It’s not often that I find myself speechless. I have heard all sorts of stories in my office—as a sexuality counselor, I am often humbled by the trust that people place in me and how much they disclose about their private lives. But one conversation I had with a patient literally made my jaw drop.
The patient is a postmenopausal woman with stage III breast cancer. She had a mastectomy followed by radiation and chemotherapy and is now on an aromatase inhibitor. Like many women taking an aromatase inhibitor, she has significant vulvo-vaginal atrophy resulting in dyspareunia. Unlike other women with a similar history, she has not experienced a reactive loss of libido. She is very much in love with her partner—observing the two of them together in my office was joyful. They looked at each other often, finished each other’s sentences, and reminded me again how fortunate I am to do the work that I do.
I knew from the referral letter I had received from her oncologist that she had been prescribed local estradiol tablets at a low dose to treat the vulvo-vaginal atrophy. This in itself was unusual; most of the oncologists I have encountered do not prescribe local estrogen at all, and in fact, some warn me in their referral letters that I should under no circumstances even mention this treatment to the patient. But that’s a discussion for another day. . .
This woman had been using the tablets twice a week for about two months and told me that she thought that perhaps things were getting a little better. And that’s when she said that she had some difficulty getting the medication. I looked at her quizzically and motioned with my hand that she should continue.
“Well,” she said, “the pharmacist refused to fill the prescription.”
That’s when my jaw dropped and I lost all capacity for speech.
I know that pharmacists have refused to provide women with emergency contraception in some jurisdictions. I also know that some pharmacists refuse to dispense oral contraceptives to young women. This is allowed by law in some states, while in others it is permitted only if there is another pharmacy where the prescription can be filled. Some states allow the religious beliefs of the pharmacist to have an impact on their work. But why would a pharmacist refuse to fill a prescription written by an oncologist for a medication that has no religious connotations?
The provision of local estrogen to women with breast cancer is controversial. There are also geographic prescribing practices; I have spoken to physician groups across North America, and in some areas, prescribing local estradiol is an accepted practice, while in others, it is extremely rare. In a study of 285 gynecologists, 89% regarded the use of local estrogen therapy to be safe for women with breast cancer and would use it themselves if they had breast cancer (Streicher, 2013).
But should a pharmacist not talk to the prescribing physician before taking a unilateral decision that prevented a patient from taking medication prescribed to improve her symptoms and quality of life? The patient told me that she contacted her oncologist and told her what had transpired at the pharmacy. It then took some time for the oncologist to speak to the pharmacist, and eventually her prescription was filled. However, this caused her a significant amount of distress and trust was lost; she initially lost trust in her oncologist after hearing the pharmacist’s refusal. After talking to her oncologist again, she no longer trusts the pharmacist.
There were other ways for the pharmacist to deal with this. He/she could have called the oncologist and asked for clarification in case the prescription was wrong. He/she could have explained to the patient (customer) that he/she had concerns and wanted to talk to the oncologist before filling the prescription. Or the pharmacist could have filled the prescription and trusted the oncologist. Or should the oncologist have included a note on the prescription that the prescriber and the patient were aware of the potential risks of the medication for this particular patient?
In the end, she used the medication and her sex life is improving. Her relationship with the pharmacist has not.
Streicher, L. Physician attitude regarding local estrogen therapy for treatment of personal vaginal atrophy in the presence of breast cancer. Abstract #14; Journal of Sexual Medicine 2013; 10 (sup; 2: 158-178).