Symptoms In Pharmacy - Womens Health (w20)

Question 1

What is urethritis ?

Answer 1

Infection/inflammation of urethra
- classed as a lower urinary tract infection (UTI)

Question 2

What is cystitis ?

Answer 2

Infection or inflammation of the bladder
- a lower urinary tract infection

Question 3

How does cystitis occur ?

Answer 3

• 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

Question 4

What are causes of cystitis ?

Answer 4

• 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)

Question 5

What are some of the normal symptoms of cystitis ?

Answer 5

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

Question 6

What are some symptoms of cystitis that require referral ?

Answer 6

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

Question 7

How can you self manage cystitis and prevent it from re-occurring ?

Answer 7

• 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

Question 8

What are OTC management options for cystitis ?

Answer 8

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)

Question 9

What are examples of alkalising agents used to treat cystitis ?

Answer 9

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

Question 10

What chyme is available to test women for UTIs within the pharmacy and what does it treat in what age bracket ?

Answer 10

• pilot scheme
• treats uncomplicated UTIs in women aged 16-65
• offers treatment is urine dipstick is positive or symptoms strongly suggest of UTI

Question 11

What antibiotics can be given for Cystitis ?

Answer 11

Trimethoprim or Nitrofurantoin for 3 days

Question 12

When would you refer a patient with cystitis to a GP ?

Answer 12

-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

Question 13

What is vaginal candidiasis (thrush) ?

Answer 13

• 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

Question 14

What are symptoms of vaginal candidiasis (thrush) ?

Answer 14

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)

Question 15

What are some risk factors associated with vaginal candidiasis (thrush) ?

Answer 15

• 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

Question 16

How can vaginal candidiasis (thrush) be prevented ?

Answer 16

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)

Question 17

What are the three types of azole antifungals used to manage vaginal candidiasis (thrush) ?

Answer 17

1) topical vaginal cream
2) pessary
3) oral capsule

Question 18

What is an example of a topical vaginal external cream used to treat vaginal thrush ?

Answer 18

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

Question 19

What is an example of the internal topical vaginal cream used to manage vaginal thrush ?

Answer 19

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

Question 20

What pessary can be used to manage vaginal thrush ?
* there are multiple doses

Answer 20

• 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

Question 21

What is an example of an oral capsule used for management of vaginal thrush ?

Answer 21

• 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

Question 22

What are the symptoms of candidiasis (thrush) in males ?
* CALLED CANDIDAL BALANITIS

Answer 22

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

Question 23

What is used for management of thrush in males (candidiasis) ?

Answer 23

Management: Azole external cream BD for 6 days or oral fluconazole STAT

Question 24

When would you refer a patient with candidiasis (thrush) to a GP ?

Answer 24

-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

Question 25

What is primary dysmenorrhea ?

Answer 25

Primary Dysmenorrhoea= Pain without underlying causes
Manage in community pharmacy

Question 26

What is dysmenorrhea ?

Answer 26

Period pains

Question 27

What is mittelschmerz ?

Answer 27

Mittelschmerz = ovulation pain. This pain is mid-cycle at the time of ovulation. It usually lasts a few hours, some report some bleeding too.

Question 28

What are some non-drug management options to hep manage primary dysmenorrhea ?

Answer 28

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

Question 29

What are some OTC drug management options for dysmenorrhea ?

Answer 29

• 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

Question 30

What is menorrhagia ?

Answer 30

Term refers to heavy menstrual bleeding, this excessive blood loss interferes with a woman’s physical, social, emotional and material quality of life

Question 31

What drug can be supplied OTC to help manage menorrhagia ?

Answer 31

Tranexamic acid

Question 32

How does tranexamic acid help manage menorrhagia ?

Answer 32

Inhibits fibrinolysis —> increased clot formation —> reduced blood loss

Question 33

When would you refer a patient with menorrhagia to a GP ?

Answer 33

• 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

Question 34

What is perimenopause ?

Answer 34

Perimenopause = Woman has irregular cycles of ovulation and menstruation leading up to menopause, continues for 12 months after final period

Question 35

What is menopause ?

Answer 35

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.

Question 36

What are menopause symptoms ?

Answer 36

• Vasomotor symptoms: hot flushes, sweats
• Musculoskeletal symptoms: joint and muscle pain
• Urogenital symptoms: vaginal dryness, urinary frequency, UTIs
• Other symptoms: low mood, reduced libido

Question 37

When do you refer a patient with menopause to a GP ?

Answer 37

• 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