Get POP ready

As two desogestrel contraceptives get MHRA approval for pharmacy supply without prescription, how will women – and community pharmacy – benefit from the switch? 

A recent inquiry by the All Party Parliamentary Group on Sexual and Reproductive Health (APPG SRH) found that women in England have difficulty accessing contraception, resulting in more unplanned pregnancies and increased demand for maternity and abortion care. 

In 2018, 45 per cent of pregnancies and a third of all births in England were unplanned or associated with feelings of ambivalence, while around 10 per cent of births were unintended, according to data from the National Survey of Sexual Attitudes and Lifestyles (NATSAL). What’s more, Public Health England estimates that one third of women cannot access contraception from their preferred setting and the Covid-19 pandemic has exacerbated a marked reduction in services. 

All of this suggests a serious unmet need for contraception, so the recent announcement by the Medicines and Healthcare Products Regulatory Agency (MHRA) that progestogen-only contraceptive pills (POPs) containing desogestrel will be available to buy in pharmacies without the need for a prescription is surely good news all round.

Benefits for women

Although still available free of charge from doctors and sexual health clinics, Lovima 75mcg film-coated tablets, manufactured by POM to P specialist Maxwellia, and Hana 75mcg tablets, manufactured by HRA Pharma, are the two products that have been reclassified.

Unsurprisingly, both manufacturers cite overcoming the barriers of access to contraception as a key driver for the development of the products, which aim to give women a greater choice in how they manage their contraceptive needs.

Maxwellia CEO Anna Maxwell says: “It is clear that the limited and restricted way women can currently access contraception isn’t working for many of them.”

HRA Pharma’s chief strategic operations and innovation officer Frederique Welgryn suggests that the availability of Hana in pharmacies will help to improve women’s access to contraception in a variety of ways. She adds: “For those using barrier or natural methods, there could potentially be increased use of a more effective contraceptive.”

Healthcare organisations are all broadly in agreement about the benefits for women.

Michelle Riddalls, CEO of consumer healthcare association PAGB, says being able to access two different brands of contraceptive pill over-the-counter, under the supervision of a trained pharmacist is a “landmark moment” for women’s health in the UK, adding: “We would welcome that at any time at PAGB, but it’s particularly important when NHS resources generally are overstretched because of the Covid-19 pandemic.”

The timing of the switch has also been welcomed by the Faculty of Sexual and Reproductive Healthcare (FSRH) and the Royal College of Obstetricians and Gynaecologists (RCOG), which have both lobbied for the reclassification.

“The fragmented sexual and reproductive healthcare system is notoriously difficult for women to navigate, and successive cuts to public health budgets have made it harder for women to get the contraception they need,” says FSRH president Dr Asha Kasliwal. “Availability over the counter in pharmacies will make it easier for women to access essential contraception to avoid unplanned pregnancies during and beyond Covid-19.” 

Meanwhile, Dr Edward Morris, president of the RCOG, says the organisation is “delighted” that all those who need POP can now access it through pharmacy, adding that the RCOG has “called for this for some time and it was a key recommendation of the College’s ‘Better for Women’ report”.

Opportunities for pharmacy

As well as being a game changer for women, the reclassification also shines a very public light on pharmacy’s potential.

Michelle says reclassifying medicines from POM to P status “recognises the hugely important role that pharmacists play within the health system as a whole” and gives community pharmacy an opportunity “once again to demonstrate not only its value, but its potential”. 

This potential could prove vital in supporting customers’ sexual health as the country comes out of the pandemic. Frederique says: “Early anecdotal indications show sexual activity increasing as restrictions ease.” And PAGB data has found that 31 per cent of people are more likely to visit a pharmacy first before seeking help elsewhere, since the start of the pandemic.

Of course, as with other pharmacy medicines, the cash margin for pharmacy POPs will be higher than for the dispensed version, although Anna suggests that the switch can also bring growth to pharmacy in other ways by “opening up the opportunity to offer other products and services, such as advice on breast awareness, body mass index (BMI) and cervical screening”.

Affordability barrier

The obvious counter question to this is whether the price point represents a barrier for women in terms of affordability, thus dismantling the benefits of ease of access.

Simphiwe Sesane, contraceptive nurse and faculty registered trainer at MSI Reproductive Choices, says: “While this reclassification is a positive move, cost will be a barrier for some [so] we would like to see it available for free through NHS community pharmacies too.”

Simphiwe is not alone. Royal Pharmaceutical Society (RPS) president Claire Anderson says that although pharmacy should “embrace” the switch because of the ease of access it promotes, “ultimately, these products should be available free from the pharmacy as they are from the GP so we have a level playing field”.

The FSRH is also calling for the pills to be available to everyone free from community pharmacies, as well as the reclassification of other contraceptives moving forward. The British Pregnancy Advisory Service (BPAS) says: “We firmly believe that all contraception should be free”, and the Primary Care Women’s Health Forum (PCWHF) goes as far as to say: “We would be very concerned if the option of access to free contraception was ever altered.”

The manufacturers’ response to the price/access barrier question is that women still have the option of getting these POPs from their GP or other sexual health service for free. 

“It is important to note that desogestrel will continue to be available on prescription free of charge, giving women the choice to visit the GP or family planning clinic if they wish,” says Frederique. “But the reclassification means there is increased choice and accessibility for some women who, because of lifestyle preferences and/or convenience, are willing to pay for their contraceptive choices.” 

Indeed, HRA Pharma says its research shows the price is “in line with what women will be happy and willing to pay”, and Maxwellia’s research puts a figure of 44 per cent on the number of women it says are “willing to pay for convenience”.

Training and support

Clare Murphy, BPAS chief executive, calls the reclassification “an uncontroversial move” and says pharmacies can learn from the transition of emergency contraception to a pharmacy medication in the early 2000s, “eschewing needlessly intrusive consultations” to ensure any consultation at the counter is “swift and straightforward”.

Although highly experienced in customer consultations, there is a need for all pharmacy staff to be vigilant when it comes to the practical side of offering these progestogen-only pills.

While acknowledging that “it’s absolutely right women should be able to talk to pharmacists as the experts in medicine to support them with their sexual health”, Thorrun Govind, RPS English Pharmacy Board chair, stresses that “it is vital that the consultation process is stringent”. 

“We are not second-rate doctors, we are healthcare professionals in our own right who work with other HCPs in the interests of patients,” she says. “When a customer goes into any community pharmacy to obtain any medication, the staff need to be prepared to go through the necessary questions as part of the procedure.”

Claire adds that because people are much more aware of the safety of medicines now, pharmacy staff should “be prepared to answer customers who might be asking if it’s safe”. Her advice is to complete not only the manufacturers’ training, but any additional training pharmacy teams need to be able to explain how the products work, as well as their safety.

Maxwellia has created a Lovima pharmacy training guide, which is available in various formats across multiple platforms, along with an optional suitability checklist to support pharmacists run through the short consultation and supply to women who are suitable. Anna says this will enable them to “provide a better service to the woman than she would get from the GP”. You can also complete Lovima’s e-learning module to support your learning.

Similarly, HRA Pharm has developed online and print training materials to support pharmacy teams – accredited by the NPA – along with an optional pharmacy supply aid checklist to aid consultations.

What pharmacy teams need to know 

“When women come into the pharmacy to either ask for more information about the pill switch or to request a supply, counter staff will be their first point of contact. So it’s really important we make sure it’s done right and we ‘make every contact count’,” says Thorrun Govind, the Royal Pharmaceutical Society’s English Pharmacy Board chair.

Pharmacist Sultan ‘Sid’ Dajani, owner and superintendent pharmacist at Wainwrights Chemist, agrees. He has been talking to his team about how to have these conversations, and says there are four things pharmacy staff need to bear in mind:

1. First impressions count, so make sure you know how to talk to a customer asking about pharmacy progestogen-only contraceptive pills, and how to reassure them when referring on to the pharmacist
2. These conversations provide another opportunity to spot signs of domestic violence or abuse, so be aware of the ‘Ask for ANI’ protocol, as well as local safe havens for people who might need them
3. Use WWHAM to find out if anything has changed for the customer on repeat sales. Listen out for red flags, such as bleeding, and ask if they know all the side effects if they are buying a repeat. Staff need to be comfortable asking the pharmacist to queue-jump a patient if they need to be seen sooner than the other customers in front of them
4. The ongoing aim for pharmacy staff is that they are upskilled and recognised as the professionals they are. If a team member still doesn’t think they are getting the training they need, they should keep asking until their voice is heard. Even though the pharmacist is the accountable person, counter staff meet the customer first, so they are the ones in the firing line from the customer’s perspective if the initial contact goes wrong.

Types of contraceptives 

There are multiple contraceptive options available, through GPs, pharmacies, family planning services and other healthcare providers. The choice of contraceptive type may be influenced by a variety of factors, and it is important that the patient is free to make an informed choice of the method that is most appropriate for their individual circumstances. 

Options include: 

• Long-acting reversible contraceptives (LARCs) – for example intra-uterine device (IUD, or the copper coil), intra-uterine system (IUS, or the hormonal coil), hormonal implant or contraceptive injection. LARCs are considered the most effective contraception because they do not need a woman to remember to use them, but they must be administered by a doctor or trained nurse. When conducting consultations with women considering contraceptive options, ensure the patient is aware of the availability of LARCs 
• Oral hormonal contraceptives – for example a progestogen-only pill or a combined oral contraceptive pill
• Topical hormonal contraceptives – for example vaginal ring or contraceptive patch)
• Barrier-type contraceptives – for example condoms, caps or diaphragms. Condoms are the only form of contraception that can prevent sexually transmitted infections (STIs) and HIV. 

Useful resources 

• Hana
• Lovima
• Lovima learning module.