Help Patients Choose a Contraceptive

Pharmacists in many provinces can now prescribe contraceptives.

Help sort through options wherever you practice.

Consider patient preferences when discussing available contraceptives...including efficacy, dosage forms, and frequency of use.

For example, refer patients for an IUD (Mirena, etc) or implant (Nexplanon) if they want the most effective contraceptive.

Point out that these last from 3 to 10 years...and fertility usually returns within 1 or 2 cycles after removal, like most other options.

But explain that it may take up to a year for fertility to return after the last depot medroxyprogesterone (Depo-Provera) injection.

If patients prefer an oral product, clarify that there’s not one “best” combo OC. Consider starting a monophasic OC with 30 or 35 mcg/day of ethinyl estradiol (Min-Ovral, Marvelon, etc).

There’s no evidence that lower estrogen doses are safer...and lower doses often lead to more breakthrough bleeding.

Advise that it’s easier to use a MONOphasic pill continuously if patients want fewer periods. Continuous use of MULTIphasic OCs has a higher risk of breakthrough bleeding.

Usually save progestin-only pills (Jencycla, Movisse, etc) for patients who are breastfeeding or need to avoid estrogen. Keep in mind, these are less forgiving if a dose is missed or taken late.

Evaluate comorbidities to identify risks...or possible benefits...of using contraceptives.

For instance, avoid estrogen-containing products in patients at risk of blood clots, such as those who have migraine with aura...or are over age 35 and smoke. In these cases, lean toward an IUD or implant.

Watch for interactions. For example, CYP3A4 inducers (phenytoin, etc) can reduce the efficacy of any pill, patch, ring, or implant. Generally advise using an IUD or depot medroxyprogesterone instead.

Ask about other symptoms contraceptives may improve. For instance, suggest any combo OC to help treat acne or menstrual pain.

Also educate that continuous use of a combo OC can minimize anemia, endometriosis, menstrual migraine, etc.

Use our resource, Choosing a Contraceptive, to guide choices for patients with obesity...and to help manage common side effects.

Key References

  • JAMA. 2021 Dec 28;326(24):2507-2518
  • MMWR Recomm Rep. 2016 Jul 29;65(3):1-103
  • Dickey RP, Seymour ML. Managing Contraceptive Pill Patients and Other Hormonal Contraceptives. 17th ed. New Orleans, LA: EMIS, Inc. Medical Publishers, 2021
Pharmacist's Letter Canada. May 2023, No. 390513

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