Symptoms In Pharmacy - Womens Health (w20) Flashcards
What is urethritis ?
Infection/inflammation of urethra
- classed as a lower urinary tract infection (UTI)
What is cystitis ?
Infection or inflammation of the bladder
- a lower urinary tract infection
How does cystitis occur ?
- Occurs when bacteria pass up along urethra and enter and multiply within the bladder, causing inflammation
- However, usually caused by bacteria from the GI tract, most commonly E.coli
What are causes of cystitis ?
- Wiping back to front, exposing urethra to faecal bacteria
- Previous infection not fully clearing
- Diabetes- sugary environment for bacteria to thrive
- ‘Honeymoon cystitis’- sexual intercourse causing minor trauma or pushing bacteria along urethra
- Irritant effects of toiletries- bubble baths & vaginal deodorants
- Irritant effects of chemicals- spermicides and disinfectants
- Post-menopausal changes to vaginal lining —> thins and less lubrication therefore more prone to trauma/irritation—-> cystitis
- Some medication- cyclophosphamide + methenamine (no evidence to suggest that contraceptive pill increases risk)
What are some of the normal symptoms of cystitis ?
Normal Symptoms
- Signs of impending attack: itching or pricking sensation in urethra
- More frequent desire to pass urine
- Urgent need to pass urine throughout day and night
- Can only pass few burning, painful drops of urine (dysuria)
- Bladder may not feel completely empty after urinating
- Cloudy and strong-smelling urine: sign of bacterial infection
What are some symptoms of cystitis that require referral ?
Symptoms Needing Referral
- Haematuria (blood in urine)- may just be severe UTI, but could be kidney stone (blood with pain) or potentially bladder/kidney cancer (blood but no pain)
- Symptoms suggestive of upper UTI- pain in lower back, loin pain and tenderness, systemic symptoms such as fever, nausea and vomiting
- Abnormal vaginal discharge- local fungal or bacterial infection
- Cystitis symptoms & alteration in vaginal discharge & lower abdo pain= ? chlamydia
How can you self manage cystitis and prevent it from re-occurring ?
- Avoiding irritants
- No need to clean vagina with douches or deodorants- it self-cleans - Drink plenty of water
-Traditional advice to drinks loads to encourage urination to flush out the bacteria, but this will cause discomfort. Best to drink normally to ensure hydration - Empty bladder fully
-Wait 20 seconds after passing urine then strain to empty final drops. Leaning back may help, rather than the usual sitting posture.
-Wipe front to back after a bowel motion
- Urinate after sexual intercourse
What are OTC management options for cystitis ?
1) Pain relief
- paracetamol and/or ibuprofen fro up to 2 days
- help with dysuria and any discomfort felt
2) alkalising products
- potassium citrate or sodium citrate
- idea that they make urine more alkaline to help with dysuria
- will cause symptomatic relief but not treat the cause (infection)
What are examples of alkalising agents used to treat cystitis ?
1) Potassium citrate
- Only to take stated dose of product- some cases of severe hyperkalaemia reported
- Contraindicated in patients taking medication which may also cause hyperkalaemia
- Potassium-sparing diuretics (e.g. spironolactone), ACE inhibitors
- Available as potassium citrate mixture- unpleasant taste, so dilute well with cold water
- Available as potassium citrate granules
2) Sodium citrate
- Only take stated dose of product
- Contraindicated in patients with hypertension, heart disease or are pregnant
- Available as granules
What chyme is available to test women for UTIs within the pharmacy and what does it treat in what age bracket ?
- pilot scheme
- treats uncomplicated UTIs in women aged 16-65
- offers treatment is urine dipstick is positive or symptoms strongly suggest of UTI
What antibiotics can be given for Cystitis ?
Trimethoprim or Nitrofurantoin for 3 days
When would you refer a patient with cystitis to a GP ?
-Children
-Males
-Pregnant females
-Post-menopausal women- could be vaginal atrophy
-Catheterised patients
-Upper UTI symptoms
-Symptoms of systemic infection- fever/nausea/vomiting
-Haematuria or abnormal vaginal discharge
-Symptoms lasting longer than 2 days
-Recurrent cystitis- could be diabetes
-Failed treatment
What is vaginal candidiasis (thrush) ?
- Common yeast infection, known as thrush which is caused by Candida albicans, this is usually harmless, but can be uncomfortable and recurrent
NOT a sexually-transmitted infection (STI)
However, if infected, the patient’s partner may also have it and need treatment too
What are symptoms of vaginal candidiasis (thrush) ?
1) Itch (pruritis) around the vagina
Intense and burning in nature
Skin may be excoriated and raw from scratching if severe
Check this is not due to using any new toiletries- could be dermatitis not thrush
2) Vaginal discharge
Normal= thin and watery, no smell
Candidiasis= white/cream-coloured, thick like cottage cheese, sometimes an unpleasant smell but not always
Bacterial infection= yellow/green-coloured, strong foul odour
3) Vaginal soreness
4) Dysuria (pain on urination)
5) Dyspareunia (painful sexual intercourse)
What are some risk factors associated with vaginal candidiasis (thrush) ?
- The yeast likes to grow in warm, moist conditions and develops if the balance of vaginal bacteria changes
- Age
Most common in women of childbearing age due to low vaginal pH and presence of glycogen - Recently taken a course of antibiotics
- Pregnancy
Attributable to hormonal changes causing increase in glycogen - Diabetes (especially if poorly controlled)
- Weakened immune system
E.g. because of HIV or chemotherapy
How can vaginal candidiasis (thrush) be prevented ?
1) Dry area properly after washing
2) Avoid tight/nylon tights or underwear (Wear cotton underwear instead as more airy)
4) Avoid perfumed soaps and shower gels, vaginal douches and deodorants, and foam baths (These strip away protective lining of vagina)
5) Wipe front to back after bowel motions (Candida may be transferred from bowel)
What are the three types of azole antifungals used to manage vaginal candidiasis (thrush) ?
1) topical vaginal cream
2) pessary
3) oral capsule
What is an example of a topical vaginal external cream used to treat vaginal thrush ?
External cream
- Clotrimazole 2% cream (Canesten®)
Used for immediate symptomatic relief of itch
Apply thinly to vulva and surrounding area BD-TDS until symptoms disappear
Common side effects: Itching/burning sensation
Can damage latex contraceptives- use alternative precautions for at least 5 days after using product
Need to be motivated to continue using it if using alone
What is an example of the internal topical vaginal cream used to manage vaginal thrush ?
Internal cream
- Clotrimazole 10% cream (Canesten®)
Administer intravaginally using the applicator supplied
One-off treatment, best administered at night
Common side effects: Itching/burning sensation
Convenient but some women uncomfortable with the formulation
Can damage latex contraceptives- use alternative precautions for at least 5 days after using product
Not to be used during periods- may wash out
What pessary can be used to manage vaginal thrush ?
* there are multiple doses
- Clotrimazole 500mg, 200mg or 100mg (Canesten®)
Administer intravaginally as high as possible using the applicator supplied
- 500mg pessary: One-off treatment at night, can be repeated in 7 days if infection returns (only this is available via Common Ailments Scheme)
- 200mg pessary: One pessary daily at night for 3 days
- 100mg pessary: Two pessaries daily at night for 3 days OR one pessary daily at night for 6 days
Common side effects: Itching/burning sensation
Convenient but some women uncomfortable with the formulation
If using longer course, must be motivated to complete course
Can damage latex contraceptives- use alternative precautions for at least 5 days after using product
Check patient understanding with regards to application
Not to be used during periods- may wash out
Do not use tampons/intravaginal douches/spermicides etc during treatment
What is an example of an oral capsule used for management of vaginal thrush ?
- Fluconazole 150mg oral capsule (Canesten®)
One-off dose, to be swallowed whole
May take 12-24 hours for symptoms to improve
**Key drug interactions: warfarin, statins, phenytoin, rifampicin, ciclosporin and theophylline.
Single dose may not affect drug levels too much, but will need to refer to GP.***
Side effects are mild and transient; include nausea, abdo discomfort, flatulence and diarrhoea.
Convenient and acceptable formulation
What are the symptoms of candidiasis (thrush) in males ?
* CALLED CANDIDAL BALANITIS
Symptoms may include:
- Irritation, burning and redness around the head of the penis and under the foreskin
- White/cream-coloured discharge, thick in consistency like cottage cheese
- Discharge which may or may not have an unpleasant smell
- Difficulty pulling back the foreskin
What is used for management of thrush in males (candidiasis) ?
Management: Azole external cream BD for 6 days or oral fluconazole STAT
When would you refer a patient with candidiasis (thrush) to a GP ?
-First occurrence of symptoms- to confirm diagnosis
-Allergic to antifungals
-Pregnant or breast feeding
-Immunocompromised
-More than 2 thrush attacks in previous 6 months
-Previous exposure to STI or partner with STI
-Women aged under 16 or over 60
-Abnormal/irregular vaginal bleeding
-Blood-stained vaginal discharge // Foul smelling discharge
-Vulval or vaginal sores/blisters/ulcers
-Associated lower abdo pain or dysuria
-Adverse effects related to treatment (redness/irritation/swelling)
-No improvement within 7 days of treatment
OTC licensing of candidiasis products reflect these referral criteria
What is primary dysmenorrhea ?
Primary Dysmenorrhoea= Pain without underlying causes
Manage in community pharmacy
What is dysmenorrhea ?
Period pains
What is mittelschmerz ?
Mittelschmerz = ovulation pain. This pain is mid-cycle at the time of ovulation. It usually lasts a few hours, some report some bleeding too.
What are some non-drug management options to hep manage primary dysmenorrhea ?
Non-drug management:
- Exercise (endorphins help)
- TENS machine (alters ability to receive/perceive pain signals)
- Acupuncture
- Locally applied low-level heat (heat pads or even warm bath)
- Supplements like fish oil or vitamin B- evidence is patchy
What are some OTC drug management options for dysmenorrhea ?
- Simple analgesia (NSAIDs best)
- Hyoscine butylbromide (antispasmodic)– evidence is patchy
- Caffeine (enhance analgesic effect)
- ibuprofen 200-400mg TDS with food
- naproxen 500mg initially then 250mg 6-8hours later if needed (max 3 days of treatment supplied OTC )
- NSAIDs include aspirin
What is menorrhagia ?
Term refers to heavy menstrual bleeding, this excessive blood loss interferes with a woman’s physical, social, emotional and material quality of life
What drug can be supplied OTC to help manage menorrhagia ?
Tranexamic acid
How does tranexamic acid help manage menorrhagia ?
Inhibits fibrinolysis —> increased clot formation —> reduced blood loss
When would you refer a patient with menorrhagia to a GP ?
- Women under 18 or over 45 years of age
- Tried tranexamic acid for three menstrual cycles without a reduction in bleeding
- Breastfeeding women
- Obese or diabetic patients (could be PCOS)
- If tranexamic acid contraindicated or cautioned- e.g. in history of convulsions, taking warfarin, taking oral contraceptives
- Signs of iron-deficient anaemia: tiredness, paleness
- Irregular bleeding/abnormal bleeding/bleeding between periods/prolonged periods – may be endometrial cancer
- Bleeding between periods/pain during sex/ bleeding after sex/ bleeding after menopause – may be cervical cancer
- History of clotting- e.g. PE, DVT
What is perimenopause ?
Perimenopause = Woman has irregular cycles of ovulation and menstruation leading up to menopause, continues for 12 months after final period
What is menopause ?
Menopause = Biological state having occurred when a woman has not had her period for 12 consecutive months. The ovaries stop maturing eggs and secreting oestrogen + progesterone, menstruation stops and she can no longer conceive.
What are menopause symptoms ?
- Vasomotor symptoms: hot flushes, sweats
- Musculoskeletal symptoms: joint and muscle pain
- Urogenital symptoms: vaginal dryness, urinary frequency, UTIs
- Other symptoms: low mood, reduced libido
When do you refer a patient with menopause to a GP ?
- Contraindications to treatment
- Experienced side effects
- Symptoms don’t sound like vaginal atrophy
- Hx of endometriosis
- Already on systemic HRT / using a different local HRT
- Anyone who doesn’t fit selling criteria (e.g. women under 50, last period was less than 1 year ago etc)
- If symptoms worsen/don’t improve after 7 weeks Tx
- Red flag symptoms:
Vaginal – undiagnosed bleeding, smelly/unusual discharge, severe itching
Vulva – changes to look/texture/colour, soreness, rashes, lumps, swelling
Pain – pelvic, when passing urine
Lower abdominal – pain, bloating, swelling
