W20 Women's health

Question 1

What are some examples of Women’s health issues?

Answer 1

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

Question 2

What is Cystitis?
What is it caused by?

Answer 2

*Terms ‘cystitis’ and ‘UTI’ often used interchangeably
(commonly ref to as UTI)
*‘Cystitis’ is used to describe a collection of urinary symptoms including dysuria (pain on urinating), frequency and urgency
*Occurs when bacteria pass up along urethra and enter and multiply within the bladder, causing inflammation
*50% cases- no cause identified
*However, usually caused by bacteria from the GI tract, most commonly E.coli

Question 3

What are the causes of Cystitis?

Answer 3

*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 4

What are the symptoms of Cystitis?

What symptom needs referral?

Answer 4

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

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 5

Cystitis – Self-management (& preventing recurrence)

Answer 5

*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 6

What is the OTC Management for Cystitis?

Answer 6

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)

Question 7

Alkalising Agents

Answer 7

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

Sodium citrate
* Only take stated dose of product
* Contraindicated in patients with hypertension, heart disease or are pregnant
* Available as granules

Question 8

Cystitis- Antibiotics

Answer 8

*Some community pharmacies involved in a pilot scheme to test and treat
UTIs within the pharmacy
*Only able to treat uncomplicated UTIs in women aged 16-65 years
*Offer treatment if urine dipstick positive, or if symptoms strongly suggestive
of UTI
*Options: Trimethoprim or Nitrofurantoin for 3 days
*Would likely see these antibiotics on a prescription for UTIs too

Question 9

Cystitis- Who to Refer to GP

Answer 9

• 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 10

What is Vaginal Candidiasis?

Answer 10

*Common yeast infection, known as thrush
*Caused by Candida albicans
*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 11

Vaginal Candidiasis- Symptoms

Answer 11

• Candidiasis= white/cream-coloured, thick like cottage cheese, sometimes an unpleasant smell but not always

*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
* Bacterial infection= yellow/green-coloured, strong foul odour
*Vaginal soreness
*Dysuria (pain on urination)
*Dyspareunia (painful sexual intercourse)

Question 12

What are the Risk Factors of Vaginal Candidiasis?

Answer 12

*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  glycogen
*Diabetes (especially if poorly controlled)
*Weakened immune system
* E.g. because of HIV or chemotherapy

Question 13

Prevention of Vaginal thrush:

Answer 13

*Dry area properly after washing
*Avoid tight/nylon tights or underwear
* Wear cotton underwear instead as more airy
*Avoid perfumed soaps and shower gels, vaginal douches and deodorants, and foam baths-These strip away protective lining of vagina
*Wipe front to back after bowel motions
* Candida may be transferred from bowel

Question 14

Vaginal Candidiasis- Management

Answer 14

Manged with azole antifungals:
1. Topical vaginal cream
2. Pessary
3. Oral capsule
*No one option better than other- all equally effective in managing infection.
*Usually decided based on patient preference
*Some OTC products available as a mixture of formulations- to treat infection and provide symptomatic relief
*Offer treatment for free via Common Ailments Scheme

Question 15

Management of Thrush:
Topical vaginal cream (External cream)
What is name of drug/brand names?
Symptoms?

Answer 15

*Clotrimazole 2% cream (Canesten®)
*Used for immediate symptomatic relief of itch
*Apply thinly to the 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

(Cream to be used with pessary or supply fluconazole 150mg capsule as altd)

Question 16

Management- Topical vaginal cream (Internal cream)

What is the drug/brand name?
Side effects?
How to apply?

Answer 16

*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 17

Management of vaginal thrush?Pessary

Answer 17

• 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 18

What Oral capsule is given for vaginal thrush?

Symptoms?

Answer 18

• 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 19

What are the symptoms of Candidiasis in males?(candidal balanitis)

Answer 19

*Male may catch infection from a female partner
*May be asymptomatic
*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
*Will only usually treat partner if they are symptomatic (area up for debate)
*Management: Azole external cream BD for 6 days or oral fluconazole STAT

Question 20

Candidiasis- When to refer to GP

Answer 20

• First occurrence of symptoms- to confirm diagnosis
• Allergic to antifungals
• Pregnant or breast feeding
• Immunocompromised- HIV/cancer
• 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 21

What is Dysmenorrhoea?

What are the two types?

Answer 21

Period pain

*Primary Dysmenorrhoea= Pain without underlying causes
-Manage in community pharmacy

*Secondary Dysmenorrhoea= Pain with underlying disease, e.g. endometriosis or pelvic inflammatory disease
-Presents in older women (30+) with other symptoms. Refer to GP.

Question 22

Primary Dysmenorrhoea

Answer 22

Primary Dysmenorrhoea
*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
Dysmenorrhoea
*Classically presents as cramping lower abdominal pain that often begins the day before bleeding starts
*Pain gradually eases after the start of menstruation and is often gone by the
end of the 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
*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 the timing of pain to differentiate

Question 23

Primary Dysmenorrhoea- Management

Answer 23

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

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

Question 24

Dysmenorrhoea- NSAIDs

Answer 24

*Pain of dysmenorrhoea linked to increased prostaglandin activity
*NSAIDs block synthesis of prostaglandins, which is why they are effective in treating period pains
*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

Question 25

Menorrhagia

Answer 25

*Term refers to heavy menstrual bleeding or periods that last longer than 7 days
*This excessive blood loss interferes with a woman’s physical, social, emotional and material quality of life
*Average menstrual blood loss: 30-40mL per cycle
*Menorrhagia: 60-80mL or more per cycle
*However, ‘heavy’ bleeding is often determined by patient & is subjective
*Only OTC product: Tranexamic acid

Question 26

Menorrhagia- Tranexamic acid

Answer 26

*Type of antifibrinolytic drug
* Inhibits fibrinolysis  increased clot formation  reduced blood loss
*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

Question 27

Menorrhagia- When to Refer to GP

Answer 27

*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 28

Oral Contraception

Answer 28

*Majority of oral contraceptives are POM
*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)

Question 29

Oral Contraception:
Contraindications?
When to take?
Missed pills?
Side effects?

Answer 29

Contraindications
* Blood clots, cancer, soya/peanut allergy (Lovima® contains soya bean oil, so avoid in both allergy types)
Interactions
* Refer anyone with clinically relevant interaction (e.g. antiepileptics)
When to start taking
* 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

Missed pills
* 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
* Common: irregular periods, altered mood, headaches, nausea, weight changes
* If vomits within 3-4 hours, follow missed pill rules

Question 30

Oral Contraceptives

Answer 30

*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

Question 31

Emergency Hormonal Contraception

Answer 31

*Also known as the morning after pill
*Need to handle queries for EHC sensitively in a private area
*2 products licensed OTC:
* Levonorgestrel 1500 microgram tablet (Levonelle®)
* Ulipristal acetate 30mg tablet (Ella One®)
*Can sell OTC to patients aged 16+
*Some areas have PGDs where it can be supplied for free under locally
agreed protocol (usually from 13 years)
*Next period may be sooner, later or on time. If lighter, shorter or 3 days
later than usual, need to take pregnancy test.

Question 32

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

Answer 32

*What happened?
* Failure of barrier contraceptive method (e.g. condom splits)
* Missed contraceptive pills (exact number of missed days varies between pill types-
refer to FFPRGC 2006 guidance)
* Unprotected sex
*When did it happen?
* Careful when wording this question & explain why asking
* EHC most effective the sooner it is taken after unprotected sex
* The answer will influence what you can supply them
*Is there a chance that they’re they already pregnant?
* If so, EHC won’t work and they need referral
* Was last period normal/lighter/later?
* Any other episodes of unprotected sex during this cycle?

Question 33

EHC- Other points to consider

Answer 33

• Supply to a patient representative
• Can be supplied if deemed a genuine request and treatment is clinically appropriate (should telephone patient if rep can’t fully answer questions needed to make a safe supply)
• Moral beliefs
• Should not refuse supply based on your own religious or moral beliefs
• Need to put patient first, especially as referrals not always possible
• Advance supply of EHC
• Can be supplied in advance of unprotected sex or in case barrier fails
• Need to ensure that it’s still clinically appropriate, that patient is competent and is going to use it appropriately
• Long-term contraception and sexual health
• Meant for emergency use, not as a long-term contraception. May be appropriate to discuss long-term contraception options at point of supply
• EHC doesn’t protect against STIs – may need referring to sexual health clinic

*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.