Ex. 5 L4 - Transgender, Abortion, Contraceptives (46) Flashcards
Barriers to communication w/transgender care
-Lack of insurance knowledge for medication delivery to transgender patients
-Stigmatization
-Phase of transition from assignment at birth to social identity
-Insecurity and fear in healthcare setting
-Lack of awareness of guidelines on care for transgender patients
Contraception - Transgender men
Progestin-only contraceptives
-Do not interfere w/testosterone use
-POP pills - norethindrone and drospirenone are options
LARCs - implants, IUDs, progestin-only injectable
-Reversible
Combination hormonal contraceptives
-Controversial dur to the presence of estrogen in patients on testosterone during transitioning phase
-No contraindications to current use; low dose or estradiol alone can be used to stop menses
non-hormonal contraceptives
-Copper IUDS may increase existing menstrual bleeding
-Great for patients that wish to avoid progestin and estrogen products due to existing amenorrhea
Irreversible contraceptives
-Tubual ligation - fallopian tubes are cut “tied”
Excision of fallopian tubes - removal of fallopian tubes
Contraception - Transgender women
Barrier contraceptives:
-Condoms
-Condoms with spermicide
Irreversible contraceptives
-Orchiectomy - removal of the testicles
-Vasectomy - blockage of vas deferens tubes
Emergency contraception methods
**Copper IUD **
-Interferes with sperm viability and function
-Most effective EC across all BMIS
-In-office procedure
Ulipristal Acetate
-Inhibits ovulation and leads to follicular rupture
-Effective up to 5 days; better efficacy than LNG up to 194 lbs; effective after LH surge has begun
-Interaction with hormonal contraception; rx only
Levonorgestrel
-Inhibits ovulation
-OTC; no interaction with other meds
-May be less effective >165lbs (BMI 25)
Labeled for 72 hours
Emergency contraception:
Efficacy:
More effective the sooner used
Frequency of admin”
Copper IUD: one insertion
Ulipristal acetate (Ella): one RX pill per cycle
Levonorgestrel: One OTC dose as needed
How to start
-Within 5 days of unprotected sex
-Wait five days to re-start hormonal BC if ulipristal used (only use ulipristal once per cycle)
Side effects: Common
-Nausea/vomiting, headache, dizziness, breast pain, stomach pain
-If patient vomits within 2 hours of taking, consider repeating doses
-Next period may start early/late; may have spotting
Potential benefits
-Pregnancy prevention
Return of fertility
-Immediate
Medication abortion: when, how why
When
-Up to 70 days (10 weeks) gestation
-Gestational age = first day of last menses
Who
Contraindications: Current IUD, long-term systemic corticosteroids, chronic adrenal failure, coagulopathy/anticoagulant therapy, inherited porphyria, intolerance/allergy
How
-Two drug
-Regimen also used for early pregnancy loss (spontaneous abortion/miscarriage)
Mifepristone and Misoprostol
Mifepristone (mifeprex)
-Selective progesterone receptor modulator
-Antiprogesterone - inhibits the actions of pro. at the pro. receptor sites
-Decidual necrosis, cervical softening, increased uterine contractility, prostaglandin sensitivity
Misoprostol (Cytotec)
-Prostaglandin EI analogue
-Cervical softening
-Uterine contractions
How to use medication abortion
Mifepristone 200mg orally x 1 dose
Misoprostol 800 mcg buccally 24-48 hrs later
2 * 200 mcg tabs in each cheek (30 mins)
Counseling: medication abortion
Bleeding
-Bleeding and cramping are expected
Heavier than menses
Contact
-HEAVY bleed (>2 pads/hour for 2 consecutive hours; blood clots larger than a lemon)
-Chills and any fever >101F or 100.4 F for >4 hours
Adverse effects
-NVD
-HA, dizziness
-Hot flushes, chills
Pain
-NSAIDs recommended
-Most severe ~2.5-4 hours after misoprostol
Q: Jenna, a 23 y/of comes to your pharmacy asking about Plan B options. She says it has been 4 days since she had unprotected sex. What other questions would you ask this patient?
Q: After Jenna answers your questions, you learn that she can see her provider today, is not currently taking hormonal birth control, and weighs 150 lbs. Provide the patient information regarding her options for emergency contraception
Pharmacists prescribing: what the law covers
Types of contraception
-Oral patch, ring, injection, EC
Training
-specific training or graduate from state school
Procedures
-Age restrictions, notification to other providers, last visit with other provider
Compensation
-Insurance requirement to compensate
Pharmacist prescribing procedure
1) Birth control Screening
2)Pharmacist review
3) Screen for pregnancy
4) Check BP
5)General counseling
6) identify different methods patient is eligible for
7) assess preferences
8) method counseling
Landscape In Indiana
428,540 women live in contraceptive deserts
-99,870 women live in counties that do not have a single health center providing all contraceptive options
>53% of pregnancies are unintended
House enrolled act NO.1568
Pharmacist to complete a training program
Pharmacist cannot require an appointment
Person seeking contraception must be 18 or older
Can be first time product is prescribed
Suggest patient see other healthcare provider if available on site
-Self-screener to be admin to patient (risk assessment)
-Assess BP at least once every 6 months
-Provide initial prescription for up to six months; can renew for an additional six months
-Refer to PCP
-Provide a written record of method prescribed
To utilize house enrolled act NO.1568
-Indiana pharmacist license
-Received education and training in pregnancy prevention and hormonal contraceptives
-Be acting in good faith and exercising reasonable care
-Pharmacy provides appropriate space to prevent the spread of infection and ensure confidentiality
Potential opportunities for techs
-Inform patients
-Schedule appointments
-Check patients in and out
-Provide paperwork
-Perform blood pressure check
-Ring up product
Screening interval for BC
Every six months
Patient education and counseling for BC
Birth control guide - FDA
Patient education in product labeling
Counseling
-Admin and storage
-Potential SE and risks
Backup contraception
-When to seek emergency medical attention
-Risk of STIs and transmission
Advise to consult with PCP
Refer anyone that may be subject to abuse or trafficking to appropriate agency
Documentation and records
Keep the following records in hard copy/digital format at the location where this service is provided and have all readily available for inspection
-Current copy of the statewide protocol
-Certificate of training completion
-Documentation of all assessments and plans for seven years
-Provide patient record of contraception prescribed
-Refer to PCP
-Notification of PCP is not required, but may be helpful
Pharmacist Conscience Clause
-Refusal to fill a prescription on religious/moral grounds
-Some states have laws allowing pharmacists to refuse fil
-Some states have laws requiring pharmacists to fill
Concerns with contraceptive communication
-Feel unable to discuss concerns
-Insufficient info about options
-Lack of patient-centeredness
-Inaccurate knowledge
-Use of scare tactics and authority
Disparities in counseling minorities
-Less patient centered communication
-Less info/shorter visits
-Lower understanding of doctors info
-Feel pressured to use contraception/limit family size
-Experience stereotypes (i.e. assuming multiple sex partners)
-Testosterone use and pregnancy risk
Approaches to counseling
Tiered effectiveness
-Reproductive life planning
-One key question
-PATH
-Shared decision making
-Others
Tiered effectivness
Showing and ranking different options based on efficacy
Reproductive life planning counseling
Whether, when, and how to have children
Based on priorities, resources, and values
Comprehensive and culturally appropriate
One key question counseling
“Would you liked to become pregnant in the next year”
Yes
-Assessment and care based on core preconception factors
-Folic acid supplementation
No
-Discussion about current method satisfaction, and accurate use
-Discuss all available options
Idk/I’m ok either way
-Pregnancy ambivalence -> more likely to not be using contraception or d/c use
-Determine if appropriate intervention
-Folic acid supplementation if potential for pregnancy
PATH method
PA - Parenting Attitudes
Pregnancy attitudes
T - timing
H - How important delaying pregnancy is
PATH approach
Do you think you might like to have (more) children at some point?
When do you think that will be?
How important is it to you to prevent pregnancy (until then)?
Shared decision making
-Increased knowledge
-More confidence in decisions
-More active involvement
-Selection of more conservative treatment
Shared Decision making - key steps
Choice Talk and info sharing
-Inform that reasonable options are available
Option talk and deliberation
-Provide more detailed info about options
Decision talk and making
-Support consideration of preferences and decision
What does contraceptive coercion look like?
-Promoting LARCs as “best”
-Perceived racial targeting
-Decision aids
-“Pressure” to select
-Incomplete discussion of SE
Benefits of satisfaction w/contraceptive choice
-Less likely to use inconsistently/incorrectly
-Prevent unwanted pregnancy
-Catalyst for opportunity
Method satisfaction
Continuation Rates
Decision making process
Chosen method
Limiting coercion in contraceptive
Present ALL options with pros/cons
Visual decision aids to independently review
Awareness of biases
Questions to support deliberation of choices
What do you expect from contraception?
Do you have all the info you think you need to weigh these options?
Thinking about this decision, what is the most important aspect for you to consider?
What aspects of contraception are you most concerned about?
How do the benefits and risks compare?
Are there important people that you want to talk to about making this decision?
