With access to routine GP appointments becoming increasingly difficult for many people across the UK, there has never been a better time for pharmacy-based sexual health services

Recent statistics show that the proportion of unplanned pregnancies has almost doubled since the first Covid-19
lockdown. Teenage conception rates in England and Wales continue to rise, and the number of abortions is at a record high. In June, the Royal Pharmaceutical Society, the Company Chemists’ Association, the National Pharmacy Association and the Faculty of Sexual and Reproductive Healthcare (FSRH) called on the Government to commission a national free emergency hormonal contraception (EHC) service from community pharmacies in England.

"A nationally commissioned service would improve access to EHC for all women and help to tackle health inequalities, mirroring successful approaches in Scotland and Wales. There’s currently huge inequity in access to free emergency contraception due to the variation in services commissioned by the NHS across England,” says Tase Oputu, chair of RPS English Pharmacy Board. “Only around half of all community pharmacies are commissioned to provide free emergency contraception, which leads to access by accident, rather than by design. 

"All women should have equal, free access to emergency contraception to help prevent unplanned pregnancies, just as they do with other methods of contraception. Amidst the cost-of-living crisis, having to pay for emergency contraception hits those on low incomes the hardest.”

Alastair Buxton, director of NHS services at Community Pharmacy England, says that community pharmacies are well placed to offer a wider range of sexual health services.

“The expansion of the Pharmacy Contraception Service late last year was a positive step towards improving women’s sexual health, through widening accessibility and convenience for patients,” he says.

“The commissioning of further sexual health services was recommended by Nuffield Trust and The King’s Fund in their Vision for Community Pharmacy report. For example, supply of emergency contraception could be added to the Pharmacy Contraception Service, helping position pharmacies as local health and wellbeing hubs.”

Normalising sexual health

A pharmacy’s private consultation room enables pharmacists to offer sexual health advice in a secure and confidential setting. However, according to Mark Burdon, community pharmacist and advisor to Eroxon, many customers may be unaware of the sexual health services on offer from the pharmacy.

“One essential way to advertise sexual health services,” he says, “is to display posters in-store (near the pay-point or adjacent to relevant fixtures), advertising the availability of a discrete consultation space and giving indications of the topics customers might wish to discuss privately – for example, erectile dysfunction, vaginal dryness, sexual health and contraception.

"Stocking new, scientifically backed treatments that customers or their partners can pick from the shelf presents a great opportunity to drive sales across a category where some customers are too shy to ask for health advice.”

Jacquie Lee, Numark medication safety officer and information pharmacist, says that pharmacy teams can help to normalise the symptoms of sensitive conditions such as erectile dysfunction and vaginal dryness by communicating that millions of people experience them. “When receiving enquiries about products, it’s important to make every conversation count and consider wider sexual health,” she says.

“For example, if a customer is asking for emergency hormonal contraception, consider opportunities for safe sex advice, contraceptive choice consultation, and chlamydia screening/treatment. Product displays and sexual health campaigns are a great way to start a conversation. Giving them a prominent position within a pharmacy breaks taboos around talking about sex, and can encourage customers to discuss any concerns with a pharmacist.”

The FSRH is currently developing a new contraceptive course aimed specifically at community pharmacists, called ‘Essentials of Contraception for Pharmacy Professionals’. “Normalising the conversation is key to being able to discuss potentially sensitive topics well,” says Dr Cindy Farmer, FSRH vice president (professional learning and development).

“As per our other ‘Essentials’ series, the intended learning outcomes will include developing the skills and confidence needed to be able to consult with people about their sexual and reproductive healthcare needs. Advancing education and training is vital for having a skilled sexual and reproductive health (SRH) workforce and continues to be a key objective for the FSRH.”

One challenge is knowing when and how to bring the topic of sexual health into a pharmacy consultation. “Sexual health is very much a patient/customer-driven conversation, or involves finding a window of opportunity where sexual health becomes relevant,” says Jonathan Burton, community pharmacist at Right Medicine Pharmacy in Scotland.

“This may arise during a conversation on a related topic, in the right context, such as whether someone is sexually active if they have symptoms of a urinary tract infection. Or if talking about weight or cardiovascular risk, pharmacists could ask proactively if they are sexually active, in relation to erectile dysfunction. Pharmacists could also talk about sexual health and sexual dysfunction as a side-effect of antidepressants when discussing mental health.” 

Lee says that community pharmacy teams need to work in partnership with commissioners to seamlessly deliver an integrated package of sexual health services. “In addition to contraception, erectile dysfunction and vaginal dryness, this may include provision of relationship support and advice, signposting to local clinics, STI screening and treatment, and pregnancy testing,” she says. “This provision helps to reduce inequalities in access, improve patient experience and protect public health.”

Pharmacy contraception services

The Pharmacy Contraception Service was commissioned by NHS England in April last year for the ongoing supply of free oral contraception from community pharmacies, therefore expanding pharmacies’ role in women’s health. This service was then extended to include both the initiation and ongoing supply of oral contraception from December 2023, via a patient group direction (PGD), clinical checks and annual reviews.

The Pharmacy Contraception Service doesn’t currently include the supply of emergency contraception. However, the two topics are closely linked, and it is often difficult to discuss one and not the other: contraception advice may include information on emergency contraception, and supplying emergency contraception at the pharmacy counter could be used as a prompt to discuss regular contraception.

“In Scotland, national EHC services have been commissioned for many years and are embedded into pharmacies,” says Burton. “This provides an opportunity to have a conversation with women, and sometimes their partners, about wider sexual health, sexually transmitted infections and regular contraception.”

Community pharmacies are well-placed to offer free EHC due to their accessibility, extended opening hours and valued clinical advice. Some pharmacies already supply free EHC through a locally commissioned service, and many pharmacies sell EHC over the counter, often as part of a wider sexual health focus.

“Well pharmacies offer the morning-after pill in a private and convenient environment for women over 16,” says a spokesperson for the multiple. “Pharmacists will conduct a consultation in a private room, asking about health and menstrual history, to ensure EHC is suitable. While this might seem daunting, pharmacists are professionals dedicated to providing safe and effective treatment without judgment. They can also refer to other local NHS services if needed. Additionally, some Well pharmacies provide chlamydia screening tests.”

Dr Farmer says that free oral EHC from community pharmacies could ease pressure on SRH clinics and GP surgeries. “The FSRH believes that free oral emergency contraception should be available alongside appropriate and accurate information as a funded service in all community pharmacies across the UK for those who need it,” she says.

“Currently, all UK nations except England have this service. Having a nationally commissioned EC service that is promoted universally would enhance public awareness, increase the number of locations offering oral EC, ensure consistency and widen access and support for high-risk communities and vulnerable patients.”

In January this year, the FSRH and other organisations including the British Pregnancy Advisory Service (BPAS) called for oral emergency contraception to be reclassified from a pharmacy (P) medicine to GSL. The BPAS says that patients who had experienced an unplanned pregnancy said embarrassment deterred them from getting emergency contraception, and the majority of women would prefer that a pharmacist consultation was optional.

Dr Farmer says that reclassification would allow these medicines to be obtained from more general sales outlets (such as supermarkets and garages) that are potentially open later and are more accessible, particularly in rural communities. “Counselling, safeguarding or health checks can still be completed by a suitably trained healthcare provider who is not a prescriber or pharmacist,” she says.

“All individuals must have unimpeded access to this form of contraception at the time and place of need, with appropriate information. This should include information on appropriateness of use, drug interactions, details of alternative methods of emergency contraception and signposting to online STI testing and local SRH services.”

Erectile dysfunction advice

Sexual health is often associated with women’s health conditions and services – contraception, painful sex and fertility, for example, along with cervical smears. But sexual health problems can have a significant impact on men’s health and wellbeing too.

In June, new research by Eroxon found that men are facing the emotional strain of erectile dysfunction, with 67 per cent of sufferers saying they feel ashamed or embarrassed because of their condition. In the same poll, 47 per cent admitted that their condition had reduced them to tears, and 57 per cent of men said that anxiety was the most common challenge they faced regarding their erectile problems.

Nearly 70 per cent of men with the condition find it difficult to discuss their intimacy issues with a healthcare professional; more than half struggle to talk to their partner about their problem, or they simply avoid the subject altogether. 

“Once a discussion is initiated, it is imperative to reassure the customer and show compassion,” says Burdon. “Listening is key. This is a health issue, just like any other.

“Pharmacists will need to acknowledge that it is a legitimate and common problem and reassure customers that there is help available. After discussion, an assessment can be made and a recommendation given for a medical device, such as Eroxon or vacuum pump, medication or a referral to the GP.”

Erectile dysfunction (ED) may be more than just a sexual health problem in some cases – studies show that seven out of 10 men will experience erectile dysfunction before any other signs of angina. “It’s important during any consultation for ED to take the opportunity to probe clinical history in order to discern any underlying (and potentially undiagnosed) health conditions,” says Burdon.

“Ask about onset and frequency, medical history, medication being taken, and any stressful life events. Likewise, male customers who are prescribed medication for conditions such as cardiovascular problems, diabetes, multiple sclerosis, Parkinson’s disease or thyroid disorders should be sensitively approached and offered a private consultation to discuss the possibility of ED and advise about available options, including lifestyle improvements. 

“Some medications, such as diuretics, antihypertensives, fibrates, antipsychotics, antidepressants and corticosteroids, can cause ED, so consideration should be given to offering private consultations about ED.”

To make treatment more accessible without any embarrassment, Well pharmacy has launched an online ED treatment service, with pharmacist-reviewed subscription plans. “Erectile dysfunction affects men of all ages,” says a Well spokesperson.

“It is often associated with getting older, but the truth is the inability to maintain an erection isn’t always 
age-related. Most adverts for ED medication target older men, which has built up this perception that the condition only affects men of a certain age, but ED is a young man’s problem too. There are a number of different treatments available at a range of price points. But it is also important to remember that key healthy lifestyle changes can also have a positive impact on the physical causes of ED; these include quitting smoking, limiting alcohol consumption and losing weight.”

Burton says that pharmacists need to recognise that medication is not the only option for ED. “I’m based in two pharmacies, one in a village and one on a university campus, so I see people of all ages and at different life stages,” he says.

“ED may be associated with confidence or relationship issues, especially in new relationships. Pharmacists and pharmacy teams may need to have some training to enable conversations with customers about normal sexual relationships and how any problems or concerns could affect sexual performance. It is also important to be aware of key risk factors for ED, such as weight, alcohol and illicit substances, and of comorbidities in older patients.”