Ex. 5 L4 - Transgender, Abortion, Contraceptives (46)

Question 1

Barriers to communication w/transgender care

Answer 1

-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

Question 1

Contraception - Transgender men

Answer 1

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

Question 2

Contraception - Transgender women

Answer 2

Barrier contraceptives:
-Condoms
-Condoms with spermicide
Irreversible contraceptives
-Orchiectomy - removal of the testicles
-Vasectomy - blockage of vas deferens tubes

Question 3

Emergency contraception methods

Answer 3

**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

Question 4

Emergency contraception:

Answer 4

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

Question 5

Medication abortion: when, how why

Answer 5

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)

Question 6

Mifepristone and Misoprostol

Answer 6

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

Question 7

How to use medication abortion

Answer 7

Mifepristone 200mg orally x 1 dose
Misoprostol 800 mcg buccally 24-48 hrs later
2 * 200 mcg tabs in each cheek (30 mins)

Question 8

Counseling: medication abortion

Answer 8

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

Question 9

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?

Question 10

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

Question 11

Pharmacists prescribing: what the law covers

Answer 11

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

Question 12

Pharmacist prescribing procedure

Answer 12

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

Question 13

Landscape In Indiana

Answer 13

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

Question 14

House enrolled act NO.1568

Answer 14

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

Question 15

To utilize house enrolled act NO.1568

Answer 15

-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

Question 16

Potential opportunities for techs

Answer 16

-Inform patients
-Schedule appointments
-Check patients in and out
-Provide paperwork
-Perform blood pressure check
-Ring up product

Question 17

Screening interval for BC

Answer 17

Every six months

Question 18

Patient education and counseling for BC

Answer 18

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

Question 19

Documentation and records

Answer 19

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

Question 20

Pharmacist Conscience Clause

Answer 20

-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

Question 21

Concerns with contraceptive communication

Answer 21

-Feel unable to discuss concerns
-Insufficient info about options
-Lack of patient-centeredness
-Inaccurate knowledge
-Use of scare tactics and authority

Question 22

Disparities in counseling minorities

Answer 22

-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

Question 23

Approaches to counseling

Answer 23

Tiered effectiveness
-Reproductive life planning
-One key question
-PATH
-Shared decision making
-Others

Question 24

Tiered effectivness

Answer 24

Showing and ranking different options based on efficacy

Question 25

Reproductive life planning counseling

Answer 25

Whether, when, and how to have children
Based on priorities, resources, and values
Comprehensive and culturally appropriate

Question 26

One key question counseling

Answer 26

“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

Question 27

PATH method

Answer 27

PA - Parenting Attitudes
Pregnancy attitudes
T - timing
H - How important delaying pregnancy is

Question 28

PATH approach

Answer 28

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)?

Question 29

Shared decision making

Answer 29

-Increased knowledge
-More confidence in decisions
-More active involvement
-Selection of more conservative treatment

Question 30

Shared Decision making - key steps

Answer 30

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

Question 31

What does contraceptive coercion look like?

Answer 31

-Promoting LARCs as “best”
-Perceived racial targeting
-Decision aids
-“Pressure” to select
-Incomplete discussion of SE

Question 32

Benefits of satisfaction w/contraceptive choice

Answer 32

-Less likely to use inconsistently/incorrectly
-Prevent unwanted pregnancy
-Catalyst for opportunity

Question 33

Method satisfaction

Answer 33

Continuation Rates
Decision making process
Chosen method

Question 34

Limiting coercion in contraceptive

Answer 34

Present ALL options with pros/cons
Visual decision aids to independently review
Awareness of biases

Question 35

Questions to support deliberation of choices

Answer 35

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?