PMY3304- CONTRACEPTION 1: MOA

What is the role of the pharmacist with contraception?

• appropriately prescribe/supply contraception and emergency contraception, including otc products and via Pharmacy First service

• provide evidence-based information about the various contraceptive methods to enable shared decision making and informed choices. Raise awareness of Long-Acting Reversible Contraception (LARC)

• Counsel patients on safe and effective use of contraception and emergency contraception

• ascertain and manage drug interactions

• participate in medicines review and/or audits and service evaluations. Remember that new conditions, lifestyle changes, and increasing age will affect ongoing contraception choice.

• promote safer sexual practices, and the importance of self-checks (breast) and engaging with screening and STI services as appropriate.

give a brief overview of the menstrual cycle

• Luteinising Hormone (LH) and follicle-stimulating hormone (FSH) are secreted by anterior pituitary gland whereas oestrogen and progesterone are secreted by the ovaries. There are monthly changes and a complex neuroendocrine feedback loop

what is the main purpose of the menstrual cycle?

to release an egg, and to subsequently prepare the endometrium for implantation (if the egg is fertilised)

what happens at the beginning of each menstrual cycle?

at the beginning of menstruation, the level of FSH increases causing the development of follicles within the ovary (follicular phase). This leads to maturation of the ovum and stimulation of the ovary to produce oestrogen (specifically oestradiol)

what does increased levels of oestrogen in the menstrual cycle result in?

results in the release of LH

what is LH responsible for?

responsible for the final maturation of the follicle and release of the egg at ovulation

what happens if there is no fertilisation in the menstrual cycle?

assuming there is no fertilisation, the large concentration of LH causes the empty follicle to develop into the corpus luteum which secretes oestrogen and progesterone over the next 11 to 12 days (luteal phase)

what happens around day 27 of the menstrual cycle?

the levels of oestrogen and progesterone fall and menstruation commences soon after. the ovum and endometrial lining are discarded during menstruation

What is amenorrhoea?

the absence or cessation of menstruation, there are two types — primary and secondary

what is dysmenorrhoea?

is painful cramping, usually in the lower abdomen, which occurs shortly before and/or during menstruation. There are two types —primary and secondary

what is an ectopic pregnancy?

a fertilised ovum implanting and maturing outside the uterine cavity. Most implant in the fallopian tube

what is endometriosis?

growth of endometrium-like tissue outside the uterus. Endometriotic deposits are most commonly distributed in sites such as the pelvis, ovaries, peritoneum, and uterosacral ligaments. Endometriosis is associated with menstruation and can lead to chronic inflammation and scar tissue formation.

what is menarche?

the first menstrual period; the establishment of menstruation

what is menorrhagia (heavy menstrual bleeding)?

excessive menstrual blood loss which interferes with a woman’s physical, social, emotional, and/or material quality of life

what is Mittelschmerz pain?

benign mid-cycle ovulation pain

what contraception is available in the UK?

CHC- COC pill, transdermal patch, and vaginal ring

POP, progestogen only implant, progestogen only injectable

Intrauterine- progestogen only (LNG-IUD and Cu-IUD)

Barrier methods- male condom, female condom, and diaphragm or cap (plus spermicide)

Natural family planning methods- fertility awareness methods (FAM) and the lactational amenorrhoea method (LAM)

Sterilisation methods- male sterilisation (vasectomy), female sterilisation (tubal occlusion)

what is bridging contraception?

offered if a woman’s choice of contraceptive method is not available or is not appropriate when the woman presents. Quick starting as bridging contraception is outside the product license in many instances although it is supported by the Faculty of Sexual and Reproductive Healthcare (FSRH)

what is emergency contraception?

prevents unintended pregnancy after unprotected sexual intercourse or contraceptive failure

what does the FSRH clinical guidance recommends providers who cannot offer all EC methods?

should give women information regarding the other methods and signpost them to services that can provide them

how does Cu-IUD work as emergency contraception?

inhibition of fertilisation through the (toxic) effect of copper on the ovum and sperm. Copper in the cervical mucus also inhibits the passage of sperm into the upper reproductive tract. Cu-IUD also causes also causes an inflammatory response within the endometrium, which could impair impantation. Cu-IUD is effective immediately following insertion

how does levonorgestrel 1.5mg oral tablet (prescription only and various P medicine products) work?

mainly prevents ovulation and fertilisation if intercourse has taken place in the preovulatory phase, when the likelihood of fertilisation is the highest. It is not effective once the process of implantation has begun.

how does Ulipristal acetate 30mg oral tablet work?

ellaOne P medicine- synthetic selective progesterone receptor modulator: inhibits or delays ovulation via suppression of the luteinising hormone (LH) surge

where are levonorgestrel EC and ulipristal acetate EC available?

available OTC and via pharmacy first- EHC

What is the most effective method of emergency contraception and how is it used?

• Cu-IUD is most effective, it can be inserted up to 5 days after the first unprotected sexual intercourse in a natural menstrual cycle, or up to 5 days after the earliest likely date of ovulation (whichever is later). A Cu-IUD provides effective ongoing contraception and the effectiveness is not known to be affected by weight or BMI (unlike oral EC). Cu-IUD doesn’t have the same interaction profile as oral EC.

what should be done when the Cu-IUD is not appropriate for EC?

if Cu-IUD is not appropriate, advise about oral EC after assessing its suitability, including the requirement for it to be taken as soon as possible. Ulipristal acetaate EC has been demonstrated to be effective for EC up to 120 hours after unprotected sexual intercourse. Levonorgestrel EC is licensed for up to 72 hours after unprotected sexual intercourse (evidence suggests it is ineffective if taken more than 96 hours after)

what is the most effective oral EC?

Ulipristal acetate EC has been demonstrated to be more effective than Levonorgestrel EC. The available evidence suggests that oral EC administered after ovulation is ineffective

what should be considered when assessing suitability of emergency contraception?

• SELF AND AGE

• SYMPTOMS

• MEDICINES

• MEDICAL CONDITIONS

• PREGNANT/BF?

• EXTRA MEDICINES

• TIME

• HISTORY

• OTHER SYMPTOMS

• DANGER

What should be assessed in terms of self and age before giving EC?

safeguarding assessment/ legal age of consent/ fraser guidelines

what should be assessed in terms of symptoms for EC?

adapt questions to why they deem emergency contraception is necessary

what should be assessed in terms of medicines for EC?

including medicines taken in the last four weeks and if already using/ taking regular contraception

what should be assessed in terms of medical conditions for EC?

e.g. conditions that could affect absorption, liver problems, severe asthma controlled by glucocorticoids

what should be considered in terms of extra medicines for EC?

tried EC before (used it since last period/used it within this cycle already?)

what should be considered in terms of time for EC?

when did this occur— levonorgestrel EC is licensed for up to 72 hours of unprotected sexual intercourse whereas ulipristal acetate is licensed for up to 120 hours

what should be considered in terms of medical history for EC?

BMI (as this can affect effectiveness), allergies

what other symptoms should be considered for EC?

e.g. symptoms of a STI

what should be considered in terms of danger for EC?

safeguarding assessment (sexual/domestic abuse, rape, and non-consensual sex)

what are the key counselling points for levonorgestrel EC and ulipristal acetate EC?

• how and when to take (dose and directions)

• side-effects

• what to do if they vomit within 3 hours of taking

• signs of an ectopic pregnancy (e.g. lower abdominal pain)

• when to expect the next menstrual period and what to do if is late, and when to do a pregnancy test

• ongoing contraceptive/protection

• when regular contraception can be recommended

• STI risk, safer sex practices, and next steps

what is the mechanism of action of CHC?

• act primarily to inhibit ovulation. Oestrogen and progestogen components cause reduced production of luteinizing hormone (LH) and follicle stimulating hormone (FSH). Without surge, ovulation does not occur.

• have contraceptive effects on cervical mucus and endometrium

• the oestrogen component of the CHC causes the endometrium to proliferate and grow. The progestogen component of the CHC prevents hyperplasia (excessive growth) of the endometrium by opposing the effects of oestrogen

how do progestogen only pills work?

• increase the volume and viscosity of cervical mucus, thereby preventing sperm penetration into the upper reproductive tract. They suppress ovulation in varying degrees. They also reduce the number and size of endometrial glands preventing implantation, and reduce the activity of cilia in the fallopian tube.

how does the progestogen only implant work?

inhibits ovulation. Causes changes in cervical mucus (preventing sperm penetration)

how do progestogen only injectables work?

medroxyprogesterone acetete and norethisterone enantate

• inhibits ovulation and causes changes in the cervical mucus (preventing sperm penetration). In addition, changes to the endometrium make it an unfavourable environment for implantation

what is the MOA of LNG-IUD and Cu-IUD?

there is potential for them to interfere with implantation, their mane mode of action is pre-fertilisation effects

LNG-IUD- progestogenic effects on the endometrium and cervical mucus. most women will continue to ovulate while using this. Effective for contraception 7 days after insertion.

Cu-IUD- inhibition of fertilisation through the effect of copper on the ovum and sperm. Copper in the cervial mucus also inhibits the passage of sperm into the upper reproductive tract. An inflammatory response within the endometrium could impair impantation. Effective immediately following insertion.

what is the MOA of male and female condoms?

provide a barrier to ejaculate, pre-ejaculate, cervicovaginal secretions

can be used as a primary method of contraception or as an additional method

reduce the risk of STIs and HIV

the use of condoms lubricated with spermicide is NOT recommended

Various products (e.g. petroleum jelly) are likely to damage condoms made from latex

what is the MOA of diaphragms and cervical caps?

• provide a barrier to sperm reaching the cervix

• when inserted correctly, they fit into the vagina to cover the cervix. As only the cervix is covered by these methods, they do not prevent exposure of the vaginal mucosa to semen or exposure of the penis to cervicovaginal secretions.

• to be used in conjunction with a spermicide. The spermicide is held against the cervix by the diaphragm or cap and provides a chemical barrier to sperm

• various products like petroleum jelly are likely to damage diaphragms or caps made from latex

what is the MOA of male sterilisation?

operation is called a vasectomy, can be achieved by the interruption of the vas deferens, preventing sperm from entering the ejaculate

male sterilisation is not effective immediately

what is the MOA of female sterilisation?

the operation to sterilise a woman is called tubal occlusion. can be achieved by the occlusion or interruption of the fallopian tubes, preventing fertilisation

what are the two main types of natural family planning?

fertility awareness methods and lactational amennorhoea methods

is the withdrawal method recommended?

coitus interruptus- not advised as a method of contraception on its own, or as an alternative to abstinence or condom use, in women using fertility indicators to avoid pregnancy

how does FAM work?

involves monitoring and recording fertility indicators such as the woman’s:

• basal body (waking) temperature

• changes in cervical secretions and the cervix

• length of menstrual cycle

how do LAM work?

involves BF after childbirth to prevent pregnancy (breastfeeding delays the return of ovulation)

the following conditions must all be met:

• complete amenorrhoea

• fully or nearly fully breastfeeding (85% or more of its feeds are coming from breast milk)

• less than 6 months postpartum

what should be considered in term of a general assessment for contraception suitability?

• self and age

• medical conditions/co-morbidities

• pregnancy or BF

• medication

• history

• other

• danger

what should be considered in terms of self and age when assessing suitability of contraception?

for example >50 years old, <18 years old, and particularly <16 years old

what should be considered in terms of medication before starting a patient on contraception?

what regular medications, including liver enzyme-inducing drugs in the last 4 weeks

what history should be considered before prescribing a patient contraception?

• lifestyle factors (smoking)

• known allergies (latex or anaesthetics, medical history e.g. cancer), reproductive history (postpartum/breastfeeding) and future plans

what else should be considered before prescribing a patient with contraception?

STIs, testing and/or refer for sexual health counselling. Determine if the woman is up-to-date /engaging with screening/smear services and if there is any unexplained vaginal bleeding

what is Gillick competent?

people aged 16 or over are entitled to consent to their own treatment. This can only be overruled in exceptional circumstances. Children under the age of 16 can consent to their own treatment if they’re believed to have enough intelligence, competence and understanding to fully appreciate what’s involved in their treatment

when should fraser guidelines be used?

if a girl younger than 16 years of age requests contraception without parental consent, assess her competency to consent to treatment and document whether she meets/does not meet the requirements of the fraser guidelines following the template under the pharmacy first scheme

what should be done if a woman with learning and/or physical disabilities requests contraception?

support her to make her own decisions. If the woman cannot understand/take responsibility, carers and other involved parties should work together about the woman’s contraceptive need and establish a care plan