1.18: Hormonal contraception- from emergency coverage to long-term therapy
At the end of this case, students will be able to:
- Identify currently available emergency contraception (EC) products and their role in current practice
- Describe key differences, including efficacy and adverse effects, between different EC options currently available in the market
- Assess cost and ethical considerations related to EC
- Identify necessary patient assessments before prescribing or administration of hormonal contraceptives
- Determine an appropriate contraception plan using a patient case considering the patient’s age, social habits, underlying disease states, and current medications
- Identify important counseling points to provide to patients for safe and effective use of contraception
Introduction
Since the first emergency contraceptive (EC) pills were approved by the Food and Drug Administration (FDA) in the 1990s, advancements have led to several methods that are currently available to prevent pregnancy after unprotected or inadequately protected sexual intercourse. Despite this, 45% of pregnancies in the United States remain unintended. 1 This is primarily due to barriers to access and lack of awareness among women about their own risk of unintended pregnancy as well as safe and effective use of contraception. 2
Levonorgestrel (Plan B ® , My Choice ® , Take Action TM , etc.) is the only EC that is available over the counter to anyone regardless of age or gender and without parental consent. Ulipristal acetate (Ella ® ), copper intrauterine device (Cu-IUD, ParaGard ® ), and combined oral estrogen-progestin regimen (the Yuzpe method) are all EC methods that require a prescription. 2 ,3, 4 Additionally, the Cu-IUD requires insertion by a trained healthcare professional. Both levonorgestrel and ulipristal have been shown to be less effective in patients who are overweight or obese, a concern considering more than 60% of adult patients in the US are overweight or obese. 4 All EC options can be used within five days of unprotected intercourse; however, levonorgestrel efficacy may decrease after 72 hours.
Prescription-only EC methods create major barriers to access as it delays care and can be a time consuming and expensive process. Pharmacies across the nation who have elected to prohibit dispensing of ECs or allow their pharmacists to refuse to dispense pose another barrier. From an ethical standpoint, it is important for healthcare professionals to understand the underlying mechanism of action of the EC methods so it is not confused with medical abortion methods. EC is effective in preventing pregnancy only before implantation phase, which means EC would not terminate an existing pregnancy. 2
Use of EC products can be especially beneficial in specific circumstances, such as in the case of missed dose(s) or drug-drug interaction where oral contraceptive efficacy is compromised. However, use of EC products as a primary contraceptive method is not recommended. 5 Consistent use of EC as a primary method of contraception is not as effective as combined oral contraceptives (COC), can cause increased menstrual irregularities, and is often more expensive. Further, despite its availability during the past 20 years, there is limited data to show that EC availability has decreased pregnancy rates. 2 Twenty-five percent of women who are at risk for unintended pregnancy in the US experience challenges in obtaining a primary contraceptive method (e.g., difficulty obtaining a visit with a physician, inconvenient clinic hours or not desiring a pelvic exam). 6
As of 2021, fifteen states allow pharmacists to prescribe oral contraceptives, and more states are working on legislation. 7,8 Pharmacists must be prepared with adequate knowledge of necessary patient-assessment processes; differences between pharmacotherapy products’ efficacy, safety, side effects, and drug interactions; and rules and regulations surrounding their prescribing activities. The US Medical Eligibility Criteria (MEC) and Selected Practice Recommendations (SPR) published by the CDC guide appropriate selection of contraception products for patients seeking contraception based on comorbidities, efficacy, and other factors. 9,10
Case (part 1)
You are a pharmacist in a community pharmacy in a rural area.
CC: “My boyfriend and I had sex last night and didn’t use a condom. Do you have that pill I can take?”
Patient: RG is a 19-year-old college sophomore that has been coming to your pharmacy for the last year and a half for her sumatriptan and levothyroxine. Today, she presents looking a little pale and uncomfortable. She waits for the line at the pharmacy counter to die down before coming up to speak to you.
HPI: RG has been dating her current boyfriend for two years and they began having consensual monogamous sexual intercourse a few months prior. They have used condoms in the past but ran out and hadn’t stopped at the pharmacy to pick up more. RG reports this was her first time having unprotected sex.
PMH: hypothyroidism (2 years); headaches (1-2/month)
FH:
- Mother: alive (55 years), HTN and hypothyroidism
- Father: alive (58 years), HTN
SH:
- Current sophomore studying electrical engineering at a public university
- Drinks socially 3-4 drinks every other weekend
- Denies use of nicotine, illicit substances, and non-prescribed medications.
SDH: Uninsured. Works part time at the campus bookstore. Lives in campus housing. Does not have a car on campus. Current PCP is located 6 hours away.
Medications:
- Sumatriptan 100 mg by mouth at onset of headache (may repeat if headache persists after 2 hours)
- Levothyroxine 88 mcg by mouth daily
Allergies: NKDA
Labs:
- BP 124/82 mmHg
- HR 68 bpm
Case Questions
- One of the largest barriers to contraceptive care is the ability to access medications. How might RG struggle to access contraception? How might current laws and ethical principles factor into access to care?
- RG does not have insurance and cannot afford the cost of Plan B? What options are available to help minimize costs?
- RG mentions she has heard some emergency contraception can cause an abortion. How would you respond to this?
- Based on access, cost and patient concerns, what would be an appropriate recommendation for RG?
Case (part 2)
RG returns to the community pharmacy to initiate a hormonal contraceptive after seeking her third course of EC in three months. She just finished her menstrual cycle and has not had unprotected sex since she last saw you for her EC. RG has one sexual partner and is in a committed relationship. She has never taken an oral contraceptive due to cost as she is uninsured and due to fears that it would make her gain weight.
Many of her friends who started OCs when she was a teenager told her they made them gain 15-20 lbs. She reports using EC is becoming expensive and her boyfriend doesn’t like using condoms. RG wants to know if there is an affordable oral contraceptive she can start – she heard that pharmacists can now prescribe contraceptives.
RG has never taken any daily medications and is worried that she may struggle to remember taking a pill but doesn’t think she would like the ring product. She reports that her menstrual cycle is fairly heavy and some of her friends told her their oral contraceptive shortens their period to every few months. RG would like to use one of these products to help alleviate symptoms of her menstrual cycle but wonders if there are any health risks associated with that.
Case Questions
- What family history and/or past medical history would be significant to collect in your assessment for RG? Why?
- What factors should be considered when assisting RG in choosing an appropriate contraceptive method?
- If RG had a PMH of VTE instead of migraines, how would her contraception selection and health risks from contraceptives change?
- How could RG’s cultural or religious beliefs impact her contraception preference, use, and adherence?
Author Commentary
The development of safe, effective contraception is widely considered to be one of the greatest public health achievements of the 20 th century. 11 There are an increasing number of safe and effective choices for contraceptive methods to reduce the risk for an unintended pregnancy, however with this comes an increasing need for healthcare providers’ knowledge of evidence-based guidance to offer quality family planning care. This includes choosing the most appropriate contraceptive method, counseling on appropriate and consistent use of the contraceptive, and identification and resolution of adverse effect and adherence challenges. In addition to tolerability, accessibility and affordability of contraception should be ensured. Contraception recommendations by family medicine physicians were found to be inconsistent with CDC guidelines 23% of the time for oral contraceptives and 40% of the time for intrauterine devices (IUDs). The Direct Access study was the first study to evaluate the use of a collaborative drug therapy protocol by pharmacists for contraception prescribing. 12 It demonstrated that community pharmacists have the knowledge and skill to adequately screen female patients seeking contraception and select the most appropriate product to meet individualized patient needs. 12 ,13
EC is an effective option for those who do not desire pregnancy if taken up to 120 hours from unprotected or inadequately protected sexual intercourse. The CDC US MEC for contraceptive use (2010) includes no medical conditions in which the risks of EC outweigh the benefits. 9,10 Thus, all women should be offered or made available EC when requested and should not be delayed waiting for pregnancy testing. Pharmacists can dispense and counsel patients on appropriate use of these products as well as improve access through knowledge of the laws and ethical considerations pertaining to these products. Pharmacists should make an effort to minimize barriers to dispensing of ECs and refer the patient to a colleague if morally conflicted.
Patient Approaches and Opportunities
Pharmacists working in community and ambulatory care settings can and should screen all female patients for contraception use and access. Pharmacists should be aware of US MEC and SPR guidance published by the CDC that are available online and available as mobile applications for quick access. Using these and other resources available including online access to contraception, females should be provided with an appropriate contraceptive method that is safe, effective, and affordable. They should also be well educated on what to do in the setting of missed doses, adverse effects (e.g., breakthrough bleeding), and drug-drug interactions. Pharmacists have the knowledge and opportunity to provide education and counseling on EC and non-contraceptive risks and benefits. Online and application-based services are also available to access contraceptives (e.g. PillClub, NuRx).
In addition to decreasing the risk of unintended pregnancy, many contraceptive methods reduce the risk of endometrial and ovarian cancers, are therapeutic agents for menstrual-related disorders and have other benefits. 14 ,15 Women should be empowered with the necessary education and counseling to make a shared decision in which method, if any, to use to prevent pregnancy and/or to ameliorate or treat symptoms related to their menses.
Related chapters of interest:
- From belly to baby: preparing for a healthy pregnancy
- More than just diet and exercise: social determinants of health and well-being
- An ounce of prevention: pharmacy applications of the USPSTF guidelines
- Sex education: counseling patients from various cultural backgrounds
- Digging deeper: improving health communication with patients
- PrEPare yourself: let’s talk about sex
External resources:
- Practice Bulletin No. 152. Emergency Contraception from Obstetrics and Gynecology. https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2015/09/emergency-contraception
- Planned Parenthood. https://www.plannedparenthood.org/
- United States (US) Medical Eligibility Criteria (MEC) for Contraception Use, 2016. https://www.cdc.gov/reproductivehealth/contraception/mmwr/mec/summary.html
- US Selected Practice Recommendations (SPR) for Contraception Use, 2016. https://www.cdc.gov/mmwr/volumes/65/rr/rr6504a1.htm
- Birth Control Pharmacist. https://birthcontrolpharmacist.com/
References
- Finer LB, Zolna MR. Declines in Unintended Pregnancy in the United States, 2008-2011. N Engl J Med . 2016 Mar 3;374(9):843-52.
- Trussell J, Raymond E, Cleland K. 2017. Emergency Contraception: A Last Chance to Prevent Unintended Pregnancy.
- Practice Bulletin No. 152: Emergency Contraception. Obstet Gynecol . 2015 Sep;126(3):e1-11.
- Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Division of Population Health. BRFSS Prevalence & Trends Data [online]. 2015. https://www.cdc.gov/brfss/brfssprevalence/index.html . Accessed Nov 21, 2018.
- Halpern V, Raymond EG, Lopez LM. Repeated use of pre- and postcoital hormonal contraception for prevention of pregnancy. Cochrane Systematic Review 2014 Sep 26;(9): CD007595.
- Landau SC, Tapias MP, McGhee BT. Birth control within reach: a national survey on women’s attitudes towards and interest in pharmacy access to hormonal contraception. Contraception 2006;74(6):463-470.
- Mospan CM. Prescribing oral contraceptives: a new pharmacist role. US Pharmacist 2018 https://journalce.powerpak.com/ce/prescribing-oral-contraceptives-a-new . Accessed Nov 21, 2018.
- National Alliance of State Pharmacy Associations. Pharmacist prescribing: Hormonal contraceptives. https://naspa.us/resource/contraceptives/ Accessed January 19, 2020.
- Curtis KM, Tepper NK, Jatlaoui TC, et al. U.S. Medical criteria for contraceptive use, 2016. MMWR Recomm Rep . 2016;65(4):1-66.
- Curtis KM, Jatlaoui TC, Tepper NK, et al. U.S. Selected practice recommendations for contraceptive use, 2016. MMWR Recomm Rep . 2016;65(4):1-66.
- Centers for Disease Control and Prevention. Achievements in public health, 1990-1999: family planning. MMWR Morb Mortal Wkly Rep. 1999;48:1073-1080.
- Gardner JS, Miller L, Downing DF, et al. Pharmacist prescribing of hormonal contraceptives: results of the Direct Access study. J Am Pharm Assoc . 2008;48:212-221.
- Wu JP, Gundersen DA, Pickle S. Are the contraceptive recommendations of family medicine educators evidence-based? A CERA survey. Fam Med 2016;48(5):345-352.
- Shulman LP. The state of hormonal contraception today: benefits and risks of hormonal contraceptives: combined estrogen and progestin contraceptives. AJOG 2011;S9-13.
- Maguire K, Westhoff C. The state of hormonal contraception today: established and emerging non-contraceptive health benefits. Am J Obstet Gynecol . 2011;205(suppl 4):S4-8.