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Last year’s POM to P switch of the mini pill highlighted the important role pharmacies play in supporting the nation’s sexual health. But there’s a lot more to it than contraception.
Like many aspects of the NHS, sexual health services have been adversely affected by the pandemic.
A survey conducted by the British Association for Sexual Health and HIV (BASHH) found that in-person services for patients needing sexually transmitted infection (STI) tests and treatments, contraception and medication have shrunk drastically since the pandemic hit the UK in March 2020. And Public Health England (PHE) estimates that one in three women cannot access contraception from their chosen setting.
For this reason – and others we will explore in this feature – it is likely that more people will be visiting their local pharmacy for sexual health advice and treatments this year and beyond.
Contraception
While some forms of contraception are not available over the counter from pharmacies, the number that are was expanded last year when the Medicines and Healthcare Products Regulatory Agency (MHRA) announced that progestogen-only contraceptive pills (POPs) containing 75mcg desogestrel would switch from POM to P.
The two products reclassified were Lovima, manufactured by Maxwellia, and HRA Pharma’s Hana.
Pharmacy organisations welcomed the move, with the PAGB summing up their sentiments by saying: "Making these progestogen-only contraceptive pills available without prescription in the UK is a historic milestone for women and women’s health. This is the first time that any form of daily contraceptive pill has been licensed for over the counter sale in the UK, 60 years after the pill was originally offered by the NHS – initially to married women only."
President of the Faculty of Sexual and Reproductive Health Dr Asha Kasliwal added: "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."
The switch presents a fantastic opportunity for pharmacy. The advertising of these pills as being available over the counter could open up once taboo conversations on contraceptive choices and highlight pharmacy’s expertise to a large part of the population.
"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," says Royal Pharmaceutical Society English Pharmacy Board Chair Thorrun Govind. "So, it’s really important that we make sure it’s done right, and we make every contact count."
Both Maxwellia and HRA Pharma have created pharmacy training guides and suitability checklists to support pharmacies in their consultations and to help them make sure women are suitable candidates for the POP. According to Maxwellia, this training will help pharmacy teams "provide a better service to the woman than she could get from the GP."
Top tips for customer care when discussing the mini pill
Pharmacist Sultan ‘Sid’ Dajani, owner and superintendent pharmacist at Wainwrights chemist, has four top tips for pharmacy staff to bear in mind:
- First impressions count. Make sure you know how to talk to a customer asking about pharmacy progestogen-only contraceptive pills
- These conversations provide an 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
- Use WWHAM to find out if anything has changed for customers on repeat sales. Listen out for red flags, such as bleeding, and ask if they know about all the side effects if they are buying a repeat
- 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.
STIs
It is important that customers make sure they are testing regularly between partners.
Whilst contraception stops pregnancy, most methods – except condoms – won’t stop people from catching or passing on a sexually transmitted infection (STI).
STIs are generally acquired by sexual contact when viruses or bacteria travel from person to person via bodily fluids such as semen or blood.
Despite a 32 per cent decline in STI diagnoses between 2019 and 2020 – largely thought to be due to Covid-19 restrictions keeping people apart – STI rates remain a concern.
Unfortunately, STIs can lead to many serious conditions, so it is important to help customers recognise symptoms and understand the importance of protecting themselves.
Common STIs
This is the most common STI in the UK. It is particularly prevalent among teenagers and young adults, with as many as one in 10 sexually active young people infected, according to the organisation Sexual Health London.
Chlamydia is a bacterial infection and is easily transmitted during sex without a condom. It can also be passed on from an infected woman to her baby.
Whilst most people have no symptoms and do not know they have it, chlamydia can cause pain when passing urine and unusual discharge from the vagina, penis or bottom. Women may also experience pain in the stomach, bleeding after sex and bleeding in between periods; men may have pain and swelling in the testicles.
If left untreated, chlamydia can spread to other parts of the body and lead to long-term health problems, particularly for women, who may go on to suffer from pelvic inflammatory disease (PID), ectopic pregnancy and/or infertility. It is important, therefore, to make sure customers are regularly testing themselves between casual partners.
Testing for chlamydia involves a urine or swab test. A physical examination by a nurse or doctor is not always needed. Women under 25 years of age may be offered a chlamydia test when visiting pharmacies as part of the National Chlamydia Screening Programme, and testing kits are also available for over the counter sale. Once diagnosed, chlamydia can usually be treated with antibiotics.
The second most common STI diagnosis, gonorrhoea is caused by bacteria called Neisseria gonorrhoeae, which is usually found in discharge from the penis and in vaginal fluid.
Typical symptoms include a thick green and yellow discharge from the vagina or penis, pain when urinating and – in women – bleeding between periods. Like chlamydia, symptoms are not always present, with around one in 10 men and almost half of all infected women experiencing no symptoms. The infection can also be passed from a pregnant woman to her baby.
Gonorrhoea can be diagnosed by testing a sample of discharge picked up using a swab. In men, a urine test can also diagnose the condition. It is usually treated with a single antibiotic injection and symptoms should improve within a few days. However, a case of antibiotic-resistant gonorrhoea was reported in London last December – and as of 9 February, three more have been reported – prompting the UK Health Security Agency (UKHSA) to urge the public to use condoms "consistently and correctly with all new or casual partners" to reduce the risk of gonorrhoea and other STIs.
"Finding this strain of gonorrhoea in the UK serves as a stark reminder of the problem of antibiotic resistance," said Dr Katy Sinka, the UKHSA’s STI section head. She added that anyone who has any STI-related symptoms should "avoid sexual contact and get a sexual health screen".
If gonorrhoea is left untreated, it can lead to serious long-term health problems, including PID and infertility.
This is the third most common STI and is caused by herpes simplex virus type 2.
Symptoms of herpes include:
- Small blisters that burst to leave red, open sores around the genitals, anus, thighs or bottom
- Tingling, burning or itching around genitals
- Pain when urinating
- Unusual vaginal discharge.
If a customer complains of these symptoms, especially blisters around the genitals, even if they have not had sex in a long time, they should book a sexual health check. Blisters can take months or even years to appear, and it is important to treat them as soon as possible.
There is no cure for genital herpes. Symptoms clear up by themselves, but they can come back during flare-ups – much like cold sores, which are caused by a related virus, herpes simplex type 1. Antiviral medicines may help to shorten an outbreak.
Pharmacy staff can offer self care tips to help with outbreaks such as:
- Keep the area clean using plain or salt water to prevent blisters becoming infected
- Apply an ice pack wrapped in a flannel to soothe pain
- Apply petroleum jelly or painkilling cream to reduce pain when urinating.
The importance of STI testing
As many people don’t develop symptoms once they have contracted an STI, it is important for customers to make sure they are tested regularly between partners. This ensures that infections can be detected and treated without being passed on to someone else.
The UK Health Security Agency recommends that everyone has an STI screen, including an HIV test, annually if they are having sex without a condom and/or with new or casual partners.
The guidance refers to two groups of people in particular:
- Sexually active women and other people with a uterus or ovaries under 25 years old, who should be screened for chlamydia on a change of a sexual partner, or every year
- Gay and bisexual men who have sex with other men should test for HIV and STIs annually or every three months if having sex without a condom with new or casual partners.
Testing is free and available through online services or local sexual health services such as STI clinics or drop-ins. The services are confidential, and staff will only liaise with other healthcare professionals if they suspect a person is at risk of harm.
Erectile dysfunction
In 2018, sildenafil, an erectile dysfunction drug, was made available as a pharmacy medicine. For the first time, male customers did not have to be prescribed the drug but could, after a quick consultation, purchase it for themselves from a pharmacy.
"When it comes to erectile dysfunction, although it is very common for many men, it’s one of those things that they rarely ever speak to a healthcare professional about," says Ade Williams MBE, lead pharmacist at Bedminster Pharmacy in Bristol, "which is not to say that they’re not seeking help, but they’re seeking help in the wrong place.
"Having the pharmacy, which is the most commonly accessible part of the healthcare system, helping to address this in a way that also looks much more holistically at men’s health, builds in a sense of trust, builds in a sense of confidence and also helps them to link that in to all the messages that we’re very keen to pass on."
Research has shown that men who visit a pharmacy for treatment for their erectile problems are more likely to return to the pharmacy for other healthcare advice.
“You may feel confident about the product and discussing erectile problems, but for your customer, it may be the first time”
As their first point of contact, it is important that pharmacy support staff approach the issue with professionalism and tact.
"You may feel confident about the product and discussing erectile problems, but for your customer, it may be the first time they have talked about it," says Viatris, manufacturer of Viagra Connect. "Remember to reflect the language they use, maintain a professional tone and if they have concerns, give them the option of speaking to the pharmacist. Similarly, if you think they might need additional support, you can also refer them to the pharmacist for further advice."
There are numerous lifestyle factors that could be influencing erectile problems. These include:
- An unhealthy diet
- Being overweight
- Alcohol consumption
- Recreational drug use
- Not exercising enough
- Smoking.
Pharmacy staff can help customers by tactfully offering advice on how to minimise these risk factors. For example, you could signpost them to your pharmacy’s smoking cessation service or direct them towards the NHS Stop Smoking App. Providing information about weight management products and services can help too.
To initiative conversations, you could have a display of useful information with leaflets for customers to take away, as well as signposting to appropriate local services.
Top tips for customer care when discussing sildenafil
To help make sure you deliver the best possible customer care for men concerned about erectile dysfunction (ED), Viatris offers this advice:
- When conducting consultations, offer your customer use of the private consultation room, or the option to go to a discrete area away from the pharmacy counter if they want to. Make sure to look for visual signs of them feeling awkward
- Remember to check with the patient if they’ve had any health or medication changes since they previously bought the drug
- A pharmacist should authorise every sale of Viagra connect [and other sildenafil products]. Bear in mind the need to be discrete. It’s better to ask the customer to wait a moment while you go and check, rather than shout across the pharmacy
- Talk to the pharmacist about when they want customers to be referred to them when completing the pharmacy checklist. For example, should you get them as soon as you’re not sure about something or would they prefer you to take customers through the whole checklist before referring to them?
Once the pharmacist has confirmed that you can sell medication to the patient, make sure you give them four key pieces of advice in order for them to get the best results with the drug:
- Avoid taking it with grapefruit or grapefruit juice
- Take no more than one tablet a day. Swallow whole with water
- Take one hour before planned sexual activity
- It can start to work within 30 minutes and men can get an erection in response to sexual stimulation for up to four hours after taking the dose.
Access Viagra Connect learning resources here.
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