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Pharmacists increasing access to reproductive health care
James Keagy 3674

Pharmacists increasing access to reproductive health care

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CPE

Ashley H. Meredith, PharmD, MPH, BCACP, BCPS, CDCES, FCCP

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People in the United States still struggle to access sexual and reproductive health care, as evidenced by the unintended pregnancy rate of 45%.1 Unintended pregnancies are those that are mistimed or unwanted, and they are often associated with a lack of access to or inappropriate use of contraception.

Despite evidence that shows access to contraception is the most effective way to reduce unintended pregnancies, more than 19 million patients of reproductive potential find themselves living in contraceptive deserts.2 A contraceptive desert is a geographic area that lacks reasonable access to a health center that offers all contraceptive methods.2

Beyond accessing contraception, other aspects of reproductive care are also a challenge for many people. Once pregnant, more than 25% of people do not seek adequate prenatal care.3 The existing struggle to access sexual and reproductive health care is compounded by the recent Supreme Court decision in Dobbs v Jackson, which removes federal protections around abortion access and returns the decision about abortion to the individual state.4

Increased burdens are being placed on pregnancy-capable patients that keep them from accessing the full spectrum of sexual and reproductive health care.4

The traditional model of health care involves scheduling an appointment with a provider, attending the scheduled provider appointment, and then often making a second stop at a community pharmacy to receive any prescribed medications. In and of itself, this model presents challenges for many people who may not be able to afford to take time off work to attend provider visits; lack reliable and convenient transportation; or require other support to attend visits, such as childcare. However, approximately 90% of people in the United States live within 5 miles of a community pharmacy and 95% live within 10 miles, representing a potentially more convenient health care delivery site compared to the existing reproductive health care deserts.5 Many community pharmacies have already created services to fill these gaps and address existing barriers to access. Pharmacy services can span the reproductive spectrum and include preconception care, contraception prescribing, and prenatal support.6

Learning objectives

At the conclusion of this knowledge-based activity, pharmacists and pharmacy technicians will be able to:

  • Describe current barriers to adequate reproductive care.
  • Review abortifacients commonly seen in pharmacy practice.
  • Discuss available options for emergency contraception prescribing and dispensing in the pharmacy.
  • Describe strategies for implementing pharmacist sexual and reproductive health services considering current legislation.
  • Summarize available resources to promote safe and effective contraceptive use.

Preassessment questions

Before participating in this activity, test your knowledge by answering the following questions. These questions will also be part of the CPE assessment.

  1. How many patients of reproductive potential currently live in a contraceptive desert without access to full the spectrum of approved contraceptive methods?
    1. 1 million
    2. 4 million
    3. 13 million
    4. 19 million
  2. What regimen is FDA-approved for medication abortion?
    1. Misoprostol monotherapy
    2. Mifepristone monotherapy
    3. Mifepristone combined with misoprostol
    4. Methotrexate combined with misoprostol
  3. What online resource can be used to find information related to pharmacist contraception prescribing?
    1. National Association of Boards of Pharmacy
    2. Birth Control Pharmacist
    3. Plan C Pills
    4. Power to Decide

Pharmacists are the most easily accessible and convenient provider to answer health-related questions. Therefore, it is crucial that pharmacists have an understanding of commonly used medications for various sexual and reproductive health services along with service opportunities given the current legislation.

Medication abortion

Medication abortion can be used up to 70 days (10 weeks) of gestation.7, 8 (Gestational age is calculated based on the first day of a person's last menses.) Medication abortion should be avoided in the presence of contraindications.The FDA-approved regimen for medication abortion includes a combination of mifepristone and misoprostol.7 The preferred regimen and dosing is mifepristone 200 mg given orally, followed by misoprostol 800 mcg buccally 24–48 hours later.7, 8 For the buccal administration of misoprostol, the person should place 2 misoprostol 200 mcg tablets in each cheek.7 After 30 minutes, they should swish with a small amount of water and swallow whatever misoprostol remains. Misoprostol may also be used vaginally or sublingually.8 Higher doses of mifepristone should not be used due to higher rates of adverse effects with no difference in abortion outcome.8 Whenever possible, the combination of mifepristone and misoprostol should be used, as monotherapy with misoprostol poses a higher risk of incomplete abortion.8

Mifepristone

Mifepristone is a selective progesterone receptor modulator that competitively inhibits the actions of progesterone by binding progesterone receptors without activating them.9

At high doses, mifepristone is also a glucocorticoid receptor antagonist that blocks the effects of cortisol and is FDA-approved for treatment of idiopathic Cushing's syndrome for patients who have failed first-line treatment or are ineligible for surgery.10 When used during pregnancy, mifepristone causes necrosis of the decidual uterine lining, softening of the cervix, increased uterine contractility, and increased prostaglandin sensitivity.Mifepristone is included in a Risk Evaluation and Mitigation Strategy (REMS) program.11 Requirements of the REMS include that prescribers must complete a prescriber agreement form and the patient must sign a patient agreement form. Initial REMS requirements also included in-person dispensing, but in December 2021, the in-person dispensing requirement was removed due to the impact of the COVID-19 pandemic on in-person provider visits. A requirement for pharmacies dispensing mifepristone to be certified was also added in order to increase access. Pharmacies must be certified by the manufacturer; however, specific details are not yet available.

Misoprostol

Misoprostol is an analog of prostaglandin E1 that causes cervical softening and uterine contractions. It is often used off-label for the medical management of miscarriages or spontaneous abortions, labor induction, and before intrauterine device (IUD) insertion.12 Additionally, it carries an FDA-approved indication for NSAID-induced ulcer prophylaxis.13

There is no REMS associated with misoprostol dispensing; therefore, any community pharmacy can stock and dispense misoprostol.

Methotrexate

Prior to the approval of mifepristone, methotrexate was used in combination with misoprostol for medication abortion based on its mechanism that interferes with DNA synthesis, repair, and cellular replication.14, 15 While it is no longer used for medication abortion, it is used for many other conditions, such as psoriasis, rheumatoid arthritis, and management of an ectopic pregnancy.14, 15, 16

Role of the pharmacist

While the majority of pharmacists may not be directly involved in the dispensing of mifepristone and misoprostol for medication abortions, they may be faced with questions about what to expect from a patient who has been prescribed these medications. Counseling points for mifepristone and misoprostol can be found in Table 1.

Table 1. Counseling points for mifepristone and misoprostol

Source: Adapted from 7, 8.

Patient question Information to address
What will the bleeding be like?
  • Bleeding and cramping are expected.
  • It will be heavier than menses.
When should I contact my provider? You should contact your provider if you experience any of the following:
  • Heavy bleeding of more than 2 pads/hour for 2 consecutive hours
  • Any blood clots larger than a lemon
  • Chills and a fever of > 100.4 °F for > 4 hours
  • Any fever > 101 °F
What are some common adverse effects?
  • Nausea, vomiting, diarrhea
  • Headache
  • Dizziness
  • Hot flushes and chills
What can I do for the pain?
  • The most severe pain can be expected 2.5–4 hours after taking misoprostol.
  • NSAIDs are recommended.

If a pharmacist is practicing in a state with restrictive medication abortion legislation, it is essential to be aware of the multiple other indications for mifepristone, misoprostol, and methotrexate. While it may not be possible to provide medications for the purpose of inducing abortion in those states, patients should not be denied access to these medications when prescribed for a reason other than medication abortion. If no diagnosis is provided, the pharmacist may call the provider to confirm the reason for use; however, significant delays in product dispensing should be avoided.

HHS issued guidance in July 2022 reminding community pharmacies of their obligation to provide discrimination-free access to medications including avoiding discrimination based on current, potential, or intended pregnancy.17

Emergency contraception

Emergency contraception is used after unprotected or inadequately protected vaginal intercourse to prevent pregnancy. It is effective only before a pregnancy is established and is ineffective after implantation.18, 19 Emergency contraception will not terminate an existing pregnancy and has not been shown to be harmful to a developing embryo.19

Three forms of emergency contraception are FDA-approved: levonorgestrel 1.5 mg, ulipristal 30 mg, and the copper IUD. It is important to note that using combined estrogen-progestin oral contraceptive pills is no longer recommended due to a decreased efficacy compared to other methods.19

Levonorgestrel

Levonorgestrel was first approved as a prescription-only product in 1998. In 2006, it became available OTC for patients > 18 years old, while remaining available via prescription only for those younger than 18 years.20 As of 2013, levonorgestrel emergency contraception has been available OTC for any person of any age to purchase.20

A single dose of levonorgestrel 1.5 mg by mouth works to inhibit ovulation.

It should be administered within 3 days (72 hours) of unprotected vaginal intercourse, and it is more effective the sooner it is taken. Following a dose of levonorgestrel, reported pregnancy rates are 2.4%.19

Ulipristal

Ulipristal (Ella–HRA Pharma America) is a prescription-only oral agent that can be used for emergency contraception up to 5 days (120 hours) after vaginal intercourse with no decrease in efficacy across this timeframe.21 It is given as a single dose of 30 mg orally and has been available in the United States since 2010.21

Ulipristal works by inhibiting ovulation and causing follicular rupture. It is important to educate people that they should not start or resume a hormonal contraception until 5 days after taking ulipristal, and a barrier method such as a condom should be used for any subsequent acts of vaginal intercourse for the remainder of the menstrual cycle. Phase 3 studies demonstrated a 1.9% pregnancy rate after a dose of ulipristal.19

Copper intrauterine device

Copper IUDs can also be used as emergency contraception if inserted within 5 days (120 hours) of unprotected vaginal intercourse.9

A copper IUD works through interference with sperm viability and function.22 Reported pregnancy rates following use of the copper IUD as emergency contraception are 0.1–2.0%.19 Once inserted, copper IUDs can provide ongoing contraception for up to 10 years.22

Because copper IUDs must be placed by a trained provider, their role as an emergency contraceptive may be limited due to accessibility barriers within the necessary timeframe.

Role of the pharmacist

Pharmacies began providing emergency contraception via protocol in 1998.23 While levonorgestrel has become widely available OTC, pharmacists can still play an essential role in the provision of emergency contraception. As emergency contraceptives will not induce an abortion, dispensing and prescribing of these agents is not restricted by legislation intended to limit abortions.Eight states specifically allow pharmacists to prescribe emergency contraception via statewide protocol or collaborative practice agreements (CPAs).24 Table 2 includes common counseling points for available emergency contraception options.

Table 2. Counseling points for emergency contraception

Source: Adapted from 19, 21, 22, 25.

Method Counseling points
Levonorgestrel
  • Use within 72 hours.
  • Efficacy is increased the sooner it is taken.
  • Repeat dose if vomiting occurs within 2 hours of taking.
  • Efficacy may be decreased with BMI > 25 kg/m2.
  • Common adverse effects
  • Nausea
  • Vomiting
  • Abdominal pain
  • Dizziness
  • Headache
  • Breast pain
  • Changes in bleeding with next menses including heavier bleeding
  • Fatigue
Ulipristal
  • Use within 120 hours.
  • Efficacy is maintained across 120-hour window.
  • Efficacy may be decreased with BMI > 30 kg/m2.
  • Wait 5 days after use to start/resume hormonal contraception and use a barrier method until next menses.
  • Do not use more than once per menstrual cycle.
  • Contact provider if vomiting occurs within 3 hours of taking itCommon adverse effects
  • Nausea
  • Dizziness
  • Headache
  • Increased pain with next menses
Copper IUD
  • Insert within 120 hours.
  • Efficacy is maintained across 120-hour window.
  • Provides effective contraception for up to 10 years.
  • Efficacy does not decrease with increased BMI.
  • Requires placement by a trained health care professional.
  • Common adverse effects
  • Pain or discomfort with placement
  • Nausea with placement
  • Dizziness with placement
  • Changes in pain and bleeding with menses
  • Spotting between periods

Abbreviations used: IUD, intrauterine device.

Opportunities for pharmacists

Pharmacists are well-positioned to provide services and education related to sexual and reproductive health. Many opportunities have been described, and a few are highlighted below.

Contraception prescribing

As of October 2022, a total of 27 states and jurisdictions within the United States have authorized pharmacists to prescribe contraception without the need for an individual CPA.26, 27 Figure 1 illustrates the status of pharmacist contraception prescribing across the United States.

Figure thumbnail gr1

Figure 1. Status of pharmacist contraception prescribing across U.S.

Current as of October 11, 2022; for some states, while legislation has passed, the service may not yet be implemented. Source: Adapted from 26, 27.

Pharmacists are empowered through statewide protocols, independent authority, and standing orders. Each state varies in the specific contraception methods that pharmacists are allowed to prescribe. Some states have limited pharmacist prescribing to only contraceptive pills, while others allow prescribing of pills, patches, vaginal rings, and injectable contraception.27

Differences also exist in who is eligible to utilize pharmacist prescribing services, with about half of states limiting pharmacists prescribing to those aged 18 years or older. Check your local legislation for the most accurate and up-to-date information.

In 2016, Oregon became the first state to implement pharmacist contraception prescribing, allowing pharmacists to prescribe contraceptive pills, patches, and rings.28 Within the first 12 months of implementation, 63% of ZIP codes in the state reported at least one pharmacy offering contraception prescribing services.28 These data from Oregon demonstrated that pharmacist contraception prescribing accounted for 10% of new oral and transdermal contraceptive prescriptions for Medicaid recipients, prevented 51 pregnancies, and saved the state an estimated $1.6 million.29, 30

It has also been shown that people obtaining contraception from pharmacists are younger, report less education, and are more likely to be uninsured.29, 31 Additionally, patients utilizing pharmacist contraception prescribing report a higher likelihood of wanting to return to the same provider for future visits compared to those who saw other health care providers and are more likely to receive a 6-month supply or greater.31, 32

However, despite permissive legislation and successes in some states, widespread implementation of pharmacist contraception prescribing has been limited. An often-cited barrier to implementation is the time required, with a complete appointment averaging 18–26 minutes.28, 33, 34, 35 (For a rundown of the typical process, see Figure 2). Other commonly cited barriers include reimbursement challenges, lack of private space, liability concerns, lack of patient awareness, and corporate policies.35

Figure thumbnail gr2

Figure 2. Basic steps in pharmacist contraception prescribing

Abbreviations used: PMH, past medical history; US MEC, United States Medical Eligibility Criteria for Contraceptive Use.

While waiting for more states to approve permissive legislation, pharmacists in 49 states can explore the use of a CPA to create contraception prescribing services.36

Some states, such as Tennessee, have a specific contraception CPA.27 Other states (e.g., Idaho, Washington, Michigan) have implemented more broad spread pharmacist contraception prescribing via their general CPA legislation.27 Individual community pharmacies in other states have also implemented contraception prescribing CPAs based on the needs of their community.33 An example CPA for contraception prescribing can be found at the website for Pharmacy Access Forms (www.pharmacyaccessforms.org/example-cdtm).

Preconception and prenatal care

In the United States, the overall infant mortality rate is 5.4 deaths per 1,000 live births.37 The leading contributor to infant deaths is birth defects, many of which can be prevented with appropriate supplementation, avoiding harmful substances during pregnancy, controlling chronic conditions, and avoiding teratogenic medications.38

In the absence of permissive legislation that allows for pharmacist prescribing of sexual and reproductive health medications, many opportunities still exist to impact preconception and prenatal care through daily interactions with patients of reproductive potential.

Simple interventions as a part of everyday practice can be implemented to have a large impact on pregnancy outcomes. For example, pharmacists can screen medication lists for safety should a patient become pregnant.38, 39

When a potentially unsafe or teratogenic medication is identified, this can be followed by a conversation with the patient about their concerns and ways to increase safety, such as use of a contraceptive method or use of an alternate medication. Recommendation of appropriate supplementation, both preconception and during pregnancy, presents another opportunity for community pharmacists.39, 40 Table 3 includes commonly recommended supplements before and during pregnancy.

Table 3 Preconception and prenatal supplementation

Source: Adapted from 41.

Vitamin or mineral Recommended amount
Calcium 1,000 mg daily
DHA 8–12 oz of low-mercury seafood per week
Folic acid 0.4–0.8 mg daily starting 1 month before conception
1–4 mg daily if at high risk of having a child with neural-tube defects
Iodine 220 mcg daily
Iron 27 mg daily
≤ 120 mg daily if iron-deficiency anemia is present
Vitamin D 600 IU daily

Abbreviations used: DHA, docosahexaenoic acid; IU, international units.

Within the robust immunization services already provided at the pharmacy, specific attention can be paid to ensuring pregnant patients receive recommended vaccines, including inactivated influenza during the flu season; tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) between 27–36 weeks of gestation for each pregnancy; and COVID-19 initial series and booster dose(s).39, 40, 42

Offering smoking cessation services to all patients prior to or during pregnancy may lead to improved outcomes for both the pregnant patient and the fetus.40, 42

Available resources

As pharmacists begin expanding sexual and reproductive health services, having easy access to resources for reference and guidance is essential.

Conclusion

Despite legislation and barriers that may limit access to the full spectrum of sexual and reproductive health, pharmacists are well-positioned to fill gaps in care. Pharmacists should seek out opportunities to provide counseling, correct misinformation, and expand services to address the needs of patients of reproductive potential.

CPE assessment

This assessment must be taken online; please see “CPE information” in the sidebar below for further instructions. The online system will present these questions in random order to help reinforce the learning opportunity. There is only one correct answer to each question.

  • How many patients of reproductive potential currently live in a contraceptive desert without access to full the spectrum of approved contraceptive methods?
    1. 1 million
    2. 4 million
    3. 13 million
    4. 19 million
  • What regimen is FDA-approved for medication abortion?
    1. Misoprostol monotherapy
    2. Mifepristone monotherapy
    3. Mifepristone combined with misoprostol
    4. Methotrexate combined with misoprostol
  • What online resource can be used to find information related to pharmacist contraception prescribing?
    1. National Association of Boards of Pharmacy
    2. Birth Control Pharmacist
    3. Plan C Pills
    4. Power to Decide
  • Following a medication abortion, when should a patient be instructed to contact their provider?
    1. After 24 hours
    2. Passing any blood clots larger than a quarter
    3. Using more than 1 pad per hour
    4. Fever of > 101 °F
  • Which medication used for emergency contraception is available OTC, without restrictions?
    1. Levonorgestrel 0.75 mg
    2. Levonorgestrel 1.5 mg
    3. Ulipristal 5 mg
    4. Ulipristal 30 mg
  • As of October 2022, how many states and jurisdictions allow pharmacist prescribing of contraception without the need for an individual collaborative practice agreement?
    1. 7
    2. 15
    3. 27
    4. 36
  • In addition to medication abortion, what is another clinical use of misoprostol?
    1. Rheumatoid arthritis
    2. Emergency contraception
    3. Ectopic pregnancy
    4. Labor induction
  • What best describes the primary role of mifepristone in a medication abortion?
    1. Interference with cellular replication
    2. Inhibition of progesterone
    3. Prevention of ovulation
    4. Decreased sperm viability
  • What is one sexual and reproductive health service pharmacists can incorporate into their practice today?
    1. Access to emergency contraception
    2. Focused immunizations before and during pregnancy
    3. Counseling on prenatal supplementation
    4. All of the above
  • What is a commonly cited barrier that limits implementation of pharmacist contraception prescribing services?
    1. Difficult to access resources
    2. Moral concerns
    3. Lack of technician engagement
    4. Reimbursement challenges

Contraindications to medication abortion7

  • Current intrauterine device (IUD)
  • Long term systemic corticosteroids
  • Chronic adrenal failure
  • Coagulopathy
  • Anticoagulant therapy
  • Inherited porphyria
  • Intolerance or allergy to medications

Accreditation information

Provider: APhA Target audience: Pharmacists Release date: December 1, 2022 Expiration date: December 1, 2025 Learning level: 2 ACPE Universal Activity Number: 0202-0000-22-282-H03-P CPE credit: 1 hour (0.1 CEU) Fee: There is no fee associated with this activity for APhA. There is a $25 fee for nonmembers. APhA is accredited by the Accreditation Council for Pharmacy Education (ACPE) as a provider of continuing pharmacy education (CPE). The ACPE Universal Activity Number assigned to this activity by the accredited provider is 0202-0000-22-282-H03-P. Advisory board: Katie Meyer, PharmD, BCPS, BCGP, Director, Content Creation; and Brooke Whittington, PharmD, Executive Resident APhA, Washington, DC. Disclosures: Ashley H. Meredith, PharmD, MPH, BCACP, BCPS, CDCES, FCCP; Katie Meyer, PharmD, BCPS, BCGP; and APhA's editorial staff declare no conflicts of interest or financial interests in any product or service mentioned in this activity, including grants, employment, gifts, stock holdings, and honoraria. For complete staff disclosures, please see www.pharmacist.com/apha-disclosures. Development: This home-study CPE activity was developed by APhA.

Sexual and reproductive health resources

Contraception medication information

Local reproductive health providers and clinics information

Medication abortion

Medication use during pregnancy

Pharmacist contraception prescribing process

Sexual and reproductive health services statistics

CPE information

To obtain 1 hour of CPE credit for this activity, complete the CPE exam and submit it online at www.pharmacist.com/education. A Statement of Credit will be awarded for a passing grade of 70% or better. You have two opportunities to successfully complete the CPE exam. Pharmacists and technicians who successfully complete this activity before December 1, 2025, can receive credit. Your Statement of Credit will be available online immediately upon successful completion of the CPE exam. This policy is intended to maintain the integrity of the CPE activity. Learners who successfully complete this activity by the expiration date can receive CPE credit. Please visit CPE Monitor for your statement of credit/transcript.To claim credit

  1. Go to http://apha.us/CPE.
  2. Log in to your APhA account, or register as a new user.
  3. Select “Enroll Now” or “Add to Cart” (click “View Cart” and “Check Out”).
  4. Complete the assessment and evaluation.
  5. Click “Claim Credit.” You will need to provide your NABP e-profile ID number to obtain and print your statement of credit.

Assistance is available Monday through Friday from 8:30 am to 5:00 pm ET at APhA InfoCenter by calling 800-237-APhA (2742) or by e-mailing infocenter@aphanet.org.

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