Contraception Services

Ways to obtain EHC

  • as P medicine during PGD or OTC

  • as POM via health clinics, GP or hospital

Offer long term options for patients and consider safeguarding issues with empathy → under 13 is considered rape especially if there is age gap or domestic violence etc.

Even if patient is not close to ovulation but still worried and would like it then still supply for patient clarity → unless they are already on the pill then explain it is not required.

During consultation - will need to ask BMI as BMI over 26 reduces efficacy of EC. EllaOne is preferred for higher BMI.

They all can be taken when breastfeeding. and can be taken until menopause.

Levonorgestrel (1500mcg) tablet

AKA LNG-EC → for emergency within 72hrs of intercourse

  • for 16 and over as P

  • under 16 as POM

  • OTC → £10/20

  • if patient has used progesterone (POP) within the last 7 days and requests EC then give levonorgestrel as UPA-EC the efficacy reduces with the extra progesterone

Ulipristal Acetate (30mg)

AKA UPA-EC → for emergency within 120hrs of intercourse and can be given to under 16s

  • EllaOne

  • OTC = £30

  • is a selective progesterone receptor modulator to inhib or delay ovulation → similar structure to progesterone so it binds to receptors instead of progesterone

  • can alter uterine lining so implantation is not achieved

Copper Coil

  • more efficient method and can be used long term too

  • needs to be discussed at consultations

  • can be fitted in at the latest between start of ovulation day and the last day for it be effective (so day 14-19)

Choosing contraceptives:

Combined hormonal:

  • usually for 16-40 year olds due to low risk of CVD.

1st line usually monophasic of ethinylestradiol with either levonogestrel or norethisterone to minimise cardiovascular risks

  • the lower the concentration → the lower the side effects

  • when counselling → include whether is 21 days with HFI or 28 days → note bleeding does not represent menstruation as it only is the uterine lining shedding. But if bleeding is unusual at any point → pregnancy testing should be encouraged.

  • with Drs knowledge and advise → stop during surgery or bed rest or known periods of immobility as this increased risk of DVT

POP

  • menarche until 55 (1st period to menopause)

  • choosing depends on trust pathway but common ones are 30mcg levonorgestrel (28 days with <3hrs missed pill window) and 350mcg norethisterone (28 days with <3hrs missed pill window)

SBA Questions

Question 1

A 17-year-old patient presents to your pharmacy requesting emergency contraception. She had unprotected intercourse 60 hours ago. Her BMI is 30. According to guidelines, what is the most appropriate oral EC to offer?

a) Levonorgestrel (LNG-EC)

b) Ulipristal Acetate (UPA-EC)

c) Either is equally suitable.

d) Neither is suitable; she must be referred for a Copper IUD.

Answer

Answer: b) Ulipristal Acetate (UPA-EC)

Your notes state that for a BMI over 26, "EllaOne is preferred." Furthermore, UPA-EC is effective within a 120-hour window, which covers the 60-hour timeframe.

Question 2

A patient who regularly takes the desogestrel POP (Cerazette) requests emergency contraception after a missed pill incident. Which EC option is LEAST suitable due to a potential reduction in efficacy?

a) Levonorgestrel (LNG-EC)

b) Ulipristal Acetate (UPA-EC)

c) Copper IUD

d) All are equally suitable.

Answer

Answer: b) Ulipristal Acetate (UPA-EC)

Your notes specify: "if patient has used progesterone (POP) within the last 7 days... then give levonorgestrel as UPA-EC the efficacy reduces with the extra progesterone." The desogestrel POP is a progesterone, making UPA-EC less effective.

Question 3

When counselling a patient starting a Combined Oral Contraceptive (COC), which of the following is a crucial point to emphasise?

a) The withdrawal bleed is a true period, confirming they are not pregnant.

b) They must stop the pill during periods of planned immobility, like major surgery.

c) A biphasic pill is always the first-line choice.

d) The pill offers protection against sexually transmitted infections (STIs).

Answer

Answer: b) They must stop the pill during periods of planned immobility, like major surgery.

This is a key safety point from your notes: "stop during surgery or bed rest or known periods of immobility as this increased risk of DVT." Option a is incorrect (it's not a true period), c is incorrect (monophasic is usually 1st line), and d is false.

EMQ

Questions 4-6:

A patient presents for emergency contraception. Select the MOST appropriate management option.

Options:

A. Supply Levonorgestrel (LNG-EC)

B. Supply Ulipristal Acetate (UPA-EC)

C. Refer for Copper IUD

D. Explain that EC is not required

Question 4

A 19-year-old woman, BMI 24, had unprotected sex 90 hours ago. She is not using any regular contraception.

Answer

Answer: B. Supply Ulipristal Acetate (UPA-EC)

The 90-hour timeframe is beyond the 72-hour window for Levonorgestrel but within the 120-hour window for Ulipristal. Her BMI is not a factor for preferring one over the other.

Question 5

A 22-year-old woman, BMI 28, had unprotected sex 24 hours ago. She has been taking a traditional POP (Norgeston) consistently for the past month.

Answer

Answer: A. Supply Levonorgestrel (LNG-EC)

Although her BMI is >26, which would normally make UPA-EC preferred, she is currently taking a progesterone-only pill. Your notes state that in this scenario, Levonorgestrel should be given as UPA-EC's efficacy is reduced.

Question 6

A 25-year-old woman had a condom break last night. She is normally on a COC and has taken all her pills correctly this cycle. She is very anxious and "just wants to be sure."

Answer

Answer: D. Explain that EC is not required

Your notes state: "unless they are already on the pill then explain it is not required." If she has taken her COC correctly, she is protected. The consultation should focus on reassuring her and reinforcing correct pill use.

Clinical Scenarios (OSCE/Patient Style)

Scenario 1: The Anxious Young Patient

Patient: A nervous-looking 15-year-old comes to the counter with a friend. She whispers, "I need the morning-after pill. It happened two days ago."

How do you, as the pharmacist, manage this situation?

* Privacy: "Of course, I can help you with that. Let's go to the consultation room so we can talk in private."

* Safeguarding & Legal Status: In the room, you would establish the facts. "For anyone under 16, this medicine is a prescription-only medication (POM). I can supply it, but I need to ask a few important questions to make sure you are safe and this is the right choice for you. Are you able to speak with your parents or a guardian about this?" (This opens the door to discuss safeguarding. As per your notes, under 13 is a legal safeguarding issue, and for under 16s, factors like age of partner and consent must be considered with empathy).

* Clinical Assessment: Proceed with the standard consultation (timing, BMI, other medications) to determine the most clinically appropriate EC (likely UPA-EC given the 2-day/48-hour timeframe).

* Outcome: "Based on our conversation, the most suitable option for you is Ulipristal (EllaOne). Because of your age, I will need to complete a quick patient group direction (PGD) to supply this to you. It's also really important we talk about finding a regular, long-term contraception and maybe registering with a GP or a youth sexual health service for ongoing support."

Scenario 2: The Post-EC Contraception Discussion

Patient: "Thank you for the EllaOne tablet. I'll take it right now. I really don't want to go through this scare again."

How do you use this opportunity to promote long-term health?

* Empower and Educate: "I'm glad you brought that up. Using emergency contraception is a great chance to think about more regular protection. What are your thoughts on long-term methods?"

* Introduce Options: "We could briefly discuss some options now. There are daily pills, patches, the implant that goes in your arm for 3 years, or coils. The longer-acting methods are very effective because you don't have to remember them every day."

* Provide a Pathway: "The next step would be to book an appointment with your GP or a local sexual health clinic. They can give you a full consultation, discuss all the options in detail, and provide the method that best suits you. Would you like me to help you find the contact details for your nearest clinic?"

Prescription Writing & Knowledge Questions

Question 7:

A GP wishes to prescribe a first-line, monophasic Combined Oral Contraceptive for a 20-year-old patient. Using your notes, what would be a typical prescription? Write the prescription using the generic drug names and a standard 21-day regimen.

Answer

A typical prescription would be:

* Drug: Ethinylestradiol 30micrograms / Levonorgestrel 150micrograms tablets

* Directions: Take one tablet daily for 21 days. Then have a 7-day tablet-free break. Repeat.

(This aligns with your notes: "1st line usually monophasic of ethinylestradiol with either levonogestrel or norethisterone.")

Question 8:

A patient is switching from a traditional POP to the desogestrel POP (Cerazette). What is a critical counselling point regarding the missed pill window for Cerazette compared to a traditional POP?

Answer:

For a *traditional POP** (e.g., Norgeston), the missed pill window is 3 hours. If the pill is >3 hours late, additional precautions are needed.

For the *desogestrel POP (Cerazette)**, the missed pill window is 12 hours. If the pill is >12 hours late, additional precautions are needed.

You must ensure the patient understands this new, longer window for their new medication.

Question 9:

A prescription for a Progesterone-Only Pill is appropriate for a patient from menarche to menopause. Write a prescription for a 28-day pack of Norethisterone POP, including the necessary caution for missed doses.

Answer:

* Drug: Norethisterone 350micrograms tablets

* Directions: Take one tablet daily at the same time each day without a break. Start the next pack immediately after finishing the current one.

* **Counselling Point (to be included):** If you are more than 3 hours late in taking your pill, take it as soon as you remember and use an additional barrier method (e.g., condoms) for the next 2 days.