Contraception

Describe the expanding role of the pharmacist in this area

Multiple states have passed legislation to allow licensed pharmacists to prescribe some hormonal contraceptives

There is a WI bill that would permit pharmacists to prescribe and dispense hormonal contraceptive patches and self administered oral contraceptives with certain procedures in place

List available pharmacologic contraceptive options

Progestin only contracpetives MOA

Thicken cervical mucus, inhibit LH surge, atrophy of endometrial lining, decrease ovum motility

Combined hormonal contraceptions MOA

Same as progestin + Estrogen suppresses ovulation via negative feedback

Explain the difference between typical and perfect use

Typical Use	Perfect Use
Takes into consideration human error and is generally what happens in real life	When a patient uses contraceptive method correctly at ALL times

Combined hormonal contraceptives advantages

• Easy to use

• Rapid reversibility

• Menstrual cycle improvements 

• Decreased risk of iron deficiency anemia

• Can tailor COC to specific patient 

• Suppression of endometriosis

• Reduction of several cancers

Combined hormonal contraceptives disadvantages

• No STI protection

• Patient adherence

• Expense and access

• Side effects 

• Serious adverse effects 

• Menstrual cycle changes

• Drug interactions

benefits of Combined hormonal contraceptives agents beyond prevention of pregnancy

• Acne treatment 

• Hirsutism treatment

• Endometriosis

• Cycle regulation
  Dysmenorrhea

• Anemia
  PCOS
  Premenstrual dysphoric disorder

• Decreased risk of ovarian , uterine and colon cancer

• Transition therapy for perimenopause

Combined hormonal contraceptives side effects

• Abdominal pain

• Chest pain

• Headaches

• Eye problems

• Severe leg pain

Combined hormonal contraceptives contraindications

• Breast cancer

• <21 days postpartum

• Severe cirrhosis

• Acute DVT/PE

• HIgh risk for recurrent DVT/PE

• Major surgery with prolonged immobilization

• Migraine with aura

• Uncontrolled HTN

• Vascular disease

• Ischemic heart disease

• Multiple ASCVD risk factors

• Age >35 >15 cigs/day

• History of stroke

 Describe how estrogenic and androgenic activity change depending on the progestin generation

1st gen	2nd gen	3rd gen	4th gen
Norethindrone	Levonorgestrel	Norgestimate	Drospirenone

*As generation inceases, androgenic activitydecreases and estrogenic activity increases

How to start Norethindrone &Norgesterol containing POP

Start anytime, backuo needed for 48 hours unless started within first 5 days of menstraul cycle

Dose considered missed if >3 hours late

DMPA injection adverse effects

BBW bone loss, signif weight gain, contraindicated in breast cancer

Copper IUD

Lasts 10 years 
Menstrual bleeding increases 35-55%

Insufficient estrogen is associated with….

Early breakthrough bleeding

Insufficient progestin is associated with….

Late breakthrough bleeding (2nd half of cycle)

Excess estrogen is associated with…

N/V, Cyclical Weight gain, Bloating, Fluid retention, Breast tenderness

Excess progestin is associated with…

Acne, Hirsutism, Depression, non cyclical weight gain

Describe how a patient should initiate contraception

First Day- Start COC on first day of menstrual cycle
+No back up needed

Sunday start- Start COC on first sunday after menstrual cycle begins
+standard pack labeling, avoids periods over weekends

Quick Start- Start COC on day that patient received prescription
+increases likelihood that pt starts contraceptive

Describe how a patient should resolve missed doses

1 pill late or missed- take ASAP, OK to take 2 pills on same day

2 or more missed 48 hours- take ASAP, OK to take 2 pills on same day, back up contracpetion until 7 days of adherence

when emergency contraception should be recommended

Used to prevent unintended pregnancy after unprotected sexual intercourse

EC options

Copper &Levonorgestrel IUDs
Levonorgestrel
Ulipristal acetate

EC counseling

N/V, irregular bleeding