W20 Women's health Flashcards
(33 cards)
What are some examples of Women’s health issues?
*Cystitis
*Vaginal thrush
*Dysmenorrhoea
*Menorrhagia
*Emergency hormonal contraception
*Progestogen only contraception
*Menopause and perimenopause
What is Cystitis?
What is it caused by?
*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
What are the 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 the symptoms of Cystitis?
What symptom needs referral?
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
Cystitis – Self-management (& preventing recurrence)
*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 is the OTC Management for Cystitis?
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
* 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
Cystitis- Antibiotics
*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
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 is Vaginal Candidiasis?
*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
Vaginal Candidiasis- Symptoms
- 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)
What are the Risk Factors of Vaginal Candidiasis?
*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
Prevention of Vaginal thrush:
*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
Vaginal Candidiasis- Management
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
Management of Thrush:
Topical vaginal cream (External cream)
What is name of drug/brand names?
Symptoms?
*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)
Management- Topical vaginal cream (Internal cream)
What is the drug/brand name?
Side effects?
How to apply?
*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
Management of vaginal thrush?Pessary
- 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 Oral capsule is given for vaginal thrush?
Symptoms?
- 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 in males?(candidal balanitis)
*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
Candidiasis- When to refer to GP
- 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
What is Dysmenorrhoea?
What are the two types?
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.
Primary Dysmenorrhoea
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
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
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
*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
