Clinical considerations when supplying emergency contraception


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28 Dec 2017

Community pharmacists can provide women with all the advice they need, says Deborah Evans

Key learning points

  • There are several different emergency contraception options available to women. Pharmacists can help advise patients which one is best for them.
  • Pharmacists should treat women seeking emergency contraception with respect and dignity.
  • The woman’s personal preferences over which emergency contraception is right for her should be taken into consideration

Emergency Contraception (EC) has been available to purchase in community pharmacies since the turn of the century, so many of us are very familiar with providing it to women and confident to make a supply. However, recent changes including updated guidance from the Faculty of Sexual and Reproductive Healthcare (FSRH), changing consumer expectations and advances in technology means that we must review our practice and the experience we give women requesting EC.

New guidance

Clinical guidance published by FSRH in March 2017 provided a clear differentiation in efficacy between the different types of emergency contraception and further information on the impact of body mass index (BMI) on effectiveness.[1]

The guidance made clear that the copper intrauterine device (Cu-IUD) is the most effective form of emergency contraception1 and if a healthcare professional cannot provide it, then women should be signposted to services that can. In this situation, they should supply oral EC to cover the woman in case the Cu-IUD cannot be accessed in time, is contraindicated or it is not what she wants.

In the community pharmacy context, this means that emergency hormonal contraception (EHC) should always be offered (unless not appropriate) alongside information about the effectiveness of the Cu-IUD and where it can be obtained.

What forms of EC can you supply and which types are best suited to different situations?

There are two forms of EHC available to women, those containing levonorgestrel (LNG – Levonelle and own-label generics) and those containing ulipristal acetate (UPA – ellaOne).

The recent updated guidelines from FSRH suggest that EHC providers should consider UPA as first-line if the Cu-IUD is not appropriate or acceptable.1

There are a number of considerations for the supply of EHC:

  1. The woman’s perspective

It is important to consider any preference or view that the woman may have about her treatment. She is likely to be very anxious, might have had previous experience using EC and may have made an assessment about the amount of risk she wishes to take. As healthcare professionals, we must do all that we can to understand what’s important to her and avoid making assumptions about her understanding. We must always avoid making judgements about why she is seeking EC and make the experience the very best we can.

  1. Is the supply within a patient group direction (PGD) or an OTC sale?

If the supply is to be made within a PGD and commissioned service, then the protocol for the PGD will need to be followed. However, pharmacists should be aware that if the PGD is only for LNG that they are professionally obligated to consider the latest available guidance and inform the woman of the difference in efficacy between the Cu-IUD, LNG and UPA so that she can make an informed choice about whether to seek an alternative.

  1. Is UPA or LNG contraindicated?

Neither UPA nor LNG should be offered to women with severe liver dysfunction.2,3 UPA is not suitable for women who have severe asthma treated by oral glucocorticoids or those who have been using ritonavir long term.[2] For those women currently taking or have taken enzyme-inducing medicines in the last 4 weeks, a Cu-IUD should be fitted or a double dose of LNG should be given as the efficacy of UPA and LNG is affected.[3] Severe malabsorption syndromes, such as Crohn’s disease, might impair the efficacy of LNG.3

Women who are breastfeeding and given UPA should be advised not to breastfeed and to discard their milk for seven days.2 For LNG, it is recommended that women should avoid nursing for 8 hours but there is no evidence for adverse effects on the infant or lactation.3

If a woman presenting for EHC has allergies to any ingredients in either type of EHC, or is taking any of the above medications, it is advised that a Cu-IUD is fitted.2,3

UPA is suitable for any woman of child bearing age, including adolescents, whereas LNG is licensed for sale for over 16s only. 

  1. Timing

UPA must be taken within five days (120 hours) of unprotected sex or failure of contraceptive method (UPSI)2 and LNG must be taken within 3 days (72 hours).3

The FSRH guidance recognises that UPA remains effective in delaying ovulation even after the start of the luteinising hormone surge (when ovulation is about to take place) whereas LNG is no longer effective at this point.[4] Therefore, UPA continues to provide pharmacy teams with a suitable option that can be offered to women given that ovulation timing is recognised as being almost impossible to predict.1

  1. Any previous UPSI this cycle or pregnancy

There is no evidence that EHC has an impact on an already established pregnancy. However, it is not intended for use during pregnancy and should not be taken by any woman suspected or known to be pregnant.

  1. Timing of ovulation

Timing of ovulation cannot be determined and therefore where in the menstrual cycle a woman is at the point of UPSI cannot be used to calculate pregnancy risk. If ovulation has already occurred, EHC is no longer effective and so it should be explained that EHC is not always effective at preventing a pregnancy.

EHC should be taken as soon as possible after unprotected intercourse, irrespective of where in her cycle the woman is and she should always be told that Cu-IUD is a more effective option for preventing pregnancy.

  1. Weight

The latest FSRH guidelines note that the efficacy of EHC may be affected by a woman’s weight or BMI. LNG has been found to be less effective in women weighing over 70kg or with a BMI over 26kg/m2 (this accounts for 50% of women in the UK).1 For those women with a higher weight or BMI, UPA can be offered as an alternative if a Cu-IUD is not appropriate or acceptable for women, as it may be less affected by weight. 1

  1. Do you have any safeguarding concerns?

Pharmacy professionals and the pharmacy team are well placed to identify people who may be vulnerable, including children. It is important that all pharmacy staff are aware of, and understand, possible signs of abuse, neglect or exploitation and how to manage these.

  1. Affordability

Pharmacists may feel that the cost of EHC is a barrier for women. However, market research5 shows that women value effectiveness above all other attributes. We should avoid making assumptions about a woman’s ability to pay for EHC but if she wishes to make her choice based on cost then it is important she understands the difference in efficacy of all options. 

Are there any scenarios where it is not appropriate to supply EHC? 

There are very few situations where it is not appropriate to supply EHC and these are mostly stated above. In all cases of supply to those under 16, the Fraser Guidelines should be referred to [5] and the outcome of the conversation must always be documented.

The consultation process provides the opportunity for pharmacists or competent members of the pharmacy team to determine whether there are any reasons why a supply of EHC is not appropriate in addition to providing information so that she might make an informed choice about her options. It also provides the chance to answer any questions or concerns that the woman may have and to provide advice on sexually transmitted infections (STIs) and other public health issues.

In my own clinical practice, I start the consultation by stating that she will be offered EHC unless there is any reason why it is not appropriate or she chooses not to have it. This reassures her and puts her at ease making the consultation feel less like a ‘test’ that she has to ‘pass’ before having access to the medicine that may alleviate her anxiety.

Advice to provide women on preventing pregnancy after supplying EHC

After using both UPA and LNG EHC, it is recommended that women use a local barrier method (e.g. condom, diaphragm, spermicide, cervical cap) until the next menstrual period starts. Although the use of UPA does not contraindicate the continued use of regular hormonal contraception, it may reduce its contraceptive action.2 Therefore, if a woman wishes to start or continue using hormonal oral contraception, she can do so after using UPA but it is important to note that she should be advised to use a reliable barrier method until the next menstrual period.

If vomiting occurs within 3 hours of EHC intake, another tablet should be taken.

As per the latest FSRH guidance, pharmacy team members should also take the opportunity during the consultation, to speak to women about having a regular contraceptive method in place (including the IUD). 1 Women should also be informed about the importance of STI testing after unprotected sex.

After EHC, menstrual periods can sometimes occur a few days earlier or later than expected. If her period does not occur then there is a possibility of pregnancy and a test should be performed. Women should be advised to make an appointment to adopt a method of regular contraception, if this wasn’t in place at the time of the UPSI.

EHC is not as effective as a conventional regular method of contraception and is suitable only as an emergency measure. Women who present for repeated courses of EC should be advised to consider long-term methods of contraception.

Any common side effects of taking EHC and what can be done to ease these

Both UPA and LNG are generally well tolerated, although some women may experience mild symptoms such as: abdominal pain, headache, irregular menstrual bleeding or nausea. Paracetamol 1000mg can be taken if the woman experiences headache or abdominal pain. EHC can be taken with or without food.

Barriers to access

Easy access to EHC is critical to prevent unwanted pregnancies and its availability and advice from pharmacy is a critical support service provided by our profession. There has been some negative press coverage about the experience women have received in pharmacy and the cost of the service [6], driving some women to seek online supply to avoid a difficult conversation.

If a pharmacist chooses not to supply EHC on the basis of religious and moral beliefs then the General Pharmaceutical Council (GPhC) states that the healthcare professional should take steps to make sure the person asking for care is at the centre of their decision-making, so they can access the service they need in a timely manner and without hindrance.7

If EHC is not supplied in these circumstances, (either over the counter or against a prescription) women must always be referred to an alternative appropriate source of supply available within the time limits for EHC to be effective. [7]

Putting the woman first

Although the consultation process can be uncomfortable for both the woman and the pharmacist, it is important to ensure women feel supported and not judged when coming in for help and/or advice on EHC. The best way of doing this is by remaining objective, yet understanding and offering the opportunity to speak privately in the consultation room.

Pharmacists should ensure the entire team is trained to treat patients with respect and sensitivity to ensure women understand all the choices available to them. Finally it is worth remembering that the woman’s experience starts as soon as she realises she may need help and through until she is assured she is not pregnant; we have an important role to support her and make a difference.

Deborah Evans works as community pharmacist and is managing director of pharmacy training and consultancy company, Pharmacy Complete. Deborah advises HRA Pharma, manufacturer of ellaOne, on the use of emergency contraception in community pharmacy. 

References

[1] Faculty of Sexual and reproductive Healthcare. Emergency Contraception CEu Clinical Guidance Document, March 2017. Available from file:///C:/Users/kelli.engel/Downloads/fsrh-guideline-emergency-contraception-mar-2017%20(2).pdf

[2] EllaOne Summary of Product Characteristics accessed November 2017

[3] Levonelle Summary of Product Characteristics accessed November 2017

[4] Glasier AF, Cameron ST, Fine PM et al. The Lancet 2010; 375: 555-562

[5] Fraser Guidelines https://www.nice.org.uk/advice/lgb17/chapter/facts-and-figures#fraser-guidelines

[6] British Pregnancy Advisory Service https://www.justsaynon.org.uk/. Last accessed: November 2017

[7] General Pharmaceutical Council In practice: Guidance on religion, personal values and beliefs June 2017


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