Guest Commentary: Up-to-date Patient Counseling Essential with OC Use
Dr. Kaunitz is professor and associate chairman in the department of obstetrics and gynecology at the University of Florida College of Medicine?Jacksonville.
The need for safe and effective contraception is a priority for all women of reproductive ages, from adolescence through menopause. The dual labeling and OTC availability of Plan B (levonorgestrel 0.75 mg tablets) emergency contraception to patients age 18 and over provided pharmacists with an entr?e to becoming an important contributor to the health care team for reproductive age women seeking/using contraception. OB/GYNs need to communicate more closely with pharmacists in their community to make sure this important emergency method is available to all women who need it when they need it.
Oral contraceptives (OCs) are among the most effective forms of contraception available. With consistent use, annual failure rates with OCs are 1% to 2%. With typical use, the failure rate is 8% overall, however, and is even higher in teens and women in their early 20s. Women using OCs need counseling regarding proper use and instructions regarding missed pills. Pharmacists are in a unique position to provide counseling that reinforces the importance of taking pills every day and missed pill instructions as they have patient contact more frequently than physicians.
The most common mistake women make that leads to pill failure is starting a new pill pack late. By extending the hormone-free (placebo) interval beyond 7 days, there is increased risk for escape ovulation and pregnancy. Retail pharmacies and third-party payors may wish to consider multiple automated reminder programs that would notify women that they need to pick up refills of oral contraceptives well before the pack is due to be completed, in an effort to avoid late starts. New OC products with 91-day regimens may reduce the risk of late starts by decreasing the need to refill 28-day packs up to 16 times per year. A new formulation also is available, which provides continuous active pills; however, this continuous formulation is still dispensed every 4 weeks, necessitating 13 refills per year.
Pharmacists should be aware that oral contraceptives have many noncontraceptive health benefits and may be used for relief of acne, dysfunctional uterine bleeding, and pain from endometriosis, heavy menses associated with uterine fibroids, hormonal headache, and perimenopausal symptoms. Within the population of women who use oral contraceptives, there will be some who use them for contraception only, others who use them only for noncontraceptive benefits, and a third group of women who use OCs for a combination of contraception and health benefits. Women who experience hormone withdrawal symptoms during the 7-day hormone-free interval may benefit from newer products that extend the active pill regimen and shorten or eliminate the hormone-free interval.
OCs do not increase the risk of stroke, heart attack, or breast cancer. All oral contraceptives, however, do increase the risk of venous thromboembolism regardless of age and smoking status. In women older than 35 years who smoke, risks of stroke and heart attack are increased with OC use. In contrast, lean, healthy nonsmoking perimenopausal women can use oral contraceptives until menopause.
Increasing pharmacists' involvement in reproductive health care has the potential to positively impact the lives of a large population of women. Patients served by pharmacists who remain up to date on the new oral contraceptive formulations and encourage consistent use and timely refills may have fewer unintended pregnancies and abortions and experience an improved quality of life due to noncontraceptive OC benefits. Involvement of well-informed pharmacists is welcomed by the reproductive health care team.