Women's Health Lecture 7, 8 PDF

College of Pharmacy. Fourth Year. Clinical Pharmacy Women's Health 1-Cystitis Background: 1-Cystitis means inflammation of the bladder (1). Cystitis is common in women but rare in men (2) because of the longer urethra, which provides a greater barrier to bacteria entering the blad...

College of Pharmacy. Fourth Year. Clinical Pharmacy Women's Health 1-Cystitis Background: 1-Cystitis means inflammation of the bladder (1). Cystitis is common in women but rare in men (2) because of the longer urethra, which provides a greater barrier to bacteria entering the bladder; fluid from the prostate gland also confers some antibacterial property. This is especially so in men under the age of 50. After 50 years of age urinary tract infections in men become more common due to prostate enlargement (1). 2-OTC products are available for the treatment of Cystitis, but when the symptoms are mild or for use until the patient can consult the Dr. (2). Etiology 1-The majority of patients who present in the community pharmacy will have acute uncomplicated cystitis (Table 5-1) (1). Bacterial infection is responsible for about 50% of all cases, and Escherichia coli is the most common causative organism (3). 2-The source is often the gastrointestinal (GI) tract (2) [(The female urethra is very short (about 3 cm) and infecting organisms are readily transferred from the perineum and anus to the bladder where they proliferate] (4). 3- E. coli infection results in increased acidity of the urine, which causes the inflammation that produces the symptoms of cystitis (3). About half of cases will resolve within 3 days even without treatment (2). Table 5-1: Causes of cystitis symptoms and their relative incidence in community pharmacy (1) Incidence Cause Most likely Acute uncomplicated cystitis Likely Pyelonephritis Unlikely Sexually transmitted disease, oestrogen deficiency Very unlikely Medicine-induced cystitis, vaginitis 1 Patient assessment with cystitis: A-Gender: Any man who present with symptoms of cystitis should be referred because of possibility of more serious problems such as renal stone or prostate problems (2). B-Age: 1-Any child under 16 years old should always be referred (Cystitis is unusual in children and it may be a sign of structural urinary tract abnormality) (1). 2-Elderly female patients (>70 years) have a higher rate of complications associated with cystitis are, therefore, best referred (1). C-Symptoms: 1-In cystitis the desire to pass urine become frequent (urinary frequency), and women may feel the need to pass urine urgently (urinary urgency) but pass only a few burning, painful drops. This frequency of urine occurs throughout the day and night (2). 2-Dysuria (pain on urination) is a classical symptom of cystitis. After urination the bladder may not feel completely empty, but even straining produce no further flow. Cystitis may be accompanied by suprapubic (lower abdominal) pain and tenderness (2). When to refer (2) 3-Associated symptoms that required -All men. referral: -Recurrent cystitis (2). Hematuria (the presence of the blood in -Failed medication (2). urine) (2). -Loin pain or tenderness (2). Vagainal discharge (may indicate local -Children under 16 years of age (1). fungal or bacterial infection) (2). -Patients with diabetes (1). Nausea, vomiting, fever, loin pain and -Duration longer than 7 days (1). tenderness (may indicate upper UTI -Haematuria (1). (kidney and ureters) (2). -Vaginal discharge (1). -Immunocompromised (1). D-Pregnancy: -Patients with associated fever and Any pregnant present with symptoms of flank pain (1). cystitis should be referred because -Pregnancy (1). bacteruria (the presence of bacteria in -Women older than 70 years of age urine) can lead to kidney infection and other problem (2). E-Previous history: Women with history of recurrent cystitis should be referred (2). F-Duration: Symptoms that have lasted longer than 5 to 7 days should be referred because of the risk that the person might have developed pyelonephritis (1). 2 G-Diabetes: Recurrent cystitis can sometimes occur in diabetic patients and required referral (2). H-Honeymoon cystitis: Sexual intercourse may precipitate cystitis attack (honeymoon cystitis) due to minor trauma or resulting infection when bacteria are pushed along the urethra (2). I-Medications: A-Failed medication required referral (2). (2) B-Cystitis can be caused by cytotoxics drugs such as cyclophosphamide. Treatment timescale: If symptoms have not improved within 2 days of beginning treatment, the patient should see the Dr. (2). Management: A-Non-pharmacological advice: Patients should be advised to drink about 5 L of fluid during every 24-h period. This will help promote bladder voiding, which is thought to help ‘flush’ bacteria out of the bladder (1). B-Pharmacological treatment: 1-The acidic urine produce by bacteria is thought to be responsible about dysuria (2). OTC treatment is limited to products that contain alkalinizing agents such as Sod. Citrate, Sod. Bicarbonate and Potassium citrate (1). e.g. of preparation available in Iraq is Citrogran® effervescent granules. 2-Product taste: The taste of potassium citrate mixture is unpleasant. Patients should be advised to dilute the mixture with water to make the taste more palatable (1). Contraindications: Potassium citrate: not recommended for anyone in home hyperkalemia may result (Patient taking ACE inhibitors, K+-sparing diuretics, Aldosterone antagonist, Angiotensin II receptor antagonists…) (2). It is also not recommended for hypertensive patient, anyone with heart diseases or pregnant women (2). 2-For pain relief, offer paracetamol or ibuprofen for up to 2 days (2). References: 1-Paul Rutter. Community Pharmacy. Symptoms, Diagnosis and Treatment. 4th edition. 2017. 2-Nathan A. Non-prescription medicines. 4th edition. London: Pharmaceutical Press. 2010.. 3 3-Alison Blenkinsopp, Paul Paxton and John Blenkinsopp. Symptoms in the pharmacy. A guide to the managements of common illness. 7th edition. 2014.. 4-Nathan A. fasttrack. Managing Symptoms in the Pharmacy. Pharmaceutical Press. 2008. 2-Dysmenorrhea (period pain) Background: 1-The menstrual cycle usually lasts 28 days but this varies and it can last between 21-45 days. Menstruation itself lasts between 3 and 7 days (1). 2-Dysmenorrhea is usually categorised as primary or secondary; primary dysmenorrhoea (PD) is defined as menstrual pain without organic pathology whereas in secondary dysmenorrhoea an identifiable pathologic condition can be identified (1) like endometriosis. (further reading 1). Patient assessment with dysmenorrhea: A-Age: 1-The peak incidence of PD occurs in women between the ages of 17 and 25 years (2). 2-Secondary dysmenorrhea (SD) is most common in women aged over 30 years and is rare in women aged less than 25 years (2). Therefore, women over 30 years should be referred (3). B-Previous history Dysmenorrhea is often not associated with the start of menstruation (menarche). This is because during the early months (and sometimes years) of menstruation, ovulation does not occur. These anovulatory cycles are usually, but not always, pain free and therefore women sometimes describe period pain that begins after several months or years of pain-free menstruation (2). C-Severity of pain: Pain is rarely severe in PD; the severity decrease with the onset of menses.Any patient presenting with severe lower abdominal pain should be referred (1). D-Timing and nature of pains (table 5-2) Table 5-2: Primary Secondary dysmenorrhea Primary dysmenorrhea (PD) Secondary dysmenorrhea (SD) Classically presents as a cramping lower Pain typically starts a few days (up to abdominal pain (2). Starts very shortly 1 week) before the onset of menses (1, 2) before or within 24 hours of the onset. of menses and rarely lasts for more than 3 days (1). The pain gradually eases after the start The pain can be relieved or worsened of menstruation and is often gone by by menstruation (2). the end of the first day of bleeding (2). 4 Therefore, any woman with symptoms suggest SD (2) (pain experienced not shortly before menses, pain that increase at the onset of symptoms ) should be referred (1). E-Other symptoms: 1- Women who experience dysmenorrhea will often describe other associated symptoms. These include nausea, vomiting, general GI discomfort, constipation, headache, backache, fatigue, feeling faint and dizziness (2). 2-Any woman with the following symptoms should be referred: Heavy unexplained bleeding (1). Presence of abnormal vaginal discharge (2). Presence signs of systemic infection (such fever, malaise) (1). 3-Premenstrual syndrome When to refer (see later) -Heavy or unexplained bleeding (1). -Pain experienced days before menses (1). F-Medication: -Pain that increases at the onset of menses (1). Women taking oral -Women over the age of 30 with new or contraceptive usually find that worsening symptoms (1). symptoms of dysmenorrhea are -Accompanying systemic symptoms, such as reduced or eliminated fever and malaise (1). altogether, therefore, any -Vaginal bleeding in postmenopausal women (1). woman with symptoms of -Presence of abnormal vaginal discharge (2). dysmenorrhea and who is taking the pill is probably best referred to the Dr. for further investigations (2). Treatment timescale: If the pain of PD is not improved after two cycles' treatment, referral to the Dr. advisable (2). Management: A-Nonpharmacological advices: 1-Symptomatic treatment with a warm bath or locally applied heat (such as hot water bottle) may provide relief (3). 2-Exercise decreases the severity of menstrual cramps through generation of endorphins, ‘the body’s own painkillers’ (3). B-Pharmacological therapy: 1-Analgesics: treatment with simple analgesics is often very effective in dysmenorrhea (2). A-NSAIDs (Ibuprofen, and naproxen) NSAIDs can be considered the treatment of choice for dysmenorrhea, provided they are appropriate for the patient (2). In addition to their analgesic 5 properties, NSAIDs also inhibit prostaglandin production, decreasing uterine contractions (4). (table 5-3). Table 5-3: doses of Ibuprofen and Naproxen for dysmenorrhea Drugs Dose (2) Ibuprofen 200-400mg three times daily. Naproxen Two tablets are taken initially then one tablet 6–8 hours later if 250mg tablets needed. Max. daily dose is 750mg and maximum treatment time is 3 days (2). B-Aspirin and Paracetamol: 1-Aspirin :Aspirin is less effective than ibuprofen in relieving the symptoms of dysmenorrhea and is more irritant to the stomach than NSAIDs (best avoided in women who experienced nausea and vomiting with dysmenorrhea) (2). Dose: for dysmenorrhea, the dose is 650- 1000mg every 4-6 hours (max. 4 gm/day) (5). 2-Paracetamol:It is theoretically less effective for the treatment of dysmenorrhea than NSAIDs (because it does not inhibit PG synthesis), however, it may buy used by patients who cannot take NSAIDs because of stomach problems or because of sensitivity (2). C-Hyoscine butyl bromide (Buscopan® 10 mg tablet) : The recommended dose for adult is two tablets four times a day (1). Side effects: Anticholinergic side effects such as dry mouth, visual disturbances and constipation can be experienced but are generally mild and self-limiting (1). It is contraindicated in patients with narrow- angle glaucoma (1). Interactions: Side effects are potentiated if it is given with tricyclic antidepressants, and antihistamines (1). D-Caffeine Some OTC products contain caffeine.There is some evidence that caffeine may enhance analgesic effect (2). Practical points 1-Take the first dose as soon as your pain begins or as soon as the bleeding starts, whichever comes first (2). 3-Take the tablets regularly, for 2–3 days of menstrual each period, rather than ‘now and then’ when pain builds up (2). 4-A patient with dysmenorrhea may respond better to one NSAID than to another. If the maximum nonprescription dosage of one agent does not provide adequate benefit, then switching to another agent is recommended (5). References: 1-Paul Rutter. Community Pharmacy. Symptoms, Diagnosis and Treatment. 4 th edition. 2017. 6 2-Alison Blenkinsopp, Paul Paxton and John Blenkinsopp. Symptoms in the pharmacy. A guide to the managements of common illness. 7 th edition. 2014. 3-Nathan A. fasttrack. Managing Symptoms in the Pharmacy. Pharmaceutical Press. 2008. 4-Marie A. Chisholm-Burns.Pharmacotherapy Principles & Practice. 4th edition. 2016. 5-American pharmacists association. Handbook of Non-prescription drugs: An Interactive Approach to Self-Care. 18th edition. 2016. 3-Premenstrual syndrome The term premenstrual syndrome (PMS) describes a collection of symptoms, both physical and mental, whose incidence is related to the menstrual cycle. Symptoms are experienced cyclically, usually from 2 to 14 days before the start of menstruation. Relief from symptoms generally occurs once menstrual bleeding begins (1). Causes The cause of PMS is unknown, but it is associated with ovulation as it does not occur before puberty, during pregnancy or after the menopause, or in women who do not ovulate. One theory is that women with PMS are abnormally sensitive to progesterone secreted following ovulation, and that this reduces levels of pyridoxine. Pyridoxine is a coenzyme in the final step of the biosynthesis of serotonin, a neurotransmitter known to have potent effects on mood, and its deficiency may contribute to the depressive symptoms (2). Symptoms (table 5-6) Sufferers often complain of a bloated abdomen, increase in weight, swelling of ankles and fingers, breast tenderness and headaches. Women who experience PMS describe a variety of mental symptoms that may include any or all of irritability, tension, depression, difficulty in concentrating and tiredness (1). Table 5-6: Common symptoms of PMS (3). Physical Behavioral Mood Swelling Sleep disturbances Irritability Breast tenderness Appetite changes Mood swings Aches Poor concentration Anxiety/tension Headache Decreased interest Depression Bloating/weight Social withdrawal Feeling out of control Treatment Treatment of the symptoms of PMS is a matter for debate and there is a high placebo response to therapy (1). 1-Pyridoxine (B6) : The dosage of pyridoxine should be limited to 100 mg daily because of the risk for peripheral neuropathy with higher dosages (4). If no benefit is perceived within 3 months, treatment should be discontinued (5). 2-Calcium 7 Calcium supplementation should provide at least 1200 mg of elemental calcium per day. It is important to ensure that a product taken by the patient provides the required amount of elemental calcium. Calcium supplements can cause mild gastrointestinal disturbances such as nausea and flatulence (3). 3-Evening primrose oil (EPO) has been used to treat breast tenderness associated with PMS. The active component of evening primrose oil is gamma- linolenic (gamolenic) acid (1). A systematic review concluded that, on the limited evidence available, EPO was of little value in the management of PMS. All preparations of EPO have since been withdrawn in UK, and there are no licensed medicines containing it, although it remains available in products marketed as food supplements (5). References: 1-Alison Blenkinsopp, Paul Paxton and John Blenkinsopp. Symptoms in the pharmacy. A guide to the managements of common illness. 7th edition. 2014. 2-Nathan A. fasttrack. Managing Symptoms in the Pharmacy. Pharmaceutical Press. 2008. 3-Paul Rutter. Community Pharmacy. Symptoms, Diagnosis and Treatment. 4th edition. 2017. 4-American pharmacists association. Handbook of Non-prescription drugs: An Interactive Approach to Self-Care. 18th edition. 2016. 5-Nathan A. Non-prescription medicines. 4th edition. London: Pharmaceutical Press. 2010. Further reading 1-[Endometriosis simply means presence of endometrial tissue outside of the uterus (1). Each section of endometrium is sensitive to hormonal changes occurring during menstrual cycle and goes through the monthly changes of thickening, shedding and bleeding. This cause pain wherever the endometrial tissue is found] (2) 8  College of Pharmacy. Fourth Year. Clinical Pharmacy Women's Health 4-Emergency hormonal contraception Dealing with requests for emergency hormonal contraception (EHC) requires sensitive interpersonal skills from the pharmacist. Enabling privacy for the consultation is essential (1). Assessment A-Age: EHC can be supplied OTC for women aged 16 years and over in UK (17 years and older in USA). For women under 16 years the pharmacist can refer to the doctor (1, 2). B-Why EHC is needed: The most common reasons for EHC to be requested are failure of a barrier contraceptive method (e.g. condom that splits), missed contraceptive pill(s) and unprotected sexual intercourse (UPSI) (1). (table 5-4 further reading 1) C-When unprotected sex/contraceptive failure occurred: 1-levonorgestrel needs to be started within 72 h of unprotected intercourse. The sooner it is started, the higher is its efficacy (1). 2-Ulipristal: taken as soon as possible but no later than 120 hours (5 days) after unprotected sex or contraceptive failure (4). D-Could the woman already be pregnant? If pregnancy is suspected (if the period is different from normal (lighter, shorter ) or more than 3 days later than usual ), the pharmacist can suggest that the woman has a pregnancy test. EHC will not work if the woman is pregnant. There is no evidence that EHC is harmful to the pregnancy (1). E-Other medicines being taken: 1-Women taking the following medicines should be referred to an alternative source of supply of EHC: [Anticonvulsants (carbamazepine, phenytoin, primidone, Phenobarbital, phenobarbitone), Rifampicin and rifabutin, Griseofulvin, Ritonavir] (1). (further reading 2) Treatment timescale EHC must be started within 72 h of unprotected intercourse in case of levonorgestrel (1) and within 120 h of unprotected intercourse in case of ulipristal (4). Treatment Levonorgestrel (1.5 mg tablet) and Ulipristal (30 mg tablet) are taken as a dose of one tablet as soon as possible after unprotected intercourse (1). 1 Mode of action : (further reading 3) Side-effects 1-levonorgestrel : The most likely side-effect is nausea, which occurred in about 14% of women taking levonorgestrel EHC. Far fewer women (1%) actually vomited (1). 2-Ulipristal: Common side effects that affect up to 10% of women are mood disorders, headache, dizziness, nausea, pain (abdominal, back or period), breast tenderness and fatigue (4). 3-For both drugs, If vomiting occurs within 3 hours of taking the tablet another tablet should be taken (4). Women who should not take EHC The product should not be taken by a woman who is pregnant (because it will not work), has severe hepatic dysfunction or has severe malabsorption (e.g. Crohn’s disease) (1). References: 1-Alison Blenkinsopp, Paul Paxton and John Blenkinsopp. Symptoms in the pharmacy. A guide to the managements of common illness. 7th edition. 2014. 2-American pharmacists association. Handbook of Non-prescription drugs: An Interactive Approach to Self-Care. 18th edition. 2016. 3-Nathan A. fasttrack. Managing Symptoms in the Pharmacy. Pharmaceutical Press. 2008 4-Paul Rutter. Community Pharmacy. Symptoms, Diagnosis and Treatment. 4 th edition. 2017. 5-Menorrhagia (Heavy menstrual bleeding) Heavy menstrual bleeding (HMB) may be defines as 'excessive menstrual blood loss which interferes with a woman's physical, social, or emotional quality of life' (1). Patient assessment with HMB: A-Clinical features of HMB The key symptom will be blood loss that is perceived to be greater than normal (1). Table 5-5:Medication that can B-Timing of bleeding alter menstrual bleeding (1). Symptoms that might suggest structural or Anticoagulants pathological abnormality include bleeding Cimetidine at times other than at menses. (1) Monoamine oxidase inhibitors Irregular bleeding between periods Phenothiazines especially if associated with postcoital Steroids bleeding is extremely significant and Thyroid hormones suggests pre-cancerous/cancer of the cervix (1). (Endometrial and cervical carcinoma are usually occurs in postmenopausal women) (1). 2 C-Medications When to refer 1-Occasionally, medicines can change -Presence of abnormal vaginal menstrual bleeding patterns (Table 5-5). discharge (2). If an adverse drug reaction is suspected -Intermenstrual and/or postcoital then the pharmacist should contact the bleeding (2). prescriber and discuss other treatment -Pelvic pain (2). options (1). -Pain on intercourse (dyspareunia) (2). -Dysmenorrhoea (2). 2-The incidence of menstrual pain is -Presence of fever (2). higher in patients who have had an -Treatment failure (1). intrauterine device fitted (1). Management and Treatment timescale 1-If menorrhagia/HMB coexists with dysmenorrhoea, the use of NSAIDs should be preferred to tranexamic acid (1). 2-If there is no improvement in symptoms within 3 menstrual cycles, then use of NSAIDs and/or tranexamic acid should be stopped (1). Note: prostaglandins in the endometrium of women who suffer from menorrhagia is higher than in normal women. The exact mechanism by which the excessive blood loss occurs remains speculative. NSAIDs in adequate dosages decrease ovulatory bleeding by approximately 30-40% (3). 1-Tranexamic acid (cyklokapron® 500 mg tablet) is effective medicine in decreasing menstrual blood loss. It reduces blood loss by up to 50% (1). 2-Tranexamic acid is an antifibrinolytic and stops the conversion of plasminogen to plasmin - an enzyme that digests fibrin and thus brings about clot dissolution (1). 3-Tranexamic acid should be taken once bleeding starts. The dose is two tablets 3 times a day for a maximum of 4 days. The dose can be increased to two tablets 4 times a day in very heavy menstrual bleeding. The maximum dose is eight tablets (4 g) daily (1). 4-Side effects are unusual. Those reported include mild nausea, vomiting and diarrhoea (affecting between 1% and 10% of patients) (1). 5-Tranexamic acid should not be taken in patients on anticoagulants, taking the combined oral contraceptive, unopposed oestrogen or tamoxifen (1). References: 1-Paul Rutter. Community Pharmacy. Symptoms, Diagnosis and Treatment. 4th edition. 2017. 2-Alison Blenkinsopp, Paul Paxton and John Blenkinsopp. Symptoms in the pharmacy. A guide to the managements of common illness. 7th edition. 2014. 3- Anna Livshits and Daniel S. Seidman. Role of Non-Steroidal Anti-Inflammatory Drugs in Gynecology. Pharmaceuticals. 2010; 3: 2082-2089. 3 6-Vaginal discharge Background: Patients of any age can experience vaginal discharge. The three most common causes of vaginal discharge are bacterial vaginosis, vulvovaginal candidiasis [fungal infection (thrush)] and trichomoniasis (a protozoan infection) (table 5-7). As thrush is the only condition that can be treated OTC (1). Table 5-7: Causes of vaginal discharge and their relative incidence in community pharmacy (1) Incidence Cause Most likely Bacterial vaginosis Likely Thrush (medicine-induced thrush) Unlikely Trichomoniasis, atrophic vaginitis, cystitis Further reading 4 Patient assessment with vaginal thrush: A-Age: Women under the age of 16 or over 60 complaining of symptoms of vaginal thrush should be Referred (2). The vagina harbours an extensive flora of bacteria and fungi. In women of child- bearing age, oestrogen promotes the production of glycogen in the vaginal epithelium. The glycogen breaks down to glucose and lowers the pH of vaginal secretions, promoting an environment favourable to the growth of Candida (3). The lack of oestrogen in children and postmenopausal women means this protective barrier is not present, with a consequent increased tendency to bacterial (but not fungal) infection (2). B-symptoms: 1-Discharge: Discharge that has a strong odour and is not white and curd- like should be referred, as trichomoniasis or bacterial vaginosis are more likely causes (1). Any blood staining of vaginal discharge should be referred (2) 2-Itch (pruritus): Vaginal itching tends to be most prominent in thrush compared with bacterial vaginosis and trichomoniasis where itch is slight or absent (1). (The hallmark symptoms of vaginal thrush in most women are vulvar pruritus and burning. This is usually accompanied with soreness and irritation) (4) Vaginal pruritus may actually be caused by some of the products used to relieve the symptoms that often contain local anesthetics which may cause sensitivity reactions (2) (further reading 5). 4 3-Dysuria (pain on urination): Vaginal thrush associated with lower abdominal pain or dysuria may indicate a urinary tract infection and required referral (3). C-Previous history: 1-Any woman with first occurrence of the symptoms required referral (2). 2-Patients with recurrent attacks: more than two within the previous 6 months may indicate an underlying cause such as diabetes and should be referred ( 3). D-Pregnancy: Any pregnant woman with vaginal thrush should be referred (1, 2). (During pregnancy almost one in five women will have an episode of vaginal candidiasis. This high incidence has been attributed to hormonal changes with a consequent alteration in the vaginal environment leading to the presence of increased quantities of glycogen (2). E-Diabetes: Diabetic woman with vaginal thrush required referral (1). (Patients with poorly controlled diabetes (type 1 or 2) are more likely to suffer from thrush because When to refer hyperglycaemia can enhance -First occurrence of symptoms (2). production of protein surface -Known hypersensitivity to imidazoles or other receptors on C. albicans vaginal antifungal products (2). organisms. This hinders -Pregnancy or suspected pregnancy (2). phagocytosis by neutrophils, -More than two attacks in the previous 6 months thus making thrush more (2). (1) difficult to eliminate). -Previous history of STD (2). -Exposure to partner with STD (2). F-Sexually Transmitted -Patient under 16 or over 60 years (2). Diseases (STDs): -Abnormal or irregular vaginal bleeding (2). Women who have previous -Any blood staining of vaginal discharge (2). history of STDs should be -Vulval or vaginal sores, ulcers or blisters (2). referred (with previous -Associated lower abdominal pain or dysuria (2). history of STDs the current -Adverse effects (redness, irritation or swelling condition may not be thrush associated with treatment) (2). or may include dual -No improvement within 7 days of treatment (2). infections with other -Patients with diabetes (1). organisms (2). G-Medication: What treatment had the patient tried before seeking our advice (failed medication required referral) (2). Broad spectrum antibiotics, corticosteroids, cancer chemotherapy, and medication that affecting the estrogen status of the patient (oral contraceptives, hormon replacement therapy (HRTt), tamoxifen) can predispose women to thrush. 5 So the prescriber should be contacted to discuss suitable treatment options and, if appropriate, alternative therapy (1). (Some women find that an episode of thrush follows every course of antibiotics they take. The Dr. may prescribe an antifungal at the same time as the antibiotic in such cases) (2). Treatment timescale: Patient should seek medical advice if symptoms do not improve within 3 days or are not gone within 1 week (5). Management: Topical imidazoles and one systemic (oral) triazole (fluconazole) are available OTC to treat vaginal thrush. Treatment choice is driven by patient acceptability and cost (1). A-Oral Fluconazole: Dose: single dose (150 mg) taken at any time of the day (1). It is well absorbed when taken by mouth, and symptoms usually improve 12–24 hours after administration (3). S/E: GIT disturbances (nausea, vomiting, diarrhea, and flatulence) occur in up to 10 % of patients (1). D-D interactions: Oral fluconazole interacts with some drugs: anticoagulants, oral sulphonylureas, ciclosporin (cyclosporin), phenytoin, rifampicin and theophylline (2). (further reading 6) Fluconazole is not recommended during pregnancy (which already should be referred) and in breast feeding mother (present in milk) (1, 2). B-Topical imidazoles (Clotrimazole, Econazole, Miconazole, Butoconazole and tioconazole): 1-A number of formulations are available including vaginal tablets, creams, and pessaries (1). Creams are also available for application to the vulva to treat irritation (6) (The cream should be applied twice daily, morning and night) (2). 2-All internal preparations should be administered at night (this give the drug time to be absorbed, and Eliminate the possibility of accidental loss which is more likely to occur if the person is mobile) (1)[a product called Monistat 1 ® (miconazole nitrate 1200 mg suppository) has also been approved for insertion in the morning or at bedtime, allowing flexibility for patients](5).. 3-They come in 1-, 3-, and 7-night regimens, in a variety of formulations including suppositories (vaginal tablets/ovules), creams, and ointments and in combination packages (4). 4-Topical agents are safe and effective during pregnancy but pregnant need referral (1). 6 Practical points: Patient seeking an advice about vaginal symptoms may be embarrassed, it is therefore important to ensure privacy (2). 1-Vaginal antifungal can be used during the menstrual period. If desired, wait and treat the infection after the menses end. Do not, however, interrupt a course of therapy because of the beginning of period (5). 2-Sexual intercourse should be avoided until cure is complete, to avoid transfer of infection and reinfection (3. 3-Treatment of husband: Asymptomatic husband does need to be treated. Symptomatic male (typical symptoms for men are an irritating rash on the penis) with candidal balanitis (penile thrush) and whose wife has vaginal thrush should be treated with topical azoles twice daily for 6 days. Oral fluconazole can also be used (2). 4-Prevention: Thrush thrives in a moist, warm environment: keep the area cool and dry by careful hygiene, use of cotton rather than synthetic underwear and careful drying after washing the vaginal area (1, 3). 7-The protective lining of the vagina is stripped away by foam baths, soaps and douches and these are best avoided. Vaginal deodorants can themselves cause allergic reactions and should not be used. If the patient wants to use a soap or cleanser, an unperfumed, mild variety is best (2). References: 1-Paul Rutter. Community Pharmacy. Symptoms, Diagnosis and Treatment. 4 th edition. 2017. 2-Alison Blenkinsopp, Paul Paxton and John Blenkinsopp. Symptoms in the pharmacy. A guide to the managements of common illness. 7 th edition. 2014. 3-Nathan A. fasttrack. Managing Symptoms in the Pharmacy. Pharmaceutical Press. 2008. 4-Emily M. Ambizas, Bejoy Maniara. Nonprescription Management of Vulvovaginal Candidiasis. US Pharm. 2015;40(9):13-19. 5-American pharmacists association. Handbook of Non-prescription drugs: An Interactive Approach to Self-Care. 18th edition. 2016. 6-Nathan A. Non-prescription medicines. 4th edition. London: Pharmaceutical Press. 2010. Further reading 1- Table 5-4: Recommendations for use of EHC. Combined pills If two or more active ethinyloestradiol pills have been missed in the first week of pill taking (i.e. days 1–7) and UPSI occurred in week 1 or the pill-free week (1). Note: If two or more pills are missed from the last seven in a pack, EHC is not necessary providing that the next pack is started immediately, i.e. without the normal pill-free break (3). Progestogen-only If one or more POPs have been missed or taken >3 h late (>12 h late for pills (POPs) desogestrel) and UPSI has occurred in the 2 days following this (1). Progestogen-only If the contraceptive injection is late (>14 weeks from the previous injectable injection for medroxyprogesterone acetate or >10 weeks for norethisterone enantate) and UPSI has occurred (1). Barrier methods If there has been failure of a barrier method (1). 7 2-There is an interaction between ciclosporin and levonorgestrel. Here, the progestogen inhibits the metabolism of ciclosporin and increases levels of the latter. A woman requesting EHC who is taking ciclosporin should be referred (1). 3-Levonorgestrel is thought to act in one of several ways, depending on the point in the menstrual cycle at which it is used: -Before ovulation it may prevent ovulation by delaying or inhibiting the release of the ovum from the ovary. -After ovulation it may prevent fertilization by affecting the motility of the fallopian tube and preventing sperm from meeting the ovum. -fter fertilization it induces changes in the endometrium that render it unreceptive to the ovum and prevent implantation. All mechanisms are considered to be contraceptive rather than abortifacient, as clinically conception and the start of the pregnancy are not considered to have occurred until a fertilized ovum is implanted in the endometrium (3). Ulipristal works by inhibiting or delaying ovulation via suppression of the luteinizing hormone surge (4). 4- A-Bacterial vaginosis: this is the commonest cause of vaginal discharge. The exact cause of bacterial vaginosis is unknown although Gardnerella vaginalis is often implicated. Approximately half of patients will experience a thin white discharge with a strong fishy odour (1). B-Trichomoniasis: a protozoan infection (Trichomonas vaginalis) is primarily transmitted through sexual intercourse. It is uncommon compared to bacterial vaginosis and thrush. Up to 50% of patients are asymptomatic. If symptoms are experienced a profuse, frothy, greenish-yellow and malodorous discharge accompanied by vulvar itching and soreness is typical (1). 5-Allergic or irritant dermatitis may be responsible for vaginal itching, therefore, pharmacist needs to ask the patient if she recently used any new toiletries (e.g. soap, bath or shower products) or vaginal deodorants. Women sometimes use a harsh soap, antiseptics, and vaginal douches in over enthusiastic cleansing of the vagina. Regular washing with warm water is all that needed to keep the vagina clean and to maintain healthy vaginal environment (2). 6-However, these drug interactions relate to the use of multiple-dose fluconazole and the relevance to single-dose fluconazole has not yet been established. It would be prudent to avoid these combinations until further evidence is available with single-dose fluconazole (1). 8