Keeping pace with contraception: a practical refresher for pharmacists

The rapidly expanding scope of pharmacists continues to provide new opportunities for pharmacy teams to deliver accessible and timely care for Canadians. One area where our role is quickly changing is in the prescribing of contraceptives, where pharmacy scope has gradually expanded to several provinces, including BC, AB, SK, QC, NB, and NS. There is a stark need for these services; up to half of all pregnancies are unintended, often disproportionately affecting vulnerable populations such as younger individuals, Indigenous populations, new immigrants, patients living in rural communities, and patients of lower socioeconomic class. As over one million women in Canada face barriers to obtaining contraception, expanding pharmacy scope (along with coverage) can facilitate timely and equitable access to these products. Regardless of the scope in your province, providing contraception is an essential component of pharmacy practice.

Navigating Through the Options

Options for contraception include the implant, intrauterine devices (IUDs), injection, ring, patch, and pill. Within these choices, the first consideration may be to determine if patients would like a long-term solution or a more flexible method.

Long-acting Birth Control Options

• The progestin implant (Nexplanon®): Offers over 99% effectiveness for up to three continuous years. Like other hormonal long-term birth control options, common side effects include amenorrhea, headache, spotting, and breast soreness. As it is inserted subdermally in the arm, a scar may develop at the site of insertion.
• Hormonal Intrauterine Devices (IUD): Have a comparable effectiveness to Nexplanon®. Approved options (Mirena® and Kyleena®) are effective for up to five years. Mirena® is also indicated to treat heavy periods (menorrhagia).
• The Copper IUD: Offers over 99% effectiveness, however compared to hormonal alternatives it can lead to heavier periods. A unique feature is that it does not require any backup contraception when started and can also serve as an emergency contraceptive when inserted within seven days of unprotected intercourse. Copper IUDs are more affordable and available for various durations (3, 5, 10 years).
• The injection (Depo-Provera®): Administered every 12-13 weeks, it is slightly less effective at around 94%. Depo-Provera has been associated with weight gain and a loss in bone mineral density, therefore it is only recommended to be used for up to two years.

Shorter-Term Contraception and Cycle Control

Individuals who desire shorter-term contraception and greater cycle control may find the following options (all ~91% efficacy) more preferable:

• Combined oral contraceptives (COCs): The most common hormonal method. While COCs provide greater cycle control, they may also leave room for user error/adherence concerns due to the required daily dosing.
• The mini-pill (progestin only): Provides an oral option to patients who are contraindicated/intolerant to estrogen. As the mini-pill works by thickening cervical mucus and thinning uterine lining, backup contraception is necessary if the dose is more than 3 hours late.
• The contraceptive patch (Evra®): Operates on a weekly adherence schedule which may be more convenient for some patients. Patch specific side effects include skin irritation and breast soreness.
• The contraceptive vaginal ring (NuvaRing®): Used for a cycle of three weeks, plus one week off. The most common side effects specific to the ring are vaginal irritation/discharge or expulsion of the ring.

Summary of Contraceptive Efficacy and Duration

• Nexplanon® (Implant): >99% effectiveness | Lasts up to 3 years
• Hormonal IUD (Mirena®/Kyleena®): ~99% effectiveness | Lasts up to 5 years
• Copper IUD: >99% effectiveness | Lasts 3, 5, or 10 years
• Depo-Provera® (Injection): ~94% effectiveness | Administered every 12-13 weeks
• Pill, Patch, and Ring: ~91% effectiveness | Daily, weekly, or monthly adherence