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MALAYSIAN STATISTICS ON MEDICINES 2007

USE OF GYNAECOLOGICALS, SEX HORMONES AND HORMONAL CHAPTER 12 | CONTRACEPTIVES

J. Ravindran1, Nik Nasri2, Ghazali I.3, Wan Abu Bakar4, Tham S.W.5, J. Ravichandran6, Zaridah S.7, W. Zahanim W.Y.8, Intan S.S.1, Tan A.L.1

1. Kuala Lumpur Hospital 2. Universiti Sains Islam Malaysia 3. Sultan Ismail Hospital, Johor Bahru, 4. Sultanah Nur Zahirah Hospital, Kuala Terengganu, 5. Tuanku Ja’afar Hospital, Seremban 6. Sultanah Aminah Hospital, Johor Bahru, 7. Tuanku Fauziah Hospital, Kangar, 8. Kuala Krai Hospital

There has been lack of a comprehensive review on the use of gynaecological, sex hormone and hormonal contraceptive drugs in the Malaysian literature.1

The use of gynaecological anti-infectives and was 0.1976 DDD/1000 population/ day in 2007; other gynaecologicals was 0.0946 DDD/1000 population/day whereas sex hormones and modulators of the genital system showed a marked increase to 8.1348 DDD/1000 population/day.

Overall usage of anti-infectives and antiseptics showed a slight decrease from the previous year. This may be due to the common used in gynaecological practice being captured in other codes of the ATC Classification system. An example would be the total lack of data in the public hospital system and the insignificant use of (G01A F01), which is a widely used for anaerobic in gynaecological practice.

The use of showed a marked reduction in both the public and private sector. On the other hand, the use of doubled due to its ease of use. There has been a significant reduction in the utilisation of methylergometrine and ergometrine, which are drugs used in the third stage of labour and in the management of post-partum haemorrhage.2,3

Misoprostol is a drug that is licensed for peptic ulcer disease but it has been used “off-label” in Obstetrics and Gynaecology (O&G) practice for cervical priming, termination of pregnancy, induction of labour and postpartum haemorrhage.4 There has been very little use of this drug in the public sector as it has not been included in the Ministry of Health Drug Formulary. However, its use in the private sector has increased from 0.0016 to 0.0027 DDD/1000 population/day. The data is not sufficient to clarify for which indication it has been used in the private sector. There is a role for considering its use in the medical management of miscarriage as evidenced by current O&G guidelines.

Preterm labour complicates up to 15% of pregnancies.5 The majority of drugs used in labour suppression are used “off-label”. As such the burden of this complication and the drugs used in its management are not captured comprehensively in the NMUS; examples would be , and . The use of the only registered drug for labour suppression, ,5 was negligible.

Bromocriptine was still the most prevalent prolactin inhibitor used. The use of showed a decline in 2007 in both the public and private sectors. However, a reversal in this trend is to be expected in future due to worries of cardiovascular complications and the risk of concurrent use of antihypertensives with .6

Hormonal contraceptives for systemic use showed a marked increase in utilisation from 4.4113 to 5.8766 DDD/1000 population/day. This rise was contributed significantly by an increase in the usage of fixed combination progestogens and oestrogens, particularly levonorgestrel and oestrogen as well as drospirenone and oestrogen.

In general, the use of progestogens decreased slightly from 0.8777 to 0.8691 DDD/1000 population/day. However, the usage of etonogestrel declined significantly from 0.4533 to 0.0651 DDD/1000 population/day. This decline was reflected in both public and private sector usage. This may have significant implications in the provision of effective contraception with regards to reduction of maternal mortality in high risk mothers.

The usage of oestrogens more than doubled from 0.2309 to 0.5289 DDD/1000 population/day. This rise was due to an increase in both estradiol as well as conjugated oestrogen. Concerns about the implication of hormone replacement therapy and breast malignancy, may have led to the increased utilisation of tibolone seen in 2007. 7

The usage of gonadotropins and other ovulation stimulants showed a decline from 0.3619 to 0.3187 DDD/1000 population/day. This reduction is in contrast to the increasing number of centres providing Assisted Reproductive Technology. The majority of such centres are in the private sector and the response rate to the NMUS may have contributed to this apparent decline.

There has been a near doubling in the usage of cyproterone and oestrogens. This may be due to the increased burden of polycystic ovarian syndrome (PCOS).8

Certain significant changes in prescribing patterns have been noticed in NMUS 2007 as compared to 2006. The reasons for these are not entirely clear. They may be due to an increasing disease burden, cost of drugs, availability of drugs in public sector prescribing systems, and the development of Clinical Practice Guidelines. Better quality data from the private prescribers is essential for meaningful analysis and trending for future reports. 62 63 MALAYSIAN STATISTICS ON MEDICINES 2007 CHAPTER 12 | USE OF GYNAECOLOGICALS, SEX HORMONES AND HORMONAL CONTRACEPTIVES

Table 12.1 : Use of Gynaecologicals, Sex Hormones and Hormonal Contraceptives, in DDD/1000 opulation/day 2006-2007 ATC Drug Class 2006 2007 G01 Gynaecological anti-infectives and antiseptics 0.2124 0.1976 G02 Other gynecologicals 0.0731 0.0946 G03 Sex hormones and modulators of the genital system 6.3615 8.1348

Table 12.2.1 : Use of Gynaecologicals, Sex Hormones and Hormonal Contraceptives by Drug Class,in DDD/1000 population/day 2006-2007 ATC Drug Class 2006 2007 G01A Anti-infectives and antiseptics, excl. combinations with corticosteroids 0.2124 0.1976 G01A A Antibiotics 0.0648 0.0089 G01A C derivatives - - G01A D Organic acids - - G01A F derivatives 0.1476 0.1885 G01A G derivatives - - G01A X Other anti-infectives and antiseptics - 0.0001 G02A Oxytocics 0.0515 0.0408 G02A B Ergot alkaloids 0.0059 0.0022 G02A D Prostaglandins 0.0457 0.0386 G02C Other gynaecologicals 0.0215 0.0538 G02C A Sympathomimetics, labour repressants - <0.0001 G02C B Prolactine inhibitors 0.0215 0.0537 G02C X Other gynaecologicals <0.0001 <0.0001 G03A Hormonal contraceptives for systemic use 4.4113 5.8766 G03A A Progestogens and oestrogens, fixed combinations 2.6072 4.4199 G03A B Progestogens and oestrogens, sequential preparations 0.0388 0.0611 G03A C Progestogens 1.7654 1.3956 G03B Androgens 0.0267 0.0266 G03B A 3-oxoandrosten (4) derivatives 0.0245 0.0262 G03B B 5-androstanon (3) derivatives 0.0022 0.0005 G03C Oestrogens 0.2309 0.5289 G03C A Natural and semisynthetic oestrogens, plain 0.1336 0.4245 G03C B Synthetic oestrogens, plain - - G03C X Other oestrogens 0.0973 0.1045 G03D Progestogens 0.8777 0.8691 G03D A Pregnen (4) derivatives 0.3673 0.3689 G03D B Pregnadien derivatives 0.1996 0.1913 G03D C Estren derivatives 0.3108 0.3089 G03F Progestogens and oestrogens in combination 0.2108 0.2268 G03F A Progestogens and oestrogens, fixed combinations 0.0754 0.0544 G03F B Progestogens and oestrogens, sequential preparations 0.1354 0.1725 G03G Gonadotropins and other ovulation stimulants 0.3619 0.3187 G03G A Gonadotropins 0.0342 0.0211 G03G B Ovulation stimulants, synthetic 0.3277 0.2976 G03H Antiandrogens 0.0878 0.1421 G03H A Antiandrogens, plain 0.0130 0.0081 G03H B Antiandrogens and oestrogens 0.0748 0.1339 G03X Other sex hormones and modulators of the genital system 0.1544 0.1460 G03X A Antigonadotropins and similar agents 0.0251 0.0183 G03X C Selective oestrogen receptor modulators 0.1293 0.1277

64 65 CHAPTER 12 | USE OF GYNAECOLOGICALS, SEX HORMONES AND HORMONAL CONTRACEPTIVES MALAYSIAN STATISTICS ON MEDICINES 2007

Table 12.2.2 : Use of Gynaecologicals, Sex Hormones & Hormonal Contraceptives by Drug Class & Agents, in DDD/1000 population/day 2006-2007 ATC Drug Class and Agents Sector 2006 2007 G01A A Antibiotics Public 0.0596 0.0051 G01A A01 Nystatin Private 0.0040 0.0038 Total 0.0636 0.0089 Public - - G01A A03 Private 0.0012 <0.0001 Total 0.0012 <0.0001 Public - - G01A A10 Clindamycin Private <0.0001 - Total <0.0001 - G01A C Quinoline derivatives Public - - G01A C03 Private - - Total - - G01A D Organic acids Public - - G01A D03 Ascorbic acid Private - - Total - - G01A F Imidazole derivatives Public 0.0539 - G01A F01 Metronidazole Private 0.0003 <0.0001 Total 0.0543 <0.0001 Public 0.0216 0.0716 G01A F02 Clotrimazole Private 0.0585 0.1031 Total 0.0801 0.1747 Public - - G01A F04 Private 0.0035 0.0059 Total 0.0035 0.0059 Public - - G01A F05 Private 0.0069 0.0064 Total 0.0069 0.0064 Public - - G01A F07 Private - - Total - - Public - <0.0001 G01A F08 Tioconazole Private 0.0024 0.0014 Total 0.0024 0.0015 Public - - G01A F11 Private 0.0004 - Total 0.0004 - Public - - G01A F15 Private - <0.0001 Total - <0.0001 G01A G Triazole derivatives Public - - G01A G02 Private - - Total - - 64 65 MALAYSIAN STATISTICS ON MEDICINES 2007 CHAPTER 12 | USE OF GYNAECOLOGICALS, SEX HORMONES AND HORMONAL CONTRACEPTIVES

ATC Drug Class and Agents Sector 2006 2007 G01A X Other antiinfectives and antiseptics Public - <0.0001 G01A X03 Policresulen Private - <0.0001 Total - 0.0001 Public - - G01A X05 Nifuratel Private - - Total - - Public - - G01A X11 Povidone-iodine Private - - Total - - G02A B Ergot alkaloids Public - - G02A B01 Methylergometrine Private 0.0025 0.0015 Total 0.0025 0.0015 Public 0.0030 0.0007 G02A B03 Ergometrine Private 0.0004 <0.0001 Total 0.0034 0.0008 G02A D Prostaglandins Public 0.0391 0.0337 G02A D02 Dinoprostone Private 0.0050 0.0035 Total 0.0441 0.0372 Public 0.0014 0.0012 G02A D03 Gemeprost Private 0.0001 <0.0001 Total 0.0015 0.0013 Public <0.0001 <0.0001 G02A D04 Carboprost Private - <0.0001 Total <0.0001 <0.0001 Public - - G02A D05 Sulprostone Private <0.0001 - Total <0.0001 - Public <0.0001 <0.0001 G02A D06 Misoprostol Private 0.0016 0.0027 Total 0.0016 0.0028 G02C A Sympathomimetics, labour repressants Public - <0.0001 G02C A01 Ritodrine Private - - Total - <0.0001 G02C B Prolactine inhibitors Public 0.0019 0.0444 G02C B01 Bromocriptine Private 0.0155 0.0058 Total 0.0173 0.0502 Public - - G02C B02 Lisuride Private - - Total - - Public 0.0024 0.0020 G02C B03 Cabergoline Private 0.0018 0.0014 Total 0.0042 0.0035

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ATC Drug Class and Agents Sector 2006 2007 G02C X Other gynaecologicals Public - <0.0001 G02C X01 Atosiban Private <0.0001 <0.0001 Total <0.0001 <0.0001 G03A A Progestogens and oestrogens, fixed combinations Public 0.8155 1.3678 G03A A07 Levonorgestrel and oestrogen Private 0.6838 1.2585 Total 1.4993 2.6263 Public 0.3506 0.4085 G03A A09 Desogestrel and oestrogen Private 0.5492 0.7718 Total 0.8998 1.1802 Public 0.0002 0.0002 G03A A10 Gestodene and oestrogen Private 0.1087 0.3519 Total 0.1088 0.3522 Public 0.0043 0.0035 G03A A12 Drospirenone and oestrogen Private 0.0949 0.2577 Total 0.0992 0.2612 G03A B Progestogens and oestrogens, sequential preparations Public - - G03A B03 Levonorgestrel and oestrogen Private 0.0388 0.0611 Total 0.0388 0.0611 G03A C Progestogens Public 0.1393 0.1271 G03A C01 Norethisterone Private 0.2283 0.3753 Total 0.3676 0.5025 Public 0.1516 0.1240 G03A C06 Medroxyprogesterone Private 0.7930 0.7041 Total 0.9445 0.8281 Public 0.0785 0.0126 G03A C08 Etonogestrel Private 0.3748 0.0525 Total 0.4533 0.0651 G03B A 3-oxoandrosten (4) derivatives Public 0.0112 0.0112 G03B A03 Testosterone Private 0.0133 0.0150 Total 0.0245 0.0262 G03B B 5-androstanon (3) derivatives Public - - G03B B01 Mesterolone Private 0.0022 0.0005 Total 0.0022 0.0005 G03C A Natural and semisynthetic oestrogens, plain Public - <0.0001 G03C A01 Ethinyloestradiol Private - - Total - <0.0001 Public 0.0323 0.0453 G03C A03 Oestradiol Private 0.0406 0.0701 Total 0.0729 0.1154 Public - - G03C A04 Oestriol Private - - Total - -

66 67 MALAYSIAN STATISTICS ON MEDICINES 2007 CHAPTER 12 | USE OF GYNAECOLOGICALS, SEX HORMONES AND HORMONAL CONTRACEPTIVES

ATC Drug Class and Agents Sector 2006 2007 G03C A Natural and semisynthetic oestrogens, plain Public - - G03C A06 Chlorotrianisene Private - - Total - - Public - - G03C A07 Oestrone Private - - Total - - Public 0.0466 0.1844 G03C A57 Conjugated oestrogens Private 0.0141 0.1247 Total 0.0607 0.3090 G03C B Synthetic oestrogens, plain Public - - G03C B01 Dienestrol Private - - Total - - Public - - G03C B02 Diethylstilbestrol Private - - Total - - G03C X Other oestrogens Public 0.0470 0.0482 G03C X01 Tibolone Private 0.0503 0.0563 Total 0.0973 0.1045 G03D A Pregnen (4) derivatives Public - - G03D A01 Gestonorone Private - - Total - - Public 0.3014 0.3087 G03D A02 Medroxyprogesterone Private 0.0400 0.0228 Total 0.3414 0.3314 Public 0.0005 0.0004 G03D A03 Hydroxyprogesterone Private 0.0153 0.0335 Total 0.0159 0.0339 Public 0.0002 0.0001 G03D A04 Progesterone Private 0.0099 0.0035 Total 0.0101 0.0036 G03D B Pregnadien derivatives Public 0.1031 0.1076 G03D B01 Dydrogesterone Private 0.0965 0.0689 Total 0.1996 0.1765 Public - - G03D B02 Megestrol Private - 0.0148 Total - 0.0148 G03D C Estren derivatives Public - - G03D C01 Allylestrenol Private 0.0070 0.0116 Total 0.0070 0.0116 Public 0.0223 0.0151 G03D C02 Norethisterone Private 0.2815 0.2823 Total 0.3038 0.2974 Public - - G03D C03 Lynestrenol Private - - Total - -

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ATC Drug Class and Agents Sector 2006 2007 G03F A Progestogens and oestrogens, fixed combinations Public 0.0135 0.0066 G03F A01 Norethisterone and oestrogen Private 0.0203 0.0078 Total 0.0339 0.0144 Public 0.0279 0.0348 G03F A12 Medroxyprogesterone and oestrogen Private 0.0023 0.0007 Total 0.0302 0.0355 Public 0.0032 0.0025 G03F A14 Dydrogesterone and oestrogen Private 0.0082 0.0018 Total 0.0113 0.0044 G03F B Progestogens and oestrogens, sequential preparations Public 0.0709 0.0798 G03F B01 Norgestrel and oestrogen Private 0.0155 0.0394 Total 0.0864 0.1192 Public <0.0001 - G03F B05 Norethisterone and oestrogen Private 0.0014 0.0069 Total 0.0014 0.0069 Public 0.0240 0.0016 G03F B06 Medroxyprogesterone and oestrogen Private 0.0007 0.0037 Total 0.0247 0.0053 Public 0.0006 - G03F B07 Medrogestone and oestrogen Private - - Total 0.0006 - Public 0.0081 0.0202 G03F B08 Dydrogesterone and oestrogen Private 0.0142 0.0209 Total 0.0223 0.0410 G03G A Gonadotropins Public 0.0122 0.0131 G03G A01 Chorionic gonadotrophin Private 0.0183 0.0048 Total 0.0305 0.0179 Public - - G03G A02 Human menopausal gonadotrophin Private 0.0003 0.0001 Total 0.0003 0.0001 Public - - G03G A04 Urofollitropin Private - 0.0001 Total - 0.0001 Public 0.0009 0.0010 G03G A05 Follitropin alfa Private 0.0008 0.0004 Total 0.0018 0.0014 Public 0.0007 0.0011 G03G A06 Follitropin beta Private 0.0009 0.0004 Total 0.0016 0.0015 Public - - G03G A07 Lutropin alfa Private <0.0001 <0.0001 Total <0.0001 <0.0001 Public - <0.0001 G03G A08 Choriogonadotropin alfa Private <0.0001 <0.0001 Total <0.0001 <0.0001

68 69 MALAYSIAN STATISTICS ON MEDICINES 2007

ATC Drug Class and Agents Sector 2006 2007 G03G B Ovulation stimulants, synthetic Public 0.1178 0.1141 G03G B02 Clomifene Private 0.2098 0.1836 Total 0.3277 0.2976 G03H A Antiandrogens, plain Public 0.0111 0.0061 G03H A01 Cyproterone Private 0.0019 0.0020 Total 0.0130 0.0081 G03H B Antiandrogens and oestrogens Public 0.0110 0.0268 G03H B01 Cyproterone and oestrogen Private 0.0638 0.1072 Total 0.0748 0.1339 G03X A Antigonadotropins and similar agents Public 0.0156 0.0112 G03X A01 Danazol Private 0.0080 0.0046 Total 0.0237 0.0158 Public 0.0012 0.0005 G03X A02 Gestrinone Private 0.0003 0.0020 Total 0.0014 0.0025 G03X C Selective oestrogen receptor modulators Public 0.0646 0.0638 G03X C01 Raloxifene Private 0.0647 0.0639 Total 0.1293 0.1277

References:

1. Pharmaceutical Services Division & Clinical Research Centre. Malaysian Statistics on Medicines 2006. Chapter 12. Ministry of Health Malaysia 2009 2. Division of Family Health Development. Report on the Confidential Enquiry into Maternal Deaths in Malaysia 2001 – 2005. Ministry of Health Malaysia 3. Division of Family Health Development. Training Manual on Postpartum Haemorrhage 2005 (revised). BPKK/CEMC/03.05. Ministry of Health Malaysia. 4. Royal College of Obstetricians and Gynaecologists. The Management of Early Pregnancy Loss. Green-top Guideline No.25 October 2006 5. Royal College of Obstetricians and Gynaecologists. Tocolytic Drugs for Women in Preterm Labour. Clinical Guideline No. 1(B) October 2002 6. Fertility and Maternal Health Drugs Advisory Committee. The use of Bromocriptine for the Prevention of Postpartum Breast Engorgement. Volume II, June 1989 7. Erel et al. Tibolone and Breast Cancer. Postgraduate Med. J; 2006; 82: 658 – 662 8. Royal College of Obstetricians and Gynaecologists. Long Term Consequences of Polycystic Ovary Syndrome. Green-top Guideline No.33 December 2007

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