Women's Health Flashcards
What are sone UTI (upper urinary tract infections)
- Pyelonephritis
- Infection/inflammation of
kidney(s) - Ureteritis
- Infection/inflammation of
ureter(s)
What are some lower urinary tract infections?
- Cystitis
- Infection/ inflammation of
bladder - Urethritis
- Infection/inflammation of
urethra
What is cystitis?
‘Cystitis’ is used to describe a collection of urinary symptoms including dysuria
(pain on urinating), frequency and urgency
What occurs in cystitis?
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
How much does cystitis affect people?
*common in women
1 in 2 women affected in lifetime
*shorter urethra in men - easier for bacteria to reach bladder
What is the cause of cystitis?
*wiping front to back after bowel motion
*previous infection not clearing
*uncontrolled diabetes
*sexual intercourse
*irritation from chemicals/toiletries
*post- menopausal changes to vaginal lining
*side effect of some medication
What are the 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
What symptoms of cystitis need 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
What can someone do to avoid/prevent cystitis?
- 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 of 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)
What are some examples of alkalising agents (cystitis)?
*potassium citrate
*sodium citrate
Overview of 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
Overview of sodium citrate
- Only take stated dose of product
- Contraindicated in patients with hypertension, heart disease or are pregnant
- Available as granules
can a pharmacy provide antibiotics for cystitis?
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
Who to refer to GP for cystitis? (red flags)
- 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 thrush/ 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
What are the symptoms to vaginal thrush?
- 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)
What are the risk factors to vaginal thrush?
- 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
- ‘Good’ bacteria killed, allows opportunistic infections to grow like thrush
- Pregnancy
- Attributable to hormonal changes causing glycogen
- Diabetes (especially if poorly controlled)
- Weakened immune system
- E.g. because of HIV or chemotherapy
What to do to prevent vaginal thrush/ avoid?
*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 + foam baths
-these strip away protective lining of vagina
*wipe front to back after bowel movements
-candida may be transferred from bowel
How do you manage vaginal thrush?
Manged with azole antifungals:
1. Topical vaginal cream
2. Pessary
3. Oral capsule
What are the treatment options for vaginal thrush?
*external vaginal cream (clotrimazole 2% cream) canesten
*internal vaginal cream (clotrimazole 10% cream)
*pessary (clotrimazole 500mg pessary)
*oral capsule (fluconazole 150mg capsule)
How does an external vaginal cream help?
- Symptomatic relief of symptoms
- Will need repeated applications to continue to get
relief, will need long course to cure infection fully - Pt must be motivated to use
- Affects barrier contraception, so will need
additional measures for 5 days
How does an internal vaginal cream help?
*One-off dose – at night for better retention
* Convenient, local Tx
* Formulation may be unacceptable for some
* Advice on how to administer w applicator
* Affects barrier contraception, so will need
additional measures for 5 days; not to use on
period
How does an oral capsule help (vg thrush)?
- One-off dose at any time of day
- Easy & acceptable formulation, but can take 24-48h
to see benefit - Several significant drug interactions
- Warfarin, statins, phenytoin, rifampicin,
ciclosporin and theophylline. - No additional precautions needed
How does a pessary help?
*One-off dose – at night (can repeat in 7 days)
* Convenient
* Formulation may be unacceptable for some
* Advice on how to administer w applicator
* Affects barrier contraception, so will need
additional measures for 5 days; not to use on
period
What are the side effects to clotrimazole products?
- Sometimes mild itching/burning sensation.
- Rare: allergic reaction – stop using and seek Dr
What are the side effects to fluconazole products?
*mild and transient
*likely GI side effects
What are the Thrush symptoms in males?
- could be asymptomatic
- 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 treatment is used to manage male thrush?
Azole external cream BD for 6 days or oral fluconazole STAT
When to refer vaginal thrush to GP? red flags
- 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
What are the two period related issues?
*dysmenorrhoea
*menorrhagia
What is dysmenorrhoea?
Period pain
* Symptoms: Cramping lower abdo pain beginning day before bleeding starts
* If cramping pain is mid-cycle, this is ovulation pain not period pain.
* 1 in 2 women suffer, while 1 in 10 have severe symptoms requiring time off work /
school
* Peak incidence: 17-25 years of age
* Usually few years after initially starting period (menarche) as ovulation doesn’t happen within
first few months/years of menstruation
What is menorrhagia
- Heavy menstrual bleeding
- Technically classed as over 60mL blood loss per cycle (normal is 30-40), however
‘heavy’ is subjective and determined by patient
Periods
What are the non drug managements of primary dysmenorrhoea?
- 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
What are drug management for primary dysmenorrhoea?
*simple analgesia (NSAIDS best)
*hyoscine butyl bromide (antispasmodic) - evidence is patchy
*caffeine (enhance analgesia effect)
What are some examples of NSAIDs 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 used for menorrhagia + what it entails?
*tranexamic acid
* 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
When to refer someone with menorrhagia to a GP?
- Women under 18 or over 45 years
- Treatment failure
- Breastfeeding
- Obese or diabetic patients (could be PCOS)
- Signs of iron-deficiency: fatigue, pallor
- Signs of endometrial cancer: irregular/prolonged bleeding, bleeding in
between periods - Signs of cervical cancer: bleeding between periods/after sex/after
menopause - Contraindications to tx: Hx of clots, convulsions, on warfarin, on COC
What is an example of an oral contraception?
- 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)
What are some contraindications of oral contraception, when to take, missed pills + side effects?
Contraindications
* Blood clots, cancer, soya/peanut allergy (Lovima® contains soya bean oil, so avoid in both allergy
types)
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
Supply amounts 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
When is it okay to supply oral contraceptives?
Not pregnant
* No bleeding between period/after sex
* No health conditions
* No allergies
* Not taking other meds
* Otherwise, refer
What are the approved emergency hormonal contraception pills? + who can sell to?
- 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)
What questions to ask when you are about to supply an EHC?
*what happened?
*when did it happen? (can’t give if its already been 5 days)
*is there a chance you are already pregnant?
EHC other points to consider?
*supply to patient representative
*moral beliefs
*advance supply of EHC
*long term contraception + sexual health
*vulnerable adults + children
What is menopause?
- Biological state when woman has not had
period for 12 consecutive months - Ovaries stop maturing eggs & secreting
oestrogen + progesterone - Menstruation stops + can’t conceive
What are the symptoms of menopause? (vasomotor, muscular, urogenital + other)
vasomotor: hot flushes, sweats
muscular: joint and muscle pain
urogenital: vaginal dryness, urinary frequency, UTIs
other symptoms: low mood, reduced libido
What can a person do to self manage menopause?
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
What are the OTC management options for menopause?
*limited options usually POM
*only vaginal atrophy managed OTC
Symptomatic Relief
* Vaginal dryness- OTC vaginal moisturisers and lubricants (Vagisil®,Vagisan®)
Treatment
* Gina® (estradiol) intravaginal tablets
What are some common side effects of gina (estradiol tablets) + when to stop immediately?
- Common side effects: headache, stomach pain, vaginal
bleeding/discharge/discomfort - STOP immediately if: signs of allergy, blood clot, jaundice, hypertension
symptoms
When can you sell estradiol OTC tablets?
Treatment of vaginal atrophy symptoms due to
oestrogen deficiency-
* in postmenopausal woman aged over 50 who haven’t had a period for at least one
year
* Can be used in woman who have or don’t have a womb
What are contraindications to estradiol tablets?
Liver disease, current/recent heart attack or ischaemic
stoke, breast/ovarian/endometrial cancer, DVT/PE, untreated vaginal
infections
* Treat vaginal infection first if possible –e.g. thrush
When to refer someone with menopause to the 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
What are some herbal remedies for menopause vasomotor symptoms?
NICE guidelines actually suggest the use of herbal remedies to help with
vasomotor symptoms:
* Black cohosh
* Isoflavones
* But states 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
