Contraception
Definition/Introduction
Contraception is the act of preventing pregnancy. This can be a device, a medication, a
procedure or a behavior. Contraception allows a woman control of her reproductive health and
affords the woman the ability to be an active participant in her family planning. This review will
not address abortion as that is not a way to prevent a pregnancy from occurring. Contraceptive
methods are technological advances intended to overcome biology. The 20 century has seen
the biggest advancements for female reproductive health expanding medical options, devices,
and even procedures. This review will focus on medications, devices, and procedures available
to couples to prevent pregnancy. It will not focus on behaviors and barrier methods available.
When considering contraceptive methods counseling should include efficiency, safety,
acceptability and availability (including accessibility and affordability). Voluntarily informing the
choice of contraceptive methods is an important guiding principle, and contraceptive
counseling, when associable, is a marked contributor to the successful use of contraceptive
methods.
Birth control methods are designed to prevent conception or interrupt or nullify implantation
and growth. Conception can be prevented by hormonally disrupting the menstrual cycle (Oral
contraceptive (OC) pills), by physically blocking the passageway (barrier methods or
sterilization), or less successfully, by abstinence during fertile periods or withdrawal method.
Implantation is impaired via the use of a foreign body (intrauterine device {IUD}) or surgical
removal (Salpingectomy or Vasectomy)[1].
Contraception is best reviewed with the patient when efficacy is the top priority. The following
are ordered by the most effective form of contraception to the least effective:
Etonogestrel contraceptive Implant
Levonorgestrel intrauterine system (LNG IUD)
Copper intrauterine device (IUD)
Female sterilization
Vasectomy
Injectables
Combined oral contraceptives
Progestin-only pill
Patch
Hormonal vaginal contraceptive ring
Lactational Amenorrhea
Diaphragm or cervical cap
Sponge
Male condom
Female condom
Spermicides
Fertility awareness-based methods
Withdrawal
Emergency Contraception
Copper IUD
Emergency contraceptive pills
Medical devices used to prevent pregnancy include intrauterine devices or subdermal implants.
The intrauterine device may or may not contain progesterone, and the subdermal implants all
contain progesterone. These devices are commonly referred to as Long Acting Reversible
Contraceptives or LARCs. The failure rate associated with the various forms of devices is less
than 1 woman per 100 women per year making them the most effective form of contraception
available, rates that are considered better than surgical sterilization. There are few absolute
contraindications and relate to uterine anatomic defects or allergy to the medication.
Contraceptive procedures involve surgical sterilization of the male and or female. The least
invasive is a vasectomy, and then tubal occlusion methods follow. Hysteroscopic sterilization is
no longer a practiced method at this time. Procedures are intended to be permanent although
surgical reversals are possible. Failure rates are slightly higher than LARC methods but still, less
than 1 woman per 100 women per year fails these surgical procedures.
The injectable currently on the market is a progesterone only, it does not have an estrogen
component and many times results in irregular bleeding. Progesterone only forms alter cervical
mucus and endometrial lining preventing conception. The injections are every 12 week and the
failure rate is 6 women per 100 women per year.
The medications commonly thought of for contraception include combined hormonal pills,
patches, rings, and progesterone only pills. Combined oral contraceptive pills are monophasic,
biphasic and triphasic. They are dispensed monthly, quarterly or annual medications. The
common combined oral contraceptive pill mimics the menstrual cycle, 21-24 days of estrogen
and progesterone to suppress ovulation, alter cervical mucus and the endometrial lining
preventing pregnancy and 5-7 days of placebo resulting in an observed menses. Continuous
contraceptive pills use an 84-day continuous exposure of active phase pills and 7 days of
placebo, or 365 days of active pills. These forms are equally efficacious and share failure rates
regardless of the format. The combined hormonal patch and contraceptive ring offer a different
entry point for the medication avoiding first pass effect and decreasing some side effects. The
patch is changed weekly with a placebo week to mimic routine menses. The vaginal ring inserts
for 3 weeks then removed for a placebo week to mimic menses. These formulations all provide
the same failure rates of 9 per 100 women per year. A complete medical history and physical
should be performed before starting any form of contraception as there may be relative and
absolute contraindications. The CDC offers a medical eligibility criteria for contraceptive use
based on the chosen form of contraception and patient medical conditions and is easily
accessed by physicians and patients.
Pharmacist in health education of contraception
Pharmacists play a vital role in contraception education by counseling patients on proper use, side
effects, and method selection (hormonal, emergency & non-prescription), expanding access beyond
traditional clinics, and even prescribing some methods under expanded scopes of practice, helping to
reduce unintended pregnancies by offering convenient, patient-centered care, especially in underserved
areas. They bridge gaps in care, address misinformation, and can facilitate access to Long-Acting
Reversible Contraception (LARC) and fertility awareness, improving overall reproductive health
outcomes.
Key Roles in Education & Provision
Patient Counseling: Explaining how different contraceptives work, correct usage, potential side effects,
and addressing patient concerns.
Expanding Access: Providing an additional, convenient entry point for contraception, especially for
hormonal methods and emergency contraception (EC), reducing barriers like wait times.
Prescribing & Dispensing: In many areas, pharmacists can prescribe or dispense oral contraceptives and
EC, sometimes through collaborative practice agreements or protocols.
Method Selection: Guiding patients to choose appropriate methods, including condoms, implants, IUDs
(referrals), and fertility awareness methods.
Debunking Misinformation: Correcting myths about hormonal contraception to improve adherence and
comfort.
Special Populations: Assisting with contraception in complex cases, like post-partum or with underlying
medical conditions, by collaborating with other providers.
Impact on Public Health
Reduced Unintended Pregnancies: By increasing access and providing education, pharmacists
Studies show pharmacists are effective at helping women start and continue contraception.
Improved Continuation Rates: Studies show pharmacists are effective at helping women start and
continue contraception.
Comprehensive Care: Connecting patients to broader reproductive health services, including screenings
and referrals.
How They Educate
Direct Consultation: Offering confidential consultations in the pharmacy.
Partnerships: Working with doctors, clinics, and universities to spread awareness.
Training: Undergoing specialized training to ensure comprehensive knowledge of various contraceptive
methods.
When compared to clinician-initiated contraception, pharmacists were more likely to prescribe
contraception to eligible women and had a higher rate of continuation at 12 months. In
addition, pharmacists providing education to both patients and prescribers can help debunk
misinformation on hormonal contraceptives which may impact access and adherence. With the
recently changing federal-and in many instances state-legislation, pharmacists will need to seek
out more opportunities to facilitate access to hormonal contraceptives and increase knowledge
surrounding emergency contraceptive options and other medications used for reproductive
health. Pharmacists have the knowledge and accessibility to assist in contraceptive care. Now,
more than ever, pharmacists' involvement in hormonal contraceptive care will be a necessary
step to ensure that our patients receive the appropriate care they deserve.
Pharmacists are encouraged to be proactive in community education, particularly targeting
younger populations through social media, high schools, and colleges to combat misinformation.
Accessibility is also critical, ensuring that contraceptive options are not only available but also
easily obtainable, with staff trained to provide supportive, discrete, and personalized care. The
ultimate goal is to empower patients with comprehensive, compassionate reproductive
healthcare, positioning pharmacists as key advocates and educators in this important field.
Pharmacists play a crucial role in access to reproductive health services. In many parts of the
country, they are the closest local resource for pregnancy tests, condoms, emergency
contraception, and prescription medications like misoprostol, and hormonal contraception.
Currently, 12 states permit pharmacist-prescribed birth control. In additional states, pharmacists
may prescribe and/or dispense hormonal contraceptives under collaborative practice
agreements, statewide protocol, or standing orders. These shifts allow patients timely access to
a broader range of reproductive health services, in the local setting, by competent and trusted
healthcare professionals.
Despite this growing capacity, focused feedback from professionals in the field found no training
resources which address making high-quality referrals in the pharmacy setting. In 2020, Provide
and Birth Control Pharmacist collaborated to introduce this skillset to pharmacy teams across
the country. Meeting Reproductive Health Needs at the Pharmacy is a learning tool that
supports the provision of client-centered information and referrals for contraception,
emergency contraception, and abortion in the pharmacy.
Conclusion
There are many important responsibilities for pharmacists when aiding patients with contraception.
Whether performing traditional or emerging roles, pharmacists should ensure patients have the best
method for them and understand how to accurately and consistently use the method. Through these
practices, pharmacists can help to reduce the rate of unintended pregnancies and to improve outcomes
for their patients
References
[Link] Control Pharmacist. Policies - State policies and protocols for pharmacist prescribing of
contraception. [Link]
[Link] Alliance of State Pharmacy Associations (NASPA). Scope of Practice.
[Link] Accessed April 22, 2022.
[Link] SC, Tapias MP, McGhee BT. Birth control within reach: a national survey on women’s attitudes
toward and interest in pharmacy access to hormonal contraception. Contraception . 2006;74(6):463-
470. - PubMed
[Link] S, Besinque K, Chung F, et al. . Pharmacist interest in and attitudes toward direct pharmacy
access to hormonal contraception in the United States. J Am Pharm Assoc (2003) . 2009;49(1):43-50. -
PubMed
[Link] S, Cieri-Hutcherson NE, Frame TR, et al. . Pharmacists’ perspectives on prescribing and
expanding access to hormonal contraception in pharmacies in the United States. J Pharm Pract .
2021;34(2):230-238. - PubMed