PHARMACISTS ROLE IN OPTIMIZING ORAL CONTRACEPTION Angela Fitch

PHARMACIST’S ROLE IN OPTIMIZING ORAL CONTRACEPTION Angela Fitch PGY 1 Resident Tahlequah, OK

OBJECTIVES ACTIVE INGREDIENTS IN ORAL CONTRACEPTIVE PILLS (OCP) KEY COUNSELING POINTS PHARMACIST’S IMPACT ON THE FUTURE OF OCP

ACTIVE INGREDIENTS

Two Active Ingredients in Oral Contraceptives ◦ Progestin ◦ Estrogen *There is a progesterin only birth control pill and is good for specific patients

Normal Endocrine Cycle Follicular Phase Four hormones play a role in the menstrual cycle -Progesterone -Estrogen -Luteinizing hormone -Follicular Stimulating Hormone Luteal Phase The Ovaries release Progesterone and Estrogen The Pituitary Gland releases the Luteinizing hormone and Follicular Stimulating Hormone Day 1 https: //www. ncbi. nlm. nih. gov/books/NBK 279054/ Days Day 28 While the estrogen and the progesterone are high the luteal phase, the other hormones are suppressed

Progestin 1 st Generation Progestins 2 nd Generation 3 rd Generation 4 th Generation Levonorgestrel Norgestimate Norelgestromin Drospirenone Medroxyprogesterone Norethindrone Norgesterel Etonorgesterel Desogestrel

Progestin Mechanism of Action ◦ Inhibits Ovulation (tricking the brain into thinking it’s always in the Leutal phase) ◦ Production of a thick cervical mucus

Estrogen ◦ Ethinyl Estradiol ◦ Mestranol: converted to EE in the body Mechanism of Action ◦ Suppresses the maturation and ovulation of the egg

KEY COUNSELING POINTS

What can oral contraceptives be used for?

How effective is “the pill” 99% If taken appropriately 92% On average

What do to if I miss a dose of the combined contraceptive pills? What dose I missed: What to do: Back up contraception needed? Missed one dose of the active pill Take your dose as soon as you remember. (That means you might be taking two pills in one day) No Missed two or more doses of the active pill Take the most recent dose as soon as you remember. Throw away the other pills you missed and keep taking the remainder of the pack (That means you might take two pills in one day) Yes, back up is needed for 7 days Missed any amount of the placebo doses Take the next placebo pill at your usual time no

What do to if I miss a dose of the progestin only contraceptive pills? ◦ Progestin only tablets have a narrow window ◦ If you miss your dose by three hours, you must use another form of birth control for the next 48 hours ◦ Take your missed dose as soon as you can and then go back to your normal time

Side effects progestin ◦ 2 nd generations progestins: highest androgenic side effects ◦ ◦ ◦ ◦ Acne Hirsutism Weight Gain Headache Nausea Breast tenderness Increased hair loss ◦ 4 th generation progestin: anti-androgenic activity

Other Adverse Effects ◦ Breakthrough Bleeding ◦ Bloating ◦ Nervousness, Irritability, Depression ◦ Decreased Libido ◦ Liver Adenomas Estrogen ◦ Blurry Vision, Chest pain, Extreme pain in Arms or Legs Blood Clots (PE/DVT)

Drug-Drug Interactions Anti-Seizure medications ◦ Carbamazepine ◦ Phenytoin ◦ Lamotrigine Antibiotics Rifampin Rifabutin What about other Antibiotics? ◦ Phenobarbital ◦ Topiramate ◦ Oxcarbazepine Smoking

PHARMACIST’S IMPACT

States that pharmacists can prescribe birth control: 13 States

Pharmacist Led Women’s Health Clinic Phoenix IHS ◦ Protocol to prescribe ALL forms of birth control including Long-Acting Reversible Contraceptives (LARCs). ◦ Screened for UTIs and could prescribe treatment options ◦ Decreased their rates of emergency contraception ◦ Significantly lowered the burden for the Women’s Clinic

Clinical Pearls Adverse Event Clinical Reason Nausea Related more with the estrogen Take with food or take in the component evening. Usually goes away with time. Could also lower estrogen dose. Acne Associated with the lower generations of progestins Switch to a 3 rd or 4 th generation progestin Breakthrough Bleeding Depends when in the Cycle: Early stages: associated to lower estrogen levels Increase the respective hormone dosage Late Stages: associated to lower progestin levels Management

Oregon Prescribing Protocol – “Oregon Standard Procedures Algorithm ”

Resources from the CDC

Resources for pharmacists Hormonal Contraceptive Certifications ◦ Oregon Comprehensive Contraceptive Education and Certification for the Prescribing Pharmacist ◦ Birth Control Pharmacist ◦ APh. A-Increasing Access To Hormonal Contraceptive Products ◦ CDC- Contraception App (Medical Eligibility Criteria)

Other Resources for Patients Online Services for Doctor’s Appointments ◦ Lemon. AID Online Services for Doctor’s Appointments/ and mailing prescriptions ◦ Twentyeight. Health ◦ Nurx ◦ Pill. Club ◦ Prjktruby ◦ Simple. Health

References Alilia Medical Media. How Birth Control Pills Work, Animation. Youtube. 16 July 2018. www. youtube. com/watch? v=h. I 2 C 7 Tsn. Sfk Davtyan, Camelia. "Four generations of progestins in oral contraceptives. " Proceedings of UCLA healthcare 16 (2012): 1 -3. Helms, Stephen E. , et al. "Oral contraceptive failure rates and oral antibiotics. " Journal of the American Academy of Dermatology 36. 5 (1997): 705 -710. Jones, Ervin E. "Androgenic effects of oral contraceptives: implications for patient compliance. " The American journal of medicine 98. 1 (1995): S 116 -S 119. Reed, Beverly G. , and Bruce R. Carr. "The normal menstrual cycle and the control of ovulation. " (2015). Reilly, Allison. “I Forgot to Take Birth Control: What Do I Do? ”. Planned Parenthood of the St. Louis Region and Southwest Missouri. 4 Nov. 2019. Plannedparenthood. org Shrader, Sarah. “Module 1 Hormonal Contraception: Intro, Physiology, Etiology” University of Kansas. Fall 2018