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PMP-103 > Symptoms in the Pharmacy - Women’s Health > Flashcards

Symptoms in the Pharmacy - Women’s Health Flashcards

1
Q

overview of women’s health:

A

Cystitis
Vaginal thrush
Dysmenorrhoea
Menorrhagia
Emergency hormonal contraception
Progestogen only contraception
Menopause and perimenopause

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2
Q

Why explain why you are asking questions about health in detail to patients?

A

can be private and sensitive

take patient into private area

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3
Q

What is Cystitis?

A

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

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4
Q

When does Cystitis occur?

A

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

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5
Q

Cystitis - common in females, why?

A

wrethra is longer in women

more coplex if UTI is found in make

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6
Q

How long does cystitis last?

A

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

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7
Q

Cystitis- Causes

A

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)

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8
Q

Normal symptoms of cystitis:

A

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

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9
Q

Symptoms Needing Referral Cystitis

A

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

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10
Q

Cystitis – Self-management (& preventing recurrence)

A

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

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11
Q

cranberry juice?

A

do not recommend unless patient is adamant to try it - can interact with other drugs (statins’)

symptomatic relief

no evidence it can CURE cystitis

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12
Q

Cystitis- OTC Management for pain relief and alkalising products.

A

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)

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13
Q

Alkalising Agents;

A

Potassium citrate
Sodium citrate

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14
Q

Sodium citrate

A

Only take stated dose of product

Contraindicated in patients with hypertension, heart disease or are pregnant

Available as granules

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15
Q

Potassium citrate

A

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

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16
Q

What are the antibiotic options to treat cystitis?

A

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

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17
Q

Trimethoprim or Nitrofurantoin how long to take it for?

A

3 days

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18
Q

Cystitis- Who to Refer to GP?

A

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

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19
Q

What causes vaginal thrush?

A

Common yeast infection
Candida albicans
Not an STI
If infected, partner might need treatment too

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20
Q

Vaginal Candidiasis- Symptoms?

A

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)

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21
Q

Vaginal Candidiasis- Risk Factors

A

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

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22
Q

Prevention of vaginal thrush:

A

Dry area properly after washing

Avoid tight/nylon tights or underwear

Avoid perfumed soaps and shower gels

Wipe front to back after bowel motions

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23
Q

Vaginal Candidiasis- Management
Manged with azole antifungals:

A
  1. Topical vaginal cream
  2. Pessary
  3. Oral capsule
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24
Q

Can OTC products be given for vaginal thrush?

A

yes - mixture of formulations

Offer treatment for free Via Common ailment Scheme

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25
Q

Management- Topical vaginal cream
EXTERNAL cream

A

Clotrimazole 2% cream (Canesten®)
- immediate symptomatic relief of itch
- apply thinly to VULVA and surrounding area BD-TDS until symptoms disappear

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26
Q

Side effects of topical vaginal cream EXTERNAL

A

Itching/burning sensation
can damage latex contraceptives - use alternative precautions for at least 5 days after using product

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27
Q

Management- Topical vaginal cream
INTERNAL cream

A

Clotrimazole 10% cream (Canesten®)
Administer intravaginally using the applicator supplied
One-off treatment, best administered at night

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28
Q

side effects of Topical vaginal cream INTERNAL

A

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

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29
Q

Management- Pessary

A

Clotrimazole 500mg, 200mg or 100mg (Canesten®)

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30
Q

How to apply pessary?

A

Administer intravaginally as high as possible using the applicator supplied

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31
Q

Different dosage of pessaries:

A

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

32
Q

Side effects of pessary

A

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

33
Q

Management- Oral capsule

A

Fluconazole 150mg oral capsule (Canesten®)

One-off dose, to be swallowed whole
May take 12-24 hours for symptoms to improve

34
Q

What are the Key drug interactions for oral Capsule:

A

warfarin, statins, phenytoin, rifampicin, ciclosporin and theophylline

Single dose may not affect drug levels too much, but will need to refer to GP

35
Q

Side effects of oral capsule e.g. Fluconazole

A

mild and transient; include nausea, abdo discomfort, flatulence and diarrhoea.
Convenient and acceptable formulation

36
Q

Candidiasis symptoms in males (candidal balanitis)

A

Male may catch infection from a female partner
May be asymptomatic

37
Q

Symptoms of Candidiasis in MALES;

A

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

38
Q

What is the Management for Candidiasis in males?

A

Azole external cream BD for 6 days or oral fluconazole STAT

39
Q

Candidiasis- When to refer to GP

A

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

40
Q

Dysmenorrhoea

A

period pains

41
Q

Primary Dysmenorrhoea

A

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

42
Q

Secondary Dysmenorrhoea

A

Pain with underlying disease, e.g. endometriosis or pelvic inflammatory disease

43
Q

Primary Dysmenorrhoea
DETAILED

A
  • 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]
44
Q

Dysmenorrhoea is different to mittelschmerz

A

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

45
Q

Primary Dysmenorrhoea- Management
Non-drug management:

A

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

46
Q

Primary Dysmenorrhoea- Management
Drug management:

A

Simple analgesia (NSAIDs best)
Hyoscine butylbromide (antispasmodic)– evidence is patchy
Caffeine (enhance analgesic effect)

47
Q

Dysmenorrhoea- NSAIDs

A

Pain of dysmenorrhoea linked to increased prostaglandin activity

NSAIDs block synthesis of prostaglandins, which is why they are effective in treating period pains

48
Q

Treatment for Dysmenorrhoea

A

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

49
Q

What is Menorrhagia?

A

Heavy menstrual bleeding

Excessive blood loss interferes with a woman’s physical, social, emotional and material quality of life

50
Q

what is the average menstrual blood loss for a woman compared to Menorrhagia

A

30-40mL per cycle

Menorrhagia: 60-80mL or more per cycle

51
Q

Only OTC product to treat/ manage Menorrhagia
is:

A

Tranexamic acid

52
Q

Menorrhagia- Tranexamic acid is a type of what drug

A

antifibrinolytic

Inhibits fibrinolysis > increased clot formation > reduced blood loss

53
Q

How to administer Tranexamic acid for Menorrhagia

A

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

54
Q

Menorrhagia- When to Refer to GP

A

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

55
Q

Are Oral Contraception POM?

A

majority

56
Q

Example of oral contraception:

A

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)

57
Q

Contraindications - oral contraception

A

Blood clots, cancer, soya/peanut allergy (Lovima® contains soya bean oil, so avoid in both allergy types)

58
Q

Interactions - oral contraception

A

Refer anyone with clinically relevant interaction (e.g. antiepileptics)

59
Q

When do you take oral contraception?

A

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

60
Q

What if oral contraception pills are missed?

A

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.

61
Q

side effects of oral contraception?

A

Common: irregular periods, altered mood, headaches, nausea, weight changes

If vomits within 3-4 hours, follow missed pill rules

62
Q

supplies of oral contraception

A

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

63
Q

Emergency Hormonal Contraception
- morning after pill

A

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.

64
Q

how old to sell OTC emergency contraceptive?

A

16+

Some areas have PGDs where it can be supplied for free under locally agreed protocol (usually from 13 years)

65
Q

EHC- What do you need to know to supply safely?

A

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?

66
Q

EHC- Other points to consider

A

Supply to a patient representative

Moral beliefs

Advance supply of EHC

Long-term contraception and sexual health

67
Q

EHC- Other points to consider
Vulnerable adults and children

A

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.

68
Q

Menapause different types

A

Perimenopause
Menopause

69
Q

Perimenopause

A

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

70
Q

Menopause

A

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

71
Q

Menopause- Symptoms

A

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

72
Q

Menopause- Self-management

A

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

73
Q

Menopause- OTC Management

A

Vasomotor symptoms
Black cohosh
Isoflavones
St John’s Wort used for depression)

Urogenital Symptoms
Vaginal dryness- OTC vaginal moisturisers and lubricants (Vagisil®,Vagisan®)

74
Q

NICE advice on herbal medicines in menopause

A

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

75
Q

Menopause – When to refer to GP?

A

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

PMP-103 (33 decks)

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