Emergency and ongoing contraception in the COVID-19 pandemic


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In Australia you can expect increased demand of emergency contraception during the COVID-19 outbreak, write Dr Safeera Hussainy and Dr Kathleen McNamee

Dr Safeera Hussainy, Adjunct Senior Lecturer and Chief Investigator: National Health and Medical Research Council (NHMRC) Centre for Research Excellence in Sexual and Reproductive Health for Women (SPHERE), Department of General Practice, Faculty of Medicine, Nursing and Health Sciences, Monash University.

Dr Kathleen McNamee, Medical Director, Family Planning Victoria; Adjunct Senior Lecturer, Obstetrics and Gynaecology, Monash University.

Pharmacists, we commend and thank you for everything you are doing in this COVID-19 pandemic as front-line health professionals. Your time and hard work have all been redirected towards keeping the health of the public safe and often dealing with very challenging scenarios and patients.

Mental health and wellbeing, PPE and medication management issues (demand, supply including in emergency situations, and home delivery) have been at the forefront of pharmacy practice in this pandemic. The sexual and reproductive health needs of the public in these unprecedented times has possibly been overlooked and we would like to inform you of some latest updates and developments about emergency and ongoing contraception so that your practice continues to be in line with the shifting evidence.

Below we summarise relevant recommendations from the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG), The Faculty of Sexual and Reproductive Healthcare (FRSH) in the UK, Marie Stopes Australia and Family Planning Alliance Australia (FPAA).

An increased demand for emergency hormonal contraception (EHC)

The FSRH in the UK has deemed emergency contraception an essential sexual and reproductive health service during the COVID-19 outbreak and here in Australia you can expect an increased demand for EHC – levonorgestrel and ulipristal acetate. As people are self-isolating, an increase in unprotected sex, reproductive coercion especially amongst vulnerable groups, and imperfect use of ongoing contraception (e.g. missed oral contraceptive pills) are all anticipated, thus increasing the demand for EHC. It is critical that you are able to continue to provide EHC in this context when unplanned pregnancies are expected to rise.

The EC Wheel (desktop and smartphone versions both available, Figure 1) can help guide your clinical decision-making when selecting the best form of EC from an available choice of levonorgestrel, ulipristal acetate and the copper-IUD. You are encouraged to arrange an emergency copper IUD insertion for patients if you know of skilled GP providers or have a local family planning clinic in your area. The Wheel considers factors such as time since unprotected sex, the person’s medical conditions and the medications they take. It uses a traffic light system for recommending methods (green = method may be used, yellow = method can be used but more effective method is recommended if available, red = method not recommended and/or further assessment needed).

Figure 1. The Emergency Contraception Wheel

Source: European Consortium for Emergency Contraception. Available from: http://www.ec-ec.org/ecmethod/

EHC requests via telehealth and from third parties

The FSRH in the UK has recommended telephone or video consultations for EHC requests, provided with a ‘click-and-collect’ or postal service from community pharmacies in order to limit face-to-face contact. If you have the capacity to provide telehealth, in the telephone or video consultation you can establish a therapeutic or advance need (for future use) for EHC as you would do in-person by asking the necessary questions, and you can also provide the person with information on their chosen method.

There have been recent reports of third parties being denied EHC. Whilst PSA guidance on EC has long established that it is appropriate for a third party to purchase EHC in the pharmacy on behalf of a woman who has not been seen by you previously, third-party supply may become even more necessary in the pandemic and should not be a barrier to access.

Emergency supply of oral contraceptive pills (OCPs)

Under new legislation brought in during the COVID-19 crisis, you are allowed to dispense 1 month’s emergency supply of a medication to a patient when a prescription cannot be obtained. In the case of OCPs, the majority of these are packaged in a box of 4 strips equalling 4 months’ supply. Prior to the pandemic if a patient presented for an emergency OCP supply, pharmacists could have chosen to provide 1 of these 4 strips or the whole box. During the pandemic it is recommended that you provide a 3- or 4-month supply depending on the number of strips in the box to avert the risk of unintended pregnancy from missed pills or from pill packs running out.

Extended use of long-acting reversible contraception (LARC)

The FPAA and RANZCOG have stated that supporting existing, continued use of LARC (IUDs, implants) is an essential sexual and reproductive health service during the pandemic as LARC methods are more than 99% effective with normal use. The continued provision of LARC is especially important for young people, people with serious health conditions and post-abortion. It is important to know where to refer your patients for LARC insertion in your local area.

New guidance about the off-label extended use of LARC during the pandemic is available from FPAA. It is advised that women who are unable to visit a clinic for replacement or removal of their IUD or implant can instead talk with their doctor about their options including deferral to a later date beyond the licensed expiry date. The extended duration of off-label use are summarised in the table below. Note that Kyleena cannot be extended beyond its licensed duration of 5 years. If you are asked about this it is important to refer the patient to her doctor for further advice and to offer condoms in the meantime.

Table: Recommended extended durations of use of LARC methods during the COVID-19 pandemic

LARC method

Licensed duration of use

Extended/off-label duration of use

Etonogestrel implant (Implanon NXT)

3 years

4 years

52 mg levonorgestrel IUD (Mirena)

5 years

6 years

19.5 mg levonorgestrel IUD (Kyleena)

5 years

Cannot be extended beyond 5 years

Standard sized T shaped banded copper IUD

10 years

12 years

5-year copped IUD (Load 375, Copper T short)

5 years

6 years

 

References

The Faculty of Sexual and Reproductive Healthcare. Essential Services in Sexual and Reproductive Healthcare. 24 March 2020. Accessed 17 April 2020. Available from: https://www.fsrh.org/documents/fsrh-position-essential-srh-services-during-covid-19-march-2020/    

Royal Australian and New Zealand College of Obstetricians and Gynaecologists. COVID-19: Access to reproductive health services. Updated 8 April 2020. Accessed 21 April 2020. Available from: https://ranzcog.edu.au/news/covid-19-access-to-reproductive-health-services

Marie Stopes Australia. Situational Report: Sexual and Reproductive Health Rights in Australia. Updated 17 April 2020. Accessed 17 April 2020. Available from: https://resources.mariestopes.org.au/SRHRinAustralia.pdf

Family Planning Alliance Australia. Position Statement. LARC access during the COVID-19 pandemic. 6 April 2020. Accessed 17 April 2020. Available from: https://www.fpv.org.au/assets/resources/FPV20_PositionStatement_LARC_60420_FA.pdf  

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