By Veronica Vernon, PharmD, BCPS, BCACP, NCMP
Five years ago, I started as the first clinical pharmacist in women’s health at the Indianapolis VA Medical Center. My passion and desire to encourage fellow pharmacists and student pharmacists to practice in this exciting space grows as each year passes. Empowering patients to feel in control and well informed regarding their health and medications is one of the most rewarding aspects of my job.
I currently practice in an internal medicine resident physician clinic, where I focus on chronic disease state management and women’s health-related concerns. I also still have the pleasure of spending time in a gynecology clinic, focusing on conditions such as menopause, premenstrual dysphoric disorder, urinary incontinence, pregnancy and lactation concerns, endometriosis, and polycystic ovarian syndrome. As a women’s health advocate and APhA–ASP Chapter Advisor at the Butler University College of Pharmacy and Health Sciences, I was thrilled to see the recent launch of the APhA–ASP Women’s Health Campaign.
How you can get started
Performing blood pressure screenings and point-of-care tests can serve as an excellent initial step into the world of women’s health. According to CDC, heart disease continues to be the leading cause of death for women in the United States. The United States Preventive Services Task Force (USPSTF) recommends all adults aged 18 and older receive a blood pressure check. Point-of-care testing for hemoglobin A1C and cholesterol can allow the student pharmacist and pharmacist to make recommendations regarding lifestyle changes, medications, and follow-up with other health professionals.
Student pharmacists and pharmacists can also guide patients to preventive services that cannot be performed in a pharmacy currently, such as Pap smears and mammograms. USPSTF recently updated the cervical cancer screening guidelines. All women ages 21 through 29 years should have a Pap smear performed every 3 years. Those who are ages 30 through 65 may extend the interval to every 5 years if they obtain high-risk human papillomavirus (hrHPV) testing in conjunction with a Pap smear. Alternatively, this age group can also forego the Pap smear and just receive hrHPV testing alone every 5 years.
Mammogram screening, according to the American Cancer Society, should be performed yearly for women ages 45 through 54. Women ages 40 through 44 have the option of obtaining yearly mammograms, and women who are 55 or older may decrease the mammogram frequency to every other year. USPSTF has slightly different recommendations, advising biennial mammograms for women at an average risk for breast cancer who are ages 50 through 74 and suggesting mammograms be considered in those ages 40 through 49 on an individual basis.
Vaccination administration and education serve as another entry point for women’s health services and play an important role in my everyday practice. HPV not only leads to cervical, vaginal, vulvar, and anal cancers, but also oropharyngeal cancer, according to CDC. When examining combined male and female data, oropharyngeal cancer is the leading HPV-related cancer. Cervical cancer continues to be the main HPV-related cancer in women. In a recent study of pregnant women, only 49% reported receiving the flu shot before or during pregnancy, and 54% obtained Tdap.1 When working with patients who desire to conceive, it is essential to ensure all vaccinations are up to date. The measles, mumps, and rubella vaccine is not recommended to be administered during pregnancy; recognizing the need for immunization in the preconception period is ideal.
Preconception and prenatal counseling
In addition to counseling on and administering any necessary vaccinations, student pharmacists and pharmacists can engage in other tenants of preconception and prenatal counseling. CDC recommends all women receive at least 400 mcg of folic acid each day prior to conception and during pregnancy. Education on the use of ovulation predictor kits and pregnancy tests can be extremely beneficial for patients who are trying to conceive. Reviewing medications that could be of concern when pregnancy occurs is also important.
Two resources that can assist in guiding recommendations related to the use of medications in pregnancy and lactation include Drugs in Pregnancy and Lactation, and Medications and Mother’s Milk. I use an app, InfantRisk Center, which includes information from Medications and Mother’s Milk. There is a yearly subscription fee, but I have found it to be a valuable resource when I need a quick recommendation regarding the use of a medication in a lactating patient.
Educate on options
As reported by the National Alliance State Pharmacy Associations, six states and Washington, DC, have passed legislation permitting pharmacists to furnish or prescribe contraception under a statewide protocol. As 45% of pregnancies in the United States are unintended and 16% of women have reported a delay or inability to obtain contraception, improved access to care is needed.2,3 CDC also recommends patients receive a year’s supply of contraception when at the pharmacy. Student pharmacists can educate patients on their contraception options and promote the use of effective, reliable methods of contraception.
Hormonal forms of contraceptive also have additional indications beyond preventing pregnancy, such as treating acne, polycystic ovarian syndrome, and decreasing painful menses. CDC published updates to the U.S. Medical Eligibility Criteria for Contraceptive Use and U.S. Selected Practice Recommendations for Contraceptive Use in 2016. These two documents, which are available in the “Contraception” app, are important resources to use when making recommendations.
Long-acting reversible contraceptives (LARC), which include intrauterine devices (IUD) and the implant, Nexplanon, have the lowest rates of pregnancy. Advances in contraception continue to occur, as a new vaginal ring was recently approved in August. Annovera can be used for an entire year.4 Patients will place the ring for 3 weeks, remove it for 1 week (and place it in a case), and reinsert it to start the cycle over. Student pharmacists should also feel comfortable discussing barrier methods of contraception with patients, such as condoms and diaphragms. Emergency contraception is another area in which opportunities exist. Student pharmacists can assist in the appropriate selection of either levonorgestrel or ulipristal or referral for a copper IUD. All contraceptive discussions should be patient-specific.
As women transition to menopause, pharmacists can be an invaluable resource. In addition to performing screenings for cardiovascular disease and osteoporosis, student pharmacists and pharmacists can assist in the management of menopausal symptoms. Pharmacists are eligible to become a North American Menopause Society Certified Menopause Practitioner (NCMP). I sat for the NCMP exam in my second year of practice in order to expand my scope of practice at my site.
I see my patients who are experiencing menopause symptoms in my clinic now and initiate, adjust, and discontinue therapies. I manage hot flushes (also called hot flashes) and vaginal symptoms in my clinic in addition to non-pharmacological therapies. Student pharmacists can easily engage patients in a discussion of non-pharmacological methods to reduce hot flushes, such as staying well-hydrated, dressing in layers, using fans, yoga, and relaxation techniques. Vaginal moisturizers, such as Replens, are available OTC and can provide much needed relief to women with vaginal irritation and dryness.
There at each stage of life
Pharmacist engagement in women’s health continues to expand. A myriad of opportunities exist. Student pharmacists can actively engage in women’s health activities prior to graduation. Collaborating with local pharmacists or conducting health fairs or screenings in your community can open opportunities. Identifying resources you can use when working with female patients, such as thorough pregnancy and lactation references, is necessary. Advocacy efforts to improve contraceptive access at the state and federal level and recognizing contraceptive resources for patients are other methods to engage in optimizing women’s health.
Pharmacists continue to be the most accessible health professionals and can meet the needs of female patients throughout each stage of life.