15.3 Women's & Men's Health: Contraception, Emergency Contraception, Menopause, BPH, ED & Overactive Bladder

Women's & Men's Health: Contraception, Emergency Contraception, Menopause, BPH, ED & Overactive Bladder

Pharmacists are often the most accessible health professional for sexual and reproductive health questions. In several provinces they prescribe hormonal contraception directly. This section covers contraceptive selection and safety, emergency contraception, menopause, preconception care, and common men's and bladder health problems.

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1. Hormonal Contraception

Combined Hormonal Contraceptives (Pill, Patch, Ring)

• Mechanism: combined estrogen-progestin methods inhibit ovulation. Typical-use failure is about 7% a year, mainly because of missed doses.
• Unacceptable risk (WHO and SOGC medical eligibility, category 4), which means progestin-only or non-hormonal methods instead:
  • smoking 15 or more cigarettes a day at age 35 or older;
  • migraine with aura;
  • blood pressure of 160/100 mmHg or higher;
  • past or current VTE, or a known thrombogenic mutation;
  • ischemic heart disease or stroke;
  • current breast cancer;
  • less than 21 days postpartum;
  • severe liver disease or liver tumours;
  • complicated valvular heart disease;
  • lupus with antiphospholipid antibodies.
• Common early effects: breakthrough bleeding (usually settles within 3 months), nausea and breast tenderness.
• Missed combined pills (simplified SOGC approach):
  • Take the most recent missed pill as soon as possible, even if that means 2 pills in one day.
  • If 2 or more consecutive active pills are missed, use condoms or abstain until 7 consecutive active pills have been taken.
  • Missed in the first week (after the hormone-free interval) with unprotected sex in the previous 5 days: consider emergency contraception.
  • Missed in the third week: skip the hormone-free interval and start the next pack.

Progestin-Only and Long-Acting Methods

• Progestin-only pills: norethindrone 0.35 mg must be taken within the same 3-hour window every day. Drospirenone 4 mg has a 24-hour window.
• Injectable medroxyprogesterone every 13 weeks: delayed return of fertility and reversible bone-density loss.
• Long-acting reversible contraception (LARC) is the most effective, with under 1% failure a year: the etonogestrel implant, the levonorgestrel intrauterine system, and the copper IUD.

Interactions

• Enzyme inducers reduce hormonal contraceptive efficacy: rifampin and rifabutin, carbamazepine, phenytoin, phenobarbital, topiramate (higher doses), St. John's wort, and some antiretrovirals. Recommend an IUD (copper or levonorgestrel) or injectable medroxyprogesterone, or add condoms during use and for 28 days after stopping the inducer.
• Other antibiotics (for example, amoxicillin and doxycycline) do not reduce contraceptive efficacy.
• Estrogen lowers lamotrigine levels, so seizure control can change when a combined contraceptive is started or stopped.

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2. Emergency Contraception (EC)

Counselling:

• EC does not protect against later unprotected sex in the same cycle.
• Spotting can occur, and the next period may be early or late.
• Take a pregnancy test if the period is more than about 7 days late.
• Start regular contraception and discuss STI testing.

Conscientious objection: a pharmacist who objects to providing EC must still ensure timely access, by directing the patient to a nearby pharmacy or provider that can help without delay. They do not refer the patient for an unnecessary medical assessment, and they do not leave the patient without options.

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3. Preconception and Pregnancy

• Folic acid: 0.4 mg daily, usually in a multivitamin, starting at least 3 months before conception and continuing through early pregnancy. Higher doses (1 to 4 mg) are advised by SOGC for people at increased risk of neural tube defects: a previous affected pregnancy, certain antiseizure drugs, diabetes, obesity or malabsorption.
• Review teratogens before pregnancy: valproate, isotretinoin, warfarin, ACE inhibitors and ARBs, methotrexate, mycophenolate and statins (section 13.3).

4. Menopause

• Menopausal hormone therapy (MHT) is the most effective treatment for hot flashes and night sweats. The benefit-risk balance is most favourable when started before age 60 or within 10 years of menopause.
  • Add a progestogen (or use a levonorgestrel IUS) if the patient has a uterus, to protect the endometrium.
  • Transdermal estrogen carries a lower VTE and stroke risk than oral estrogen.
  • Contraindications: breast cancer, VTE, coronary disease or stroke, unexplained vaginal bleeding, and active liver disease.
• Genitourinary syndrome of menopause: low-dose vaginal estrogen has minimal systemic absorption and does not need a progestogen. Moisturizers and lubricants help too.
• Non-hormonal options for hot flashes: SSRIs and SNRIs (venlafaxine, escitalopram, low-dose paroxetine), and gabapentin. Avoid paroxetine and fluoxetine with tamoxifen, because CYP2D6 inhibition reduces activation to endoxifen.

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5. Men's Health and Bladder Health

Benign Prostatic Hyperplasia (BPH)

• Alpha-1 blockers (tamsulosin, silodosin, alfuzosin; doxazosin and terazosin need dose titration):
  • work within days;
  • cause dizziness and first-dose orthostatic hypotension;
  • can cause intraoperative floppy iris syndrome, so patients should tell their eye surgeon before cataract surgery. Stopping the drug beforehand does not reliably prevent it.
• 5-alpha-reductase inhibitors (finasteride 5 mg, dutasteride):
  • shrink the prostate over 6 to 12 months;
  • lower PSA by about 50% (double the measured value when interpreting);
  • should not be handled crushed or broken by people who are or may become pregnant.
• Combination therapy is used for large prostates. Tadalafil 5 mg daily helps BPH symptoms, with or without erectile dysfunction.
• Drugs that can precipitate urinary retention: anticholinergics, sedating antihistamines, decongestants and tricyclics.

Erectile Dysfunction

• PDE5 inhibitors:
  • Sildenafil 25 to 100 mg about 1 hour before sex; a fatty meal delays its onset.
  • Tadalafil 10 to 20 mg as needed (effect up to 36 hours), or 5 mg daily.
• Contraindicated with nitrates (no nitrate within 24 hours of sildenafil or vardenafil, or 48 hours of tadalafil) and with riociguat.
• With alpha-blockers: start at a low dose once the alpha-blocker dose is stable.
• Seek urgent care for an erection lasting more than 4 hours, or for sudden loss of vision or hearing.
• New ED can be an early sign of cardiovascular disease.

Overactive Bladder and Incontinence

• First line: bladder training, pelvic floor exercises, timed voiding, and less caffeine and evening fluids.
• Review drug causes: diuretics (especially loop diuretics), sedatives, alpha-blockers in women, and cholinesterase inhibitors.
• Antimuscarinics (oxybutynin, tolterodine, solifenacin, fesoterodine, darifenacin, trospium) cause dry mouth and constipation. They add to anticholinergic burden and can impair cognition, so avoid oxybutynin in older adults and people with dementia. Trospium crosses the blood-brain barrier least.
• Mirabegron (a beta-3 agonist) avoids anticholinergic effects. Monitor blood pressure. It is a moderate CYP2D6 inhibitor.