By Yifan Zhou, Pharmacy Student & Tiana Tilli, PharmD, RPh, ACPR at Wholehealth Pharmacy Partners
A CPhA survey from earlier this year found that over 70% of Canadian women trust pharmacists to screen, prescribe, counsel and provide recommendations for birth control.1-2 Pharmacists are well positioned to help patients find a contraceptive option that best suits their individual needs so they can take charge of their reproductive health.1-3 Pharmacists in Alberta, Saskatchewan, Quebec and Nova Scotia can prescribe birth control, but all pharmacists have an important role to play in promoting reproductive health! This two-part series will provide insights into key clinical pearls to incorporate into your practice.
Part 1: Newer Oral Contraceptive Options to Be Aware Of
Addressing Discontinuations of Oral Contraceptives
It’s becoming increasingly common to hear of medications leaving the market and oral contraceptives are no exception. What can be unique is how attached patients feel to their birth control of choice as it is an intimate product with the potential for serious consequences (pregnancies!) if issues arise. As such, proactive communication with patients is key to easing the transition to generics or alternatives.
When facing a discontinuation, proactively identify and recommend the most similar product still available on the market. Since side effects usually diminish with continued use, patients who are stable on one oral contraceptive option will likely have a smoother transition continuing an alternative with a similar constitution.4 This can be done by recommending an alternative with a similar amount of estrogen, within the same progestin generation, and which has the same number of phases. If a patient was stable on a triphasic contraceptive option, they may prefer this in their new option as they mimic natural hormone cycles.5 Furthermore, finding an alternative with consistent pill appearance is important as differences in medication appearance can cause confusion and lead to lower adherence.6-8
A recent discontinuation example occurred with Tri-Cyclen®. There were no generic options available until Tri-Jordyna™ 21 and Tri-Jordyna™ 28 came to market in the last few months. Communicating to patients that Tri-Jordyna has the most similar constitution, number of phases, and appearance to Tri-Cyclen® can make the transition as smooth as possible.
Impact of Weight on Emergency Contraceptive Selection
There have been concerns over levonorgestrel emergency contraceptive (e.g., Plan B®) having decreased efficacy in women over 165 to 176 pounds and lack of efficacy in women over 176 pounds.9,10 Although evidence is inconclusive, there are alternatives that patients may feel more comfortable relying on.
The copper IUD (Mona Lisa®) is the most effective emergency contraceptive, having a failure rate of 0.1%.11 It works primarily by preventing fertilization and implantation, and patient weight does not have an impact on its efficacy.11 It can be used for emergency contraception up to 7 days after intercourse and can be effective even after fertilization has occurred.11
Ulipristal acetate (Ella®) is a hormonal emergency contraceptive pill that has a failure rate of 0.9-2.1%.12 Compared to Plan B®, Ella® is less impacted by patient weight and more effective, especially in the 72 to 120 hours after intercourse timeframe as it still prevents ovulation after luteinizing hormone surge has started.12-15 Ella® can be taken up to 5 days post-intercourse but is only effective prior to fertilization.13,16 As of 2016, Ella® is available in Canada in single dose packages.17 Having Ella® in stock can improve timely access for patients and bring them relief in difficult situations.
Being aware of newer oral contraceptive options, and having them available at your pharmacy, can had help reduce barriers to reproductive health care for your patients. It can also help build a trusting patient-pharmacist relationship when you’re able to provide guidance at a particularly vulnerable time for patients, such as when hearing of a discontinuation of a relied-on medication or when requiring emergency contraception. The introduction of Tri-JordynaTM replaces the long-established Tri-Cyclen®, which patients may have used for years and be looking for an alternative that offers continuity of care. The introduction of unit dose Ella® provides a more accessible packaging for pharmacies to keep on-hand, which patients who weigh more than 165 pounds may feel more confident using for emergency contraception. Read on for part two of this series for key clinical pearls about non-oral contraceptive options and how they can meet unique patient needs.
- The Canadian Pharmacists Association. More than one million Canadian women continue to face barriers accessing birth control and other health care services [internet]. Canadian Pharmacists Association. 2020 [cited 2020 June 17]. Available from: https://www.pharmacists.ca/news-events/news/more-than-one-million-canadian-women-continue-to-face-barriers-accessing-birth-control-and-other-health-care-services/?lang=en
- Abacus Data. CPhA – Accessing Treatment for Women’s Health Issues [internet]. Abacus Data. 2020 [cited 2020 June 17]. Available from: https://www.pharmacists.ca/cpha-ca/assets/File/cpha-on-the-issues/CPhA-Women’s-Health-Report-Abacus-Data_Final.pdf
- Vogel, L. Canadian women opting for less effective birth control. CMAJ Jul 2017, 189 (27) E921-E922; DOI: 10.1503/cmaj.1095446
- Barr NG. Managing adverse effects of hormonal contraceptives. American Family Physician. 2010 Dec 15;82(12):1499-506.
- Cohen J. Clinical use of biphasic and triphasic pills. IPPF Med Bull. 1985;19(4):1-2.
- ACOG Committee. Brand versus Generic Oral Contraceptives. The American College of Obstetricians and Gynecologists [internet]. 2019 [cited 2020 June 17]. Available from: https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2007/08/brand-versus-generic-oral-contraceptives
- Lumbreras B, López-Pintor EImpact of changes in pill appearance in the adherence to angiotensin receptor blockers and in the blood pressure levels: a retrospective cohort studyBMJ Open 2017;7:e012586. doi: 10.1136/bmjopen-2016-012586
- Aaron S. Kesselheim, Katsiaryna Bykov, Jerry Avorn, Angela Tong, Michael Doherty, and Niteesh K. Choudhry. Burden of Changes in Pill Appearance for Patients Receiving Generic Cardiovascular Medications After Myocardial Infarction. Annals of Internal Medicine 2014 161:2, 96-103
- Government of Canada Recalls and Safety Alerts. Emergency contraceptive pills to carry warnings for reduced effectiveness in women over a certain body weight [internet]. Government of Canada. 2014 [cited 2020 June 24]. Available from: https://www.healthycanadians.gc.ca/recall-alert-rappel-avis/hc-sc/2014/38701a-eng.php
- Glasier A, Cameron ST, Blithe D, et al. Can we identify women at risk of pregnancy despite using emergency contraception? Data from randomized trials of ulipristal acetate and levonorgestrel. Contraception. 2011;84(4):363-367. doi:10.1016/j.contraception.2011.02.009
- Gemzell-Danielsson K, Berger C, P G L L. Emergency contraception — mechanisms of action. Contraception. 2013;87(3):300-308. doi:10.1016/j.contraception.2012.08.021
- Levy DP, Jager M, Kapp N, Abitbol JL. Ulipristal acetate for emergency contraception: postmarketing experience after use by more than 1 million women. Contraception. 2014 May 1;89(5):431-3.
- Rosato E, Farris M, Bastianelli C. Mechanism of Action of Ulipristal Acetate for Emergency Contraception: A Systematic Review. Front Pharmacol. 2016 Jan 12;6:315. doi: 10.3389/fphar.2015.00315. PMID: 26793107; PMCID: PMC4709420.
- Jamin C. Contraception d’urgence : différence d’efficacité entre lévonorgestrel et ulipristal acétate selon le diamètre folliculaire au moment du rapport non protégé [Emergency contraception: efficacy difference between levonorgestrel and ulipristal acetate depending on the follicular size at the time of an unprotected sexual intercourse]. Gynecol Obstet Fertil. 2015;43(3):242-247. doi:10.1016/j.gyobfe.2015.01.010
- Jatlaoui TC, Curtis KM. Safety and effectiveness data for emergency contraceptive pills among women with obesity: a systematic review. Contraception. 2016;94(6):605-611. doi:10.1016/j.contraception.2016.05.002
- Fine P, Mathé H, Ginde S, Cullins V, Morfesis J, Gainer E. Ulipristal acetate taken 48-120 hours after intercourse for emergency contraception. Obstet Gynecol. 2010;115(2 Pt 1):257-263. doi:10.1097/AOG.0b013e3181c8e2aa