Contraceptive care: clinical pearls for pharmacists

A CPhA survey from earlier in 2020 found that over 70% of Canadian women trust pharmacists to screen, prescribe, counsel and provide recommendations for birth control.^1-2 Pharmacists are well positioned to help patients find a contraceptive option that best suits their individual needs so they can take charge of their reproductive health.^1-3 Pharmacists in Alberta, Saskatchewan, Quebec and Nova Scotia can prescribe birth control, but all pharmacists have an important role to play in promoting reproductive health! This two-part series will provide insights into key clinical pearls to incorporate into your practice.

Part 1: Newer Oral Contraceptive Options to Be Aware Of

Addressing Discontinuations of Oral Contraceptives

It’s becoming increasingly common to hear of medications leaving the market and oral contraceptives are no exception. What can be unique is how attached patients feel to their birth control of choice as it is an intimate product with the potential for serious consequences (pregnancies!) if issues arise. As such, proactive communication with patients is key to easing the transition to generics or alternatives.

When facing a discontinuation, proactively identify and recommend the most similar product still available on the market. Since side effects usually diminish with continued use, patients who are stable on one oral contraceptive option will likely have a smoother transition continuing an alternative with a similar constitution.⁴ This can be done by recommending an alternative with a similar amount of estrogen, within the same progestin generation, and which has the same number of phases. If a patient was stable on a triphasic contraceptive option, they may prefer this in their new option as they mimic natural hormone cycles.⁵ Furthermore, finding an alternative with consistent pill appearance is important as differences in medication appearance can cause confusion and lead to lower adherence.^6-8

A recent discontinuation example occurred with Tri-Cyclen®. There were no generic options available until Tri-Jordyna™ 21 and Tri-Jordyna™ 28 came to market in the last few months. Communicating to patients that Tri-Jordyna has the most similar constitution, number of phases, and appearance to Tri-Cyclen® can make the transition as smooth as possible.

Impact of Weight on Emergency Contraceptive Selection

There have been concerns over levonorgestrel emergency contraceptive (e.g., Plan B®) having decreased efficacy in women over 165 to 176 pounds and lack of efficacy in women over 176 pounds.^9,10 Although evidence is inconclusive, there are alternatives that patients may feel more comfortable relying on.

The copper IUD (Mona Lisa®) is the most effective emergency contraceptive, having a failure rate of 0.1%.¹¹ It works primarily by preventing fertilization and implantation, and patient weight does not have an impact on its efficacy.¹¹ It can be used for emergency contraception up to 7 days after intercourse and can be effective even after fertilization has occurred.¹¹

Ulipristal acetate (Ella®) is a hormonal emergency contraceptive pill that has a failure rate of 0.9-2.1%.¹² Compared to Plan B®, Ella® is less impacted by patient weight and more effective, especially in the 72 to 120 hours after intercourse timeframe as it still prevents ovulation after luteinizing hormone surge has started.^12-15 Ella® can be taken up to 5 days post-intercourse but is only effective prior to fertilization.^13,16 As of 2016, Ella® is available in Canada in single dose packages.¹⁷ Having Ella® in stock can improve timely access for patients and bring them relief in difficult situations.

Being aware of newer oral contraceptive options, and having them available at your pharmacy, can had help reduce barriers to reproductive health care for your patients. It can also help build a trusting patient-pharmacist relationship when you’re able to provide guidance at a particularly vulnerable time for patients, such as when hearing of a discontinuation of a relied-on medication or when requiring emergency contraception. The introduction of Tri-Jordyna^TM replaces the long-established Tri-Cyclen®, which patients may have used for years and be looking for an alternative that offers continuity of care. The introduction of unit dose Ella® provides a more accessible packaging for pharmacies to keep on-hand, which patients who weigh more than 165 pounds may feel more confident using for emergency contraception. Read on for part two of this series for key clinical pearls about non-oral contraceptive options and how they can meet unique patient needs.

Part 2: Non-Oral Contraceptive Options to Meet Unique Patient Needs 

Responding to Non-Adherence to Daily Dosing Regimens

Noticing late refills on oral contraception or the purchase of emergency contraception can serve as an opportunity for pharmacists to recommend alternatives that may fit better into a patient’s lifestyle. Newer long-acting options available in Canada include implants (e.g., Nexplanon®), intrauterine devices (IUD) (e.g., Mirena®, Mona Lisa®), and injections (e.g., Depo-Provera®). These options are highly effective with typical use failure rates of 0.1%, 0.1-0.8%, and 4%, for implants, IUDs, and injections, respectively.¹⁸

Nexplanon® is a progestin implant, approved by Health Canada in May 2020 and likely to start becoming available on the Canadian Market in Fall 2020.¹⁹ It is a thin, flexible rod that is inserted into the subdermal layer of the inner upper arm via a minor surgical procedure done in a provider’s office.²⁰ Patients can feel the implant by palpating the area, but it is not easily visible by others.²¹ It is effective for up to 3 years.²² IUDs are progestin-containing or copper devices inserted into the uterus.²³ Progestin-containing IUDs (Mirena®, Kyleena®) are effective for up to 5 years while copper IUDs (Mona Lisa®) are effective for 3-10 years depending on the model.^24,25 Depo-Provera® is an intramuscular injection that is administered every 3 months by a healthcare professional, including pharmacists in jurisdictions where scope allows.²⁵ In contrast to other long-acting options, return to fertility isn’t immediate and can take 8-10 months after the last injection.^25-27

Considerations for Transgender Men and Gender Nonbinary Individuals

A transgender male or gender nonbinary individual with an intact uterus and ovaries can experience pregnancy, even while taking testosterone, and may require contraception.²⁸ Patients may wish to preserve the ability to conceive and carry a child and therefore require reversible options.²⁸ Talk to your patients about their fertility desires and preferred birth control characteristics.

Unique yet important considerations for this patient population include potential concerns about interference with masculinizing hormone therapy and body dysphoria.²⁹ Some patients may be taking masculinizing hormones and worry about feminising effects and antagonistic properties of estrogen. In these cases, non-hormonal contraceptive (e.g. copper IUD) and progestin-only contraceptive (e.g., progestin-only pills, IUD, implant, or injection) may be preferred.³⁰ Some patients may have dysphoria regarding their pelvic anatomy and the process of inserting an IUD may be traumatic and anxiety inducing.²⁹ Implants may be a good alternative as they are inserted into the inner, upper arm.²⁰ Some patients may find taking daily oral contraception or experiencing monthly menstrual bleeding to be a reminder of their sex assigned at birth.³⁰ Progestin injections may be a preferred as they’re administered every 3 months and induce amenorrhea in more than 50% of patients by the first year.²⁵

Maintain a gender affirming approach throughout these conversations.This involves referring to the patient by their preferred name and pronouns.²⁹ It also includes asking the patient for their preferred term to use for body parts (e.g. front-hole) rather than defaulting to medical terms (e.g., vagina).²⁹

There is a vast, and sometimes overwhelming, array of contraceptive options available in Canada. Pharmacists are uniquely poised to proactively intervene to guide patients in selecting the option that best suits their unique needs. Newer long-acting options, like implants (e.g., Nexplanon®), intrauterine devices (e.g., Mirena®, Mona Lisa®), and injections (e.g., Depo-Provera®) may fit better into patients’ busy lifestyles than traditional options that require daily administration. Nexplanon® may also be the contraceptive option of choice for transgender men and gender nonbinary individuals as it doesn’t interfere with masculinizing hormone therapy or require insertion which may traumatic due to potential pelvic anatomy dysphoria.²⁹ Ultimately, it comes down to whichever option best meets your patient’s needs. Use these clinical pearls to be confident in your recommendations and empower your patients to make informed decisions about their reproductive health!

References:

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