Contraceptive care: clinical pearls for pharmacists, Part 2

This two-part series provides pharmacists with clinical pearls to help patients find a contraception option that best suits their individual needs and reproductive health goals. In Part 1 of this two-part series (found HERE), we reviewed newer oral contraceptive options. In Part 2, we’ll delve into non-oral contraceptive options to meet unique patient needs!

Part 2: Non-Oral Contraceptive Options to Meet Unique Patient Needs 

Responding to Non-Adherence to Daily Dosing Regimens

Noticing late refills on oral contraception or the purchase of emergency contraception can serve as an opportunity for pharmacists to recommend alternatives that may fit better into a patient’s lifestyle. Newer long-acting options available in Canada include implants (e.g., Nexplanon®), intrauterine devices (IUD) (e.g., Mirena®, Mona Lisa®), and injections (e.g., Depo-Provera®). These options are highly effective with typical use failure rates of 0.1%, 0.1-0.8%, and 4%, for implants, IUDs, and injections, respectively.¹⁸

Nexplanon® is a progestin implant, approved by Health Canada in May 2020 and newly available on the Canadian Market.¹⁹ It is a thin, flexible rod that is inserted into the subdermal layer of the inner upper arm via a minor surgical procedure done in a provider’s office.²⁰ Patients can feel the implant by palpating the area, but it is not easily visible by others.²¹ It is effective for up to 3 years.²² IUDs are progestin-containing or copper devices inserted into the uterus.²³ Progestin-containing IUDs (Mirena®, Kyleena®) are effective for up to 5 years while copper IUDs (Mona Lisa®) are effective for 3-10 years depending on the model.^24,25 Depo-Provera® is an intramuscular injection that is administered every 3 months by a healthcare professional, including pharmacists in jurisdictions where scope allows.²⁵ In contrast to other long-acting options, return to fertility isn’t immediate and can take 8-10 months after the last injection.^25-27

Considerations for Transgender Men and Gender Nonbinary Individuals

A transgender male or gender nonbinary individual with an intact uterus and ovaries can experience pregnancy, even while taking testosterone, and may require contraception.²⁸ Patients may wish to preserve the ability to conceive and carry a child and therefore require reversible options.²⁸ Talk to your patients about their fertility desires and preferred birth control characteristics.

Unique yet important considerations for this patient population include potential concerns about interference with masculinizing hormone therapy and body dysphoria.²⁹ Some patients may be taking masculinizing hormones and worry about feminising effects and antagonistic properties of estrogen. In these cases, non-hormonal contraceptive (e.g. copper IUD) and progestin-only contraceptive (e.g., progestin-only pills, IUD, implant, or injection) may be preferred.³⁰ Some patients may have dysphoria regarding their pelvic anatomy and the process of inserting an IUD may be traumatic and anxiety inducing.²⁹ Implants may be a good alternative as they are inserted into the inner, upper arm.²⁰ Some patients may find taking daily oral contraception or experiencing monthly menstrual bleeding to be a reminder of their sex assigned at birth.³⁰ Progestin injections may be a preferred as they’re administered every 3 months and induce amenorrhea in more than 50% of patients by the first year.²⁵

Maintain a gender affirming approach throughout these conversations. This involves referring to the patient by their preferred name and pronouns.²⁹ It also includes asking the patient for their preferred term to use for body parts (e.g. front-hole) rather than defaulting to medical terms (e.g., vagina).²⁹

There is a vast, and sometimes overwhelming, array of contraceptive options available in Canada. Pharmacists are uniquely poised to proactively intervene to guide patients in selecting the option that best suits their unique needs. Newer long-acting options, like implants (e.g., Nexplanon®), intrauterine devices (e.g., Mirena®, Mona Lisa®), and injections (e.g., Depo-Provera®) may fit better into patients’ busy lifestyles than traditional options that require daily administration. Nexplanon® may also be the contraceptive option of choice for transgender men and gender nonbinary individuals as it doesn’t interfere with masculinizing hormone therapy or require insertion which may traumatic due to potential pelvic anatomy dysphoria.²⁹ Ultimately, it comes down to whichever option best meets your patient’s needs. Use these clinical pearls to be confident in your recommendations and empower your patients to make informed decisions about their reproductive health!

References:

18. Trussell J, Lalla AM, Doan QV, Reyes E, Pinto L, Gricar J. Cost effectiveness of contraceptives in the United States. Contraception. 2009 Jan;79(1):5-14. doi: 10.1016/j.contraception.2008.08.003. Epub 2008 Sep 25. Erratum in: Contraception. 2009 Aug;80(2):229-30. PMID: 19041435; PMCID: PMC3638200.
19. Canadian Drug Product Database. Product Information Nexplanon® [internet]. Government of Canada. 2019 [cited 2020 June 24]. Available from: https://health-products.canada.ca/dpd-bdpp/dispatch-repartition.do
20. Merck. Nexplanon® Frequently Asked Questions [internet]. Merck Sharp & Dohme B.V. 2020 [cited 2020 June 25]. Available from: https://www.nexplanon.com/questions/#:~:text=NEXPLANON%20can%20be%20removed%20at,arm%20where%20NEXPLANON%20is%20located.
21. Your Life. Frequently Asked Questions – The Contraceptive Implant [internet]. Bayer AG. 2018 [cited 2020 June 26]. Available from: https://www.your-life.com/en/your-questions/implant/#:~:text=The%20implant%20is%20about%20the,who%20is%20looking%20for%20it.
22. Ali M, Bahamondes L, Bent Landoulsi S. Extended Effectiveness of the Etonogestrel-Releasing Contraceptive Implant and the 20 µg Levonorgestrel-Releasing Intrauterine System for 2 Years Beyond U.S. Food and Drug Administration Product Labeling. Glob Health Sci Pract. 2017 Dec 28;5(4):534-539. doi: 10.9745/GHSP-D-17-00296. PMID: 29263025; PMCID: PMC5752601.
23. Stoddard A, McNicholas C, Peipert JF. Efficacy and safety of long-acting reversible contraception. Drugs. 2011 May 28;71(8):969-80. doi: 10.2165/11591290-000000000-00000. PMID: 21668037; PMCID: PMC3662967.
24. Mona Lisa®. Which Mona Lisa® IUD to recommend? [internet]. Searchlight Pharma Inc. 2018 [cited 2020 June 25]. Available from: http://www.monalisaiud.ca/hcp/which-mona-lisa-iud-to-recommend/           
25. Pfizer Canada Inc. Product Monograph Depo-Provera® [internet]. Pfizer Canada Inc. 2018 [cited 2020 June 24]. Available from: https://www.pfizer.ca/sites/default/files/201803/DEPO-PROVERA_PM_E_210121_13Feb2018.pdf
26. Randic L, Vlasic S, Matrljan I, Waszak CS. Return to fertility after IUD removal for planned pregnancy. Contraception. 1985;32(3):253-259. doi:10.1016/0010-7824(85)90048-4
27. Merck Canada Inc. Product Monograph Nexplanon® [internet]. Merck Canada Inc. 2020 [cited 2020 June 26]. Available From: https://pdf.hres.ca/dpd_pm/00055878.PDF
28. Krempasky C, Harris M, Abern L, Grimstad F. Contraception across the transmasculine spectrum. American Journal of Obstetrics and Gynecology [Internet]. 2020 Feb 1;222(2):134–43. Available from: http://resolver.scholarsportal.info.myaccess.library.utoronto.ca/resolve/00029378/v222i0002/134_catts.xml
29. Wesp L. Transgender patients and the physical examination. In Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People 2016. Department of Family and Community Medicine, University of California, San Francisco, San Francisco, CA.
30. FSRH Clinical Effectiveness Unit. FSRH CEU Statement: Contraceptive Choices and Sexual Health for Transgender and Non-Binary People (October 2017) [internet]. The Faculty of Sexual & Reproductive Healthcare of the Royal College of Obstetricians & Gynaecologists. 2017 [cited 2020 June 17]. Available from: https://www.fsrh.org/standards-and-guidance/documents/fsrh-ceu-statement-contraceptive-choices-and-sexual-health-for/