectively alleviates vasomotor symptoms. oestrogen, progestogen and androgen receptors. The 2 hydoxy metabolites 3. It preserves bone density. have primarily oestrogenic properties. This means they act like an 4. It overcomes urogenital complaints like vaginal dryness and oestrogen and stimulate the oestrogen receptors in body tissues. However, dyspareunia. 5. It improves mood. another metabolite known as the ∆-4 isomer does not act like an oestrogen, but instead binds to progesterone and androgen receptors. 6. It has beneficial cardiovascular effects. Livial can be broken down into these metabolites at the level of individual 7. It does not stimulate the endometrium thus avoiding withdrawal tissues , which means the action of Livial at an organ system may depend bleeding. 1 on the metabolite conversion in that specific tissue . This is the concept 8. It does not proliferate breast tissue and hence no breast of Tissue-Specific action. tenderness and unchanged mammographic density. 9. The Tissue-Specific activity of Livial improves the quality of life of 2 Specific binding affinities of tibolone and its metabolites the postmenopausal women with less side effects.

Estrogen Progestogen Androgen It is recommended that Livial should be prescribed to women who have receptor receptor receptor been postmenopausal for at least 12 months. For women who are taking Tibolone + + + cyclical HRT , they should be about 52 years old before changing to 3 α and 3 ß OH tibolone + – – Livial. Although not an absolute contraindication, women who take Livial earlier may experience unwanted and irregular bleeding which may lead ∆ 4 - tibolone isomer – + + to loss of compliance.

References: 1. Coelingh Bennink HJT ( 1997 ) . Clinical experience with tibolone , a tissue-specific hormone . Gynecol Endocrinol 11 Suppl 1:57-62 . 2. Markiewicz L, Gurpide E (1990) . In vitro evaluation of estrogenic , estrogenic antagonist and progestogenic effects of a steroidal drug and its metabolites on human endometrium . J. Steroid Biochem. 35,5 : 525-41 . 3. Hammar M (1998) . A double-blind randomized trial comparing the effects of tibolone with continuous combined hormone replacement therapy in postmenopausal women with menopausal symptoms . Br J Obs Gynae 105;904-11 4. Chetrite G et al (1997) . Effect of tibolone and its metabolites on estrone sulphatase activity in MCF-7 and T47D mammary cancer cells . Anticancer research 17:135-40 . 5. Rymer J et al (1994) . A study of the effect of tibolone on the vagina in postmenopausal women . Maturitas 18 :127-33 . 6. Berning B et al (1996) . Effects of two doses of tibolone on trabecular and cortical bone loss in early postmenopausal women : a two-year randomized placebo-controlled study. Bone 19:395-99 . 7. Studd J et al (1998) . Tibolone increases bone mineral density in osteoporotic postmenopausal women in a randomized study . Obstet Gynecol 92:574-9 . 8. Rymer J et al (1993) . Effects of tibolone on serum concentrations of lipoprotein(a) in postmenopausal women . Acta Endocrinologica 128:259-62 . 9. Haenggi W et al (1995) . Microscopic findings of the nail-fold capillaries - dependence on menopausal status and hormone replacement therapy . Maturitas 22 :37-46 . 10. Tax L et al (1987) . Clinical profile of Livial (OD14) . Maturitas Suppl 1:3-13

9 Disclaimer: The information and opinion expressed herein are not necessarily those of the MPS. In addition the inclusion of articles and advertisements does not mean that MPS advocates or rejects its use. Current Choices In CPE Talks KKLam, RPh, MMPS

An opinion gathering evaluation was carried out during one of the On whether a charge on talk is acceptable, 83% would let MPS CPE talks held on a Sunday. This report is to provide some decide on whether to charge a fee or not and 17% stated that guidance for future talks on the issues investigated. they will pay RM50/- a year. However none wanted to pay RM100/- 83% of the respondents preferred to have the talks on Sundays. However, as the evaluation was carried out on a Sunday, results 60% of those who attended the talk did not come might have been biased towards a Sunday crowd, hence their prepared (defined as having thought about or read on the preference for Sundays. There might be other groups who would subject, or reviewed some patient records). However, prefer other days but who weren't present. this did not correspond with the lack of questions during the Q & A session since not being prepared could mean For those who preferred other days, that is on a week day, the best that there were areas of doubt which would require time stated was the evening, although this seems rather obvious as clarification. The rest (40%) who came prepared may most pharmacists work during the daytime during the week. For mean that they were mentally better prepared to absorb those who preferred Sundays, afternoon is the preferred time (90% the knowledge. of respondents). 79% said that they would come alone whereas 21% said that they For each session, the preference is for one topic (58%) although the would not attend if they cannot bring along a friend. There are idea of at least 2 topics was not completely rejected (42%). It many interpretations to this. The majority may consider this a would seem a good idea then to have no more than 2 topics for learning program and would come to learn and not consider it so each session. much as a social event. On the other hand, they may consider this an event for networking or to renew ties with fellow The majority (50%) preferred a once-a-month talk, although a large pharmacists. group (42%) does not mind once every 2 weeks. Finally 58% of the group were from community (retail) pharmacy, For CPE through the mail, the choice was for once a month (72%) 17% from hospital pharmacy, and the rest (25%) were from other whilst a smaller group (28%) did not mind fortnightly mailings. areas.

Detail Results of the Evaluation

1. Preference for day of talks Weekdays 17% 5. At what frequency would Once a month 72% Sundays 83% you prefer CPE through the Once every two months 28% Other days (please specify) mail?

2. Preference for time of talks Morning 4% 6. Are you willing to pay a RM50/- a year 17% (Weekdays) Afternoon 4% fee to attend the talks? More than RM100/- a year 0% Evening 92% Up to MPS to decide 83%

(Sundays) Morning 2% 7. Did you come prepared for the Yes 40% Afternoon 90% talk (thought about or read on No 60% Evening 8% subject matter, reviewed patient records, etc)

3. How many topics should 1 topic 58% 8. Did you come alone to this talk? Yes I came alone 79% be included in one session 1 - 2 topics 19% I would not attend if 21% besides the main medical/ > 2 topics 23% my friend does pharmaceutical topic? not come along

4. The talks should be held Once a week 8% 9. I work in Hospital Pharmacy 17% Once every two weeks 42% Community Pharmacy 58% Once a month 50% Others 25%

10 Disclaimer: The information and opinion expressed herein are not necessarily those of the MPS. In addition the inclusion of articles and advertisements does not mean that MPS advocates or rejects its use. VOL 1 • ISSUE 1 • 2003

FAMILY PLANNING: FROM THE ISLAMIC PERSPECTIVES Compiled by : Dr.Harlina Halizah Hj Siraj MD(UKM) MOG(UKM), Obstetrics and Gynaecology Department, Faculty of Medicine UKM

To strengthen the argument, one needs to be reminded on the ten cardinal rights of children in Islam as compiled below by Prof. Abdel Rahim Omran:

Compiled from the Al-Quran & Hadith by Prof. Abdel Rahim Omran 1. Right to genetic purity 2. Right to life 3. Right to legitimacy and good name 4. Right to breast-feeding, shelter and maintenance 5. Right to separate sleeping arrangement for boys and girls 6. Right to religious upbringing 7. Right to education and life skills 8. Right to future security 9. Right to equitable treatment regardless of gender 10. Right to obtain financial support from legitimate sources

Table 1 : Ten Cardinal Rights Of Children In Islam

4. Common Perceptions on Family Planning among Muslims 1. Introduction Many Muslims perceive the concept of planning a family as unparalleled to the Family Planning (FP) is an important aspect of Preventive Medicine in health care. It is true Islamic teachings. Family Planning is being regarded as: also the first pillar of Safe Motherhood Initiatives introduced by World Health •infanticide or killing of children in fear of poverty and future mishaps Organization (WHO) in the struggle to reduce maternal mortality worldwide. • contradicting to the concept of predestination However, FP providers all over the world have to face numerous challenges in the •denial of the ability of Allah to provide attempt to convince men and women to accept the service. Most of the time, cultural • against the call for multitude and religious factors have been quoted to be the major deterring factors in accepting Such misconceptions can be properly eliminated if the Muslims are exposed to FP services. As a result to this, many families which might benefit from the service are sound arguments and proofs from the Holy Quran and Al-Hadith, as well as the prevented from receiving it. This short paper will try to address the issues of Family consensus and opinions of the contemporary scholars. Planning from the perspective of Islam, one of the major religions in the world . Hopefully, it will throw some light to facilitate health providers in counseling devoted Family Planning is not a form of infanticide as it interferes with the process of Muslim couples to accept FP services available. ovulation (release of the female cells or ova), delivery of the male cells (sperms) and prevention of fertilisation (the process where the ovum is fertilised by the sperm). In 2. Health in Islam other words, no infant or newborn is being killed by the method of contraception. As a complete way of life, Islam regards health as an important and essential aspect of human survival. Restoration of health in Islam encompasses not only the physical As Muslim practitioners, we are truly aware of the limitations and shortcomings of being, but also the emotional, spiritual and social aspects of a human life. Muslims human efforts. Hence, we believe that Allah will have the final decision in must not only be healthy as individuals, but at the same time, as collectively as everything that we have planned. Family Planning service is mainly an effort to families and communities. In general, the principle of `Prevention is better than cure' space out pregnancies. However, the final consequence will remain to be within applies significantly in Islam. It is interesting indeed to analyse the provision and the domain of Allah alone. Muslim health providers must never fail to relate this allocation in Islam as regards to Family Planning. Or in short, what are the answers to important concept to their clients who sought Family Planning advice and services. the most frequently asked questions (FAQs) on Family Planning among the concerned: • Is Family Planning allowed in Islam ? The concept that every single child born into this world is already being allocated •Are the methods of contraception available today permissible from with his or her own provision by Allah should not prevent one from practising the perspective of Islam ? Family Planning. Muslims must never doubt the ability of Allah to provide for He is the Most Bountiful and Most Generous. However, the provision (rizq) of every 3. Shall Muslim consider Family Planning at all? single child must be managed by the parents until the child could fend for him or The discussion on FP among the concerned Muslims should not be based upon the herself. And the management of this provision is the main issue here, not just by standpoint that children are mainly troublesome, burdens and obstacles to adults' accepting the simple fact that Allah will provide no matter what! The parents must achievements. On the other hand, the focus of the discussion should be the true fact be able to work hard and smart enough to provide for all the children's need - that children are charming gifts and honours from Allah bestowed upon humankind. It which include not just food and clothing, but attention, time and companionship is high time that today's parents value their children as dearly as possible. Children are for each and every child we have. not simply born to be fed and reared until they reach adulthood and finally be able to fend for themselves. In Islam, children are regarded as bounties from Allah. As for the view that FP is against the call for multitude, one should be reminded Meanwhile, parenthood is indeed a grave responsibility. Our children need to be that there are almost two billions Muslims all over the world today. While we are nurtured, loved and guided throughout their lives. All pregnancies should be intended aware that number can represent strength, quality remains to be an important and planned. This is essential and crucial to ensure a conducive environment and determining factor for success. Muslims should be reminded of the saying of the climate for the pregnancy as well as for the growing years for the child. As human Prophet Muhammad (PBUH) that emphasized the importance of quality: beings, we are blessed by Allah with the intelligence and cognitive faculty , to be able (Translation) 'A strong believer is much preferred by Allah than a weak one.' In this to think and work out as to how our fertility can be regulated and subsequently, case, a well-planned family will be a perfect training ground for bright and childbirth can be properly spaced out. innovative young Muslims of the future. 11 Disclaimer: The information and opinion expressed herein are not necessarily those of the MPS. In addition the inclusion of articles and advertisements does not mean that MPS advocates or rejects its use. Let us all be reminded of the five capabilities of families before embarking into However, it allows the Muslim to plan his family due to valid reasons and expansion of the family size as outlined by Prof. Abdel Rahim Omran in his book recognized necessities. The common method of contraception at the time of the "Family Planning in The Legacy of Islam": Prophet was coitus interruptus (withdrawal). The Companions of the Prophet engaged in this practice during the period when the Quran was being revealed to them. 1. Physical ( Health ) - especially mother's health 2. Economic - Financial and material support He specified the valid reasons as follows : 3. Cultural - Proper education and religious upbringing • Fear that the progeny or delivery may endanger mother's health. 4. Time availability - Companionship ( quality time ) • Fear that the burden of children may strain the family's means to the extent 5. Community support - area of schooling & child care that one might accept or do something haram to satisfy their needs. • Fear that the children's health & upbringing may suffer. Table 2 : Five capabilities for muslim families • Fear that the new progeny may harm a suckling child. 5. Special Features of Family Planning in Islam He confirms that modern contraceptive methods are similar in purpose to coitus Islam provides a list of special features and pre-requisites for Family Planning to be interruptus and are allowed by analogy (qiyas). He also quoted Ahmad ibn accepted in Islam. The list is as follows : Hambal as requiring the consent of the wife. As to abortion, he objects to it especially after the fetus is completely formed.' 1. Practised only within marriage 2. A part of an overall agenda of family formation 9. Fatwa on Family Planning 3. Practised with the consent of both 4. Method is legitimate and safe 5. Should not lead to depopulation Official Fatwa of the Malaysian National Council for 6. Every pregnancy should be intended and planned for Islamic Affairs (1981) 7. Prevention of infertility is an integral part of family Contraception to limit the number of offspring is haram (forbidden) unless planning under harus (permissible) individual circumstances. Contraception that is 8. In accordance with the basic concepts of Islam - Islam as a not permanent in nature is permissible when the following condition set by religion of ease, quality and moderation the Shariah are met: 9. No law should coerce –the wife is too weak or ill 10. Not acceptable if to avoid having girls or to avoid –the couple carries a hereditary illness maternity roles –the wife has too frequent pregnancies.

Table 3 : Special features of Family Planning in Islam To space the children for reasons of health (of the parents & children), education (eg. educational facilities) and family happiness (housing, leisure 6. The Quran and Family Planning etc.) is harus (permissible). A quote from the Grand Imam of Al-Azhar , Egypt , Syeikh Gadel Haq on the issue of Family Planning was as follows : 10. Methods of Contraception 'A thorough review of the Holy Quran revealed NO TEXT prohibiting the The principle for any method of contraception to be permissible is that it should be prevention of pregnancy or diminution of the number of children' safe and not harmful. It has been agreed by most of the scholars that the reversible methods of contraception are permissible and allowed. Intrauterine contraceptive On the other hand, the Quran specified the period of lactation or breast-feeding device (IUCD) had been regarded by some as a form of early abortifacient as it was for babies as in the two verses below: thought to prevent the implantation of a fertilised ovum. However, it is now a well- Al-Baqarah: 233 proven fact that the primary mechanism of action of IUCD is by impairing the 'And mothers shall suckle their children two years for those who wish to complete viability of sperms and interference of the sperms' motility. breast-feeding.' As for the irreversible method of contraception such as female and male Al-Ahqaf : 15 sterilization, there are still a lot of arguments and debate. As for the author's 'His bearing and weaning is thirty months...... ' personal opinion on female sterilization such as bilateral tubal ligation, it should be the last resort offered to women since there are many alternative methods In 1959, another grand Imam of Al-Azhar , Sheikh Shaltut stated : (IUCD / implants) which are as equally effective. This is to prevent the irreversible 'The Quran fixed the period of lactation at two years and the Prophet warned method from being abused and misused. against feeding a baby from the milk of a pregnant mother. This argues in favour of allowing steps to be taken to prevent pregnancy during the period of breast-feeding.' As for the male sterilization such as vasectomy, Prof. Abdel Rahim Omran suggested that many more thorough discussions between theologians and 7. The Sunnah and Family Planning physicians regarding the topic should be conducted. In an authentic Hadith (saying of the Prophet Muhammad PBUH) as translated: The Malaysian National Fatwa Council in 1981 published the ruling on 'A companion of the Prophet (PBUH), Jabir reported: "We used to practice al-azl sterilization as follows : (coitus interruptus) during the time of the Prophet (PBUH). The Prophet (PBUH) came to know about it, but did not forbid us (from doing it)". Sterilising a man or women is forbidden (haram). It was believed that the Companions of the Prophet PBUH to have practiced al-azl Regarded as a permanent form of contraception - permanently during the time of the Prophet were as follows : impairs a person's reproductive function. Exceptions can be made •Ali Abi Talib • Abdullah bin Abbas - eg. when a woman cannot use any form of contraception for • Saad ibn Waqqas • Hassan ibn Ali health reasons or a pregnancy can endanger her life. • Abu Ayyub Al-ansari

8. Opinion of Contemporary Scholars 11. Conclusion Prof. Dr. Yusuf Qardhawi (1980) has stated the following opinion on Family Through this short account on the Family Planning from the perspective of Islam, it Planning : is hoped that many of the health providers would be guided and would be able to The preservation of the human species is unquestionably the primary objective of review each individual case whenever clients request for a proper counseling on marriage, and such preservation of species requires continued reproduction. Family Planning. It is indeed an unfortunate event if such an important aspect of Accordingly Islam encourages having many children and blessed both male and Preventive Medicine like Family Planning could not be efficiently delivered to the female progeny. mass.

12 Disclaimer: The information and opinion expressed herein are not necessarily those of the MPS. In addition the inclusion of articles and advertisements does not mean that MPS advocates or rejects its use. VOL 1 • ISSUE 1 • 2003

Dr Hean-Choon Ong MBBS, FRCOG, M.Med.O&G, FICS, FAMM Consultant Obstetrician & Gynaecologist, Taman Desa Medical Centre, Kuala Lumpur

During the past 50 years, we have gradually learned that there is more to this include feelings for the partner, partner problems, & the the menopause than just the end of fertility. One of the issues is sexuality presence/absence of vaginal dryness and painful intercourse (dyspareunia). in post-menopausal women (PMW). Sex matters to them in their middle The outcome areas that are affected include sexual responsiveness years, and continues to play an important role in their lives (enjoyment, arousal, orgasm), frequency of sexual activity beyond their menopause. Reduced sex drive has a more (frequency of coitus, frequency of all sex acts and satisfaction detrimental impact on their mental well-being than any with frequency), and libido (frequency of sexual thoughts, other climacteric symptom! frequency of masturbation).

Sexuality statistics during the menopause Quality of sexual life in the menopause • eight out of 10 women say that maintaining a This becomes an important issue with increasing satisfying sex life is very important to them. age. Tender loving care or its lack is a dominant • 75% say sex is an important part of their issue. Changes in individual body image makes the relationship with their partner. PMW " less attractive". This is coupled with the • one-third report a recent reduction in sex life. low self-esteem that occurs. Partner relationships, • more than half report a significant effect on more so their quality, becomes significant (poorer feeling of self-worth. quality associated with increased menopausal • about a quarter of them have libido symptoms. problems and may complain that this is affecting their relationship. Libido during menopause • 50% of PMW are still sexually active; of the There is a significant decline in libido with other 50% who are not, 63% was because of menopause transition. Age is not a significant factor loss of their partner, and only 23% admitted a in this! More so, the decline is influenced by loss of interest in sex. decreased estrogen production, and elevated FSH • only 2% will specifically seek treatment for reduced levels. sex drive. Lack of estrogen deprives the brain and all the female body Issues influencing management of the natural lymph that contributes to the perception of female Three issues prevail: sex identity, of a satisfying sexual function, and to the sensuality & 1. whether there is a change in female sexual function in mid-life seductivity that improves the quality of sexual relationships. 2. whether any such change is due to ageing or reflects the menopause All these cause a progressive loss of libido, and crisis of the self- 3. the relative contributions of hormonal, health & psychological perception as an object of desire in the PMW. factors to any such change. Estrogen lack also deprives sweat and sebaceous glands of the stimulus to In the discussion of sexuality during the menopause, directions to produce the peculiar chemical secretion (pheromone), responsible for the consider would include : "scent of woman", so critical in sexual attraction. Estrogen is also the i) feeling of well-being & perception of attractiveness permitting factor for the action of vasoactive intestinal peptide (VIP), the ii) libido & sexual interest neurotransmitter for the endothelial and vasal changes that lead to vaginal iii) sexual activity, i.e. sexual intercourse/coitus, and related vaginal lubrication. Thus, estrogen lack leads to vaginal dryness and dyspareunia. factors iv) partner relationships. Other factors that affect libido include : – motivational-affective & relational factors It is important to note that vaginal dryness and declining libido are 2 – implication & quality of couple relationships different things, which are not necessarily related. – partner attitudes & problems.

Sexuality changes during menopause This explains the variability of libido in women during their menopausal Menopause transition is significantly associated with decline in sexual years. Sexual function is also affected by factors like being gainfully interest, decreased likelihood of coitus and increased dyspareunia. The employed, interpersonal stress, daily hassles, and educational level. decrease in sexual interest is related to the hormonal changes during natural menopause, and also to the decreased well-being, Vaginal changes cessation/lack of employment, and presence of troublesome symptoms Atrophic changes occur in the vagina, which becomes paler, shorter & associated with menopause. The determinants or potential barriers to narrower. There is vaginal dryness, irritation and itchiness. Persistent

13 Disclaimer: The information and opinion expressed herein are not necessarily those of the MPS. In addition the inclusion of articles and advertisements does not mean that MPS advocates or rejects its use. discharge may occur as a result of trauma (e.g. coitus), or infection. Post- Tibolone (Livial) provides the same benefits as HRT on sexuality. In coital bleeding may also occur. This may lead to painful coitus (dyspareunia), addition, it improves on sexual performance, desire and drive, areas where and sometimes, no coitus (apareunia). The prevalence rates of genital HRT does not perform so well. This tissue-specific therapy could be an complaints during the menopause in population surveys are - vaginal dryness important alternative to conventional HRT therapy. (20-40%), dyspareunia (10-40%), vaginal pain/discharge (0-20%). Testosterone therapy Sexual activity Studies indicate that women who are testosterone-deficient experience Postmenopausal women report a decrease in sex frequency. Influencing loss of sexual desire. There is no sudden change in testosterone level at factors include - *vaginal changes, *decreased libido, *change in attitude menopause, rather androgen levels start to decline over the 10 years to sex, i.e. no sex or less sex during menopause, *age & health of the male before menopause when women are in their 40s. By menopause, partner. There is a decrease in potency in the male with age. testosterone levels are typically only 10-50% of peak values. Treatment with testosterone implants in PMW have shown significant and sustained Studies on the proportion of men and women reporting no interest in sex, improvements in sexual function. in relation to age, reveal as follows : age 40-50 yrs – 7% Tibolone (Livial) 51-55 – 20% Livial is a tissue-specific agent possessing estrogenic, progestogenic, and mild 56-60 – 31% androgenic activities. It has beneficial effects on libido. By 3 months of therapy, significant improvement in sexual desire is seen, which is Couples not having sex has been reported as follows : maintained as long as therapy continues. The areas of improvement include age 45-50 yrs– 14% sexual attraction, sexual interest, initiation of sexual activity, sexual fantasies, 51-60 – 42% coital activity, intensity of orgasmic response, and coital difficulty.

The avoidance of coitus may lead to further atrophic vaginal changes, Livial improves libido to a greater extent than conventional HRT. On the which may result in vaginal or introital rigidity. McCoy Sex Scale, all 10 factors are improved by Livial, while HRT improves only on coital frequency, enjoyment, arousal, dryness, pain or problems. Management options HRT (Hormone replacement therapy) Livial also improves on vaginal dryness and dyspareunia. Significant improvement in KPI (karyo-pyknotic index) indicates significant estrogenic ERT (Estrogen replacement therapy) effect on vaginal lubrication.

The conventional HRT/ERT preparations do have beneficial effects on Tibolone use in women after hysterectomy & complaining of decreased sexual function. sexual function results in improvement of sexual function by 4-6 weeks, and almost complete elimination of symptoms by 10-12 weeks. Use of HRT controls and improves on troublesome vasomotor and psychological tibolone for 3 months in PMW shows significant decrease in severity of complaints. This can clear the cloud over the PMW's psyche and mind, sexual problems after the menopause. and allow renewed/increased sexual interest. HRT is also effective against the symptoms of urogenital atrophy. Painful intercourse is relieved by HRT, Tibolone therefore offers a significantly greater improvement in sexual which restores wetness to a dry vagina. frequency, enjoyment and satisfaction in PMW compared to conventional HRT.

HRT also leads to an overall increase in general well-being, and makes the Counselling PMW feel good about herself, It improves on self-image & esteem by In societies that regard sexuality as the prerogative of youth, many PMW will lessening worry about self, worry about age, enhances good spirits, and hesitate to ask their physicians about diminishing pleasure in sex. This attitude restores optimism. has to change! There is a need for more information about the importance of sexuality in women in their middle years. With a better self-image & relief of troublesome complaints, the PMW looks better, dresses better, and commands a better outlook in life. All these Postmenopausal women need to be educated that something can be done enhances the woman's self-perception of her own attractiveness, and her to address their sexual symptoms and enable them to fully enjoy life. image as an object of desire by her partner. Studies have shown that Physicians need to be sensitive to this area of need, and in their own these HRT benefits are also associated with increased libido special ways, bring up this subject of sexuality with their and sexual interest on the part of the clients. partner/husband. Conclusion Sexual performance, however, is Talking about sex and sexuality has enhanced by combined estrogen- always been a taboo or uncomfortable androgen therapy, and not by ERT or task in Asian cultures. Nevertheless, combined HRT. No doubt, one must in our holistic approach to the remember that androgens may management of postmenopausal have unacceptable androgenic women and their problems, we side-effects. must not forget this important Some studies have shown that area of need. Only then, can combined HRT use can reduce we help the PMW in her dyspareunia, relieve vaginal golden years, to enjoy a more dryness, and improve on complete and better quality of subjective well-being, but life. No doubt, sex and there is no significant increase sexuality problems can be in sexual desire, coital addressed more effectively, but frequency, and frequency of this does not preclude the need orgasm. HRT is also low in for a proper physical, loving and effectiveness for sex drive. caring relationship in life!

14 Disclaimer: The information and opinion expressed herein are not necessarily those of the MPS. In addition the inclusion of articles and advertisements does not mean that MPS advocates or rejects its use. VOL 1 • ISSUE 1 • 2003

Are you Man enough...?

Mood changes Low sex drive

Loss of energy Sleep disturbances

Decreased muscle strength

Increased body fat

Do you have Symptoms of Andropause/ "Male Menopause"? ?

With compliments from: Organon (M) Sdn Bhd (73127H) No.29-1, 29-2, 29-3, Jalan USJ 9/5Q Subang Business Centre, 47620 UEP Subang Jaya, Selangor. Tel: 03-8024 0532 Fax: 03-8024 0539 Organon (S) Pte Ltd 19 Loyang Way, #06-22, Singapore 508724. Tel: 02-65467727 Fax: 02-65467737 2001A 760 E-mail: [email protected]

15 Disclaimer: The information and opinion expressed herein are not necessarily those of the MPS. In addition the inclusion of articles and advertisements does not mean that MPS advocates or rejects its use. Medications For Men:

by Dr Clarence Lei Chang Moh - FRCS Urol, FAMM, Consultant Urologist, Normah Medical Specialist Centre, Kuching, Sarawak

INTRODUCTION

Andropause in men is analagous to menopause in women. However, and hepatotoxicity seen in the decline of androgens in men is gradual and a more appropriate term other oral preparations. The is PADAM or Partial Androgen Deficiency in Aging Men. The diagnosis usual initiation dosage of of PADAM is made on clinical criteria (eg. PADAM score) confirmed by Andriol is 80 mg twice a day biochemical assay of hormones (usually testosterone and LH, luteinising for 3 weeks. Maintenance hormone)1. dosage is 80mg OM and 40mg ON.

INDICATIONS (ii) Mesterolone is a dihydro-testosterone derivative, which cannot be metabolised to When PADAM is diagnosed, the benefits of hormonal replacement are estrogen. It is used in a dosage of 75mg per day (in 3 discussed with the patient. The benefits are not only in the arena of sexual divided doses) initially, followed by maintenance dosages of 25-50mg twice function but also in cognitive functions, bone metabolism, cardiovascular, a day. lean body mass and visceral obesity. Treatment should be initiated before complications become serious. The aim of treatment is replace testosterone (b) Injectable Androgens to near physiologic levels. Medications including Testosterone The most popular is Sustanon (also from Organon) which is a preparation Replacement Therapy, should be only part of effects to improve quality of consisting of different esters of testosterone whereas one ester is of rapid onset life. Other aspects of healthy lifestyle eg exercise, dieting, relationships, and short duration of action, the other esters have slower onsets and longer spirituality and stress management are also important. durations of action. The preparation (250mg in 1ml) is given by deep intramuscular injection every 3 weeks. CONTRA-INDICATIONS (c) Testosterone Implants Prostatic cancer is usually androgen dependent. Therefore androgens are These are inserted subcutaneously. They contain pure testosterone and absolutely contraindicated in prostatic cancer (and breast cancer). To provide a supply of testosterone over a few months. rule out prostate cancer, the doctor needs to take a history, do a digital rectal examination (DRE) of the prostate and a serum PSA (prostatic (d) Transdermal testosterone specific antigen, normal 0 - 4). If any of these are suspicious, the patient These allow testosterone to be absorbed directly into blood stream. They are should be referred to a urologist for transrectal ultrasound (TRUS) of of 3 different types. prostate and probably prostate biopsy. The DRE and PSA has to be (i) Scrotal patches – Scrotal skin needs to be shaved to keep patch in repeated yearly and whenever any prostatic symptoms arise. place. (ii) Non-scrotal patches – these have significant skin irritation. Androgens also have a stimulating effect on hemopoiesis. A raised (iii) Jel - just rub on – this appears to be popular in USA haemoglobin (often also associated with sleep apnoea) is a relative Currently (c) and (d) are not available in Malaysia. contraindication.

EFFICACY & SAFETY TYPES OF ANDROGENS Andriol has been shown to raise the serum free and total testosterone levels2. The main androgen is testosterone. When used appropriately, efficacy and safety is good in my experience as well as in long term studies3,4. OPTIONS

In Malaysia the commonly available preparation for testosterone SUMMARY replacement therapy (TRT) are: TRT has a definite role in improving the quality of life in men with PADAM. a) Oral Testosterone ® (i) Andriol (from Organon) or testosterone undecanoate. This is mostly Reference: 1) Gooren LJG. The age related decline of androgen levels in men: clinically significant? Br J Urol. 1996, 1978: 763-8 absorbed from the digestive tract via the lymphatic system; hence it is 2) Marumo K, Buba S, Musai M. Role and efficacy of androgens replacement therapy in patient with hypogonadism. Int J Imp Res.1997; 9 Supp 1. 1:546. better absorbed with meals. Therefore it avoids inactivation in the liver 3) Gooren LJG. A ten years safety study of the oral androgen testosterone Undecanoate. J Androl 1994; 15: 212.5

16 Disclaimer: The information and opinion expressed herein are not necessarily those of the MPS. In addition the inclusion of articles and advertisements does not mean that MPS advocates or rejects its use. VOL 1 • ISSUE 1 • 2003

Acne There is decrease in circulating levels of free testosterone and androgens because of increase in SHBG (sex hormone binding globulin) levels; because of this, acne formation is less in users. Studies on Mercilon have shown complete remission of acne in 15-45% (mean 38%) of users, and improvement in 42- 65%.

Blood pressure CurrentCurrent InnovationInnovation inin Mercilon does not affect the mean systolic or diastolic blood pressure. Metabolic effects Ultra-lowUltra-low dosedose pillspills No effect on total blood cholesterol is present. A slight but significant rise in HDL cholesterol & HDL constituents like apolipoprotein A-1 is seen. Potentially Dr Hean-Choon Ong, MBBS, FRCOG, M.Med.O&G, FICS, FAMM Consultant Obstetrician & Gynaecologist, Taman Desa Medical Centre, Kuala Lumpur thus, there is lowered risk of ischemic heart disease and arterial disease. Mercilon has minimal influence on carbohydrate metabolism. Hormonal methods of contraception, particularly oral contraceptives (OCs) are amongst the most popular methods of family planning, and amongst the top four Estrogens probably influence a number of hemostatic parameters in a dose- reliable/efficient methods. Over 40 years have passed since the first clinical report dependent way. Significantly, during use of Mercilon, no change in anti- was published on the effectiveness of a hormonal contraceptive in 1956. Since thrombin III activity has been observed. then, rapid advances have been made with regards to OCs, particularly reduction of side-effects to the minimum, while maintaining good contraceptive efficacy. Quality of life Users of Mercilon have shown improvement in quality of various life items. Safety-driven developments These include physical health, mood, work life, school life, household Through the years, research and development in OCs have been directed at newer activities, vision, living situations, social relationships, family relationships, and safer combinations. Minimising the estrogen dose has always been an leisure-time activities, and sex life. Overall, there is a better daily life and important aim in the development of combined OCs. improvement in general well-being. The greatest improvement reported by users is in their sex-life ! Reduction in estrogen dose from 50µg to 30µg to 20µg was achieved in the early 90s. With this, both estrogen-related side-effects (e.g. breast pains/fullness, nausea, Its safety and reliability makes Mercilon ideal for use in older women during headache), and risk of venous thrombo-embolism are expected to be reduced. their climacteric period, with useful desirable effects. (see Figure)

New third generation progestogens were developed over the years, i.e. desogestrel, gestodene, and norgestimate. These are more selective in nature, Desirable effects of Mercilon when used in women during their climacteric especially desogestrel, binding more to progesterone receptors than to androgen years receptors, and thus, have favourable effects on lipo-protein profiles. 1. Maintains sexuality, by its good cycle control, slowing of skin aging, improved body image, increase in libido, and decreased Mercilon - a new era in oral contraception! vaginal dryness Mercilon, developed by Organon, was the first ultra-low dose OC introduced in 1992, combining the lowest dose of ethinyl-estradiol (20µg) with a highly selective 2. Controls effectively vasomotor symptoms, and psychological symptoms progestogen, desogestrel (150µg). Overall, studies have shown that Mercilon is 3. Relieves the symptoms of pre-menstrual tension, and also dysmenorrhoea associated with excellent reliability, good cycle control, low incidence of side- 4. Helps to decrease bone loss effects, negligible effects on body weight, and high user acceptability. 5. Gynaecologically, offers protection against conditions like cancer of uterus & ovary, benign breast disease, pelvic infections, ectopic pregnancy, etc Reliability Mercilon has excellent contraceptive reliability, with recorded pregnancy rates of 0.02 Pearl Index (method failure) and 0.16 Pearl Index (user failure). This is because Side-effects Mercilon effectively inhibits follicular development and ovulation. Besides, it also Minor side-effects are reduced with Mercilon, i.e. nausea, headache, breast creates a hostile cervical mucus, interfering with sperm penetrability. pains, nervousness (less than 5%). Discontinuation rate due to these is about 7%. The drop-out rate due to irregular bleeding is 5.8% over 12 months. Cycle control Much less spotting and breakthrough bleeding are seen with Mercilon. Withdrawal bleeding is induced in over 90% of users. Amount of blood loss during the menstrual Tolerability of Mercilon is very high ! cycle shows no change in 60%, and is reduced in 30-40%. The duration of bleeding shows a tendency to decrease by about 50%. Improvement of compliance Absence of irregular bleeding is seen in over 90% by cycle 12. Equally important To enhance compliance, the Mercilon Reminder Card has been introduced with is that 80% of those with irregular bleeding accept this without any concern, and great success. Users found this to be useful and easy, and this greatly helped only 20% are unhappy about this. them to remember taking their Mercilon pills.

Because of its good cycle control, Mercilon is ideal in the drug therapy of DUB Conclusion (dysfunctional uterine bleeding), especially when this occurs in a young woman, Mercilon has been shown to be a highly effective oral contraceptive, and has who also desires contraception! been referred to as the gold standard for low-dose & ultra low-dose oral contraceptives. It is currently, the first choice OC for the young woman who Body weight desires effective contraception. However, especially for the increasing group of There is negligible effect on body weight in Mercilon users, even in age groups older and more matured women, who like to continue oral contraceptive use below 20 years, and 20-29 years. An earlier trial recorded only a small increase of into their 40s, the use of minimal dose of estrogen, like in Mercilon, is 0.3kg over 24 months. particularly relevant!

References: 1. Potts, M., (1990), " Benefits and risks of oral contraceptives ", in ' Oral Contraception into the 1990s ', Ed H.W. Halbe and H. Rekers, The Parthenon Publishing Group UK & USA , The Proceedings of a symposium held at the XII World Congress of Gynecology and Obstetrics, Rio de Janeiro, Brazil, October 1988, pp 11-20 2. Guillebaud, J., (1990), "Contraception for women over 35 years of age ", in ' Oral Contraception into the 1990s ', Ed H.W.Halbe and H. Rekers, The Parthenon Publishing Group UK & USA, The Proceedings of a symposium held at the XII World Congress of Gynecology and Obstetrics, Rio de Janeiro, Brazil, October 1988, pp 75-83 3. Atsma, W.J., (1990), " Mercilon - a new, ultra-low dose contraceptive containing 150ug desogestrel and 20ug ethinylestradiol ", in ' Oral Contraception into the 1990s ', Ed H.W. Halbe and H. Rekers, The Parthenon Publishing Group UK & USA, The Proceedings of a symposium held at the XII World Congress of Gynecology and Obstetrics, Rio de Janeiro, Brazil, October 1988, pp 85-92 4. Lammers, P., (1991), "Acceptability studies with Mercilon ", in ' Reducing the estrogen dose in oral contraception ', Ed O. Ylikorkala, The Parthenon Publishing Group UK & USA, The Proceedings of a symposium held at the 7th World Congress on Human Reproduction, Helsinki, 1990, pp 31-38. 5. Kuhl, H. and Jung-Hoffman, C., (1991), " Pharmacokinetics and pharmacodynamics of oral contraceptive steroids ", in ' Reducing the estrogen dose in oral contraception ', Ed O. Ylikokala, The Parthenon Publishing Group UK & USA, The Proceedings of a symposium held at the 7th World Congress on Human Reproduction, Helsinki, 1990, pp 73-85 6. Drife, J.O., (1996) " The benefits and risks of oral contraceptives today ", 2nd Edition, The Parthenon Publishing Group, London and New York 7. Fraser, I. S., (1994), " Modern choices for contraception ", in the ' The Female Patient ', vol. 4, No. 3, Excerpta Medica, pp 5-23 8. ' The Essentials of Contraceptive Technology ' 1997, Ed R.A. Hatcher, W. Rinehart, R. Blackburn, J.S. Geller, Johns Hopkins Population Information Program, Chapter 5 " Low-dose Combined oral contraceptives " pp 5-1 to 5-19 9. Vemer, H. ( 1994), " More choices in contraception ", in ' The Reproductive Revolution. The role of contraception and education in population and development ' Ed P. Senanayake, The Proceedings of an International Symposium, Vienna, The Parthenon Publishing Group, London and New York, pp 119-125 10. ' Mercilon ', Scientific Brochure 1999, N.V. Organon 17 Disclaimer: The information and opinion expressed herein are not necessarily those of the MPS. In addition the inclusion of articles and advertisements does not mean that MPS advocates or rejects its use. Continuing Education-Mandatory or Voluntary? Does it Really Protect Society from Incompetent Health Professionals?

Review and Adaptation of an article written by Patricia A. McPartland KKLam, RPh, MMPS

Introduction 4. The patterns and methods of CE should be planned and conducted It has been reported that the knowledge one acquired while in the in terms of one of three modes of education : inquiry, instruction, undergraduate days has a half-life of approximately five years. What performance this means is that half of what one learns in the university will become 5. The provision of CE should be expanded to pervade all aspects of obsolete in five years. And with the ever-increasing pace of expansion professional life of knowledge and techniques, the pharmacist will be hard pressed to 6. Professions should collaborate in planning and providing keep up with it. On the other hand, a patient's life and well being often continuing professional education depends on keeping up-to-date on the latest developments. 7. The process of recredentialing should be thoroughly re-thought to determine the appropriate role of CE It is obvious then that one needs to participate in the process of continuing education. There is no hard and fast rule as to how much Several other objectives of CE to consider are: continuing education is enough. Different health professionals require Clarifying the professions' functions, mastery of theoretical knowledge, different number of hours. But whatever the quantum, the professionals self-enhancement, formal training, credentialing, creation of a do enjoy a choice of whatever educational programs that they wish. subculture, legal reinforcement, public acceptance, ethical practice, penalties, relations to users of services. MPS CE The Malaysian Pharmaceutical Society is continuously promoting the However, the final objective of continuing education is to prepare the development of continuing education for pharmacists. This is carried pharmacist to use the best ideas in pharmaceutical care of the moment out in a number of ways. One of them is through the mail. This and that implies also that the pharmacist must expect that those ideas consists of published articles mailed out and the pharmacist is required will be modified or replaced. to answer some questions after reading the article. This mailing reaches out to all pharmacists who are registered with the program. Another Compulsory Continuing Education? way is for the pharmacist to attend seminars/talks organised by the Would CCE automatically result in health care professionals being Society or by pharmaceutical companies that provide the sponsorship. more competent ? While some programs run only for an afternoon on a Sunday, there are others that require one full day, and still others that run over the A community pharmacist may choose to participate in courses, or weekend and even others that take up to four days. Still, other means receive mailed articles, that are unrelated to his daily responsibilities. of continuing education are those run in-house by respective Thus, although the courses may be interesting, they are perhaps at the government institutions or companies, or those that the individual time, irrelevant to the pharmacist. pharmacist undertakes through their own initiative in the country or overseas. Pharmacists may be attending continuing education workshops that are sponsored. They may have participated in continuing education Each year, MPS would invite all those who have participated in these offerings, which were not directly related to their jobs. They chose programs to give a report. And in all these cases, the program is these courses based on various factors like timing, or maybe the evaluated and credits awarded to the pharmacists concerned. venue.

What then if the pharmacist has accumulated all these credit points? Participants may also take any course that is available simply to meet What is the driving force that gets the pharmacist to participate in requirements by any authority or by their employee. continuing education? Some thought towards periodic evaluations was also put forward. Objectives of CE The philosophy and practice of continuing education should be One of the objectives of the continuing education is to protect the learner-centred. The professional should be made to realise the value public from incompetent practitioners, but mandatory continuing of continuing education, which would then motivate him/her to take education does not necessarily or sufficiently ensure this result. It part in the professional development voluntarily, keeping in mind that does not guarantee learning, and the acquisition of knowledge and the following would help : skills does not ensure that they will be applied to improve performance. It is not a matter of whether the professional knows 1. The primary responsibility for learning should rest with the something or not, but more importantly, whether the knowledge gained individual is put to good use. 2. The goals of CE should be concerned with the entire process of professionalization Education may only partially contribute to competence. In what seems 3. CE should be considered part of a process which continues like a deficiency of knowledge or skills can be due to inadequate throughout life equipment, lack of supervision, conflicting expectations or regulations

18 Disclaimer: The information and opinion expressed herein are not necessarily those of the MPS. In addition the inclusion of articles and advertisements does not mean that MPS advocates or rejects its use. VOL 1 • ISSUE 1 • 2003

governing professional performance and many other factors that have In the health care sector, there is actually keen competition to provide little to do with deficiencies in knowledge or skills. If by mandating continuing education to clients by the industry and hence the planners education to assure accountability, then education becomes the end have an incentive to make their programs appealing. Therefore, a rather than the means to competence. Thus alternative ways of mandatory CE with the captive audience does not necessarily mean developing competence and accountability are looked to less and less. less effort is made to develop a challenging and exciting educational experience. Mandating continuing education may actually limit learning. Initially, learning from continuing education may have been considered a Currently, there are extremely wide ranges of educational alternatives. desirable activity, but once mandated, the requirement becomes a There are workshops from a large listing of continuing education necessity and "qualifying" becomes more important than learning. programs including home study offerings either through the mail or through the internet. Therefore, health care professionals can meet People who are motivated to learn are more likely to be better their requirements with little effort. With this variety and flexibility, informed than people who are merely serving time in class. This is pharmacists may choose courses that are most stimulating to them and especially when adults are forced to learn against their own educational settings which best fit their individual preferences. inclinations and desires, the resulting resentment is likely to become a major block to any kind of meaningful learning. Consequently, As a Final Word participation in compulsory continuing education might lead to A CE program should not remain static. Different working increased statistics of adult participation but be characterised by environments demand different requirements. The credit hours and mental absenteeism. content must be appropriate and fitting to the situation. Textbooks and case histories may thus be inappropriate. Other factors like differences And if there is a captive audience, then education may suffer because in personalities, political climates or budget/economic conditions, may there could be less effort given to developing a challenging and significantly alter practice. Therefore, within a specific environment, it exciting educational experience. is much more meaningful to build a curriculum and organise workshops that use a professional's personal experiences as a starting There is also the issue of discrimination. If pharmacists must participate point, engage participants in a collaborative analysis and exploration in a certain number of courses, what happens to those who cannot of these experiences and encourage professionals to reflect continually afford to pay the cost of these educational offerings? The question of on their interpretation of appropriate practice in actual work settings. time and venue of courses could also work against those who may practice away from urban areas. This will give pharmacists less Newer technologies (CD, VCD, computers, internet) now permit the incentive to go to the rural areas where services are lacking. convenience to reach practically any pharmacist in the country be it in their home, workplace and even in their car. Arguments to Support Mandatory Continuing Education One can say that pharmacists need to continue their education in order The whole process of CE has to be evaluated. It is not enough simply to to be competent; the health care that the public receives is in jeopardy ensure that the instructor is appropriately qualified and experienced, if pharmacists fail to remain current in their field; pharmacists can and to measure participants' opinions of instructor performance, or the increase their competencies through education; most pharmacists goals and objectives of courses. Some measure to show that the would not engage in formal learning within their own discipline unless participants' knowledge has in fact been increased is needed. The required to do so; and increased knowledge will result in improved present method of evaluating by just counting hours of attendance is performance of pharmacists. far from sufficient. Some people may just sit there accumulating hours. They may not be able to or inclined to absorb the information or to As it is an inherent responsibility of all pharmacists to keep their apply it in practice. If they choose, they can even sleep or daydream knowledge up-to-date; making the CE mandatory would not make it and still get the credit. Thus, participants should also be evaluated to any different. determine whether or not there has been a successful learning experience. There may be those who oppose mandating continuing education because it limits learning and freedom. However, society often limits It is also necessary to provide motivation to learn as the motivated is individuals' freedom when it is necessary for the good of the public. more likely to learn. Restricting the speed at which one can drive a car or restricting the use of drugs are examples. Certainly, protecting the public from an unknowledgeable professional is necessary.

Since health care is not static but dynamic, individual members of the profession cannot retain their integrity if they themselves remain static.

Participating in continuing education programs also provide additional benefits. These programs can stimulate and enhance the abilities of health care professionals. CE courses provide an opportunity to get away from normal routines and be exposed to new ideas. They can also help prevent burnout and allow networking with professional colleagues.

19 Disclaimer: The information and opinion expressed herein are not necessarily those of the MPS. In addition the inclusion of articles and advertisements does not mean that MPS advocates or rejects its use. Healthy living with no weight gain, Improvement on 13 quality of life issues, Beautiful skin & Improvement in sex life1

For further information, contact: Organon (M) Sdn. Bhd. (73127-H) Tel: 03-8024 0532 Fax: 03-8024 0539 E-mail: [email protected]

Organon (S) Pte Ltd Tel: 02-65467727 Fax: 02-65467737 E-mail: [email protected]

Product Information (Abbreviated) Mercilon tablets for oral use Composition Each pack consists of 21 tablets. Each tablet contains: desogestrel (a progestogen) 0.15 mg, ethinylestradiol (an estrogen) 0.02 mg Indication Oral contraception. Dosage and administration The first tablet of the first pack is taken on the first day of menstruation without interruption for 21 days, followed by a 7-day tablet-free period. Contraindications • Pregnancy • Cardiovascular or cerebrovascular disorders, e.g. thrombophlebitis and thromboembolic processes, or a history of these conditions. • Severe hypertension. • Severe liver disease or a history of this condition if the results of liver function tests have failed to return to normal; cholestatic jaundice; a history of jaundice of pregnancy or jaundice due to the use of steroids; Rotor syndrome and Dubin-Johnson syndrome. • Known or suspected estrogen-dependent tumours. • Endometrial hyperplasia. • Undiagnosed vaginal bleeding. • Porphyria. • Hyperlipoproteinaemia, especially in the presence of other risk factors predisposing to cardiovascular disorders. • A history during pregnancy or previous use of steroids of severe pruritus or herpes gestationis. Interactions Irregular bleeding and reduced reliability may occur when oral contraceptives are used concomitantly with drugs such as anticonvulsants, barbiturates, antibiotics (e.g. tetracyclines, rifampicin, etc.), activated charcoal and certain laxatives. Oral contraceptives may diminish the glucose tolerance and increase the need for insulin or other antidiabetic drugs in diabetics. Adverse reactions The following adverse reactions have been associated with estrogen and / or progestogen therapy: • Genito-urinary tract intermenstrual bleeding, post- medication amenorrhoea, changes in cervical secretion, increase in size of uterine fibromyomata, aggravation of endometriosis, certain vaginal infections, e.g. candidiasis. • Breast tenderness, pain, enlargement, secretion. • Gastro-intestinal tract nausea, vomiting, cholelithiasis, cholestatic jaundice. • Cardiovascular system thrombosis, rise of blood pressure. • Skin chloasma, erythema nodosum, rash. • Eyes discomfort of the cornea if contact lenses are used. • CNS headache, migraine, mood changes. • Various fluid retention, reduced glucose tolerance, change in body weight. Full prescribing information: Available on request.

References: 1. K Diergarten et al. Effect of a desogestrel-containing low-dose oral contraceptive (MERCILON) on quality of life issues in a large observational clinical evaluation in Germany. Gynecol Endocrinol 2000; 14 (Suppl 2): 196, P114.