1. A man comes into your pharmacy requesting the emergency hormonal contraceptive (morning-after-pill) for his girlfriend. He states that unprotected intercourse occurred 4 days ago. The girlfriend is not present at the pharmacy. You should refuse the request because:

A. no attempt has been made to contact a doctor
B. levonorgestrel is not licensed for use after 72 hours (3 days)
C. you have not personally interviewed the patient
D. you do not know the patient
E. you do not know the man

Who can take it?
       First it is important to know the standard questions to ask, these should be known by heart by any pharmacists. If you do not have confidence its easy just to read the levonelle questionnaire, eventually you will learn it. Here's what to ask:

"Are you over 16?"
To legally buy the morning after pill in the UK the patient must be over 16 (there are exceptions in specialist clinics and PGD's in registered pharmacy's).

"Is it for yourself?"
The patient taking the medication must be interviewed. This serves purposes of acquiring all relevant information that other people might not know, this can be something simple such as "When was the last period?", or something more personal such as "have you had unprotected sex at any other time since your last period". So the main point here is to interview the patient.

"When was the last time you had unprotected sex?"
This must be within 72 hours, the sooner the patient takes it after unprotected sex the more effective it is. If it is more that 72 hours the chance of the medication working is low, refusal of sale is appropriate here, and refer to a doctor or specialist. The use of emergency contraception has been known to work for a small percentage of people 5 days after of unprotected sex, however for sale of OTC "morning after pill" the licensed time allowed is upto 72 hours.

"When was you last period?"
The ideal period is within 4-5 weeks, i.e. with the normal period time. If the time they say is longer than 5 weeks, this is a sign that they may already be pregnant.

"Have you got any allergies to Levonorgestrel?"
This question is to prevent any adverse allergic reactions occurring, most patient that are taking it for the first time may not know, but you have to ask to make sure. Anaphylactic reactions is the only main contraindication to levonorgestrel, however there's a few over conditions to consider.

"Have you had unprotected sex at any other time with this menstrual cycle?"
This question has two functions, one, to determine if there is a risk of pregnancy in a previous occasion of unprotected sex. The second function is to see if they have taken the morning after pill previously within the same cycle. Levonorgestrel for emergency contraception is ok to take more than once in the same cycle, however referral is probably the best option in this case.

"Are you on any other medication or do you have any other medical conditions"
There are some medical conditions that may effect the absorption of levonorgestrel such as abdominal disorders such as Crohn's disease. Drug interactions occur with rifampicin and other enzyme inhibitors. Amoxicillin does not affect effectiveness of the morning after pill, but should, for extra safety, be cautioned with oral contraceptives (e.g. microgynon). Another important part is if they actually need emergency contraception, i.e. are they already on oral contraceptive medication, and if they missed a pill when it is necessary just to take extra precautions and when it is necessary to take the morning after pill (full information on this will be updated later on)

The main aim of the questions is to
MAKE SURE THE MEDICINE WILL WORK
MAKE SURE THEY ARE NOT ALREADY PREGNANT
MAKE SURE THEY WON'T HAVE ANY ALLERGIC REACTIONS

After sale advice:
WARNING!! IF THE PATIENT HAS LIED THEY MAY RESULT IN AN ECTOPIC PREGNANCY, this means the foetus will grow in the wrong place. This is due to the medication causing the environment where the foetus grows to detach, in some cases the egg will pass out of the body with blood, in other cases the egg may still remain in the uterus and still grow but in the wrong location. If you think the patient may have lied in any way it may be worth giving this information to let them know the severity of misinformation.

The morning after pill may cause nausea and vomiting, if the patient throws up within 3 hours of taking the pill, the pill may not work, referral is recommended at this point. However a very small percentage of people experience vomiting as a side effect.
The next period may be disrupted, this can either mean it may start earlier or a little later than normal.
The tablet must be taken as soon as possible
The patient should avoid any activities of food that can make then nauseous.


 
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