Contraception Flashcards
How many pregnancies are unplanned?
40 - 60% of pregnancies are unplanned
How many unintended preganncies end in abortion?
50% of unintended pregnancies end in abortion
Abortion Rates
Approximately 1/3 of individuals have had at least one induced abortion
What are the two phases of the menstrual cycle? When do they start?
FOllicular Phase
Luteal Phase
The follicular phase is from the start of menstruation to the moment of ovulation. The luteal phase is from the moment of ovulation to the start of menstruation (the final 14 days of the cycle).
How long is the luteal phase?
Always 14 days long –> 14 days from the start of menstruation
Describe the menstrual cycle
- Hypothalamus release Gonadotropin releasing hormone which causes anterior pituitary to release FSH and LH
- Days 1-4: Increase FSH. FSH stimulates 15-20 primordial follicles in the ovary to start dveloping. As they develop, granulosa cells surrounding them secrete estrogen.
Days 5-7 - One follicle dominant
- Estrogen causes negative feedback onto the anterior pituatary and hypothalamus. As estrogen rises, LH and FSH release are supressed. Stops menstrual flow
Stimulates thickening of endometrial lining
↑ production of thin, watery cervical mucus - Prior to ovulation, estrogen levels drop as follicle is getting to release the ovum. There is a spike in LH that causes the follicles to reach the surface of the ovary and release the ovum. Consistently high estrogen levels stimulate the pituitary to release a mid-cycle surge of LH.
- Luteal Phase. Follicle that released ovum collapses and becomes corpus luteum. The corpus luteum secretes high levels of progesterone and little estrogen and androgens. Progesterone maintains negative feeddback to stop LH and FSH production.
- If ovum fertilized occurs, fetus secretes HCG (human chorionic gonadotrophin) to keep corteus luteum alive.
- If not fertilized, corpeus luteum degenerates and stops producing estrogen and progesterone. This drop removes negative feedback to hypothalamus and pituatary and levels of FSH levels rise again and cycle is restarted (release GnrH). Also, triggers endometrium to break down and mentsrutaion occurs.
What is the main job of FSH and LH?
FSH - Stimulates dvelopment of follicles
LH- Causes ovulation
What is estrogen?
Sex steroid hormone that acts on estrogen receptors to promote female secondary sexual charcteristics
- Develop the breast tissue, vulva, vagina and uterus around puberty
- Development of endometrium
- Cause mucous in cervix to thin so sperm can penetrate it around the time of ovulation
What is progesterone?
Steroid sex hormone
- Produced by corpus luteum after ovulation
- If preganancy occurs, the placenta takes over production of progesterone around 5-10 weeks of preganncy
What does progesterone do?
- Act on same tissues as previously acted on by estrogen:
i) Thickening and maintain endometrium
ii) Thicken cervical mucous
iii) Cause slight increase in body temp
What is menstruation?
Starts on Day 1 of cycle
- Superficial and middle layers of endometrium seperate from basal layer of endometrium
- Tissue broken down in uterus and released through cervix and vagina
- FLuid containing blood released from vagina and lasts 1 to 8 days
Main role of GnRH
Stimulates pituitary to release FSH and LH
MAin role of FSH
Stimulates maturation of follicles in ovaries
Main role of estrogen
Stimulates thickening of the endometrium (uterine lining)
Suppresses FSH (negative feedback)
Signals LH
Main role of LH
Triggers ovulation
Main role of progesterone
Produced by the corpus luteum (mass of cells resulting from the ruptured follicle when the ovum is released)
Makes the endometrium favourable for implantation
Signals the hypothalamus and pituitary to stop FSH and LH production (negative feedback)
How long is an average menstrual cycle?
Average cycle is 28 days (range 21-40 days)
What is day 1 of the cycle?
Day 1 of cycle = first day of period (menses)
Describe hormone changes in menstrual cycle
When does ovulation occur?
28-32 hours after LH surge
What are the methods of contraception?
Hormonal
Barrier
Permanent
Natural family planning
What are the componenets of hormonal contracpetions?
Estrogen:
Ethinyl estradiol (EE)
–> Synthetic form of estradiol
–> Most common form
Estetrol (approved in Canada in 2021)
–> Plant source
Progestins (NOT progesterone; synthetic form that acts on estrogen receptors)
Numerous options:
–> Synthetic hormones that activate progesterone receptors
Structurally similar to testosterone
–> Androgenic effects (acne, oily skin, hirsutism)
Anti-androgenic:
–> Cyproterone acetate –> Diane-35 –> used for acne in Canada –> works as birth control, but not indicated in Canada
–> Drosperinone
MOA of Hormonal COntraceptions.What does each hormonal drug do?
Estrogen and progestin provide negative feedback which inhibits ovulation
Estrogen:
Suppresses release of FSH
Progestin:
Suppresses release of LH and FSH
Thickens cervical mucus (impedes sperm transport)
Changes endometrial lining (not hospitable to implantation)
How can hormonal contraception be delivered?
Oral (the Pill)
Injectable
Transdermal
Intravaginal
Intrauterine (hormonal and non-hormonal options)
Implantable
What are the categories of hormonal contraception?
Combined
Pill
Patch
Ring
Progestin-only
Pill
Injection - depo
Long-acting reversible contraception (LARC) – 3-10 years
IUS/IUD
Implant
What are combined oral contraceptions?
Combination of estrogen and progestin
Types/doses of estrogen and progestin vary between products
What are the types of oral combined contraception dosing?
Cyclic
Extended Dosing
Continous Dosing
What is cyclic dosing?
Combined oral contraceptives originally developed to mimic 28-day cycle
21 days of active drug + 7 placebo days (hormone free interval; HFI)
Packs may or may not contain 7 placebo tablets
24 days of active drug + 4 days HFI
24 days of active drug + 2 days EE + 2 days HFI
What are the formulations of cyclic regimens?
Monophasic – fixed levels of EE and progestin
Biphasic – fixed EE levels; ↑ progestin in 2nd phase
Triphasic – fixed or variable EE levels; ↑ progestin in all 3 phases
Different colours of pills for different strengths
Multiphasic products
–> Attempt to imitate the normal menstrual cycle – higher proportion of progestin to EE in second half of cycle
What is the difference in the formulations of cyclic dosing in regards to tolerability?
No difference in efficacy, bleeding patterns, or adverse effects
What is extended dosing?
> 1 “cycle” of active pills then HFI
84 days of active drug + 7 days EE (low does ethanol estradoiol) (10mcg) or HFI
What is continous dosing? What do we prefer here?
Uninterrupted, no HFI
Can use any product (<50mcg EE) for continuous dosing (oral, transdermal, vaginal)
Even multiphasic products (according to SOGC)
No products in Canada over 35 mcg
Better if monophasic –> Constant levels of the same dose of hormones, less s/e due to less changing hormones
What is the difference between cyclic, extended and continous dosing?
No difference in efficacy or short-term adverse effects between cyclic and extended/continuous dosing.
Less risk of ovulation occurring (most missed doses are the beginning of the pack on time)
Risk of pregnancy is the highest –> Hormone has been gone for more than 7 days so brain starts process for FSH
How should a combined OC be started?
Most effective if started on Day 1 (first day of period) and taken daily at the same time daily
Start on the first Sunday after period starts
Avoids a weekend period –> May help with that
Quick start – start any day of cycle
When intitiating a combined OC, what is critical to counsel on?
If not starting on Day 1, then use back-up birth control method (e.g. condom) for first 7 days
Takes 7 days of continuous pill use to suppress ovulation
NEEDS TO BE ON BOARD FOR 7 DAYS
What is the biggest risk of combined OC?
Typical use: 3-8% failure rate
Forgetting to take pill or taking it late (>24 hours apart)
Starting pack late –> Biggest risk
What if a combined OC is missed?
Depends on where they are in the cycle
- Look at the monograph of the drug (if miss pill in week 1 more important than week 2 or 3)
NEED TO ASK: HAVE YOU HAD UNPROTECTED SEX IN THE LAST 5 DAYS? –> WHERE WE NEED TO THINK ABOUT EMERGENCY CONTRACEPTION
What are some initial potential a/e of the combined OC?
Common in first 3 months of starting pill:
Breakthrough bleeding (BTB) (Spotting – Not a full on period)
–> Check adherence
–> If lasts >6 months look for other causes (STIs) – check at how they are taking the pill, if forgetting, different times
–> Change to pill with ↑ estrogen/progestin (depending when BTB occurs in cycle)
Breast tenderness
–> If lasts longer than first 3 months, look for other causes
Change to pill with ↓ estrogen
Nausea
Take at HS or with food
Change to pill with ↓ estrogen
Weight gain (controversial)
Some notice ↑ appetite in first month, but overall little or minimal weight gain
Remember weight fluctuates with age and water retention
Headache or migraine
Can be hormone-related
Can either ↓ or ↑ with use
Mood changes – Depression
–> Observational study
Acne
Can worsen initially…but…
Usually improves with long-term use
Several OC have official indications for acne…but all combined OC can be beneficial
–> Lowers amount of endogenous androgens produced or (bio)available (androgens stimulate sebum production → acne)
If a continued problem, change to pill with ↓ androgenic activity
Or use topical therapy
Boys Beat No Women Having Menstrual Anger
What are some potential benefits of the combined OC?
Simple and effective birth control
Improve menstrual symptoms and regularity
–> Reduces dysmenorrhea and ovulation pain
–> Reduces PMS symptoms
Decreases incidence of:
Endometriosis
Endometrial cancers
Ovarian cancer
Ovarian cysts
Osteoporosis (↑ bone density)
Acne and hirsutism
What are the potemtial risks of combined OC?
Contraceptive failure
Especially if missed pills with <20mcg estrogen (less s/e; however, need good adherence)
Venous thromboembolism (VTE)
Risk is 2-3x higher than in non-users
Risk ↑ with age, smoking, ↑ estrogen dose
Controversy whether drospirenone increases risk
MI and stroke (arterial thrombosis)
↑ risk associated with estrogen >50mcg day, age >35 years, smoking, HTN and other CVD risks
What are the early signs of risks of combined OC?
A – Abdominal pain (severe)
Gallbladder, pancreatitis, thrombosis
C – Chest pain (severe) or shortness of breath
Pulmonary embolus or myocardial infarction
H – Headaches (severe)
Stroke, hypertension, migraine
E – Eye problems (blurring, flashing, vision loss)
Stroke, hypertension, vascular insufficiency
S – Severe leg pain (calf or thigh)
DVT
What risks were shown in observational studies with combined OC?
Breast cancer
Suggested there is an increased risk of 1.3 times
Risk may return to baseline within 10 years of discontinuation
Cervical cancer
Suggested increase risk of 1.5 times with long-term use (>5 years)
But may be associated with early sexual activity and number of sexual partners
Combined OC D.I.
Drugs that reduce the enterohepatic circulation of oral contraceptives (antibiotics effect the reabsorption of BC pills that make them less effective - not totally true)
Drugs that induce the metabolism of oral contraceptives - works less
Drugs that have their metabolism altered by oral contraceptives
Are antibiotics a drug interaction of combined OC?
NO INTERACTION
What are some drugs that induce metabolism of combined OC? How can they be managed?
CPY450 3A4 inducers
Anticonvulsants (carbamezapine, phenytoin)
Anti-infectives (rifampin)
Herbals (St John’s wort)
Management:
Use product with higher estrogen levels (>30ug EE)
Use extended dosing (skip HFIs)
Use alternative to interacting drug or other method of birth control
What drugs metabolism is altered by combined OC? Management?
Metabolism altered by oral contraceptives
Lamotrigine (significantly ↓ levels – induction of lamotrigine glucuronidation)
Management
Use alternative to interacting drug or other method of birth control
C.I. of Combined OC
Thromboembolic disease
Current or past VTE
Hypertension (>160/100mmHg)
Ischemic heart disease / Stroke
Known or suspected breast cancer
Migraine with aura
Severe / active liver disease
Post-partum
–> Wait least 3-6 weeks post-partum b/c increased risk of VTE
Smokers (>15 cigs/day)
Over 35 years old
What is the transdermal contraception?
Transdermal patch (Evra®)
0.6mg ethinyl estradiol + 6.0mg norelgestromin
Average daily release of 35ug ethinyl estradiol + norelgestromin 200ug
Efficacy:
Typical use: failure rate = 8%
How should the patch be administered?
Apply patch on Day 1
No back-up method needed
Apply first Sunday
Use back-up method for 7 days
Instructions for patch application
1 patch applied weekly x 3 weeks, then no patch for 1 week (HFI)
Apply to upper arm, buttocks, lower abdomen, upper torso
Good adhesive (<2% fall off)
Adverse Effects of Patch
Similar to oral contraceptives
Local skin irritation (20%)
Can have ↑ spotting in first 2 cycles
Less effective and ↑ risk of clots if weighing ≥90kg
D.I. of the Patch
Similar to combined OC
What is the intravaginal ring?
Flexible, non-latex vaginal ring (Nuvaring®)
EE 15ug + 120ug etonogestrel released daily
Typical use: failure rate = 8%
Intravaginal Ring Administration
Insert (anywhere in the vagina) between days 1-5
Backup birth control for 7 days if not day 1
Leave in for 3 weeks, remove for 1 week (HFI)
Missed dose of intravaginal ring or expulsion
Missed dose or expulsion
A concern if out for ≥3 hours
Expulsion rate of ~4%
Adverse effects of I.V.R., D.I.
Adverse effects
Similar to combined OC
Vaginitis (5-13%) is inserted intravaginally
Foreign body sensation / discomfort
Problems during sex
Drug interactions
Similar to combined OC
Storage of I.V.R
Store in fridge at pharmacy
Stable for 4 months at room temperature
Put expiry date on box for patient!
What are the two types of progestin-only (mini pills)?
Norethindrone 35mcg daily (no HFI)
Drospirenone 4mg OD x 24 days then 4 placebo pills
MOA of Noethindrone
Alters cervical mucus and endometrium (main moa)
In 50-60% of women can alter ovulation (suppress FSH/LH) and cause amenorrhea (no menstruation)
MOA of Drospirenone
Primarily suppresses ovulation
Norethindrone Indication
Estrogen contraindicated
History/risk of blood clots (VTE)
Smoker >35 years old
Obese
Migraine
Breastfeeding – won’t decrease milk supply
Drospirenone Indication
Estrogen contraindicated
History/risk of blood clots (VTE)
Smoker >35 years old
Obese
Migraine
Breastfeeding – won’t decrease milk supply
Administration Norethindrone
Start on Day 1 (up to day 5) and take OD continuously (no HFI)
Back-up method required for 2 days
MUST take at the same time every day (within 3 hours)
The effect on the cervical mucus only last ~24 hours
Missed pill (>3 hours) = back-up method x 48 hours
Typical use: failure rate = 5-10%
Drospirenone Administration
Start on Day 1 and take OD continuously (24/4)
Back-up method required for 7 days
Typical use: failure rate = 5-10%
Progestin Only Pill A/E
Irregular bleeding (more so in first months)
Headache
Bloating, wgt gain (water)
Acne
Breast tenderness
Potential to ↑ K+ (monitor if risk for hyperkalemia) Drosperinone, monitor it
C.I. of Progestin-Only Pill
Liver disease
Breast cancer
Drug interactions similar to combined OC
What is the injectable contraception?
Progestin injection (Depo-Provera®)
150mg medroxyprogesterone acetate
M.O.A Injection
Prevents ovulation by suppressing LH/FSH surge
↑ viscosity of cervical mucus
Potentially alters endometrial lining to make it inhospitable to implantation
Typical use: failure rate = 3-7%
Administration Injectable.When should it be injected?
Given IM q 12 weeks
Maximum effectiveness of ≤13 weeks (allows for a grace period)
If injected on Day 1-5: no back-up method
If injected after Day 5: back-up method for 3-4 weeks (monograph) –> most say 7 days (rxfiles)
Missed dose of injection
If given in ≥14th week, do pregnancy test, EC prn, back-up method for contraception
A/E Injectable
Unpredictable bleeding in first months (gets better with time)
Hormonal associations: acne, headaches, nausea, ↓ libido, breast tenderness
Weight gain (<2 kg)
“Controversial” though
May↓ bone mineral density –> Black box
Especially in first 2 years
Delayed return to fertility
Average 9 months
Benefits of Injectable Contraception
No estrogen
–> Option for smokers, migraines
Few drug interactions
Amenorrhea (~60% at 12 months)
Less adherence issues
Injectable D.I. C.I.
Drug Interactions
Few drug interactions
Contraindications – Precautions – Risks
Breast cancer
Uncontrolled hypertension / Stroke / IHD
Liver disease
What are the two types of IUD’s?
Copper intrauterine devices (IUD)
Hormonal “IUD” (or IUS) – Levonorgestrel
Copper IUD Replacement, MOA, Efficacy
Replace q 3 – 10 years
(product dependent)
MOA:
Copper is released and produces an inflammatory reaction that is toxic to sperm, makes sperm transport difficult and possibly prevents implantation
Effectiveness:
Failure rate = 0.6%
What are the two types of hormonal IUD’s?
Mirena® - replace q 5 years
Initially delivers 20mcg/day… to 10mcg/day
Kyleena – replace q 5 years
Initially delivers 17.5mcg/day…9mcg/day
Hormonal IUD MOA effectiveness
MOA:
Thickens cervical mucus to prevent sperm transport and permeability
Alters endometrial lining to prevent implantation
Can suppress ovulation in some individuals (some eventually develop amenorrhea)
Effectiveness:
Failure rate = 0.2%
Expulsion can occur (~6%/5 years)
IUD admin.When should it be inserted?
T-shaped piece of plastic with a copper wire or drug reservoir inserted by clinician into the uterus
Best if inserted on last few days of period (within first 7 days of cycle)
A/E IUD’s
↑ bleeding and cramping in first few months, but usually subsides (naproxen, nsaid, anasthetic before)
Very rare for perforations
Pelvic inflammatory disease (~1%)
C.I. IUD’s
Pregnancy
Breast, cervical, endometrial cancer
STI or pelvic infection within 3 months
Implantable Contraception, MOA and Efficacy
Howlong does it last?
Progestin-only (Nexplanon®)
Etonogestrel 68mg – up to 70mcg delivered daily
Lasts up to 3 years
MOA
Inhibits ovulation
Changes cervical mucus
Effectiveness
>99% effective
Implantable Contraception Implantation
Inserted directly under the skin of the inner side of non-dominant upper arm
Insert day 1-5 of cycle
If after day 5, use back up for 7 days
Should regularly check for the implant – will be able to feel it
A/E Implantable Contraception
Bleeding irregularities
Headache
Weight increase
Breast pain
C.I. Implantable Contraception
Pregnancy
Breast cancer
What are the avilable barrier methods?
Condoms
↓ risk of pregnancy and STIs
Available as latex, polyurethane or lambskin
Polyurethane is compatible with oil-based lubricants and is more sensitive but greater risk for breakage
Lambskin doesn’t protect against STIs
Diaphragms
Reusable, dome-shaped cap that covers the cervix
Requires initial fitting by a clinician
Sponges
Impregnated with spermicidal agents
Cervical cap
Smaller than a diaphragm – fits over cervix
Requires initial fitting by a clinician
Spermicides
Nonoxynol-9
Surfactant that destroys the cell wall of sperm (kills or immobilizes sperm)
Used with sponges, diaphragms and cervical caps
Permenant Contraception Options
Tubal ligation – occlusion of the fallopian tubes
Vasectomy – occlusion of the vas deferens
Natural Family Planning
No contraceptive devices or chemicals
Revolves around timing of ovulation
Fertility awareness (failure rate up to 24%)
Basal body temperature
Billings method
Calendar method
Standard day calendar
Coitus interruptus (failure rate up to 22%)
Abstinence (failure rate 0%)
Basal Body Temp
Take temperature first thing in the morning (at same time each day)
Increase of at least 0.2oC above baseline temperature indicates ovulation has occurred
After 3 consecutive days of increased temperature, fertile period considered over
Doesn’t predict beginning of fertile period therefore limit to only having sex after 3 consecutive days
Billings Method
Identify fertile period by recognizing change in consistency and volume of cervical mucus
Changes around time of ovulation
Cervical mucus become clearer, slippery and more elastic as ovulation nears
After ovulation, mucus becomes more viscous and less volume
Calendar Method.Risks?
Chart menstrual cycle over 6-12 cycles
Determine fertile period:
Subtract 21 from length of shortest cycle (fertility begins)
Subtract 10 from length of longest cycle (fertility ends)
Ex: Shortest cycle = 28 days; longest cycle = 30 days
28-21 = 7 (fertility begins)
30-10 = 20 (fertility ends)
Avoid having sex during fertile period (Days 7 – 20)
Doesn’t account for factors that influence timing of ovulation
Stress
Illness
Lactional Amenorhhea Method
Physiological infertility from breastfeeding caused by hormonal suppression of ovulation
98% effective IF:
Exclusively breastfeeding
Baby <6 months old
Period hasn’t resumed
What is EC?
EC is any form of birth control used after intercourse but before implantation
EC is a woman’s last chance to prevent a pregnancy
Plan B is what schedule…
Schedule III
Define Fertilization and Preganancy
Fertilization = process of combining the sperm with the ovum
Pregnancy = begins with implantation of fertilized ovum (implantation occurs ~ 6-14 days after fertilization)
Define Contraception and Medical termination
Contraception = prevention of pregnancy
Medical termination = disruption of implanted pregnancy and induction of uterine contractions
Indications for EC
Patient is of reproductive age (got there period)
Patient does not want to get pregnant
Patient has had unprotected sex within the past 120 hours
LNG – approved for up to 72 hrs, but some efficacy up to 120 hrs
UPA – approved for up to 120 hrs
Cu-IUD – up to 7 days (maybe longer)
U R Pregannt
When is the risk odf preganncy the greatest?
Risk of pregnancy is greatest 5 days before ovulation to 1 day after
What are the options for EC?
Ulipristal acetate
Levonorgestrel
Combination OCP (Yuzpe method)
–> Various products/doses
Device
Copper intrauterine device (IUD) most effective EC (small window, cost, physician need to do it)
Device EC
Copper intrauterine device (IUD)
Must be inserted by a physician (must know how to do)
Effective up to 7 days after unprotected intercourse (maybe longer?)
MOA of Device EC
Induces sterile inflammatory reaction in uterus. By-products of inflammation and Cu is toxic to sperm and egg
May prevent implantation
UPA Dose, Use, MOA
Ulipristal acetate 30mg (1 tablet) stat
Selective progesterone receptor modulator
Effective up to 5 days after unprotected sex
MOA:
Prevents or delays ovulation
Must be given before or during the peak of the LH surge
Levonesgterol Dose, Use, MOA
Levonorgestrel 1.5mg stat
1 tablet (1.5mg) stat
More effective the earlier it is taken
Decreased effect when used 72-120 hours after
MOA:
Delays ovulation
Must be given before the peak of the LH surge
May inhibit sperm/ova travel
Clinical Considerations of EC
UPA excreted in breastmilk, so express and discard milk for one week after dose
If using because of missed hormonal contraception, LNG is preferred
–> Progestin may block UPA from working
UPA - Must wait 5 days until (re-) starting hormonal contraception
–> Use back up birth control until 7 consecutive days of use
UPA and LNG – not effective if unprotected sex occurs after EC
Enzyme inducers decrease efficacy of oral EC
–> NOT a contraindication to using oral EC
Some suggest increasing the LNG dose (3mg) if used with enzyme inducers
EC and BMI
LNG – may be less effective if BMI ≥25
UPA – preferred if BMI 25-30
Cu-IUD preferred if BMI >30
Restarting Contraception after EC
LNG – same or next day for starting new contraceptive or continuing with current
Back-up contraception for 7 days
UPA – 5 days after UPA
Back-up contraception for 5 days after UPA + first 7 days of hormonal contraception (re)start
Copper IUD – start hormonal contraception 7 days before removal, or use back-up contraception for first 7 days
Or keep the IUD
Medical Risks vs EC
Pregnancy or abortion generally places women at significantly greater medical risks than would the brief use of the hormones in EC
EC Contraindications
There are no evidence-based absolute contraindications to oral EC except pregnancy and allergy to product components
IUD EC Contraindications
Pregnancy
Unexplained vaginal/uterine bleeding
Copper allergy
Active pelvic infection
What is Mifegymiso?
(Mifepristone + Misoprostol)
Medical Abortion
Mifepristone MOA
Progesterone receptor modulator
Termination of pregnancy up to 63 days
Mifegymiso Dose, Use
Mifepristone 200mg + misoprostol 800mg (4 x 200mg)
Misoprostol taken 24-48 hours after mifepristone
Misoprostol by buccal route (b/w cheek and gum for 30 mins then swallow remaining fragments with water)
Issue with STI’s
EC offers no protection against STIs
STIs should be discussed with patients at risk and physician referrals should be made if the potential for transmission exists
Increased risk for STIs when unprotected sex occurs with a new sexual partner or was a sexual assault
Age of Sexual consent
Minor < 18 years
Age of consent = 16 years
Can consent if 14 or 15 if partner isn’t >5 years older and not in a position of authority, trust or dependency
Can consent if 12 or 13 if partner isn’t >2 years older and not in a position of authority, trust or dependency
How can pharmacists help a woman who has been sexually assaulted?
Providing EC if appropriate
Providing patient education
Referring to other health care professionals
Referring to other agencies if appropriate
Reporting Sexual Assault
Referrals to the police or sexual assault crisis centre should be made only at the discretion of the individual
In general, it is the decision of the individual whether or not they would like to report a sexual assault
By law, pharmacists MUST report the assault of a minor
Acessibility
Unethical for pharmacist to promote their moral or religious beliefs
MUST refer patient to pre-arranged alternative that doesn’t compromise product’s efficacy due to the delay
If your pharmacy provides EC make sure it is always in stock – especially weekends
Can provide EC in advance (“just in case”)
Can also prescribe Ella just in case
Confidentiality of EC
EC should ideally be supplied directly to a patient who makes a request for it
No restriction on OTC sale of LNG to partners
UPA is prescribed… so only to patient
Privacy EC
Patient autonomy, confidentiality and privacy must be respected when an individual requests EC/HC
Counseling should take place in an environment that ensures the individual’s privacy
For EC contraception, determine?
Date of last menstrual period (LMP)
Time since unprotected sex
Did an additional unprotected sexual encounter occur since LMP
That the individual wants EC (maybe there not sure) – provide education
For Hormonal Contraception dtermine:
Determine:
At least 12 years old
Medical history (BP)
Risk factors / CI
CHECK BLOOD PRESSURE (CV risk, blood clot risk)
Smoking, post-partum, BLOOD CLOTS HISTORY
Medication history
Do they want to become pregnant in the next year?
DEPO Shot delaying fertility (cannot say for certainty)
EC Adverse Effects
EC-specific
Nausea = Take with food or pre-medicate with Gravol®
Vomiting = Repeat doses that are vomited within 2 (LNG) or 3 (UPA) hours of taking
Efficacy of EC
EC-specific
Should have a period within ~21 days
Progestin Only name Brands
Northindrone - Movisse®, Jencycla®
Drosperinone - Slynd
