Hormonal Contraceptive Prescribing By Pharmacists: A Brief Overview
Pharmacists in all practice settings have opportunities to assist patients who use or seek to use contraception.
Pharmacists in all practice settings have opportunities to assist patients who use or seek to use contraception. In community pharmacies, pharmacists have the important role of providing the patient with the necessary information on how to safely, and effectively use their contraceptive method. This involvement may begin during pharmacy visits to obtain OTC methods, such as condoms or emergency contraception or conversations about contraceptive methods, as the patient explores their possible options. Pharmacists then provide medication counseling, and education as the patient initiates their contraceptive and ongoing assessment of adherence, and tolerability with subsequent refills.
Pharmacists practicing in team-based care environments are also poised to assist the patient, and their care team in the selection of an agent that takes into account the patient’s concomitant drug therapies, and potential risks, and benefits of hormonal therapy given comorbid conditions.
In states where it is allowed, pharmacists may provide contraception directly to patients. In these practices, pharmacists assess the patient’s appropriateness for contraception, provide education on selecting and using a method, and provide the patient with access by furnishing or prescribing a contraceptive.
The opportunities for pharmacists to directly provide hormonal contraception through a state protocol or collaborative practice agreement (CPA) is rapidly growing. Protocols permit all pharmacists within the state to potentially prescribe or furnish contraceptives, similar to the statewide protocols for other public health issues (e.g. naloxone) seen in many states. Other states permit pharmacist provided contraception through a CPA which limits prescribing to pharmacists who have entered into a formal agreement with a medical provider.
As of April 2018, 6 states have pharmacist provided contraception in place with potential for several more states to follow with proposed legislative action. A handful of states have already passed legislation but are awaiting the writing of final rules and regulations.
The CDC publishes, and consistently updates evidence-based guidelines, and practice recommendations for clinicians regarding contraceptive use on their website. The Medical Eligibility Guidelines for Contraceptives (MEC) serves as a resource for recommendations on safe use of contraceptive methods for patients with various medical conditions and other characteristics, such as age or smoking history. The Selected Practice Recommendations (SPR) are intended to be a resource for clinicians providing evidence-based clinical guidance about the use of hormonal contraceptive methods once medical eligibility has been determined. The SPR also includes clinical guidance intended to reduce medical barriers to contraception access and appropriate use. Both the MEC and SPR are endorsed by American College of Obstetricians and Gynecologists, and the North American Society for Pediatric and Adolescent Gynecology.
The MEC summary chart is condensed to a 2-page color coded document organized by a listing of conditions or characteristics vertically, and the various types of contraceptive methods horizontally. The most effective methods are listed first and the less effective methods are listed last.
The CDC also publishes a very comprehensive summary of the MEC recommendations. When you see an asterisk in the MEC chart, you can reference the full summary for more information.
The SPR addresses a select group of common, yet sometimes controversial or complex, issues regarding initiation and use of specific contraceptive methods. The recommendations in this report are intended to serve as a source of clinical guidance for health care providers, and provide evidence-based guidance to reduce medical barriers to contraception access and use. The US SPR is arranged by contraceptive method and is subdivided into recommendations, such as how to start a method, whether backup is needed, how to manage side effects or missed doses, etc. The guidance is provided both within the text document and summarized in user-friendly charts to guide providers on how to counsel patients for all methods.
The contraception consultation begins with a health history, which will identify conditions or characteristics related to the safety of hormonal contraceptive. Most pharmacist-based programs include an assessment questionnaire containing the most important screening criteria for safety purposes, and to be reasonably certain that the patient is not pregnant.
A physical exam, and laboratory studies are not needed for the methods that a pharmacist would be initiating. The pharmacist should refer to another health care provider for preventative health care follow up. Blood pressure measurement should be taken by the pharmacist during this consultation. Uncontrolled or high blood pressure may pose an increased risk or be a contraindication to selection of the method. Weight does not need to be measured for a pharmacist to initiate hormonal contraception. However, the contraceptive patch may not be as effective in patients weighing greater than 90 kg and recording of baseline weight may be useful during follow up visits. In general hormonal contraceptives except medroxyprogesterone acetate are considered to be weight neutral. Self-reported weight is acceptable.
The updated CDC Contraception app is available for smartphones, and tablets with easy navigation between the 2 sets of guidance. It also easily links to other CDC guidance, such as STD treatment guidelines. Many providers who use smartphones for other clinical references find this to be the easiest way to access the guidelines in everyday practice. Pharmacists can also sign up for email alerts to be up to date with any new guidance updates or new tools released from CDC.
Pharmacists who engage in providing contraction should use the Joint Commission of Pharmacy Practitioners Pharmacist’s Patient Care Process to ensure quality and consistency of care. Each of the steps in the process are listed below with hormonal contraceptive specific considerations.
Pharmacists in all practice settings can use the CDC resources to provide guidance in the selection, use and monitoring of contraceptive therapy and many will find these tools to be useful in handling common questions or problems encountered in practice. Patients can greatly benefit from pharmacists who are proactive as a resource for contraception related care.