Tailoring Contraceptive Use

In this episode, TRC Healthcare editor, Sara Klockars, PharmD, BCPS, discusses tailoring contraceptive use in certain populations based on updated US medical eligibility criteria, patient preferences, and medical history. 

This is an excerpt from our October 2024 Pharmacy Essential Updates continuing education webinar series.

The clinical resources mentioned during the podcast are part of a subscription to Pharmacist’s Letter, Pharmacy Technician’s Letter, and Prescriber Insights: 

• Article: Consider Medical History When Recommending a Contraceptive
• Chart: Comparison of Oral Contraceptives and Non-Oral Alternatives
• Chart: Choosing a Contraceptive and Emergency Contraception

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Transcript

This transcript is automatically generated. 

00:00:04 Narrator

Welcome to Clinical Capsules, your go-to podcast and trusted source for quick, evidence-based insights from TRC Healthcare. 

00:00:12 Narrator

For four decades, we've been keeping healthcare professionals at the forefront of drug information and medical knowledge, and now we're bringing these vital clinical updates right to your ears every 2nd and 4th Tuesday - delivering practical, actionable takeaways in bite-sized episodes.

00:00:29 Narrator

Today, Associate Editor and Clinical Pharmacist Sara Klockars examines tailoring contraceptive use in certain populations in an excerpt from our popular Pharmacy Essential Updates webinar series. 

Let’s dive in…

00:00:48 Sara Klockars

And as our article says, we're getting questions about tailoring contraceptives for special populations due to CDC's updated US medical eligibility criteria, plus pharmacists in over 30 states can now provide contraceptives, and this has been evolving in recent years.

00:01:08 Sara Klockars

But regardless of whether your state allows this, we often get lots of questions about hormonal contraceptives, so this is a great opportunity to refresh your memories and help with safe contraceptive use.

00:01:22 Sara Klockars

So, let's kick things off with the case. Nikki is a 31-year-old and she comes to the pharmacy asking about a pill. Until now, she's been using condoms as her main form of birth control, but now she's been in a relationship for several months, so she thought the pill might be a better choice. So, what questions should you ask her? What's your next step?

00:01:44 Sara Klockars

For the pharmacist… what information do you want to know to help recommend a safe contraceptive? 

00:01:50 Sara Klockars

So, to get ourselves on the same page about the various contraceptives available when it comes to safe use, we often put contraceptives into three buckets.

00:02:01 Sara Klockars

We have non hormonal options, and these options include the copper containing intrauterine device, or IUD.

00:02:08 Sara Klockars

Barrier methods such as condoms or diaphragms and then behavioral methods such as fertility awareness-based methods.

00:02:19 Sara Klockars

Then we have two main groups of our hormonal options., we have combined hormonal contraceptives, which contain both an estrogen and a progestin, and these include combo oral contraceptives, hormonal patches like zulane, and then rings like NuvaRing. 

00:02:36 Sara Klockars

And then there are progestin only contraceptives which do not contain an estrogen. And these include oral progestin only pills like norethindrone, the injectable depomedrol, oxy progesterone or depopulate era. And then the implant added norgestrel or nexplanon and then intrauterine devices, or IUD's, with levonorgestrel such as Marina.

00:03:02 Sara Klockars

So, when sorting through all of the options, we can tailor our recommendations based on patient preferences and then their medical history and comorbidities, and then just narrowing from there.

00:03:13 Sara Klockars

So, let's briefly review that first bucket about considering patient preferences. As we know, deciding on which contraceptive option relies on shared decision making with the patient.

00:03:24 Sara Klockars

And there are many factors we can consider and discuss with patients, things like efficacy or maybe they have a preferred dosage form, and we have to think about adherence along with other considerations like cost or side effects and then ultimately have that discussion with the patient and it's the patient’s decision.

00:03:45 Sara Klockars

So, moving on to that second bucket, we need to think about some background information in the patients’ medical history. The patient's medical history may guide which contraceptive to use. For example, using oral contraceptives to treat acne or to help control heavy bleeding. But then their medical history can also determine if certain products need to be ruled out due to possible risks or safety concerns. And this is where we're going to spend most of our time today.

00:04:15 Sara Klockars

And that brings us to a recent update of the US medical eligibility criteria or what you may hear as called the MEC for contraceptive use. It's the first full update since 2016.

00:04:30 Sara Klockars

The MEC provides recommendations for the use of specific contraceptive methods by persons who have certain characteristics or medical conditions, and it's just available to help guide safe use and help us weigh those risks and benefits of the different contraceptive options out there.

00:04:50 Sara Klockars

Some of you may be familiar with the MEC summary table, but let's take a minute to review how this table is set up. And to Orient you, the conditions are on the left, and the contraceptive option abbreviations are across the top, and then we have numbers and colors in the table with the key at the bottom.

00:05:09 Sara Klockars

So, for instance…the #1 or bright green means no restriction and the method can be used. A 2 means advantages generally outweigh risks. 3 means risks usually outweigh advantages and then #4 or dark pink means unacceptable health risk and the method should not be used.

00:05:33 Sara Klockars

So, if a patient has current breast cancer, we see mostly fours, so we should avoid most contraceptive options. And then in the green box with the one is the safer option for this patient and that's the non-hormonal copper containing IUD. Since breast cancer can be hormone sensitive, we're going to want to avoid all those other hormonal options.

00:06:00 Sara Klockars

So, when evaluating a patient per contraceptive, some of the big questions we want to address involve the patient's health history. We'd want to know the patient's pregnancy status, or if they're breastfeeding, if they've ever had breast cancer or blood clot or stroke, we also want to know if they smoke cigarettes or if patients get migraines. It's also important to ask about medications or supplements. And then we want to make sure we document any pertinent findings in the patient’s profile.

00:06:32 Sara Klockars

If you're one of the pharmacists involved in prescribing contraceptives, you may be familiar with your state’s questionnaire and this example is taken from the Colorado State Board of Pharmacy approved statewide protocol for prescribing contraceptives. And it's a collaborative pharmacy practice statewide protocol authorizing qualified Colorado licensed pharmacists to perform the pertinent physical assessments and prescribe contraceptives under the conditions of the protocol.

00:06:58 Sara Klockars

And part of this protocol includes a self-screening questionnaire, which includes the questions we just reviewed in many others. And it also includes an algorithm to help guide safe use based on those patient specific conditions in medical history. 

00:07:12 Sara Klockars

So, this is just one example but be sure to check out your local legislation for the most accurate and up-to-date information for your state, and then just also keep in mind to follow your pharmacy policies and procedures as well.

00:07:27 Sara Klockars

So, after we get the patients’ answers, we want to continue to screen patients for contraindications. So, for example, we wouldn't recommend an ID for a patient with acute pelvic inflammatory disease.

00:07:39 Sara Klockars

Or for patients with history, breast cancer or other hormone sensitive cancers, we should avoid all those hormonal contraceptives, since those hormones may promote cancer growth. 

00:07:49 Sara Klockars

And then just keep in mind that estrogen increases level of clotting factors. Progestins, modulate estrogens affects and so we want to avoid combined hormonal contraceptives in patients with a history of blood clots, stroke, heart attack and we also want to lean away from estrogen containing contraceptives as risk factors stack up and those risks for thrombosis increase. 

00:08:17 Sara Klockars

So let's talk about some contraceptive considerations. For patients with certain characteristics or medical conditions, and then discuss which contraceptive options are safer for certain populations. 

00:08:31 Sara Klockars

For patients on hemodialysis, peritoneal dialysis, or with current nephrotic syndrome, we'd want to suggest a safer option of a copper or levonorgestrel IUD, an implant or a progestin only pill without drospirenone, especially in a patient with a history of high potassium. We would not want to use a drospirenone containing progestin only pill in a patient with elevated potassium. 

00:08:59 Sara Klockars

And we'd want to avoid combo hormonal contraceptives, since patients with severe CKD or nephrotic syndrome are at a higher risk of blood clots or thrombosis, than the general population. 

00:09:13 Sara Klockars

We'd also try to avoid depomedrol oxy progesterones, since in some populations this injectable has been associated with increased risk for thrombosis compared to non-users of depomedrol oxy progesterone. 

00:09:30 Sara Klockars

For most patients with diabetes, any form of contraception is acceptable. But if patients have microvascular disease, which is nephropathy or kidney disease, retinopathy or neuropathy, or other vascular disease, or if they've had diabetes for over 20 years, we should lean toward the safer options of a copper or levonorgestrel IUD implant or progestin only pill since these patients may be at risk of cardiovascular events or blood clots, especially if patients have other risk factors present. 

00:10:11 Sara Klockars

For patients with hypertension or high blood pressure alone, even if it's controlled on medications, or for patients with multiple risk factors for heart attack or stroke, such as hypertension, older age, smoking, diabetes, we do want to try and avoid combined hormonal contraceptives. The safer options to consider include an IUD implant or progestin only pill. 

00:10:43 Sara Klockars

And then risk with contraceptive use in patients with obesity is lacking robust data. Overall, we do need to consider cardiovascular and clot risk for each individual patient as these risk factors stack up, there might be an increased risk of thrombosis. And we'd want to lean away from estrogen containing options if those risks outweigh potential benefits. But with the evidence we have most forms of contraceptives are acceptable in patients with a BMI of 30 or higher. And are a category, one or two on the US MEC. 

00:11:24 Sara Klockars

There's no good comparative evidence on the risk of venous thromboembolism or blood clots among contraceptive patch or ring users by weight or BMI. But patches might have a higher blood clot risk and per package labeling are contraindicated in patients with a BMI of 30 or higher. 

00:11:48 Sara Klockars

When it comes to those who smoke, any contraceptive is acceptable, if there are no other risk factors for thrombosis…if they're underage 35 years. 

00:12:02 Sara Klockars

But for patients who are 35 or over, we want to stick with the progestin only or non-hormonal option combo OC users who smoked are at an increased risk of cardiovascular disease, especially heart attack compared to non-smokers. There's also an increased risk of heart attack with increasing number of cigarettes smoked per day. 

00:12:26 Sara Klockars

For patients with active or prior blood clots, usually consider a copper or levonorgestrel IUD and implant or progestin only pill. We do want to watch for exceptions. For example, a patient with an active claw on anticoagulants may also be experiencing heavy menstrual bleeding. So they may be on a combo OC to help limit that heavy bleeding, but generally if stopping a therapeutic dose of an anticoagulant, we'd usually consider a change to an IUD implant or progestin only pill to limit any clotting risk. 

00:13:11 Sara Klockars

And then patients are at risk of blood clots for several weeks after giving birth. So evaluating other risks of blood clots is necessary, such as smoking, obesity, prior history, blood clots. And if a contraceptive is needed right after giving birth, we'd want to recommend a progestin only option. That's where the IUD and plant injectable or pill come into place, or we would recommend a non-hormonal option such as the copper IUD. 

00:13:46 Sara Klockars

And then when it comes to combined hormonal contraceptives, we generally want to wait until after at least six weeks postpartum on clotting risk is closer to baseline, but if there are no other risk factors for blood clots, patients can consider combined hormonal contraceptives after 21 days, if they're not breastfeeding or after 30 days postpartum, if they are breastfeeding and we want to just keep in mind that combination contraceptives can also decrease milk supply if breastfeeding. 

00:14:23 Sara Klockars

Another consideration is interactions with other meds the patient is taking. So for example, some meds such as phenytoin or rifampin, can reduce the efficacy of any pill, patch or ring. So it's good to ensure patient profiles include all medications and supplements to help the pharmacist screen for interactions. 

00:14:44 Sara Klockars

So now let's say. You've gone through this whole process with Nikki. She doesn't really have a preference on what contraceptive she uses. She's heard about the pill from friends. She doesn't smoke, but she does have high blood pressure, controlled on daily lisinopril hydrochlorothiazide. She doesn't have any other risk factors for blood clots or heart disease. As we discussed earlier, patients with hypertension should generally avoid combined hormonal contraceptives, so she's not a great candidate for the patch, the ring or combo oral contraceptive. 

00:15:21 Sara Klockars

I think we'd want to discuss safer options with her, such as a progestin only option or an IUD, and then we can use the US MEC to double check and see that the IUD implant and progestin only pillar, a category 1. Depomedrol oxy progesterone is a category 2, but combined hormonal contraceptives are category 3, so we can guide her toward the safer options. 

00:15:47 Sara Klockars

And this case just reinforces that it's important to individualize your recommendations based on the patients risk. 

00:15:55 Sara Klockars

So now to wrap up this discussion with a few quick practice pearls, we can continue to ensure patient profiles are current with medical conditions, smoking status, pregnancy or breastfeeding status medications. And then the pharmacist will use this information to help weigh those risks and benefits of options. 

00:16:15 Sara Klockars

We also know that there are so many oral contraceptives available, so this is just a good reminder to pick the right product from the computer and from the shelves. And these safeguards such as double checking, NDC's and scanning barcodes to ensure it's the intended Med. So for example Camrys and Camilla look similar, but selecting the wrong one could cause problems for a patient since Camrys has estrogen and a progestin. But Camilla is a progestin only pill. Another example is amethyst and amethia, and these oral contraceptives contain different amounts of hormones. 

00:16:51 Sara Klockars

When it comes to comparing contraceptive options, we have our comparison of oral contraceptives and non-oral alternatives chart online. It lists all the different brand and generic names of products available along with the estrogen dose and the type of progestin and dose. To help sort through all of the contraceptive options. 

00:17:10 Sara Klockars

Another great resource, our updated chart “Choosing a Contraceptive and Emergency Contraception,” and it talks about what to consider when someone starting out on a contraceptive reviews considerations for patients with other conditions such as headache or endometriosis. And then it also compares emergency contraceptive options.

00:17:33 Narrator

We hope you enjoyed and gained practical insights from listening to this presentation! 

00:17:37 Narrator

Be sure to follow or subscribe, rate, and review this show in your favorite podcast app. Or find the show on YouTube by searching for ‘TRC Healthcare’ or clicking the link in the show notes. While you’re there, check out our other TRC podcasts like Medication Talk and Rumor vs Truth.

00:17:56 Narrator

Also in the show notes, we’ve linked directly to a few of the excellent resources mentioned today available to subscribers of Pharmacist’s Letter, Pharmacy Technician’s Letter, or Prescriber Insights. On those websites you’ll also find a lot more evidence-based, concise, yet comprehensive resources on this and other medication therapy topics. 

00:18:18 Narrator

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00:18:32 Narrator

And if you're a student, good news—students can access a free version of Pharmacist’s Letter, we’ve linked to that directly in the show notes as well… Check it out!

00:18:44 Narrator

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00:18:57 Narrator

Thanks for listening to Clinical Capsules!