Once a woman is considered suitable for Lovima (see previous lesson) the following counselling advice should be given. Tablets must be taken daily at the same time each day to maintain the 24-hour interval between two tablets. This should be at a convenient time when the woman is least likely to forget.
The woman should be instructed to continue to take one tablet every day until the pack is empty. When a strip is empty, she should start with a new of Lovima the next day, without interruption and without waiting for a bleed. Point out that the days of the week and arrows printed on the blister strip are designed to help the woman remember whether or not she has taken her pill.
HOW TO START LOVIMA
Women considering taking Lovima will start differently, dependent on whether they have given birth, had a miscarriage or abortion or have previously used contraception. Below are the different scenarios you may encounter and information on how to advise women appropriately.
1. STARTING LOVIMA AFTER NO HORMONAL CONTRACEPTION
First supply of Lovima in those without prior use of contraception (including emergency).
| Type of contraception | What is it? | How does it work? | How effective is it in preventing pregnancy? |
|
Male condom
|
A thin latex or polyurethane sheath | Placed over the man's erect penis before sex, it forms a physical barrier to stop sperm meeting an egg. | When used correctly it is 98% effective, but the way it is typically used it is 82% effective. |
|
Female condom
|
Soft, polyurethane sheath | Inserted into the vagina before sex, it forms a physical barrier to stop sperm meeting an egg. | When used correctly it is 95% effective, but is typically 79% effective |
|
Diaphragm/cap
|
Flexible latex or silicone dome, used with spermicide | Inserted into the vagina before sex to stop sperm reaching the egg. | When used correctly with spermicide they are 92-96% effective but typically around 71-88% effective. |
Supply of Lovima after a birth, miscarriage or abortion.
Remember to first exclude pregnancy if the women's periods have not returned after birth, miscarriage or abortion.
| When to start taking Lovima 75 microgram film-coated tablets | Need additional contraception? | |
| Following childbirth and period has not started again | Lovima can be started immediately following childbirth. If it is more than 21 days after delivery, pregnancy must first be excluded. Once this is confirmed, Lovima can be initiated before periods have started. Lovima can be started immediately following childbirth. | No additional contraception needed up to day 21 after childbirth if periods have not started again. If more than 21 days after delivery, need to use additional barrier method of contraception (e.g. condom) for first 7 days of tablet-taking. |
| Following childbirth and period has started again | Start taking Lovima on the first day of the period (day 1 is the first day of menstrual bleeding). | No additional contraception needed, except when waiting for period to start. |
| Recently had a miscarriage or abortion | Lovima can be started immediately or within 5 days after a miscarriage. | No additional contraception needed. |
2. STARTING LOVIMA AFTER OTHER CONTRACEPTION
Supply of Lovima after emergency contraception supply.
| When to start taking Lovima 75 microgram film-coated tablets | Need additional contraception? | |
| Have taken levonorgestrel | Start or continue taking Lovima immediately | Use additional barrier contraception (condom) for 7 days. |
| Have taken ulipristal | Delay taking Lovima until 5 days (120 hours) after taking ulipristal. This is because Lovima can stop ulipristal working, and vice versa. | Use additional barrier contraception (condom) for 5 days after taking ulipristal and then for a further 7 days after starting Lovima. That is 12 days in total. |
Further information on drug interactions can be found here.
Switching from a combined oral contraceptive (COC), vaginal ring or transdermal patch.
| Who to start taking Lovima 75 microgram film-coated tablets | Need additional contraception? | |
| Changing from a COC, vaginal ring or transdermal patch | Start taking Lovima on the day after the last active tablet from the present pill pack or on the day of removal of the vaginal ring or transdermal patch. | Do not need additional contraception. If there is a break between the last active COC and taking Lovima (i.e. the usual tablet-free, patch-free, ring-free or placebo tablet interval of the previous COC), need to use additional barrier contraception (e.g. condom) for the first 7 days of Lovima tablet-taking. |
Switching from a progestogen-only method of contraception.
| When to start taking Lovima 75 microgram film-coated tablets | Need additional contraception? | |
| Changing from another POP pill | Start taking Lovima without a break, on any day of changing from another progesterone only pill. | Do not need additional contraception. |
| Changing from an implant, hormonal IUS or an injectable | Start taking Lovima on the day of removal or when the next injection would be due. | Do not need additional contraception. |
3. REPEAT SUPPLY OF LCOIMA 75 MICROGRAM FILM-COATED TABLETS FROM A PHARMACY
| When to start taking Lovima 75 microgram film-coated tablets | Need additional contraception? | |
| Repeat supply when already taking Lovima | Start taking Lovima without a break | Do not need additional contraception. |
QUICK STARTING CONTRACEPTION
'Quick starting' is the term used to describe immediate initiation of a contraceptive method at the time a woman requests it (i.e. at any time during the cycle). 'Quick starting' Lovima is off-label use. Although it cannot be recommended by a pharmacist it is important to be aware of quick start contraception as it is a common practice in family planning settings and may be appropriate for some women or situations.
The benefits of quick starting to provide immediate initiation of contraception include reducing the time period where a woman is at risk of unplanned pregnancy, which is a particular benefit for those with irregular cycles or who have taken emergency contraception and reducing barriers to returning for a further contraceptive appointment (e.g. time, transport costs).
There are disadvantages, however. The safety and efficacy of starting after day 5 of the menstrual cycle has not been established. Additional contraception methods should be used for the first 7 days of tablet-taking. There is a small chance that the woman is already pregnant and there is little evidence on the risk of ectopic pregnancy when contraceptive hormones are initiated around the time of conception. There is also a theoretical risk of unintentional foetal exposure to hormones, such as desogestrel, however, pharmacovigilance data do not indicate an increased foetal risk. If pregnancy cannot be ruled after the last episode of unprotected sex, including any episodes within the 7 days it takes for desogestrel efficacy to build up.
Further information can be found in the FSRH guideline on quick starting contraception: https://www.fsrh.org/standards-and-guidance/documents/fsrh-clinical-guidance-quick-starting-contraception-april-2017/. The MHRA offers advice on the off-label use of medicines: https://www.gov.uk/drug-safety-update/off-label-or-unlicensed-use-of-medicines-prescribers-responsibilities.
BRIDGING CONTRACEPTION
There may be times when a woman's first-choice contraception is not available or not appropriate when she presents to you. For example, she may wish to use a LARC, but may need contraception before she is able to see a doctor to obtain her LARC. In this instance, Lovima could be used as a bridging option until she can begin her preferred contraception.
COUNSELLING TIP:
It is important to encourage women to advise their GP or other healthcare professionals when they have been supplied with Lovima in the pharmacy.