Lecture 7: Menstruation, Contraception, and Vaginal Infections Flashcards
Menarche
First period
- starts at age of 12. range is (11-14.5)
- influenced by factors like race, genetics, nutritional status, body mass
Period cycle
- Avg cycle is 28 days
- Range is 24-38 days,
- Generally 3-7 days
Dysmenorrhea
painful menstruation
- prevalence is highest in adolescence, 93% affected
- generally develops within 6-12 months of menarche
Premenstrual Syndrome
physical disorder or physical/emotional/behavioral changes that occur during luteal phase
Amenorrhea
absence of menstruation
Menorrhagia
abnormally heavy or prolonged bleeding
metrorrhagia
abnormal bleeding from uterus
oligomenorrhea
infrequent menstrual flow
Primary dysmenorrhea
- appropriate to use self-care measures to treat
- as soon as 6-12 months after menarche but typically several years after
- no pain during other parts of cycle,
- more likely to be regular with normal blood loss
- NSAIDS help
Prostaglandins
stimulate uterine contractions to expel menstrual fluid and control bleeding as the endometrium sloughs
Leukotreines
cause vasoconstriction and uterine contractions
Dysmenorrhea Risk factors contributing to it
- young age
- nulliparity
- early menarche (prior to age 12)
- heavy menstrual flow
- tobacco smoking
- low fish consumption
- BMI above 30 or below 20
- PMS symptoms
- stress, anxiety, depression
Secondary Dysmenorrhea
- mid to late 20s or older, usually 30s and 40s
- more likely irregular menses, menorrhagia or metrorrhagia is more common
- pattern and duration of pain can vary with cause these changes in pattern or intensity may indicate secondary disease
- There may be pain during other parts of the menstrual cycle
- NSAIDS don’t really help
Primary Dysmenorrhea symptoms
fatigue, headache, nausea, change in appetite, backache, dizziness, irritability, depression
Secondary Dysmenorrhea symptoms
vary according to cause but may include dyspareunia (genital pain) and pelvic tenderness
Ovulation
each month, an egg matures in the ovaries and is released through the fallopian tube into the uterus
Implantation
- if the egg is fertilized by the sperm, it implants on the wall of the uterus
- Leads to pregnancy
Egg is not fertilized
- it then exits the body through the cervix and vagina
- Leads to menstruation
Menstruation
- Hormone levels drop and the endometrium (uterine lining) breaks down
Primary Dysmenorrhea Exclusions for Self-Care
- severe dysmenorrhea and/or menorrhagia
- symptoms inconsistent with primary dysmenorrhea
- history of Pelvic Inflammatory Disease (PID), infertility, irregular menstrual cycles, endometriosis, ovarian cysts
- use of IUD/IUCs
- allergy or intolerance to aspirin or NSAIDs
- use of warfarin, heparin or lithium
- active GI disease
- bleeding disorders
First line treatment for dysmenorrhea
Ibuprofen or Naproxen
- begin therapy at onset of menses and pain
- treatment may be started 1-2 days prior to expected menses to improve relief
- most effective when taken on schedule
Using Acetaminophen for dysmenorrhea
- weak prostaglandin inhibitor
- may be able to treat mild symptoms
Using Aspirin for dysmenorrhea
- may increase menstrual flow
- moderately treats minimal symptoms
Non-pharmacological treatment for dysmenorrhea
- sleep
- hot bath
- heating pad
- exercise
- avoid smoking
- exposure to secondhand smoke
PMS
Premenstrual Syndrome
PMS Pathiophysiology
- fluctuations in estrogen and progesterone caused by normal ovarian function are the cyclic triggers for symptoms
- Serotonin
- allopregnanolone
- GABA receptors
Lower beta- endorphin levels
lower tolerance for discomfort and pain
PMS symptoms
- fatigue
- irritability
- labile mood with alternating sadness and anger
- crying and oversensitivity
- anxiety
- depression
- difficulty concentrating
- abnormal bloating
- breast tenderness
- appetite changes
- headache
- GI upset
- increased energy
- increased libido
- increased sense of control
Typical premenstrual symptoms
Mild physical or mood changes before onset of menses that do not interfere with normal life functions
Normal PMS
- at least one mood or physical symptom during first 5 days prior to menses
- symptoms are virtually absent during cycle days 5-10
- the symptoms have negative effect on social functioning or lifestyle but the severity is mild-moderate
Moderate-severe PMS
at least one mood or physical symptom that results in significant impairment of daily activities or relationships
Premenstrual dysphoric disorder (PMDD)
five or more symptoms, physical or mood, that are present the last week of the luteal phase with at least one symptom being significant depression, anxiety, affective lability or anger. Severity of symptoms interfere with work, school, social activities and social relationships. Symptoms should be absent the week after menses and must not be an exacerbation of another disorder like panic disorder
Premenstrual Exacerbation
a worsening of the symptoms of other, typically psychiatric disorders, there is no symptom free interval
PMS Exclusions to selfcare
- Severe PMS or PMDD
- uncertain pattern of symptoms
- onset of symptoms coincident with use of hormonal contraceptives
- contraindications to specific agents
PMS Treatment goals and approach
- Patient education to better understand PMS and the cyclic nature of the illness
- identify techniques for coping with PMS symptoms and stress
- Lifestyles modification (diet, exercise)
- Non-pharmacologic and Pharmacologic options
PMS Pharmacologic options
- Pyridoxine 80mg once daily (for mood)
- calcium 600mg and vitamin D twice daily (for emotional symptoms, mood)
- magnesium 360mg daily during luteal phase (mood)
- NSAIDs (pain)
- Diuretics- water pills (bloating)
Caffeine
- Dose: 100-200mg every 3-4 hours
- Inhibits renal tubular secretion of sodium and water
- May cause anxiety, restlessness, insomnia or irribility
- May increase GI irritation
Pamabrom
Up to 50mg 4 times daily
- common product in combination PMS products
PMS Nonpharmacologic options
- Exercise
- Health diet
- Light therapy
- Cognitive-behavioral therapy
- Acupuncture ( pricking skin w needles of medicine to alleviate pain and to treat mental, physical and emotional conditions
- Massage
Types of Contraceptions
- Sterilization
- IUD/IUC
- Implant
- Hormonal Contraceptives (pill, patch, shot, ring)
- Male Condoms
- Female Condoms
- Spermicide
- Contraceptive Sponge
- Diaphragm
- Fertility Method
- Calendar Method
- Withdrawal
Male condoms
- Names (Rubbers, Sheaths, Prophylactics, Safes, Skins)
- failure rate 15% rate
- stored in a cool dry place
- protects against STIs
Latex condoms
- oil based lubricants : will degrade
- options for spermicide
Synthetic: non latex
- conduct heat well
- available pre-lubricated
- oil based lubricants: polyurethane is not degraded; polyisoprene is degraded
Lamb cecum
- only for pregnancy prevention
- does not prevent transmission of viral organisms
- conducts heat well
- strong
- oil based lubricants: NOT degraded
Female condoms
- protects against STIs
- lower breakage rate than male condom
- failure rate: 12-21% pregnancy rate among first time users
- designed for single use
- make sure not expired
- store in cool, dry place
Spermicide
- Surface active agents that immobilize and kill sperm
- active ingredient is nonoxynol-9
- options: gel, foam, suppository, film
- high typical failure rate in first year users
- may increase risk of STIs
- avoid douching for at least 6 hours after intercourse
- allergic reactions possible
Contraceptive Sponge
- Small, circular, disposable sponge made of polyurethane and treated with nonoxynol-9
- failure rate 17-25% pregnancies in first year users
- more effective in women not given birth yet
- do not protect against STIs, may increase HIV transmission
- avoid during menstruation and within 6 weeks postpartum
Vaginal Gel Alone
- insert full dose
onset- immediate to 1 hour - apply 30-60 mins before sex
- reapply for each coital act
Vaginal gel and diaphragm/ cervical cap
Fill barrier device with 1/3 full with gel and place near cervix. Leave in place at least 6 hours post- intercourse
Onset- Immediate/ diaphragm- 6 hours. Cervical cap 48. hours
- apply up to an 1 hr before sex
Vaginal foam
- insert full dose near cervix
- Onset- immediate/ 1 hr
- apply an hr before sex
- reapply before each coital act
Vaginal suppository
- insert suppository near cervix
- onset- 10-15 mins to an hr
- apply 10-15 mins before sex
Vaginal contraceptive film
- drape film over fingertip: place film near cervix
- onset- 15 mins to 1-3 hrs
- apply 15 mins before sex
vaginal contraceptive sponge
- moisten with tap water: insert convex side against cervix
- onset- immediate/ 24 hours
- apply up to 24hrs prior to sex
- Leave in for more than 6 hours after intercourse but no longer than 30 hours total
Noncurable STIs, but vaccine preventable
- genital warts
- Hepatitis B
Curable STIs
- chlamydia
- gonorrhea
- nongonococcal urethritis
- syphillis
- trichomoniasis
Noncurable STIs
- AIDs/HIV
- Herpes
- Hepatitis C
Pregnancy Test
- detects human chorionic gonadotropin (HCG) in urine
- may work 3-4 days prior to missed period
- very accurate starting at day of missed period
- highly sensitive test- low rate of false positives
- % accuracy increases every day you get closer to when your expected to get your period
Ovulation Predictor
- Predicts ovulation to assis in conception
- indentify surge in LH that occurs before ovulation by detecting urinary excretion of LH (occurs 8-40 hrs before ovulation)
Emergency Contraception
- Copper IUD- must be inserted by provider- up to 5-8 days after sex
- Ullipristal acetate 30mg- Ella: prescription only: works up to 120 hours after sex
- Combined oral contraceptives- Yupze method: need access to prescribed contraceptives
- Plan B, Next choice One Dose, OTC, works up to 72 hours after sex
Levonorgestrel 1.5 mg adverse effects
Nausea and vomiting, headache, breast tenderness, dizziness
- repeat dose if vomiting occurs within 2 hours
Pharmacists role in EC
- counsel on adverse effects of EC
- discuss potential change in menstrual cycle- may be late: if no cycle within 21 days recommend taking pregnancy test
- recommend use of regular contraception
- explain that EC does not protect against STIs and is not 100%
Vaginal Canal
Acidic (4-4.5 pH) - prevents infections but acidity decreases with age
- colonized by many organisms but the most common is lactobacillus
Acidity and Colonization impacted by
- hormonal fluctuations
- drug therapy
- Douching/feminine hygiene deodorant products
- number of sex partners
Bacterial vaginosis
33% of vaginal symptoms, generally in younger and sexually active females
- No OTC treatment
Bacterial vaginosis (BV) Symptoms
- Thin, watery, off-white or discolored sometimes foamy discharge
- unpleasant fishy odor
- odor may increase after intercourse or menses
BV differentiating signs
Vaginal Irritation, dysuria, itching occur LESS frequently with BV than VVC or trichomoniasis, higher level of discharge than in VVC, foul odor is so common that lack of odor rules out this infections
BV Causes (Etiology)
polymicrobial infection, results from imbalance in normal vaginal flora with increased Gardnerella vaginalis and anaerobic bacteria species
Risk Factors:
- new partners
- african american race
- IUDs
- douching
- receptive oral sex
- tobacco use
- prior pregnancy
Trichomoniasis
- 15-20% of vaginal infections
- STI
- No OTC treatment
Trichomoniasis symptoms
copious, malodorous, yellow-green, frothy discharge, dysuria, no symptoms initially in 50% of affected women, men may be reservoirs asymptomatically
Trichomoniasis differentiating symptoms
- Erythema( reddening of skin) and vulvar edema( swelling of tissue) can occur, yellow discharge
- greater likelihood it is trichomoniasis over BV or VVC
Trichomoniasis risk factors
- STI caused by Trichomoniasis vaginalis
- multiple sex partners
- new partners
- nonuse of barrier contraceptives
- presence of other STIs
Vulvovaginal candidiasis (VVC)
- 20-25% of vaginal infections
- no identifiable cause for most infections
- OTC treatments available
VVC symptoms
- thick white “cottage cheese” discharge
- no odor to discharge
- normal pH
VVC differentiating symptoms
- Presence of erythema
- itching and/or vulvar edema AND absence of malodor ( unpleasant smell) increase likelihood
- thick “cheesy” discharge is a classic predictive sign
VVC Causes (Etiology)
- Cause by yeast fungal
- Caused by Candida albicans
- Candida glabrata
- Candida tropicalis and Saccharomyces
VVC risk factors
- antibiotic use
- immune suppressant use
- possibly pregnancy
- possible during and after menopause
- onset of regular sexual activity
- receptive oral sex
VVC Diagnosis
- no alteration of vaginal pH
- must wait 72 hours to test if contraceptive spermicide or antifungal product use
- must wait 48 hours after sex/douching
- wait 5 days after a period
- if pH is more than 4.5
it’s less likely to be VVC
VVC Treatment
- Selt-treatment can be done if: symptoms are infrequent ( no more than 3 in the last year or 1 in the last 2 months
- a medical professional diagnosed at least 1 previous episode of VVC
- current symptoms are mild-moderate and consistent w the characteristics signs and symptoms of VVC
- if pH is 4.5 or lower
VVC exclusions to self care
- Pregnancy
- girls <12 years old
- concurrent symptoms: fever or pain in lower abdomen, back or shoulder
- Medications that can predispose to VVC: corticosteroids, anti-cancer meds
- Medical disorders that can predispose to VC DM, HIV
Recurrent VVC: more than 3 infections a year or infection in the past 2 months
VVC Pharmacological options
Butoconazole, clotrimazole, miconazole, tioconazole are all equally effective (80-90%),
- adverse reactions: vulvovaginal burning, itching, irritation (3-7%)
- best if used at nighttime to avoid leakage
- creams may be applied to vulva for itching in addition to any of the internal options
- symptomatic relief may occur within 2-3 days but complete resolution may take longer
Butoconazole dosing
2% cream: insert vaginally for a single dose
Clotrimazole dosing
- 1 % cream: insert vaginally for 7 days, apply to vulva 2x daily for itching
- 100mg tablet: insert tablet vaginally for 7 days
- 2% cream: insert vaginally for 3 days
Miconazole dosing
- 4% cream: insert vaginally for 3 days, apply 2x daily to vulva for itchy
- 2% cream: insert vaginally for 7 days, apply 2x daily to vulva for itchy
- 1200mg suppository: insert vaginally for a single dose (may be used in the morning)
- 200mg suppository: insert vaginally for 3 days
- 100mg suppository: insert vaginally for 7 days
Tioconazole dosing
6.5% ointment: insert vaginally for a single dose
VVC counseling points
- safe and effective to use during menstruation - you can wait until period is done to treat
- avoid tampons and douching use for 3 days after
- refrain from sexual intercourse, use of latex condoms or spermicides during and 3 days after
- a sanitary pad or panty liner is recommended to avoid underwear staining
- use for the full length of time, even is symptoms lessen
Non-pharmacologic options
- Bicarbonate sitz bath
- Tea tree oil: 200mg suppository for 6 days
- Gentian violet dye: applied to tampon and inserted overnight 1-2x daily for up to 5 days
- Boric Acid: 600mg capsule 1-2x daily for 2 weeks
VVC special populations
- under 12: refer, may indicate sexual abuse
- pregnancy: self-care not appropriate, if MD indicates OTC use clotrimazole or miconazole
- safe for breastfeeding and elderly
Atrophic vaginitis
- vaginal inflammation due to atrophy of the vaginal mucosa - caused by decreased estrogen levels,
- typical in post-menopausal women or those with decreased ovarian estrogen production
AV symptoms
- decreased vaginal lubrication
- vaginal irritation
- dryness and/or burning
- itching
- leukorrhea
- dyspareunia (pain that occurs before, during or after sex)
- sometimes: thin, watery, yellow, malodorous discharge
AV exclusions to self care
- symptoms of severe vaginal dryness or dyspareunia
- vaginal bleeding that has not been examined
- symptoms that are not localized
- dryness or dyspareunia not relieved by use of personal lubricants
AV Pharmacologic
- vaginal lubricants will temporarily moisten vaginal tissues
- offer short term improvement in symptoms such as burning an ditching
- Water soluble products recommended
- petroleum jelly is difficult to remove and oil based lubricants may degrade latex condoms
Vaginal Douching
- Irrigation or rinsing
- used by women for hygiene or cosmetic purposes
- Risks: associated with increased risk of PID, allergic reactions, infections such as BV, STIs, low birth weight, cervical cancer
- Not necessary to clean vagina
- contraindicated during pregnancy
Vaginal Douching Counseling
- share risks
- determine reasons and discuss alternative methods
- all equipment should be kept clean
- wait to use until at least 8 hours post-intercourse using a diaphragm, cervical cap or spermicidal product
- wait 3 days after topical anti-fungal treatment
- do not douche 48 hours prior to gyn exam
- do not douche during pregnancy or more than twice a week unless told by doctor
Nulliparity/ parous
- a women hasn’t given birth yet to live baby
Pruritus
- itchy skin often caused by dry skin
Erythema/ Edema
- superficial reddening of the skin
- occurs in response to drug, disease or infection
- swelling of tissue caused by fluid that is trapped in your body’s tissue
