Pharmacy in Focus 115

FEMALE HEALTH

effects at the onset of therapy including nausea, headaches and mood changes. Blood pressure may also increase as a result of COC use. Within the first few months it is also common the experience some breakthrough bleeding and spotting.

There are also certain risks associated with COC use. There is a very small risk of MI and stroke and the risk of VTE can be increased by as much as five times, however the absolute risk is very low with the greatest risk being in those with a history of VTE. There is also a possible small risk of breast cancer and a very small risk of cervical cancer (however this increases with the longer duration of COC use)6

. Progesterone Only Pills (POPs)

Progesterone only pills are those that are absent of an oestrogen. They work primarily through the alteration of cervical mucus, increasing its viscosity, the prevent sperm penetration. They may also inhibit ovulation in some women. Cerazette is a desogestral only pill that inhibits ovulation7

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They are used as an alternative to the combined oral contraceptive if there are contra-indications with oestrogen. They are suitable for those women who may be breastfeeding, in those that may have a VTE or a history of thrombosis, those with hypertension, cardiovascular disease or complicated diabetes. They can also be used in patients that suffer from migraines (with or without aura) and in heavy smokers2,4

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Other advantages of POPs are that they may reduce the risk of endometrial cancer and they can also be used in women up to the age of 55, when it can be assumed that fertility has been lost naturally. Normal fertility resumes once the patient stops taking their medication.

Disadvantages of POPs are that temporary adverse effects at the onset of treatment can occur including acne and headaches. It is common that there may be menstrual irregularities with some women experiencing oligomenorrhea (irregular and light bleeding) and others experiencing menorrhagia (heavy and prolonged bleeding). Unlike COCs, there is an increased risk of functional ovarian cysts. Finally those on POPs are restricted to a regime or time frame. It is important to take a pill at the same time each day as if left too late then it may be described as a missed pill7

. 60 - PHARMACY IN FOCUS MISSED PILLS

Regarding POPs; they need to be taken at the same time each day and a missed pill is one that is 3hours or more late. There is less flexibility when using this form of contraception. Cerazette is the only exception whereas it is not deemed a missed pill until 12hours or more has elapsed. The advice for those that have missed a pill is to take one as soon as they remember and to carry on taking the pill at the right time the next day. Continue normal pill taking but extra precaution must be taken (barrier method) for two days2,8

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Regarding COCs; a missed pill is defined as one that is more than 24 hours late. If the patient misses one pill anywhere in their pack or start the new pack one day late, they will still have contraceptive cover. They should take one as soon as they remember (even if it means taking two in one day) and continue taking the pack as normal, extra contraception won’t be necessary2

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If two or more pills are missed consecutively then extra contraception will be required for the following seven days. It also depends on when during the cycle that the consecutively missed pills occurred. If it was in the first week then Emergency Contraception (EC) should be considered if unprotected sex occurred in the pill-free interval or in the first week of pill-taking. During the second week there will be no need for EC, however if it occurred in the third week then the pill free interval should not take place and the next set of pills should be started (8).

The exception to this advice is for the COC Qlaira. A pill is deemed missed if it is 12hours or more late. As Qlaira is a quadraphasic pill and the regime for a missed pill is complex it is suggested that the pharmaceutical company’s advice should be followed9

. DRUG INTERACTIONS

Oral contraceptives undergo extensive first pass metabolism. Medications that increase the action of CP450 in the liver increase the metabolism of drugs, potentially reducing their clinical effect10

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Enzyme inducing drugs include: • Antibiotics- rifampicin and rifabutin

• Many Antiepileptic medication- e.g carbamazepine, oxcarbazepine, phenytoin, barbiturates

• Antiretroviral medication- e.g ritonavir

• St John’s Wort

Lamotrigine does not interact with POPs, however COCs may increase Lamotrigine clearance leading to poor seizure control2,5,7

A full list of interactions can be found in Appendix 1 in the BNF.

INTRA-UTERINE DEVICES (IUD)

Intrauterine devices (IUDs) are a long acting reversible contraceptive method. They have the advantage over pills of once they are inserted; they are effective for 5 to 10 years (depending on type) without the need to remember to take a pill regularly. The option is either a Levonorgestrel releasing IUD or a copper IUD11

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Levonorgestrel IUD (Mirena) is T-shaped and is inserted into the uterine cavity. It releases 20mcg of levonorgestrel daily and last up to 5 years12

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Copper IUD is T-shaped and contains 380mm2 of copper. Depending on whether copper is on the stem and arms or just the stem, they are effective for between 5 and 10 years13

. Barrier Method

The barrier method is a physical means of contraception in the form of condoms. Both female and male condoms are available with male condoms being the most popular and most readily accessible.

As pharmacists we can provide advice to the patients regarding the different methods of contraception, whether it is to help maintain compliance or what to do regarding missed pills and the need for EC. If EC is required then the patient knows they can access it in a safe and confidential environment.

EMERGENCY CONTRACEPTION EC

EC is an intervention to prevent an unintended pregnancy after unprotected intercourse or potential contraceptive failure14

There are three licensed products available as EC:

• Copper Intra-Uterine Device • Levongestrel • Ulipristal Acetate

However only two of these are readily available from pharmacies: Levongestrel and Ulipristal Acetate.

Levongestrel 1500mcg (Levonelle): is licensed to be used within 72hours (3days) of unprotected sexual intercourse or contraceptive failure.

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Ulipristal Acetate 30mg (EllaOne): is licensed to be used within 120hours (5days) of unprotected sexual intercourse or contraceptive failure15

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Both are a single tablet to be taken immediately. If vomiting occurs within 3hours of taking the medication then there will be a need for a second dose.

It is important to have a private consultation with the intended user. This is to rule out pregnancy (neither is licensed for use in pregnancy) and to enable any drug interactions to be identified. This consultation helps to ensure the suitability of EC. •

BIBLIOGRAPHY 1. Health, Womens. Pregnancy-be- fore-you-get-pregnant. http://www. womenshealth.gov/pregnancy/before- you-get-pregnant/menstrual-cycle.html. [Online] 2. COMPASS. Oral Contraceptives. https://www.medicinesni.com/assets/ COMPASS/oralcontraceptive.pdf. [Online] 3. BNF. BNF Chpt 7. https://www. evidence.nhs.uk/formulary/bnf/ current/7-obstetrics-gynaecolo- gy-and-urinary-tract-disorders/73-con- traceptives/731-combined-hormon- al-contraceptives. [Online] 4. CKS, NICE. Progestogen only meth- ods. http://cks.nice.org.uk/contracep- tion-progestogen-only-methods#!sce- nario. [Online]

5. —. Combined hormonal methods. http://cks.nice.org.uk/contracep- tion-combined-hormonal-meth- ods#!scenariorecommendation:22. [Online]

6. FSRH. CEU drug interactions with hormonal contraception. https:// www.fsrh.org/documents/ceu-guid- ance-drug-interactions-with-hormon- al-contraception-jan/. [Online] 7. —. CEU guidance first prescription. https://www.fsrh.org/documents/ cec-ceu-guidance-first-prescription-coc- jan-2007/. [Online]

8. —. CEU statement missed pills. https://www.fsrh.org/documents/cec- ceu-statement-missed-pills-may-2011/. [Online]

9. CKS, NICE. Contraception emergency. http://cks.nice.org.uk/contracep- tion-emergency#!scenario. [Online] 10. WHO. EC factsheet. http://who. int/mediacentre/factsheets/fs244/en/ . [Online]

11. SPC, Qlaira. Qlaira SPC. https://www. medicines.org.uk/emc/medicine/21700. [Online]

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12. Conditions, NHS. Contraception guide combined-contraceptive-pill. http://www.nhs.uk/Conditions/contra- ception-guide/Pages/combined-contra- ceptive-pill.aspx#How. [Online] 13. —. Contraception Guide iud-coil. http://www.nhs.uk/conditions/con- traception-guide/pages/iud-coil.aspx. [Online]

14. CKS, NICE. Contracetpion IUD Levonorgestrel. http://cks.nice.org. uk/contraception-iusiud#!scenario. [Online]

15. —. Contraception IUD Copper. http://cks.nice.org.uk/contraception-iu- siud#!scenario:1. [Online]

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