Patient Preferences Play Essential Part in Contraceptive Care

In a session at the American Association of Psychiatric Pharmacists Conference 2024, Veronica Vernon, PharmD, BCPS, BCACP, MSCP, an assistant professor and vice chair of pharmacy practice at Butler University College of Pharmacy and Health Sciences, discussed various considerations need for patients with psychiatric disorders and what the best method of contraception is. She emphasized that evaluating the benefits and risks are important steps to ensuring that patients are safe and using the most effective contraception for their needs. However, she said it is also important for prescribers to consider the patient’s preference when prescribing.

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Vernon emphasized that there are a lot of different options for contraception, and just like there are various options, there are also many reasons patients could want to start contraception.

“I would like our whole medical community to come up with a new term to be more inclusive, because not everybody that uses contraception is using it to prevent pregnancy,” Vernon said in the session. “We're using it to treat endometriosis, we're using it to reduce dysmenorrhea or painful periods, for helping with blood loss.”

There are a variety of contraceptions, including oral contraception, patches, vaginal rings, intrauterine devices (IUDs), injections, long-acting reversable contraception, and emergency contraception. Oral medications are the most common reversible method and can reduce the risk of both endometrial and ovarian cancer, as well as premenstrual symptoms, blood loss, dysmenorrhea, and endometriosis symptoms. Oral contraception, patches, and vaginal rings are considered combined hormonal contraception. There are also progestin-only pills, with 3 options currently available: norethindrone, drospirenone, and norgestrel.

“What’s really exciting is we now have an over-the-counter option,” Vernon said in the session. “About the first week of March is when the company started advertising it and saying it's available for preorder now. The cost is $19.99, which for some patients is going to be pretty affordable, but for some of our other patients that's quite costly.”

Vernon then discussed injectable contraception, which is injected subcutaneously or intramuscularly every 3 months, but is associated with weight gain and a delayed return to fertility anywhere between 1o months to 2 years. She also discussed progesterone-only IUDs and copper IUDs, which have a range of usage between 3 to 10 years. She said these are discreet and effective but have a risk of expulsion and perforation (of about 1%), but cost is a major barrier for patients since there is a fee for the device (ranging from $0 to $1000) and insertion (ranging from $0 to $400). Vernon also discussed long-acting reversable contraception, which is effective for 3 years, but also has a cost barrier of $0 to $1000 and insertion fee of about $200.

Currently, there are 2 sets of guidelines in the United States, including the US Medical Eligibility Criteria for Contraceptive Use (USMEC) and the US Selected Practice Recommendation for Contraceptive Use (SPR), according to Vernon.

“The USMEC is guidance for clinicians on using contraceptive products with select medical conditions. It rates contraceptive products on a scale from 1 to 4 in terms of safety,” Vernon said in the session. “The SPR I really like…because it tells us how to handle common issues with contraception.”

According to Vernon, the USMEC uses a scale of 1 to 4 to rate safety for contraception in patients, with 1 indicating no restrictions, 2 indicating that advantages generally outweigh theoretical or proven risk, 3 indicating theoretical or proven risks usually outweigh the advantages, and 4 indicating unacceptable health risks. She added that for pharmacists who can prescribe contraception, generally if a patient falls in the 3 or 4 categories, they cannot prescribe contraception and must refer the patient to their health care provider.

Vernon also said that the USMEC is expected to be updated in late 2024.

In the no. 1 category, Vernon highlighted phenytoin, carbamazepine, barbiturates, primidone, topiramate, and oxcarbazepine as associated with no risk for copper IUDs, IUDs, and injections. However, phenytoin, carbamazepine, barbiturates, primidone, topiramate, and oxcarbazepine are in the no. 2 category with regard to implants. St. John’s Wort also falls in that category for implants, progestin-only pills, and combined hormone contraception. In the no. 3 category, those same 6 drugs are associated with progestin-only pills and combined hormonal contraception. Lamotrigine is also associated with combined hormone contraception. Finally, she said patients who smoke 15 or more cigarettes, those who are 35 years of age or older, and patients with migraine with aura should not be prescribed combined hormonal contraception.

Patients on clozapine should receive IUDs, implants, injection, or contraception that is progestin only, but if combined hormone contraception is used, patients should be monitored. Combined hormone contraception can also reduce valproic acid concentrations for patients taking valproic acid. Further, it can also reduce concentrations of lamotrigine, which could need to be increased up to 2-fold, Vernon said.

“There's a higher rate of unintended pregnancy around those who are unmarried, with low social support, are members of marginalized groups, and have mental illness,” Vernon said. “Individuals with new episodes of psychiatric conditions are also at a higher risk of unintended pregnancy, and there is a higher risk in women with a history of depressive symptoms. Their risk can be 5 times higher of using a less effective method of contraception than those who do not have a history of depression.”

Furthermore, she said that the likelihood of abortion is higher for individuals with depression or anxiety. She added that the most effective way to reduce abortion rates and prevent unintended pregnancy is by improving access to tested, effective, and affordable contraception methods. Additionally, those with depression and anxiety are more likely to not use, misuse, or discontinue contraception.

Vernon added that there is a need for more contraception providers and there are many contraception deserts.

“Over 90 million women in the United States live in what's called a contraceptive desert, meaning that there's no clinic within a 10-mile radius that can take care of them,” Vernon said in the session.

She said that strategies to improve contraception use including focusing on counseling during the first meeting and focusing on discussions that center the patients and what they want. She added that it is important to acknowledge the reproductive mistreatment of people of color and other marginalized individuals as well as consider gender-inclusive language, educational materials, and all gender intakes. Further, she added that it is also important to acknowledge prescriber bias, saying that each prescriber will have their own preference, but it is essential to prioritize that patient’s desires, preferences, and lived experiences.

“The most effective method of contraception is what that patient desires, what's going to work best for them. We're not going to push IUDs and implants on folks because that’s not what they want. We have a history of doing that in this country, and we do not want to keep doing that. We want to do what the patient wishes,” Vernon said in the presentation.

Reference

Vernon V. Integrating Contraceptive Care in Psychiatry: Best Practices. American Association of Psychiatric Pharmacists Conference 2024; Orlando, Florida; April 7-10, 2024.