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How Pharmacy Students Can Advocate for Pharmacist Prescribing of Hormonal Contraception

Can pharmacy students advocate for pharmacists prescribing hormonal contraceptives? YES, that is exactly what Wilson Pace, a graduate of the University of Utah College of Pharmacy did. When Wilson heard about the barriers and costs that women experience when accessing contraceptives. His perseverance and dedication to advocacy as a pharmacy student allowed him to take action in his leadership class. Wilson drafted a “dream bill” which became Bill 184 in Utah. Bill 184  was passed in 2019 and allowed women in Utah to receive birth control prescriptions from their pharmacist.  

Fast forward to 2022; we now have 26 states + D.C that have either statewide protocols or collaboration practice agreements that allow pharmacists to prescribe birth control. But as pharmacy students we can do more! As of early 2022, the map below shows where pharmacists can prescribe hormonal contraceptives.

As future pharmacists we know that pharmacists are the most accessible healthcare providers (9 out of 10 Americans living within five miles of a pharmacy). The benefits pharmacists can offer women who are seeking hormonal contraceptives include accessibility, limiting barriers as well as reduced costs. 

Here are three easy ways pharmacy students can advocate for pharmacists to prescribe hormonal contraceptives if their state has not passed legislation yet:

  1. Research to see if any bills have been introduced in your state. If a bill has not been introduced you can help advocate for one to be started or start your own!
  2. Contact policymakers and advocate for them to support bills that allow. You can also look up your policy makers here: 
  3. Speak up and educate others by using your voice on social media such as LinkedIn, Facebook and Instagram. Share why it is important to you that pharmacists are able to provide access to contraceptives. To help spread your message to a larger audience use hashtags such as #advocacy #pharmacystudents #birthcontrol #birthcontrolpharmacies

What if you currently live in a state that allows pharmacists to prescribe contraceptives, can you still make an impact? The answer is YES! Even if your state has allowed pharmacists to prescribe contraceptives you can still advocate here are 3 ways you can help:

  1. Check the Birth Control Pharmacies map to see if your pharmacy is listed. If your state allows pharmacists to prescribe hormonal contraceptives, encourage your pharmacist to fill out this form. This will help women be able to find a pharmacy near them. 

https://www.birthcontrolpharmacies.com/addpharmacy

  • Educate yourself by taking Birth Control Pharmacist’s free home study course to learn how to provide contraceptive care during the COVID-19 public health emergency. It is important to stay up to date on the ways you facilitate access to over-the-counter and prescription contraceptives.
  • Promote brainstorm ways that your pharmacy can promote contraceptive services. Maybe this is by creating a private area for counseling or developing ideas on how you can promote birth control services at your pharmacy.

I was interested in learning more about pharmacists prescribing hormonal contraceptives so I reached out to Dr. Rafie who allowed me to complete a rotation with her at Birth Control Pharmacist. I learned so much about legislation and advocacy during my 4 weeks on rotation. I was even able to discuss upcoming legislation that impacts pharmacists in South Carolina with my school’s Dean. Taking action as a student is a great way to impact the future of pharmacy. 

There are numerous ways pharmacy students can advocate for increased access to contraceptive services. As pharmacy students we have the power to advocate for legislation just like Wilson Pace and make an impact. Whether it is helping change an entire state’s contraceptive laws or helping a woman find a local pharmacy that provides contraceptive services it is important that we support everyone’s reproductive health and choices!

“If you want to make a difference in health care, you have to be involved…you have to advocate for your profession.” — Wilson Pace


Amy AckershoekAbout the Author

Amy Ackershoek is a pharmacy student in the Class of 2022 at the Medical University of South Carolina College of Pharmacy.

Society of Family Planning Annual Meeting Highlights

SFP Annual Meeting Highlights Quyen NguyenThe Society of Family Planning (SFP) annual meeting was held virtually on October 1st and 2nd this year with well over one thousand attendees. For those who are not familiar with SFP, it is a community of like-minded people including clinicians, academics, residents, fellows, and students who share the same interest for family planning. SFP values diversity, equity, and the science behind abortion and contraception for everyone. I had the privilege of attending the meeting as part of an APPE rotation with Dr. Sally Rafie at Birth Control Pharmacist.

There were some highlights at the meeting:

Health Disparities Among Asian Americans and Pacific Islanders

On the days of the meeting, the opening plenary was presented by a group of panelists from across the country on the history that led to health disparities among Asian American and Pacific Islanders (AAPIs) and how future generations of healthcare providers, researchers can help address this gap. My favorite part of this presentation was listening to the vulnerability of the children of immigrants, through the lens of the panelists, regarding their experience about sexual reproductive health, and how much of a taboo topic it is to talk with their parents or even healthcare providers. Coming from a family of immigrants, this presentation hit home and how much it resonated with me professionally and personally. It was, as if, they were telling my story, and I am positive many fellow AAPIs feel the same way. To tell you the least, this plenary made me feel seen and inspired me to advocate for equitable health care among fellow Asian American, Native Hawaiian and Pacific Islanders (AANHPIs) as an aspired ambulatory care pharmacist. As of now, the panelists are continuing to conduct more research to help AANHPIs in the near future regarding access to health care.

Impact of the Pandemic on Access to Care

The pandemic has changed the climate of healthcare delivery here in the United States. It was a challenge for patients, especially women and BIPOC, to visit their doctor’s office for appointments such as getting their birth control shot. Health care disparities also increased in women during the pandemic, and contraceptive visits have declined as well.

Evidence reviewed by Dr. Nguyen at the CDC and colleagues showed that the use of subcutaneous depot medroxyprogesterone acetate (DMPA-SC) in four studies with self-injection and provider-injection groups resulted in no differences in pregnancies and side effects, along with higher continuation rate in the self-administered DMPA-SC at 12 months, therefore DMPA-SC should be offered to patients to increase access to reproductive care.

Another group of panelists presented on the impact of tear gas used by law enforcement and reproductive health following the racial justice protests in 2020. What they found was 100% of the participants in their research had health problems due to tear gas, alarmingly, 54.5% had changes to menstrual health such as increased bleeding, cramping, and unusual spotting.

Innovations in Abortion Care

 The closing plenary was nothing short of relatable to what is going on in the country at the moment; the panelists presented on self-managed medication abortion in the United States among providers, patients, and seekers. Due to strict state laws regarding abortion and increased distances to abortion clinics, a telemedicine service was used to deliver medication abortion saw an increase of more than 40% within the last two years and it resulted in 96% of successful abortion and only 1% resulted in any serious adverse events.  Unrelated to this study, but if pharmacies are able to dispense medication abortion, pharmacists get to use their expertise to help ease the anxiety and panic patients are facing who want an abortion but cannot access care.

Apart from disseminating information about family planning, there were presentations on how to use oral hormonal contraceptives in other health conditions. Additionally, there was a plethora of presentations on relevant topics such as how to counsel transgender and nonbinary patients on emergency contraceptives, anti-Black racism in obstetrics and gynecology, and many more.

Movie Screening & Discussion

To close out the annual meeting, and in my opinion, one of the many amazing things that happened at this meeting was the community screening of HBO Max’s Unpregnant. This movie depicts the struggles of two girls who are minors and cannot find an abortion clinic in their state that would provide care without parental consent and how religion plays a role in hindering an abortion. So, they had to drive from Kansas to New Mexico with hardly any resources to get to the clinic.

I hope this article sparks some interests and encourages you to play a part in advocating for reproductive justice.

For more information about the Society of Family Planning, visit https://www.societyfp.org/.


About the Author

Quyen Nguyen Headshot

Quyen Nguyen, PharmD Candidate 2022, is currently attending St. John Fisher College Wegmans School of Pharmacy in Rochester, New York. She is a member of APhA and the Treasurer for Club for Advancing Interprofessional Practice and Education (CAIPE). In this role, she collaborates with other healthcare professional students to help underserved patients in her community.

A Primer on Reproductive Justice for Pharmacy Professionals

Reprodutive Justice Pharmacy

What is reproductive justice?

Reproductive justice is “the human right to maintain personal bodily autonomy, have children, not have children, and parent the children we have in safe and sustainable communities” as defined by SisterSong Women of Color Reproductive Justice Collective [1]. Reproductive justice exists in a trinity of frameworks also consisting of reproductive health and rights.

 

How does it apply to pharmacy practice?

All health care providers, including pharmacists, take oaths to serve their patients as ethically and professionally as possible. The concept of reproductive justice falls within the scope of this promise, especially as it pertains to women of color and other marginalized people.

Legislators, healthcare providers and communities can address the intersectionality of oppressive forces (e.g. racism, sexism, classism, and ageism) that influence care given and received [2]. Barriers to the realization of reproductive freedoms and choices have stood in the way of family planning and personal health for ages. If we value reproductive justice and recognize the injustices of the past and present, we can prepare providers to shape a revolutionized future for reproductive care.

 

What historical injustices should we be aware of?

In contrast to reproductive justice, reproductive oppression is the control and manipulation of people through their bodies, sexuality, labor, and reproduction, according to Forward Together [3]. The goals of reproductive justice become clear when the injustices of the past are studied and acknowledged as reproductive oppression. They are stark by today’s standards, but they also remind us of a time when such acts were considered appropriate.

Just a few examples of historical injustices:

  • Rape and forced breeding of black slaves (1700s-1800s) [4]
  • Sterilization of the “hereditarily diseased” in Nazi Germany (1934-1945) [5]
  • Experimentation on low-income, imprisoned, and/or women of color for birth control research without informed consent (mid-1900s) [6]
  • Sterilization of Native Americans (1960s-1970s) [7]
  • China’s one-child policy (1979-2015) [8]

 

Are reproductive injustices still occurring now?

Although not as extreme, reproductive injustices still exist and hide in plain sight, including [9]:

  • Promotion of abstinence
  • Propagation of social “taboos” like teen and premarital pregnancies
  • Refusal of service (denying OTC emergency contraception sales or prescription medications)
  • Low access and availability of services to immigrants
  • Providing access to reproductive and contraceptive resources but limiting their feasible attainability through scarcity, geographical distance, and cost (lack of insurance)
  • Long-acting reversible contraception (e.g. implants and IUDs) as first-line birth control methods
  • The Hyde Amendment, which restricts the use of federal funds for abortions
  • Targeted Regulation of Abortion Providers (“TRAP”) laws, which shut down abortion clinics and effectively reduce access to abortion services

 

What can pharmacy professionals do?

The changes needed to achieve reproductive justice are easier said than done but not impossible. Widespread change depends on political decisions made at state and federal levels, but each health care provider can do their part in enacting progress in their workplaces. Putting aside personal beliefs in favor of patients’ best interests is key. Pharmacists in one-quarter of U.S. states are prescribing birth control with other states following suit [10].

Pharmacists can adopt practices that align with reproductive justice like the following:

  1. Be aware of personal biases. It is normal to have them, but recognition is key to avoid acting on them. Imagine serving a patient who has a different racial or socioeconomic background from you. How would your care and demeanor differ (if at all)?
  2. Do your research. Don’t fall prey to industry claims and monetary influences. For instance, with contraception consider all methods equally initially and narrow down the choices throughout the course of the patient interview and assessment.
  3. Share decision-making. Do not assume that your patient has the same values as you when making healthcare decisions. For instance, with contraception we cannot assume that effectiveness is the most important factor for patients. There are many other values and preferences that influence their choices, such as side effects, frequency of use, return to fertility, invasiveness/discomfort, and confidentiality. In one study, 28% of black women reported feeling pressured to use a method that was not their preferred [11]. Pharmacists should educate patients on all the various options available to them and give people the freedom to make their own decisions; this will improve patient satisfaction and outcomes. Always be mindful of their values, goals, and lifestyles.

Remember that what we now view as outrageous was once normal, and always try to think years ahead of the present to lead and be better prepared for inevitable change.

References

  1. “Reproductive Justice.” Sister Song, www.sistersong.net/reproductive-justice. 
  2. McIntosh, J. “Reproductive Justice: A Practice Framework.” ACSAP 2018 Book 2: Women’s and Men’s Care, ACCP, May 2018, 171–89.
  3. Forward Together, forwardtogether.org/. Accessed on 29 August 2020.
  4. Foster, Thomas A. “The Sexual Abuse of Black Men under American Slavery.” Journal of the History of Sexuality 2011;20(3):445–64.
  5. “German Law Authorizes Sterilization for Prevention of Hereditary Diseases.” United States Holocaust Memorial Museum, newspapers.ushmm.org/events/german-law-authori- zes-sterilization-for-prevention-of-hereditary-diseases. 
  6. Blakemore, Erin. “The First Birth Control Pill Used Puerto Rican Women as Guinea Pigs.” History.com, A&E Television Networks, 9 May 2018, www.history.com/news/ birth-control-pill- history-puerto-rico-enovid.
  7. Blakemore, Erin. “The Little-Known History of the Forced Sterilization of Native American Women.” JSTOR Daily, 25 August 2016, daily.jstor.org/the-little-known- history-of-the-forced-sterilization-of-native-american-women/. 
  8. Connett, Wendy. “Understanding China’s Former One-Child Policy.” Investopedia, 28 August 2020, www.investopedia.com/articles/investing/120114/understanding-chinas-one -child-policy.asp. 
  9. McDonald-Mosley, Raegan, MD, MPH, FACOG. “Reproductive Justice and Patient- Centered Care.” Maryland Department of Health Reproductive Health Roundtable Virtual Series. 2 July 2020.
  10. “Pharmacist Prescribing of Hormonal Contraception.” Birth Control Pharmacist, https://birthcontrolpharmacist.com/policies/. 
  11. Thorburn S, Bogart LM. African American women and family planning services: perceptions of discrimination. Women Health. 2005;42(1):23-39. 


About the AuthorGayane Kechechyan Headshot

Gayane Kechechyan, PharmD Candidate is a pharmacy student in the Class of 2023 at University of California San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences. Gayane completed a summer internship with Birth Control Pharmacist.

Reproductive Health During COVID: Eliminating FDA’s Burdensome Barriers to Mifepristone

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What is Mifepristone? 

Mifepristone is the primary component in the FDA-approved regimen taken to terminate pregnancies through 10 weeks gestation and is seen as an alternative to a surgical procedure.1 Many patients view this as less invasive, allowing for more privacy and control over a personal situation. The standard oral regimen includes mifepristone 200mg followed by misoprostol 800mcg 24-48 hours later. There are alternative doses available depending on medication availability and gestational window.2 mifepristone and misoprostol work in tandem to halt the pregnancy from developing and induce cramping to evacuate the contents of the uterus. Following the administration of these medications, women typically report back to their healthcare provider one to two weeks later to ensure the medications were fully effective and that the pregnancy has been terminated. Women can expect heavy bleeding and strong abdominal cramps that are most severe during the first few hours post-treatment but typically subside over the next day or two.1,3

Current Practice of Mifepristone Prescribing

The protocol for women pursuing medication abortion counseling and treatment often begins in a doctor’s office. Patients undergo a series of health screenings including laboratory testing, an ultrasound assessment to determine gestational age, and contraindication evaluations.2,4 

Additionally, the FDA requires a Risk Evaluation and Mitigation Strategy (REMS) prior to prescribing mifepristone, stating this is necessary to ensure safe use of the medication by patients.1,4 REMS programs are typically employed when prescribing medications with major safety concerns or the potential for serious adverse effects. Beyond this program, there are numerous stipulations to prescribing and dispensing mifepristone. Patient agreement forms, healthcare provider supervision and policies that restrict dispensing this medication anywhere outside of clinics, medical offices, and hospitals, make mifepristone unnecessarily difficult for patients to obtain.

How Has the Pandemic Impacted this Process? 

Cue the COVID-19 pandemic and reproductive health becomes infinitely harder. Once the country began shutting down in March, schools, businesses, and many other public entities were at a standstill as nonessential services. While many healthcare facilities were faced with overwhelming numbers of potential patients with coronavirus, other health related surgeries and appointments were postponed to mitigate infection risk in the general population. Access to abortion is time-sensitive, so when it is unavailable it leaves many women without fundamental choices for their family planning and reproductive outcomes. 

Reproductive care, including abortion, has been regarded as nonessential in many states across the United States, barring women from access to vital medical services. Governors in Texas, Louisiana, Mississippi, Alabama, and Oklahoma have made efforts towards ending both medical and surgical abortions.5 These states, among others, have aimed to restrict access to reproductive health processes by deeming them elective rather than essential procedures. As of April 8th 2020, Temporary Restraining Orders (TROs) have impeded certain state bans on abortions while litigation remains ongoing in Ohio, Alabama, and Oklahoma.5 While certain states continue to debate reproductive health legislation, congressional lawmakers contested the FDA on behalf of their constituents earlier this month. On June 16th 2020, the FDA received a letter on behalf of over 100 members of congress urging them to ease restrictions surrounding reproductive care during the pandemic.6 

ACOG’s Efforts to Ease Reproductive Care Restrictions 

In response to certain states’ stringent limitations and the overdue revisions to modern reproductive care, the American College of Obstetricians and Gynecologists (ACOG) filed a lawsuit petitioning the FDA to remove restrictive barriers to obtaining mifepristone during the COVID pandemic. The civil rights action was officially filed May 27th, 2020 to challenge the FDA to alter the multitude of requirements to prescribing mifepristone as nationwide efforts shift towards telemedicine.7,8 Both the CDC and the FDA have encouraged the use of telehealth to allow flexibility for doctors to safely meet with their patients while foregoing unnecessary in-person appointments. Thus far, women seeking mifepristone to end an early pregnancy or manage a miscarriage have been an exception to the highly enforced transition to telemedicine.7 Likewise, women are still required to travel to their doctor’s medical office or hospital to pick up the medication rather than a contactless option like mail order. ACOG pointed out the incongruence of the FDA’s standards which require patients to be seen in person to obtain mifepristone, yet allows them to take it in their homes without medical supervision. To emphasize their point, ACOG continues by noting that out of more than 20,000 drugs regulated by the FDA, mifepristone is the only medication that has such specifications, while allowing patients to self-administer in a location of their choosing.7 

When utilized for reasons other than abortion or miscarriage, the FDA allows mailing mifepristone to patients’ homes without the barriers imposed upon women pursuing reproductive care.7 This caveat exclusively hinders women in need of reproductive care from easily obtaining the required medications without bearing the unnecessary risk of COVID-19 infection from visiting a medical clinic. Many women who refuse this option are left with less effective options which may necessitate consequential procedures, thereby increasing exposure risk for patients and healthcare workers; the very circumstance all facets of medicine are trying to avoid.7

Recent Updates to Gaining Mifepristone Access

After deliberation in federal court, ACOG accomplished what they sought out to do when issuing their lawsuit to the FDA. On July 13th 2020,  a federal district court ruled in favor of a temporary suspension of the restrictions imposed upon obtaining mifepristone.9 The ruling sided with the notion that the barriers around  mifepristone subjected countless women to the unnecessary health risks of public exposure during the COVID-19 pandemic. While the preliminary qualifications and REMS testing still applies, the court’s order allows clinicians to mail mifepristone to eligible patients seeking abortion care under the U.S. Department of Health and Human Services’ COVID-19 Public Health Emergency. Although this has the potential to vastly expand access to mifepristone, ACOG continues to encourage clinicians to practice within their state’s laws which take precedence over this ruling.10 In response to the lifted restrictions, the president of ACOG, Eva Chalas, M.D., FACOG, FACS, hailed this decision as a “necessary step forward in our collective work toward health equity”.9  

How Pharmacists Can Play a Role

As the nation strives to adapt to telemedicine, pharmacists are becoming the sole in-person healthcare provider for many Americans. Pharmacists are often conveniently positioned in stores housing groceries or necessary supplies that people continued visiting during the pandemic. As one of few essential businesses that never closed, pharmacy dispensing of mifepristone would enable women to have more timely access to mifepristone and avoid the added risks of visiting additional clinic locations. In light of telemedicine, health disparities would be reduced for patients that have difficulty accessing medical abortions in their communities. Pharmacists may be able to help fill this gap and ensure safe use of mifepristone by counseling patients on how to take it and by answering questions that may arise.4 This shift in responsibility would continue to prioritize patient safety while employing trained healthcare professionals to aid in convenience, education and accessibility to a time-sensitive medication. 

References

  1. Center for Drug Evaluation and Research. (n.d.). Mifeprex (mifepristone) Information. Retrieved June 24, 2020, (link)
  2. (n.d.). Retrieved June 27, 2020, from (link)
  3. Center for Drug Evaluation and Research. (n.d.). Questions and Answers on Mifeprex. Retrieved June 24, 2020, (link)
  4. Raifman, S., Orlando, M., Rafie, S., & Grossman, D. (2018). Medication abortion: Potential for improved patient access through pharmacies. Journal of the American Pharmacists Association, 58(4), 377-381. doi:10.1016/j.japh.2018.04.011
  5. Bayefsky, M. J., Bartz, D., & Watson, K. L. (2020). Abortion during the Covid-19 Pandemic — Ensuring Access to an Essential Health Service. New England Journal of Medicine, 382(19). doi:10.1056/nejmp2008006
  6. Congress of the United States – degette.house.gov. (2020, June 16). Retrieved June 24, 2020, from (link)
  7. ACOG V. FDA Complaint Mifepristone COVID-19, retrieved June 24, 2020 (link).
  8. ACOG Suit Petitions Court to Remove FDA’s Burdensome Barriers to Reproductive Care During COVID-19. (2020, May 27). Retrieved June 24, 2020 (link)
  9. Federal Court Blocks FDA Restriction That Unnecessarily Imposes COVID-19 Risks on Patients Seeking Abortion Care. 27 May 2020, (link)
  10. “Court’s Order Lifting Burdensome FDA Restriction: What You Need to Know.” ACOG, 15 July 2020, http://www.acog.org/news/news-articles/2020/07/courts-order-lifting-burdensome-fda-restriction-what-you-need-to-know.

About the Author

Savannah Gross, PharmD Candidate, is a third-year pharmacy student at University of Georgia College of Pharmacy

Article Reviewed by: Sally Rafie, PharmD, BCPS, APH, NCMP, FCCP

Can Contraceptives be Vegan? Important Considerations for Vegan Patients

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The Vegan Society defines veganism as “a way of living which seeks to exclude, as far as is possible and practicable, all forms of exploitation of, and cruelty to, animals for food, clothing or any other purpose”. Since veganism extends beyond just a diet for avoiding animal products, awareness of medication ingredients is also a component of this lifestyle, and patients may be curious at to where their contraceptives fit in.

Potential Uncertainties in Contraceptives

Two inactive ingredients commonly found in hormonal contraceptives which could be considered problematic for vegans are lactose and magnesium stearate. Lactose can act as a filler, a diligent powder, or as an acid in medications and magnesium stearate acts as a lubricant during tablet processing and improves medication solubility. The source of these ingredients, and the status of whether they are vegan can be cloudy. Traditionally, lactose is derived from cow’s milk via bovine rennet extraction, but it can also be produced synthetically. Similarly, magnesium stearate is typically rendered from the fat of cows, pigs, and sheep, however it can now be produced from vegetable matter. Although these ingredients can be found on the medication label, their source is not stated.

Authors of The BMJ article, Why Can’t All Drugs Be Vegetarian? found that differentiation between vegetarian and non-vegetarian lactose was poor as materials involved and the process of manufacturing was often not available. Upon contacting manufactures of lactose-containing products, they found there was uncertainty as to whether medications were suitable for vegetarians or vegans. Because of this, the authors point to clearer labeling requirements as a necessity for understanding animal content in medications.

Patient Considerations

If a patient feels that their personal definition of veganism involves avoiding ingredients such as lactose in their hormonal contraceptives, there are alternatives contraceptive options such as condoms (look for non-latex brands such as Glyde and Sir Richard’s), IUDs, the Ortho Evra patch, vaginal rings, the implant, or the Depo-Provera injection. However, it is important to note that hormones themselves are also often derived from animals. Additionally, all products, even the ones made without animal-sourced ingredients, are tested on animal subjects before they can progress to human testing and make it to market.

So, can a patient use contraceptives and still be considered vegan? The Vegan Society recommends avoiding medications that contain animal products but also re-emphasizes the ‘as far as practical and possible’ portion of their definition for what it means to be vegan. Since all oral contraceptives currently available contain lactose, most would agree that taking them falls under that category as there is no practical way that they can be completely vegan. “Sometimes, you may have no alternative to taking prescribed medication. Looking after yourself and other people enables you to be an effective advocate for veganism,” says The Vegan Society.

The Pharmacist’s Role

Lastly, the Vegan Society also reminds patients to “open up a conversation with your pharmacist or doctor” in regard to discussing the intersection of medications and veganism, and providers need to be prepared to have these conversations too. Initiating dialogue with patients about their dietary and lifestyle preferences can help with understanding what contraceptive methods they feel most comfortable and confident using and fitting into their vegan lifestyle. Pharmacists are in an optimal position to discuss the options relevant to veganism with patients by being knowledgeable about animal testing as well as active and inactive ingredients and their sources. Being proactive and having these conversations could prevent patients from stopping or changing medications that they feel do not align with their lifestyle, while helping improve adherence and satisfaction.

References:

  1. Tatham , Kate, and Kinesh Patel. “Why Can’t All Drugs Be Vegetarian?” BMJ, vol. 348, 8 Feb. 2014, pp. 18–20., (link).
  2. McKie, Joshua, and Sue Gough . “Is There a Lactose-Free Oral Contraceptive?” UK Medicines Information, 3 Aug. 2016, (link).
  3. Fry, Samantha. “Is My Medication Vegan?” The Vegan Society, 13 Oct. 2017, (link).
  4. “List of Animal-Free Medications.” The Vegan Society, (link).
  5. “Definition of Veganism.” The Vegan Society, (link).
  6. Barclay, Eliza. “Is Your Medicine Vegan? Probably Not.” NPR, NPR, 15 Mar. 2013, (link).

About the Author

Niamh O’Grady, PharmD Candidate, is a pharmacy student in the Class of 2021 at the University of California San Francisco School of Pharmacy

Reviewed by Breanna Failla, PharmD Candidate and Brooke Griffin, PharmD, BCACP

Measuring Blood Pressure: An Important Prerequisite to Prescribing Hormonal Contraception

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Why is it important to measure blood pressure before prescribing hormonal contraception?

Combined hormonal contraceptives (CHCs) are a relatively safe and effective method for your patients in preventing pregnancy and treating other disease states such as menorrhagia, endometriosis, PCOS and more. However, CHCs may increase the risk for a few serious cardiovascular events. This risk is increased if a patient has hypertension.

Screening for hypertension prior to staring CHCs is a class A recommendation for safe use according to the U.S. Selected Practice Recommendations for Contraceptive Use (SRC). In a systemic review, women who did not have their blood pressure checked prior to starting hormonal contraception had higher odds of having an acute myocardial infarction and ischemic stroke.

Also, in a small percentage of patients, CHCs can cause life-threatening hypertension, which can lead to irreversible damage to the kidneys and cause renal failure. This effect can last after the medication is discontinued.

Due to these severe adverse effects, all patients are screened for hypertension prior to starting CHCs. If a patient is hypertensive, they should be treated appropriately and have blood pressure well controlled prior to starting a hormonal contraceptive method.  

How do CHCs raise blood pressure?

The mechanism by which CHCs increase blood pressure is unknown. Regardless, CHCs can cause small increases in blood pressure in both normotensive patients and patients with hypertension which is significant enough to be recognized as a risk for hypertensive patients.

Who is at risk of complications from CHCs?

It is not advised to use CHCs in patients with severe hypertension (defined as systolic blood pressure (SBP) ≥ 160 mmHg or diastolic blood pressure (DBP) ≥ 100 mmHg). However, in people with controlled and monitored hypertension and who are also under 35 years of age, CHCs may be appropriate as long as they are otherwise healthy and do not smoke (U.S. MEC 3). It is important to mention that even if a patient has hypertension that is under control, there is still a risk present for cardiovascular events and that other contraceptive options should be considered before initiating a CHC.

Patients are at a higher risk of cardiovascular complications if they are older than 35 years of age, have a familial history of hypertension, cardiovascular disease or preexisting occult renal disease, and if the patient is obese. Providers should use discretion in patients with these preexisting conditions before starting CHCs or consider more appropriate contraceptive options.

What other options are there for patients with hypertension?

Patients with uncontrolled hypertension, or who are at risk of malignant hypertension have other options for contraception. Progestin only contraceptives such as progestin only pills (POPS), the shot, or levonorgestrel-containing IUDs are recommended over CHCs according to the CDC MEC for women with hypertension. Non-hormonal options include the copper-containing IUD, condoms, or spermicides.

References

  1. Tepper NK, Curtis KM, Steenland MW, Marchbanks PA. Blood pressure measurement prior to initiating hormonal contraception: a systematic review. Contraception 2013;87:631–8.
  2. CDC. U.S. medical eligibility criteria for contraceptive use, 2016. MMWR Recomm Rep (No. RR-X);2016.
  3. Development, updates, and future directions of the World Health Organization Selected Practice Recommendations for Contraceptive Use. Int J Gynecol Obstet 2017;136: 113–119 – 04 January 2017
  4. Armstrong, Carrie. Hormonal Contraceptives in Women with Coexisting Medical Conditions. Am Fam Physician. 2007 Apr 15;75(8):1252-1258.
  5. El-Ibiary SY, Shrader SP, Ragucci KR. Contraception. In: DiPiro JT, Yee GC, Posey L, Haines ST, Nolin TD, Ellingrod V. eds. Pharmacotherapy: A Pathophysiologic Approach, 11e. McGraw-Hill; Accessed July 22, 2020. https://accesspharmacy-mhmedical-com.mwu.idm.oclc.org/content.aspx?bookid=2577&sectionid=227710658

About the Author

Elizabeth Duxbury Pharm.D. is a recent graduate of University of California, San Diego Skaggs School of Pharmacy & Pharmaceutical Sciences in 2019.

Article reviewed by Breanna Failla, PharmD Candidate and Brooke Griffin, PharmD, BCACP

Effectiveness of Hormonal Contraceptives in Patients with Higher Weights

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Introduction

Obesity is becoming more prevalent every year and as pharmacists, it is important to revisit current contraceptive options for these patients. Overweight patients are defined as having a BMI ranging from >25-29.9 kg/m2 and obese patients a BMI >30 kg/m2. Currently there are no safety contraindications in patients with a BMI > 25 kg/m2 alone when initiating oral contraceptives according to the current CDC guidelines; however, efficacy with these agents raises a valid question. We will address efficacy of both hormonal contraceptives as well as other modes of contraception.

Currently, there are several theories on how obesity can affect the efficacy of contraceptives. One theory is that the absorption of contraceptives may be increased due to the higher cardiac output that leads to increased blood flow, thus causing a faster gastric emptying of the drug meaning that the drug has less opportunity to be absorbed. Another thought is that higher levels of lipoprotein found in obese people may compete with drugs for binding sites on albumin, causing there to be more unbound drug. Furthermore, some studies revealed that there may be an association between obesity and a lower concentration of sex hormone-binding globulin. Hepatic metabolism and excretion of drugs may also be affected by obesity. While there isn’t one clear indication that may cause these discrepancies, there have been many studies conducted to test effectiveness in various types of contraceptives.

Importantly, there is a specific term used throughout research studies to determine efficacy of different contraceptive methods called Pearl Index (PI). PI is a numerical value used to indicate the number of pregnancies that occur for every 100 women per years of use. Additionally, some trials looked at the minimum serum concentrations of hormones that were necessary to suppress ovulation thus preventing pregnancy (levonorgestrel 0.3 ng/mL).

Combined Hormonal Contraceptives (CHCs)

One study compared a CHC that contained 30 mcg of ethinyl estradiol (EE) and 150 mcg of levonorgestrel (LNG) in normal-weight versus obese women. Obese women were found to have a lower AUC and Cmax of both EE and LNG, but clinically speaking, LNG levels were above 0.3 ng/mL in each population which is clinically significant enough to suppress ovulation and prevent pregnancy.

Another study evaluated the efficacy of an extended-cycle CHC that contained 20 mcg of EE and 100 mcg of LNG for 84 days, followed by 10 mcg EE for 7 days. The study concluded that pregnancy rates were similar across weight and BMI and did not report any significant discrepancies amongst weight classes.

Vaginal Rings

For the vaginal ring containing 11.7 mg of etonogestrel and 2.7 mg of ethinyl estradiol (NuvaRing®), there was a study that evaluated normal-weight versus obese women. Like the combined oral contraceptive pill, the ring did cause lower serum concentrations of hormones in obese women, but clinically there were no differences in ovarian follicle development. This suggests that efficacy is not compromised in obese women.

DMPA Injection

In a study that looked at the efficacy of the depot medroxyprogesterone acetate (DMPA) injection in women stratified by BMI, the serum concentrations were significantly lower in obese individuals compared to normal weight women. Surprisingly, these serum concentrations were sufficient to suppress ovulation and efficacy was not compromised.

Intrauterine Device (IUD)

In a large trial conducted on levonorgestrel-containing IUDs (two strengths, 8 mcg/24h or 13 mcg/24h), PIs revealed IUDs were effective at preventing pregnancy regardless of the patient BMI.

Exception: The Patch (Ortho Evra)

It is significant to note that obese women have lower efficacy with the hormonal contraceptive patch compared to other methods. Ortho Evra or Xulane (containing 6 mg norelgestromin, 0.75 mg ethinyl estradiol per patch) package insert states that from results of clinical trials, this patch may be less effective in women weighing greater than 90 kg. In trials conducted, it was reported that out of 15 pregnancies reported during the study, 5 of them were from a patient weighing more than 90 kg. The package insert also noted that women with a body weight >90 kg accounted for less than 3% of the study population, so it may be beneficial to conduct additional trials to determine efficacy of the patch for overweight patients.

In Conclusion

While elevated BMI alone is not a contraindication when initiating some contraceptives, it is important to recognize that overweight women are at a higher risk of comorbidities such as diabetes, hypertension, and thromboembolism which may be contraindications. If an individual only has an elevated BMI, CHCs, vaginal rings, or the DMPA injection may be appropriate to use given no clinically significant differences in their efficacy. It is important to advise overweight patients against using the hormonal patch due to the higher risk of unplanned pregnancies. Lastly, it is important to counsel patients that no contraceptive option is going to be 100% effective regardless of weight.

References:

  1. Kerns J, Darney P. Vaginal ring contraception. Contraception. 2011;83(2):107–115
  2. Roumen FJ. The contraceptive vaginal ring compared to the combined oral contraceptive pill: a comprehensive review of randomized controlled trials. Contraception. 2007;75(6):420–429.
  3. Segall-Gutierrez P, Taylor D, Liu X, Stanzcyk F, Azen S, Mishell DR., Jr Follicular development and ovulation in extremely obese women receiving depo-medroxyprogesterone acetate subcutaneously. Contraception. 2010;81:487–495
  4. Westhoff CL, Hait HI, Reape KZ. Body weight does not impact pregnancy rates during use of a low-dose extended-regimen 91-day oral contraceptive. Contraception. 2012;85(3):235-239. doi:10.1016/j.contraception.2011.08.001
  5. Westhoff CL, Torgal AH, Mayeda ER, Pike MC, Stanczyk FZ. Pharmacokinetics of a combined oral contraceptive in obese and normal-weight women. Contraception. 2010;81:474–480
  6. Gemzell-Danielsson K, Apter D, Hauck B, et al. The Effect of Age, Parity and Body Mass Index on the Efficacy, Safety, Placement and User Satisfaction Associated With Two Low-Dose Levonorgestrel Intrauterine Contraceptive Systems: Subgroup Analyses of Data From a Phase III Trial. PLoS One. 2015;10(9):e0135309. Published 2015 Sep 17. doi:10.1371/journal.pone.0135309
  7. Janssen. Ortho Evra (norelgestromin/ethinyl estradiol) [package insert]. U.S Food and Drug Administration website. https://www.accessdata.fda.gov/drugsatfda_docs/label/2012/021180s043lbl.pdf. Revised August 2012. Accessed July 3, 2020.
  8. Simmons KB, Edelman AB. Hormonal contraception and obesity. Fertil Steril. 2016;106(6):1282-1288. doi:10.1016/j.fertnstert.2016.07.1094

About the Author

Samantha Kim, PharmD is a recent graduate of University of California San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences.

Article reviewed by Breanna Failla, PharmD Candidate and Brooke Griffin PharmD, BCACP

No Taxation for Menstruation: The Importance of Student Pharmacist Advocates

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Pictured: Policy Postcards sent to Michigan Legislators from an event called “Galentine’s Day”

At the University of Michigan College of Pharmacy, the APhA-ASP chapter’s inaugural Women’s Health Campaign hosted multiple events to educate and engage student pharmacists and the Ann Arbor community. While our Campaign focused on topics directly related to pharmacy, such as contraception and HPV vaccination, we have also taken the initiative to advocate for a crucial area of women’s health: menstruation.

Our American Pharmacists Association-Academy of Student Pharmacists (APhA-ASP) chapter, in collaboration with Student National Pharmaceutical Association (SNPhA), hosted an event called “Galentine’s Day” in February. This event gave student pharmacists the opportunity to purchase women’s health-related buttons to raise money for Ozone House, a shelter in Ann Arbor, MI for homeless adolescents. Our profits went toward the purchase of menstruation products for this vulnerable population, many of whom are just beginning their period. Additionally, student pharmacists wrote to their state representatives to support abolishing the “Tampon Tax” in Michigan and throughout the United States.

Pictured: Buttons from Fundraiser

With this in mind, let’s take some time to educate ourselves…

What is a “Tampon Tax”?

Currently, states have the authority to determine which products have sales tax and which are exempted. Products such as lip balm and prescription drugs, are defined as “medically necessary items” and are therefore not imposed with a sales tax. Unfortunately, feminine hygiene products are categorized as “luxury items” and taxed (for reference, Michigan sales tax is 6%). Hence the name “Tampon Tax”. This is an example of women being disproportionately affected within health care.

On average, a woman will menstruate over 2,500 days in her lifetime. This equates to almost seven years of using around 17,000 tampons and sanitary napkins. With a 6% sales tax in Michigan, costs greatly add up, especially for something that is a naturally occurring part of many women and should be considered medically necessary.

The topic of menstruation is historically taboo within society, but more recently has lessened over the years. Now, we have seen governments in the U.S. and worldwide start to legislate around this idea of “period equity”, by ensuring proper menstrual education and equal access to hygiene products. Currently, ten states have legislation explicitly exempting feminine hygiene products from the state sales tax: Connecticut, Florida, Illinois, Maryland, Massachusetts, Minnesota, New Jersey, New York, Pennsylvania, and Nevada*.

*Note: Oregon, Montana, Delaware, New Hampshire, and Alaska do not have a sales tax on any product.

Why should we abolish the “Tampon Tax”?

Feminine hygiene products are not luxury items. These products are used monthly and women should not have unfair financial burdens imposed upon them to purchase what are considered a medical necessity. This is especially true for women with lower socioeconomic status and those without homes.

The main argument against abolishing the “Tampon Tax” is the yearly tax revenue from these products. Menstrual products contribute around $5 million dollars annually to the state of Michigan to be used in various social programs and school aid funds. While loss of revenue could be detrimental to these programs, legislators can creatively think of other ways to ensure that these state programs continue to have funding. Additionally, legislators in Michigan have stated this to be a smaller matter in comparison to other policy topics. But, with a tax affecting millions of women, this legislative act should be at the forefront. The important part to keep in mind is that these products should not have been taxed in the first place as they are medically necessary to such a large portion of the population.

The importance of student pharmacist advocacy!

With managing coursework, student organizations, internships, and self-care, it can be difficult for student pharmacists to stay up to date on legislative pharmacy updates. Though it may seem overwhelming, advocacy is anything that showcases pharmacy. This can range from hosting a “Pharmacy Day at the Capitol” to providing a blood pressure screening to a community member. These acts promote pharmacy practice. We are a generation of new future pharmacists where our profession is constantly innovating and expanding; we want to practice our license to its fullest potential. And we have the power to achieve these goals through pharmacy advocacy.

Menstruation and period products do not directly correlate with pharmacy. However, as health care professionals, it is important that we advocate for all of patient care!

Coming back to our “Galentine’s Day” event, students had the opportunity to write to their state and federal legislators supporting the abolition of the “Tampon Tax”. Overall, we raised around $200 for the Ozone House and were able to mail out 41 of our policy postcards to the following:

  • Eight Michigan State Senators
  • Eleven Michigan State House of Representatives
  • Two Michigan U.S. Senators
  • Two Michigan U.S. House of Representatives

Just two weeks after mailing out our postcards, I received a letter from Senator Jim Runestead (MI-15), who not only thanked me for sharing my thoughts and concerns of abolishing the “Tampon Tax”, but as chair of the Senate Finance Committee, was going to meet to discuss the involved senate bills (currently SB123 and SB124) and finding resolutions for the women of Michigan.

Participation matters! Your voice matters! And most importantly…student advocacy is successful.

How do I get involved?

Whether you’re a pharmacist or student pharmacist, there are multiple ways to lend your voice to abolish the “Tampon Tax” and help others in need. Below are some resources to get started:

  • For student pharmacists, get involved with organizations like APhA-ASP that have committees dedicated to policy and women’s health!
  • Keep up to date with where Michigan’s SB123 and 124 are in the legislative process.
  • PERIOD. – A non-profit organization working to de-stigmatize periods, have accessible period products in public institutions, and abolish the “Tampon Tax”.
  • Helping Women Period – A non-profit organization based in Lansing, Michigan bringing free feminine hygiene products to homeless and at-risk women.
  • Ozone House – Continue our collaboration by helping those in need of menstruation products.

Together, we collectively say “No Taxation for Menstruation”!

References

  1. Censky, A. Legislators Try Again To Dismantle Michigan’s ‘Tampon Tax’ (2019). Accessed 3/18/2020: (link)
  2. Klawiter, J. Michigan Tampon Tax (2017). Accessed 3/18/2020: (link)
  3. Bryan, W. Bill introduced to remove Michigan’s ‘Tampon Tax’ (2019). Accessed 3/18/2020: (link)
  4. Zraick, K. It’s Not Just the Tampon Tax: Why Periods Are Political (2018). Accessed 3/18/2020: (link)
  5. Sagner, E. More States Move To End ‘Tampon Tax’ That’s Seen As Discriminating Against Women (2018). Accessed 3/18/2020: (link)

About the Author

Tina Bednarz, PharmD Candidate is a student at the University of Michigan College of Pharmacy

Article reviewed by Breanna Failla, PharmD Candidate and Brooke Griffin PharmD, BCACP

Thanks, Birth Control Day

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Join The National Campaign to Prevent Teen and Unplanned Pregnancy, Bedsider, and me in saying, “Thanks, Birth Control” today! Birth control is a wonderful tool that helps us help our patients with family planning and other health issues.

All the reasons I️ say “thanks, birth control” on this day every year:

  1. Thanks for fewer unplanned pregnancies (women using birth control carefully and consistently account for only 5% of all unplanned pregnancies).
  2. Thanks for giving people the freedom to plan a family on their own terms.
  3. Thanks for more economic opportunities for young women and men.
  4. Thanks for greater educational attainment.
  5. Thanks for improved maternal health.
  6. Thanks for being so amazingly awesome that it is used by 99% of women who have had sex.
  7. Thanks for helping build stronger families.
  8. Thanks for being one of the nation’s top 10 greatest public health achievements of the last 100 years, according to the CDC.
  9. Thanks for reduced public spending.
  10. Thanks for fewer abortions.
  11. Thanks for reminding us of something that has great bi-partisan support.
  12. Thanks for building stronger relationships.
  13. Thanks for fewer health disparities.
  14. Thanks for less child poverty.
  15. Thanks for helping countless individuals better plan for their future and realize their dreams.
  16. Thanks for fewer low birth weight babies.
  17. Thanks for being so darn cost effective (public funding for contraception saves nearly $6 in medical costs for every $1 spend on contraceptive services).
  18. Thanks for saving countless panties and other clothing items from being stained by unregulated periods.
  19. Thanks for helping women manage heavy and/or painful periods (and the resulting lost days from work, costs for feminine products, and treatment costs).
  20. Thanks for treating acne.
  21. Thanks for preventing cancer.
  22. Thanks for coming in lots of different forms to choose from.
  23. Thanks for helping women skip pesky periods.
  24. Thanks for treating prementrual syndrome and premenstrual disphoric disorder.
  25. Thanks for letting women and men choose control of whether/when they want to have children.
Why are YOU or YOUR PATIENTS thankful for birth control?  Tweet (#ThxBirthControl), post something on Facebook, share one of Bedsider’s clever digital postcards, or add a comment here.  Need some ideas?  The National Campaign has plenty.
Thank you and thanks birth control.

Birth Control and Population Issues

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With more women and men empowered to control their fertility with planning and birth control use, some populations are seeing drops in childbearing.  Some countries are concerned about population declines and are promoting childbearing.  The “baby bonus” programs of Australia and Singapore may ring a bell.

Other countries are considering policies that restrict access to reproductive health services, such as contraception and abortion, and actually making them illegal in some situations.  If these policies are implemented, there are serious concerns it could lead to more unsafe abortions.

Others question whether forcing women into the domestic sphere roles may backfire.  Research from Harvard’s sociology department found that declining fertility may not be linked to birth control use, but rather to gender role stereotypes placed on women.  Other countries experiencing similar drops in birth rates are working to improve conditions so that couples want to plan to have children.  An example of improving conditions is more maternity and paternity leave.

We live in an interesting time where most populations are struggling to reduce unintended pregnancies but a few are now working to promote more pregnancies.