Symptoms in the Pharmacy - Women’s Health Flashcards
overview of women’s health:
Cystitis
Vaginal thrush
Dysmenorrhoea
Menorrhagia
Emergency hormonal contraception
Progestogen only contraception
Menopause and perimenopause
Why explain why you are asking questions about health in detail to patients?
can be private and sensitive
take patient into private area
What is Cystitis?
Upper Urinary Tract Infection (UTI)
- Pyelonephritis
Infection/inflammation of kidney(s)
Ureteritis
Infection/inflammation of ureter(s)
Lower Urinary Tract Infection (UTI)
- Cystitis
Infection/ inflammation of bladder
Urethritis
Infection/inflammation of urethra
When does Cystitis occur?
when bacteria pass up along urethra and enter and multiply within the bladder, causing inflammation
50% cases- no cause identified
caused in GI tract = E.coli
Cystitis - common in females, why?
wrethra is longer in women
more coplex if UTI is found in make
How long does cystitis last?
Majority of cases are self-limiting and resolve in around 3 days
OTC management if symptoms are mild, or to help until patient can see GP
Cystitis- Causes
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)
Normal symptoms of cystitis:
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
Symptoms Needing Referral Cystitis
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
Cystitis – Self-management (& preventing recurrence)
1) Avoiding irritants
No need to clean vagina with douches or deodorants- it self-cleans
2) 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
3) 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
4) Wipe front to back after a bowel motion
5) Urinate after sexual intercourse
cranberry juice?
do not recommend unless patient is adamant to try it - can interact with other drugs (statins’)
symptomatic relief
no evidence it can CURE cystitis
Cystitis- OTC Management for pain relief and alkalising products.
Pain Relief:
Paracetamol and/or ibuprofen for up to 2 days
Help with dysuria and any discomfort felt
Alkalising Products:
Potassium citrate or sodium citrate
Idea is that they make urine more alkaline to help with dysuria
Will cause symptomatic relief but not treat the cause (infection)
Alkalising Agents;
Potassium citrate
Sodium citrate
Sodium citrate
Only take stated dose of product
Contraindicated in patients with hypertension, heart disease or are pregnant
Available as granules
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
What are the antibiotic options to treat cystitis?
can test for UTI in pharmacies
Only able to treat uncomplicated UTIs in women aged 16-65 years = dipstick +ive - offer treatment
Trimethoprim or Nitrofurantoin
Trimethoprim or Nitrofurantoin how long to take it for?
3 days
Cystitis- Who to Refer to 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 causes vaginal thrush?
Common yeast infection
Candida albicans
Not an STI
If infected, partner might need treatment too
Vaginal Candidiasis- Symptoms?
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
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
Vaginal soreness
Dysuria (pain on urination)
Dyspareunia (painful sexual intercourse)
Vaginal Candidiasis- Risk Factors
yeast = grows in warm/moist conditions and develops the balance of vaginal bacteria changes
age = common in women of childbearing age (low pH and presence of glycogen)
recent consumption a course of antibiotics
pregnancy
diabetes
weakened immune system
Prevention of vaginal thrush:
Dry area properly after washing
Avoid tight/nylon tights or underwear
Avoid perfumed soaps and shower gels
Wipe front to back after bowel motions
Vaginal Candidiasis- Management
Manged with azole antifungals:
- Topical vaginal cream
- Pessary
- Oral capsule
Can OTC products be given for vaginal thrush?
yes - mixture of formulations
Offer treatment for free Via Common ailment Scheme
Management- Topical vaginal cream
EXTERNAL cream
Clotrimazole 2% cream (Canesten®)
- immediate symptomatic relief of itch
- apply thinly to VULVA and surrounding area BD-TDS until symptoms disappear
Side effects of topical vaginal cream EXTERNAL
Itching/burning sensation
can damage latex contraceptives - use alternative precautions for at least 5 days after using product
Management- Topical vaginal cream
INTERNAL cream
Clotrimazole 10% cream (Canesten®)
Administer intravaginally using the applicator supplied
One-off treatment, best administered at night
side effects of Topical vaginal cream INTERNAL
Itching/burning sensation
Uncomfortable (formulation)
damage latex contraceptives- use alternative precautions for at least 5 days after using product
Not to be used during periods- may wash out
Management- Pessary
Clotrimazole 500mg, 200mg or 100mg (Canesten®)
How to apply pessary?
Administer intravaginally as high as possible using the applicator supplied
Different dosage of pessaries:
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
Side effects of pessary
Itching/burning sensation
Uncomfortable
If using longer course = need motivation
Not to be used during periods- may wash out
Do not use tampons/intravaginal douches/spermicides etc during treatment
Management- Oral capsule
Fluconazole 150mg oral capsule (Canesten®)
One-off dose, to be swallowed whole
May take 12-24 hours for symptoms to improve
What are the Key drug interactions for oral Capsule:
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 of oral capsule e.g. Fluconazole
mild and transient; include nausea, abdo discomfort, flatulence and diarrhoea.
Convenient and acceptable formulation
Candidiasis symptoms in males (candidal balanitis)
Male may catch infection from a female partner
May be asymptomatic
Symptoms of Candidiasis in MALES;
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 the Management for Candidiasis in males?
Azole external cream BD for 6 days or oral fluconazole STAT
Candidiasis- When to refer to 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
Dysmenorrhoea
period pains
Primary Dysmenorrhoea
Pain without underlying causes
Manage in community pharmacy
1 in 2 women suffer, while 1 in 10 have severe symptoms, requiring time off work or school
Peak incidence: 17-25 years of age
Secondary Dysmenorrhoea
Pain with underlying disease, e.g. endometriosis or pelvic inflammatory disease
Primary Dysmenorrhoea
DETAILED
- cramping lower ab pain - begins before start bleed
- pain eases after menstruation - gone by end of first day of bleeding
- Not associated with the start of menstruation (menarche) because ovulation doesn’t happen within the first few months/years of menstruation
[ Women often state that period pain begins several months/years after pain-free menstruation
[Women often state that period pain begins several months/years after pain-free menstruation]
Dysmenorrhoea is different to 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
Therefore important to identify timing of pain to differentiate
Primary Dysmenorrhoea- Management
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
Primary Dysmenorrhoea- Management
Drug management:
Simple analgesia (NSAIDs best)
Hyoscine butylbromide (antispasmodic)– evidence is patchy
Caffeine (enhance analgesic effect)
Dysmenorrhoea- NSAIDs
Pain of dysmenorrhoea linked to increased prostaglandin activity
NSAIDs block synthesis of prostaglandins, which is why they are effective in treating period pains
Treatment for Dysmenorrhoea
Ibuprofen: 200-400mg TDS with food
Naproxen: 500mg initially then 250mg 6-8 hours later if needed. Max 3 days treatment can be supplied OTC.
NSAIDs not appropriate if allergy (incl. aspirin), asthma or GI bleeds.
Could offer these patients paracetamol- doesn’t work on prostaglandins but may have some benefit
Take painkillers regularly for 2-3 days each period, not just PRN
What is Menorrhagia?
Heavy menstrual bleeding
Excessive blood loss interferes with a woman’s physical, social, emotional and material quality of life
what is the average menstrual blood loss for a woman compared to Menorrhagia
30-40mL per cycle
Menorrhagia: 60-80mL or more per cycle
Only OTC product to treat/ manage Menorrhagia
is:
Tranexamic acid
Menorrhagia- Tranexamic acid is a type of what drug
antifibrinolytic
Inhibits fibrinolysis > increased clot formation > reduced blood loss
How to administer Tranexamic acid for Menorrhagia
Only take once heavy bleeding has started (not before)
Two x 500mg tablets TDS until symptoms alleviated, for a maximum of 4 days OTC
If bleeding very heavily, can increased to a maximum of eight tablets a day (4g daily)
Can repeat for each menstrual cycle
Menorrhagia- When to Refer to 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
Are Oral Contraception POM?
majority
Example of oral contraception:
P med: desogestrel 75mg tablets (Lovima® and Hana®)
Type of progesterone-only pill (POP)
Can be 99% effective in preventing pregnancy
Must only sell:
As a form of contraception (i.e. no other indication)
To women of childbearing age (under 18s to be supplied based on clinical judgement as no info on safety or efficacy in SPC)
Dose: 1 tablet daily (no break between packs)
Contraindications - oral contraception
Blood clots, cancer, soya/peanut allergy (Lovima® contains soya bean oil, so avoid in both allergy types)
Interactions - oral contraception
Refer anyone with clinically relevant interaction (e.g. antiepileptics)
When do you take oral contraception?
Take on Day 1 of period, otherwise will need additional barrier contraception if starting on days 2-5.
RPS has guidance on when to start in other situation, e.g. after EHC, after childbirth, after miscarriage, if switching between contraceptives
What if oral contraception pills are missed?
Under 12 hours: Take ASAP and continue as normal
Over 12 hours: Protection lost, take ASAP and use barrier methods for 7 days. May need EHC.
side effects of oral contraception?
Common: irregular periods, altered mood, headaches, nausea, weight changes
If vomits within 3-4 hours, follow missed pill rules
supplies of oral contraception
First supply- up to 3 months can be supplied
Repeat supply- up to 12 months can be supplied
Women under 18- up to 3 months can be supplied
Only OK to supply if:
Not pregnant
No bleeding between period/after sex
No health conditions
No allergies
Not taking other meds
otherwise, refer
Emergency Hormonal Contraception
- morning after pill
2 products licensed OTC:
Levonorgestrel 1500 microgram tablet (Levonelle®)
Ulipristal acetate 30mg tablet (Ella One®)
Next period may be sooner, later or on time. If lighter, shorter or 3 days later than usual, need to take pregnancy test.
how old to sell OTC emergency contraceptive?
16+
Some areas have PGDs where it can be supplied for free under locally agreed protocol (usually from 13 years)
EHC- What do you need to know to supply safely?
what happened?
- failure of barrier contraceptive (condom splits)
- missed contraceptive pill
-unprotected sex
when>
- explain why asking
- EHC most effective the sooner its taken after unprotected sex
- answer will influence
already pregnant?
- last period normal/lughter/later?
- Any other episodes of unprotected sex during this cycle?
EHC- Other points to consider
Supply to a patient representative
Moral beliefs
Advance supply of EHC
Long-term contraception and sexual health
EHC- Other points to consider
Vulnerable adults and children
Cannot sell to under 16s, but they may fall under local PGD
Should be aware of issues such as non-consensual intercourse, child protection issues, vulnerable adults, consent and confidentiality
RPS and Dept of Health have guides with practical advice on managing vulnerable adults, e.g. if domestic violence suspected
Children under 13 are deemed too young to consent, so cases should be reported to social services
Sexual activity with children under 16 is an offence, but may be consensual. Law will not prosecute mutually agreed sex between young people of a similar age, unless it’s abuse or exploitation
Can provide contraception and sexual health advice to children under 16 and patient confidentiality applies- do not need parent consent.
Should obtain consent to share information; this does not apply if it’s in the child’s best interest to share (e.g. to prevent harm or to protect the child). Can seek advice from experts without disclosing identifiable details, however.
Menapause different types
Perimenopause
Menopause
Perimenopause
Woman has irregular cycles of ovulation and menstruation leading up to menopause, continues for 12 months after final period
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
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
Menopause- Self-management
Hot flushes & night sweats
Keeping cool- light clothing, cool showers, using fans
Keep bedroom cool at night
Avoid triggers- caffeine, spicy food, smoking, alcohol
Exercise & lose weight if overweight
Mood changes
Plenty of rest, take exercise, relaxing activities such as yoga
Weak bones (> oestrogen = > risk osteoporosis)
Regular weight-bearing and resistance exercise, healthy diet with sources of calcium, getting some sunlight
Stop smoking, less alcohol & calcium/vit D supplements
Menopause- OTC Management
Vasomotor symptoms
Black cohosh
Isoflavones
St John’s Wort used for depression)
Urogenital Symptoms
Vaginal dryness- OTC vaginal moisturisers and lubricants (Vagisil®,Vagisan®)
NICE advice on herbal medicines in menopause
Despite NICE guidelines suggesting black cohosh or isoflavones may help with vasomotor symptoms, they state that the following should be explained:
Some evidence for it, but not robust
Multiple preparations are available and their safety is uncertain
Different preparations may vary
Interactions with other medicines have been reported
Menopause – When to refer to 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
