Female Health Flashcards
Define LUTI.
Bladder infection usually caused by bacteria from GI tract.
What are the risk factors of LUTI?
Female (15-34 yrs)
Pregnancy
Sexual intercourse (coitus)
Hx or FHx of UTI
Catherisation
Immunosuppression
What are the symptoms of LUTI?
Pain on urination (dysuria)
Frequency
Urgency
Feeling of incomplete voiding of bladder
Nocturia
Foul smelling/cloudy urine.
Suprapublic tenderness/discomfort
Delirium/reduced functional ability
All in the absence of discharge
What are the treatment options for LUTI?
Acute uncomplicated UTI usually resolves within a 3 days.
Self-care: Drink plenty of fluids 6-7 glasses, paracetamol +/or NSAIDs for symptomatic relief. Hygiene - wipe front to back, avoid caffeine, alcohol and acidic drinks. Don’t resist urge to urinate.
Pharmacy first: Uncomplicated UTI in female 16-64 yrs. Gateway point: px with 2/3 key diagnostics symptoms and moderate/severe symptoms. Nitrofurantoin 100mg MR capsules 1BD for 3 days or 50mg tab/cap 1 QDS for 3 days. AND self care
No evidence: Symptomatic relief (alkalinise urine = KCitrate (cystopurine 3g granules), Sodium citrate (Cymalon) = 1 sachet TDS for 2 days. D mannose
C/I: Male, children
Caution: HPT, Pregnancy, CKD, CVD. Both contain cranberry - check for interactions.
Explain the pharmacy first pathway for LUTI.
What is the exclusion criteria for LUTI?
Male
< 16 or 64 yrs
Pregnant or breastfeeding (RE missing, lighter menstruation, pregnancy testing)
Urinary catheter
Recurrent UTI (2 in 6 months or 3 in 12 months)
Symptoms of pyelonephritis (confusion, temp, kidney pain, new flu like illness, rigours, N+V)
Vaginal discharge
Urethritis
STI suspicion
Immunosuppression
EGFR = <45ml/min
< 3 diagnostic symptoms at gateway point.
Mild symptoms - ask to return if no improvement in 48 hrs.
Safety net: If symptoms rapidly/significantly worsen at any time or if don’t improve within 48 hrs of ABx, seek medical attention.
What causes thrush?
Candida Albicans
What are the risk factors of thrush?
Broad spectrum ABx
Cushing’s disease
Uncontrolled diabetes
Medication: SGLT2i, CS
Immunosuppression (HIV, Chemotherapy)
Increase in endogenous/exogenous oestrogen: Pregnancy, COC pill, HRT.
Local factors: Heat, moisture, maceration,
Topical CS, local irritants.
Female
What are the symptoms of thrush?
Vulval/vaginal itching
Vulval/vaginal/penile soreness, redness, burning and irritation
Vaginal/penile discharge usually white, cheese like and non malodorous
Superficial dysparenunia
Dysuria (pain or discomfort during urination)
What are the treatment options for thrush?
Oral fluconazole 150mg caps STAT dose (first line). C/I in pregnancy and breastfeeding. Usual azole interactions.
Topical azole:
- Clotrimazole 2% external cream (16-60 yrs, applied BD to TDS until symptoms improved, > 7 days = GP)
- Clotrimazole 500mg pessary: Inset one stat dose at night.
- Can be combined with an oral tx if infection is internal and external.
What counselling is given to prevent thrush?
Avoid tight fitting clothes especially synthetic materials.
Wear loose fitting, natural fibre underwear.
Avoid using perfumed products/soaps around genitals.
Clotrimazole can damage condoms/diaphragms.
Clears up within 7-14 days of starting tx.
Don’t need to tx partner(s) unless they have symptoms.
What are the alarm symptoms for thrush?
First presentation
< 16 yrs and > 60 yrs
Diabetic
Pregnant or breastfeeding
2 episodes in 6 months
Px/partner with STI Hx
Abnormal menstrual bleeding/ lower ab pain.
Systemic symptoms: fever, chills, lower back pain.
Foul smelling discharge: bacterial vaginosis
No improvement in 7 days
Vulval or vaginal sores, ulcers or blisters
What are the causes of bacterial vaginosis?
Overgrowth of anaerobic organisms and loss of lactobacilli. Vagina loses its normal acidity and pH increased to > 4.5
What are the risk factors of bacterial vaginosis?
Sexually active
Douches, Deodorant, Vaginal washes
Menstruation
CuIUD
Smoking
What are the symptoms of bacterial vaginosis?
Fish-smelling vaginal discharge
Grey/white watery discharge
Not usually associated with soreness, itching/irritation
What are the tx options for bacterial vaginosis?
GP referral = can’t manage OTC.
Non-pregnant women with asymptomatic BV don’t require tx.
For symptomatic: Oral metronidazole (1st line) or gel, clindamycin
What counselling is given to px with thrush?
Avoid: Douches, deodorant and vaginal washes:
- Use water and plain soap to wash your genital area.
- Avoid perfumed soaps/shower gel
- Don’t put antiseptic liquids in the bath.
Define dysmenorrhea.
Painful cramping, lower abdomen, which occurs shortly before or during menstruation or both.
Caused by production of uterine prostaglandins during menstruation leading to uterine contractions and pain.
Define primary dysmenorrhea.
Young females, pain begins with onset of period lasts 24-72 hrs.
Starts 6-12 months after menarche.
Define secondary dysmenorrhea.
Refer: pelvic pathology e.g. fibroids, endometriosis, PID, IUD insertion, starts after several years of painless cycles. Pain may continue after menstruation stops. Irregular bleeding, chronic pain vs cramping.
What are the risk factors of dysmenorrhea?
Early age of menarche
Heavy menstrual flow
Nulliparity
Family Hx of Dysmenorrhoea
Stress
What are the symptoms of Dysmenorrhea?
Pain, cramping in an abdomen, spreading to lower back and inner thigh.
Starts before menstruation and continue for up to 72 hrs.
Cyclical mastalgia (breast pain)
N+V
What are the tx options for Dysmenorrhea?
Feminax Ultra (P):
- 15-50 yrs
- Naproxen 250mg tabs (P) pack of 9
- Provides relief from period pain and menstrual cramps.
- 1st day: 2 tabs when pain starts then take 1 after 6-8 hrs when needed.
- 2nd /3rd day: 1 tablet every 6-8 hrs
- Max. 3 days tx.
Paracetamol, Ibuprofen
What general counselling is given for dysmenorrhea?
Heat: warmth to abdomen e.g. hot water bottles, heat packs.
Warm bath
Tea e.g. regular, camomile or mint
TENS machines
What are the red flags symptoms for Dysmenorrhea?
Severe ab pain
Pregnant
Persistent intermenstrual / post coital bleeding
Symptoms of secondary dysmenorrhea (irregular bleeding, chronic pain vs. Cramping)
Naproxen specific: < 15 > 50yrs, Hx of peptic ulceration or active GI bleed, asthma (if worsens symptoms).
Define menorrhagia.
Heavy menstrual blood loss.
What are the causes of menorrhagia?
Uterine fibroids
Endometriosis
PID
Coagulation disorders
Hypothyroidism
Diabetes
Liver/kidney disease
Anticoagulant or chemotherapy
What are the tx options for menorrhagia?
Tranexamic Acid 500mg tablet (P):
- 18-45 yrs with regular 21-35 day cycles.
- Once bleeding starts, 2x500mg tablets tds. If still heavy can increase to max 8 tablets/day.
- Max 4 consecutive days
Refer: No reduction in bleeding after 3 cycles, Irregular bleed, pregnancy, breastfeeding, PCOS, Hx endometrial cancer in 1st degree relative, obese, diabetic.
OTC: NSAIDs.
POM: COC, Northisterone, LNG-IUS, LA progesterone inj, surgery
What are the red flags symptoms of menorrhagia?
Unusual vaginal discharge
Fever
Females > 45yrs develop heavy periods
Irregular periods
Persistent intermenstrual or postcoital bleeding
Pregnant
Hx endometrial cancer in 1st degree relative.
What is amenorrhoea?
Absence of menstruation
What is primary amenorrhoea?
Refer:
- Failure to start period by 15y with normal 2’ sexual characteristics.
- By 13y with no sexual characteristics
What is secondary amenorrhoea?
Absence of periods for 6 months.
Causes: pregnancy, exercise, menopause, stress, birth control, thyroid disorders, tumours, PCOS
Define Chlamydia.
Infection of the urogenital tract causes urethra inflammation (males) and cervix/urethra inflammation (females)
What are the symptoms of Chlamydia?
Asymptomatic
Post-coital bleeding,
Intermenstrual bleeding
Increased/purulent vaginal discharge
Mucopuruent cervical discharge
Deep Dysparenunia
Dysuria
Pelvic pain/tenderness
Inflamed or friable cervix
Men:
Dysuria
Urethral discharge/discomfort
Epididymo-orchitis or reactive arthritis.
What are the complications of Chlamydia?
PID
Pregnancy complications
Epididymo-orchitis
What are the tx options for Chlamydia?
GUM Referral
Clamelle (Azithromycin 500mg) OTC
- > 16 yrs who have tested positive but no symptoms or sexual partner has chlamydia with no symptoms.
- If symptoms present - GP referral
Doxycycline 100mg BD = first line
Define PID.
Pelvic inflammatory disease: Not an STI but commonly caused by STI
What are the risk factors of PID?
Multiple sexual partners
UPSI
Interruption of cervical barrier (IUD insertion, giving birth, surgery)
What are the symptoms of PID?
Lower abdominal pain (bilateral)
Vaginal discharge
Abnormal bleeding
N+V
Pain during sex/on urinating
Refer for suspected case of PID for diagnosis/tx.
Explain the use of EHC as contraception.
Levonorgestrel and Ulipristal Acetate
Taken ASAP after UPSI
Levonorgestrel effective up to 72hrs
Ulipristal effective up to 120hrs (caution with OC)
Ulipristal P since 2015, Levonorgestrel POM and P (levonelle one step)
Both available on PGD.
Explain the use of OTC EHC contraception.
Levonorgestrel 1500mg tabs (on PGD)
Levonelle one step (P) > 16yrs
Ella one (Ulipristal Acetate) no min age
Requires consultation with pharmacists before sale.
Can only be sold to women who need it.
Effective up to 72 hrs after UPSI
Right to refuse sell but MUST refer.
What are the key features of levonorgestrel 1500mcg?
16+
Taken within 72hrs of UPSI
If vomiting occurs within 2 hrs of taking levonorgestrel , take another dose.
Levonorgestrel can be taken at any point in the menstrual cycle.
Not recommended in severe liver dysfunction, risk of ectopic pregnancy or fallopian tube inflammation.
Interactions: reduced efficacy with enzyme inducers - carbamazepine, griseofulvin, phenytoin, barbiturates e.g. primidone, rifabutin, rifampicin, Ritonavir, St. John’s Wort.
Can continue with regular contraceptives.
What are the key features of Ulipristal 30mg?
Taken within 120hrs ( 5 days) of UPSI.
If vomiting occurs within 3 hrs - take another ASAP.
Ulipristal can be taken with or without food at any point in the menstrual cycle.
Not recommended in sever liver disease and in women with severe asthma who are on oral glucocorticoid.
Interaction: Reduced efficacy with enzyme inducers.
Can be used with regular contraceptives but it can reduce the efficacy of COC and POP. Use reliable barrier method until next period.
Explain the use of EHC in breastfeeding.
Levonorgestrel is secreted into breast milk. - Breastfeeding should take place immediately before taking the tablet and women should avoid nursing for at least 8 hrs.
Ulipristal acetate is excreted in breast milk:
- Breastfeeding not recommended for 1 week.
- During this time, express and discard the breast milk in order to stimulate lactation
Menstruation:
- Delayed, take pregnancy test if > 5 days late for levonorgestrel os for Ulipristal.
What counselling is given to px for OTC EHC?
Taken ASAP.
If vomit or have diarrhoea: Ulipristal (3 hrs repeat), Levonorgestrel (2hrs repeat)
Next period may be early or late
If next period > 7 days later or unusual take pregnancy test
Doesn’t protect against STD
Advise on LT contraception if necessary.
Levonorgestrel can be used while breastfeeding.
Which conditions should you be cautious about when giving contraception?
Sudden severe chest pain
Sudden breathlessness
Unexplained swelling or severe pain in calf of one leg
Severe stomach pain
Unusual severe, prolonged headache
Sudden partial or complete vision loss
Sudden hearing disturbances
If on oral hormonal contraception = REFER!
