A practice tool for initiating and managing combined hormonal contraceptives for contraception: Assessment, decision-making and monitoring.

The CHC Practice Tool follows a systematic approach to take the pharmacist through the steps in assessing patients, initiating a product and providing patient education and follow-up. Pharmacists can use this tool to help guide them in initiating prescriptions for CHC or for ongoing management. The tool also captures when patients should be referred to their primary care provider.

SL, a 24-year-old, asks the pharmacist in their community pharmacy to prescribe an oral contraceptive. The pharmacist practises in a province that has regulations permitting pharmacists to prescribe contraceptives. The pharmacist recognizes SL and knows the following: pronouns she/her, biologic sex is female, gender-identifies as a woman and ethnicity is of South Asian descent.

Monitoring of the patient’s use and experience with the CHC should be completed as per the follow-up plan in step 3. Patients should be asked about their satisfaction with the product and if they like this method of contraception. In terms of adherence , several questions can be asked. Instead of asking an open-ended question about adherence, more direct questions may be more helpful, such as, “How many pills have you missed in the last week?” or “How have you responded with regards to missed doses?” Patients should be asked about the occurrence of side effects , when they occurred and how they were managed. The pharmacist should also be prepared to provide information to help a patient with side effects they have experienced. The pharmacist should also ask the patient about any changes in health status , for example, new medical conditions, changes to weight, changes to smoking status and any changes to medications. Finally, a BP measurement should be taken to monitor for any changes. If the pressure is ≥140/90, the patient should be referred. Application to your patient : SL returns to the pharmacy in 3 months for her refill. She has had no headaches with the CHC that was prescribed and is happy with the product. She had some initial light BTB while taking the pills for the first month, but this has now resolved. She has not missed any pills during this time. Her blood pressure is 124/78. As per the prescribing regulations in their province, the pharmacist provides the appropriate amount of CHC for the next refill. The pharmacist mentions that they will follow-up with her at her next refill and to call if she has any concerns.

Pharmacists are well positioned to manage contraception. This article describes the development and application of a CHC Practice Tool to support pharmacists in this management. This tool reinforces a systematic approach that considers evidence, pharmacists’ expertise and patient preferences. ■

It is estimated that over 40% of pregnancies in Canada are unintended, and nearly half of unintended pregnancies are in individuals on some form of contraception. 1 Effective contraception, such as combined hormonal contraceptives (CHCs), are underused in Canada. 1 Identified barriers to obtaining effective contraceptives include individuals not being adequately informed or educated, not having trained health care professionals and difficulty accessing a prescriber. 2 Adherence to contraceptives is poor, with approximately 60% of patients using them incorrectly or inconsistently, 3 and the most common reason for discontinuation of CHCs are side effects. 4 Pharmacists play a key role in reproductive health services worldwide. 5 Pharmacists in the community provide a convenient location for access to effective contraception, but they are often an underused resource. 6 - 8 Pharmacists’ expanded scope of practice in many Canadian provinces provides opportunity for them to improve contraceptive access. 6 Pharmacists can now prescribe contraceptives in Alberta, Saskatchewan, Nova Scotia, Quebec and most recently New Brunswick and British Columbia. 6 , 9 , 10 A practical, evidence-based practice tool can help pharmacists in making CHC prescribing decisions. The purpose of the CHC Practice Tool is to provide a framework to support pharmacists at the point of care with managing CHC for contraceptive purposes. We present a case to highlight how pharmacists can apply the systematic approach featured in the tool ( Figure 1 ). CHC Practice Tool

The content of the CHC Practice Tool was informed by current contraception guidelines, published literature and research team experience. 11 The pocket card version was developed and then incorporated into an online version ( https://srhresearch.ca/hormonal-contraceptive-tool/ ). The tool was initially developed and available in January 2021 and revised in June 2023. The developed prototype for the pocket card was reviewed by experts in the field ( n  = 2) and then pilot tested in a cohort of community pharmacists ( n  = 10) for acceptability, visual appeal and applicability. A similar pilot was completed for the online version ( n  = 10). Feedback from the initial pilot was that the tool had applicability to practice, it was comprehensive and the information flowed well. The pilot participants had additional suggestions that were addressed with subsequent revisions, including a figure with the overall framework and a table of CHC products. The pilot of the online version had similar findings, with the additional recommendation of providing a tool to document assessments and prescribing decisions. Of note, a documentation tool aligning with the practice tool has now been developed and is available at the URL given above.

Limitations of the practice tool include that it only addresses prescribing of CHC for contraceptive purposes and not for other possible conditions (e.g., acne, dysmenorrhea, endometriosis). This is to align with regulations in some provinces that allow pharmacist to prescribe CHC for contraception only. In addition, the tool provides a series of questions to guide patient assessment, but it is not an all-inclusive list. Pharmacists may need to expand questions in some areas for a more comprehensive assessment. Another limitation is that the tool will need to be updated at regular intervals to incorporate new evidence, recent guidelines or product changes. Finally, the tool does not cover the assessment and management of other hormonal contraceptives, such as progestin-only contraceptives. This could be a consideration for future iterations of the tool.