MSOP 1010 - CDM Women's Health PDF

MSOP 1010 Professional Practice & Prescribing Clinical Decision Making – Women’s Health Dr. Suky Bhamra  Learning Objectives Identify the steps required to facilitate decision making when considering issues which affect women’s health. Gather i...

MSOP 1010 Professional Practice & Prescribing Clinical Decision Making – Women’s Health Dr. Suky Bhamra  Learning Objectives Identify the steps required to facilitate decision making when considering issues which affect women’s health. Gather information to enable application of a structured decision making process when making a differential diagnosis. Identify management options for female patients presenting with ‘women’s health problems’.  Lecture Overview Women’s health: Vaginal thrush Bacterial Vaginosis (BV) Trichomoniasis Dysmenorrhoea (Period Pain) Menorrhagia (Heavy periods) Polycystic ovary syndrome (PCOS) Adenomyosis Endometriosis Fibroids Emergency hormonal contraception (EHC) Menopause  Women’s Health Appropriate questions - WWHAM? And beyond… Consider nature of the condition Confidentiality Commonly women’s health conditions are associated with: - Female reproductive system - Urinary system (covered in detail in CDM – renal lecture) Anatomy of the Female Reproductive System  Anatomy of the Reproductive Systems Female reproductive system Male reproductive system  Aetiology The vagina is a nutrient rich environment with its own microflora. Normal vaginal pH = 3.8-4.5 (provides natural resistance to pathogens) The vagina naturally produces a watery discharge = a fluid or mucus that keeps the vagina clean, lubricated, and protects it from infection. It is usually clear with no odour. The amount and characteristics of the discharge produced can be affected by: - Hormonal changes/ ovulation - Pregnancy - Medication During ovulation women often produce more discharge which is a thicker consistency.  Aetiology Glycogen is found in the epithelium of the vagina which is broken down into acids by enzymes and bacteria (e.g. lactobacilli). This maintains a low pH environment in the vagina which is unsuitable for pathogens to survive. Glycogen concentration is controlled by oestrogen production; therefore changes in oestrogen affect the level of glycogen. If oestrogen levels decrease - glycogen levels decrease too = this increases the pH of the vagina increasing the chance of opportunistic pathogens to cause an infection.  Vaginal Candidiasis = Thrush Cause: - Yeast infection = Candida albicans - Candida albicans is a normal inhabitant of the mouth, vagina, skin and GI tract. - When there is a change in vaginal pH or circulating sex hormones, Candida can multiply, leading to symptomatic vulvovaginal candidiasis (genital thrush). Epidemiology - 75% of women will suffer with at least one episode of vaginal thrush in their lifetime. - 40-50% of women will experience more than one episode. - Can affect women of all ages  Vaginal Candidiasis = Thrush Risk factors: - Oestrogen exposure (hence more common during reproductive years & pregnancy) - Immunocompromised state – e.g. HIV positive women. - Poorly controlled diabetes mellitus - Treatment with broad-spectrum antibiotics - Local irritants - e.g. soaps, shower gels, and ‘feminine hygiene’ products, and tight-fitting, synthetic clothing - Sexual intercourse - Women receiving oral sex may be at greater risk of vulvovaginal candidiasis, and it can rarely be passed on to sexual partners. - Contraception - e.g. use of spermicidal jellies and creams and oral contraceptive pills - Hormone replacement therapy (HRT)  Vaginal Candidiasis = Thrush Signs and symptoms: - Itching - Soreness/ irritation - Vaginal discharge = creamy/white, non smelling - Burning/ stinging on urination - Pain during sexual intercourse Can occasionally be passed on to sexual partners  Vaginal Candidiasis = Thrush Differential diagnosis: - Bacterial vaginosis - itch is not usually prominent, and discharge is usually white. - Chlamydia - vaginal discharge and dysuria but does not usually present with itch. - Gonorrhea - rarely presents with itch but is associated with pain and discharge. - Genital herpes - may present with redness, itch, and ulceration; discharge is uncommon; and acute vulval pain is often the defining symptom - Vulval eczema or psoriasis - may cause itch similar to that caused by vulvovaginal candidiasis. - Allergy - to chemicals / latex condoms - Malignancies - malignancies of the vulva, vagina, cervix, or uterine lining are rare but present with vaginal discharge.  Differentiating Discharge Discharge Possible cause Smells fishy Bacterial vaginosis Thick and white, like cottage cheese Thrush Green, yellow or frothy Trichomoniasis With pelvic pain or bleeding Chlamydia or gonorrhoea With blisters or sores Genital herpes NHS UK  Vaginal Candidiasis = Thrush Referral: ‒ First time sufferers ‒ More than 2 cases in 6 months ‒ Pregnant/ breastfeeding women ‒ Women below 16 or over 60 years old ‒ Blood stained discharge ‒ Irregular vaginal bleeding ‒ Associated symptoms : abdominal pain, painful urination, fever, diarrhoea, nausea, vomiting. ‒ Ulcers on vulva/ vagina ‒ Immunocompromised patients e.g. diabetics ‒ No improvement in 7 days  Vaginal Candidiasis = Thrush Treatment options: - Antifungals (imidazoles)= clotrimazole, miconazole, fluconazole - Anti-itch/ irritation = Benzocaine, Lidocaine - Formulation: topical cream, internal cream, pessary, oral capsule  Vaginal Candidiasis = Thrush Treatment: - Antifungals (imidazoles) = inhibit replication of yeast cells by interfering with the synthesis of ergosterol (the main sterol in the yeast cell membrane) Active Ingredient Pharmaceutical Product Associated Advice Canestan cream - Suitable for 16-60 year olds – over the counter - External cream = 2% clotrimazole - OTC can only sell it if previously diagnosed thrush - Internal cream = 10% clotrimazole - Formulations available = cream (internal/ Canesten pessary = 500mg external), pessary. Clotrimazole clotrimzole - Pessaries best used at night/ before bed to avoid seepage. 150mg fluconazole (Canestan oral - Suitable for 16-60 year olds – over the counter capsule) - One capsule as a single dose (anytime of the day) - Absorbed well when taken orally Fluconazole - Symptoms improve within 12-24 hours - Mild adverse effects e.g. GI disturbances, nausea, vomiting & diarrhoea  Vaginal Candidiasis = Thrush Treatment: - Anti-itch/ irritation = Benzocaine, Lidocaine Active Ingredient Pharmaceutical Product Associated Advice Lanacane cream - Soothes itching & irritation = benzocaine 3% - For external use only - For short term use only -If persists for more than 7 days, or worsens, seek Benzocaine medical advice. - For adults, the elderly and children aged 12 years and over. Vagisil medicated cream - Relief of vaginal itch/ irritation = lidocaine 2% - Suitable from 12 years + Lidocaine  Vaginal Candidiasis = Thrush Treatment: 1st line = topical imidazoles e.g. clotrimazole 2% cream - Usually for 7 days 2nd line = systemic therapy e.g. fluconazole 150mg capsule as a single dose Some preparations are also suitable for male thrush.  Vaginal Candidiasis = Thrush Who is it for? - OTC treatment not suitable for under 16, over 60s , 1st time sufferers, if pregnant or diabetic What are the Symptoms? - Is it thrush like symptoms? Not thrush if discharge is smelly, not white in colour How long have they had it? - Recurring? More than 2 times in 6 months Action taken? -What did they use before, did it work, did they get on with it ok? OTC treatment failure? Medication? - broad spectrum antibiotics, corticosteroids, contraceptive pill/HRT, diabetes etc Other questions : - Is it the first time they have had it? - Has it been diagnosed before? - Potential cause known?  Vaginal Candidiasis = Thrush Preventing vaginal thrush – associated advice Avoid wearing tight-fitting underwear or tights - wear stockings instead and cotton underwear Avoid highly perfumed toiletries, vaginal deodorants and douches Wipe front to back Use water and an emollient as a soap substitute to clean the vagina Apply a greasier moisturiser to the skin around the vagina several times a day to protect it (but be aware that these moisturisers can weaken condoms) Use pessaries at night to prevent ‘leak back’ Topical treatments can damage latex (i.e. caution if using condoms)  Bacterial Vaginosis (BV) BV is an abnormal vaginal discharge. Cause: - Change in the natural balance of bacteria in the vagina. - Vagina contains lactobacilli = produce lactic acid, this makes the vagina slightly acidic, which prevents other bacteria from growing there. - Shortage of lactobacilli can cause over growth of other bacteria such as Gardnerella vaginalis, Prevotella species, Mycoplasma hominis, and Mobiluncus species. - Vaginal pH increases to greater than 4.5. - Not classed as an STI - prevalence higher amongst sexually active women - 'sexually associated'.  Bacterial Vaginosis (BV) Risk factors: - Change in sexual partner(s) - Bubble baths/ use of perfumed products around the vagina - Intrauterine device (IUD – contraceptive) - Smoking Signs and symptoms: - 50% of women with BV = asymptomatic - Clear - greyish coloured discharge - Foul smelling discharge (fishy odour) - No soreness, itching, or irritation like with other vaginal conditions  Bacterial Vaginosis Referral: - Unsure of what it is - OTC treatment failure Treatment: OTC treatment = vaginal pH correctors - Canesbalance BV gel = relieves unpleasant odour and abnormal discharge, restricts the growth of bad bacteria and supports good bacteria. Contains: Lactic acid, Glycogen, Propylene glycol, Methylhydroxypropyl cellulose, Sodium lactate, water. - It is a 7-day treatment that starts to soothe symptoms in just 2-3 days. - Antibiotics e.g. metronidazole tablets or gel can be prescribed  Trichomoniasis Cause: = a sexually transmitted infection (STI) caused by a tiny parasite Trichomonas vaginalis (TV) Signs and symptoms: - Symptoms develop within a month of infection - Can affect men and women – up to half will not have any symptoms - Abnormal vaginal discharge that may be thick, thin or frothy and yellow-green in colour - More discharge than normal - Discharge may have an unpleasant fishy smell - Soreness, inflammation and itching around the vagina - Pain or discomfort when passing urine or having sex Referral: - Any of these symptoms need to be referred Treatment: - Doctor will usually prescribe antibiotics = e.g. metronidazole  Dysmenorrhoea (Period Pain) Cause: - Period pain occurs when the muscular wall of the womb contracts. - The wall of the womb starts to contract more vigorously to encourage the womb lining to shed away during menstruation. - Caused by the production of uterine prostaglandins during menstruation. - Primary dysmenorrhoea = absence of underlying pelvic pathology. - Secondary dysmenorrhoea = caused by an underlying pelvic pathology e.g. endometriosis, fibroids, or endometrial polyps.  Dysmenorrhoea (Period Pain) Signs and symptoms: - Pain in lower abdomen can radiate to back and legs - Pain is spasmodic/cramps, dull ache - May be associated with nausea and vomiting - Can start 1-2 days before period and may last 2-3 days while bleeding - Feeling tired/ fatigue - Headaches - Mood changes In addition to these symptoms, patients with secondary dysmenorrhoea may experience: - Heavy periods - Irregular periods - Bleeding between periods - Painful intercourse/ bleeding after intercourse  Dysmenorrhoea (Period Pain) Treatment: = Pain relief ‒ Paracetamol ‒ NSAIDs = reduce prostaglandin production - Ibuprofen (Ibuprofen lysine – faster acting e.g. Feminax Express) should be used first line unless contraindicated - Naproxen (Feminax Ultra) – licensed in 2008 for women 15-50 years - Diclofenac - Aspirin ‒ Tranexamic acid  Dysmenorrhoea (Period Pain) Other medicines which can be prescribed: - Antispasmodics e.g. Hyoscine butylbromide & Alverine citrate - Combined oral contraceptives Non-pharmacological treatment options Hot water bottle/ heat patch TENS machine (transcutaneous electrical nerve stimulation) Acupuncture Exercise Dietary modification (avoid caffeine), vitamin supplements e.g. Vit B, E and fish oils.  Menorrhagia Menorrhagia = heavy periods Causes: May be caused by other conditions such as: - Polycystic ovary syndrome (PCOS) - Pelvic inflammatory disease (PID) –infection in the upper genital tract - can cause pelvic or abdominal pain and bleeding after sex or between periods - Fibroids – non-cancerous growths that develop in or around the womb and can cause heavy or painful periods - Endometriosis – when small pieces of the womb lining are found outside the womb - Adenomyosis - lining of the womb (uterus) starts growing into the muscle in the wall of the womb. - Underactive thyroid gland (hypothyroidism) - Cervical or endometrial polyps – non-cancerous growths in the lining of the womb or cervix (neck of the womb) - Blood clotting disorders - Cancer of the womb  Menorrhagia Diagnosis by patient’s description: - Interferes with daily activities - Frequent change of sanitary towels (every 1-2 hours) - Using multiple sanitary products together - Clotting/ passing blood clots over 2.5cm (10p coin) - Periods can last 7 days or more - Feeling tired/ short of breath Can affect a woman: - Physically - Emotionally Can disrupt everyday life  Menorrhagia Treatment: Combined contraceptive/ intrauterine device (IUD) Pain relief: - Paracetamol - NSAIDs – ibuprofen/ naproxen - Mefenamic acid Medicines to reduce clotting = tranexamic acid Check iron levels as can lead to anaemia  Menorrhagia Tranexamic acid (500mg)= anti-fibrinolytic - stops the conversion of plasminogen to plasmin an enzyme which digests fibrin and causes clot dissolution. It helps blood clot faster as the endometrial lining sheds and reduces excessive blood loss. - Dose = 2 tablets three times a day for a maximum 4 days - If bleeding is still really heavy an additional 2 tablets can be taken – Max 8 tablets daily. - Suitable from 18 years + - Only suitable for women who have a regular menstrual cycle - Refer if over 45 years, diabetic, history of PCOS or endometrial cancer - Not suitable if taking oral contraceptives or anticoagulants  Polycystic ovary syndrome (PCOS) PCOS is a hormonal issue which affects women of reproductive age. It is a chronic condition with no cure, but symptoms can be managed. Irregular periods, usually with a lack of ovulation, can make it difficult to become pregnant. PCOS is a leading cause of infertility. Causes: Exact cause of PCOS is unknown, but it's thought to be related to abnormal hormone levels.  Polycystic ovary syndrome (PCOS) Causes: Exact cause of PCOS is unknown, but it's thought to be related to abnormal hormone levels. 1. Hormone imbalance Raised levels of testosterone – a hormone often thought of as a male hormone (androgen), but all women usually produce small amounts too. Raised levels of luteinising hormone (LH) – this stimulates ovulation, but may have an abnormal effect on the ovaries if levels are too high Low levels of sex hormone-binding globulin (SHBG) – a protein in the blood that binds to testosterone and reduces its effect raised levels of prolactin (only in some women with PCOS) – a hormone that stimulates the breast glands to produce milk in pregnancy The changes may also be caused by the resistance to insulin. 2. Resistance to insulin Insulin (a hormone produced by the pancreas) controls the amount of sugar in the blood. It helps to move glucose from blood into cells, where it's broken down to produce energy. Insulin resistance means the body's tissues are resistant to the effects of insulin. The body therefore has to produce extra insulin to compensate. - High levels of insulin causes the ovaries to produce too much testosterone, which interferes with the development of the follicles (the sacs in the ovaries where eggs develop) and prevents normal ovulation. Insulin resistance can also lead to weight gain, which can make PCOS symptoms worse, as having excess fat causes the body to produce even more insulin. 3. Genetics PCOS sometimes runs in families. This suggests there may be a genetic link to PCOS, although specific genes associated with the condition have not yet been identified.  Polycystic ovary syndrome (PCOS) Symptoms: PCOS can cause hormonal imbalances, irregular periods, excess androgen levels and cysts in the ovaries. Heavy, long, intermittent, unpredictable or absent periods Infertility Acne or oily skin Excessive hair on the face or body (hirsutism) Hair thinning/ loss Weight gain, especially around the belly. People with PCOS are more likely to have other health conditions including: Type 2 diabetes Depression Hypertension High cholesterol Heart disease Endometrial cancer (cancer of the inner lining of the uterus). Pregnancy risks = higher risk of pregnancy complications: high blood pressure (hypertension), pre-eclampsia, gestational diabetes and miscarriage. Polycystic ovary syndrome (PCOS) Treatment: Lifestyle changes = healthy diet, weight loss, exercise Medicines: To manage hormone imbalance = contraceptive pill, IUD Metformin is often used to treat type 2 diabetes, but it can also lower insulin and blood sugar levels in women with PCOS (off-label use). Fertility treatment to stimulate ovulation = clomifene or letrozole (used to treat/ prevent reoccurrence of breast cancer), in vitro fertilisation (IVF) treatment (IVF). For hair loss/ excessive hair growth = contraceptive pill (to balance hormones) Excessive hair growth = anti-androgens e.g. finasteride (usually used to treat prostate enlargement), spironolactone (usually used to treat oedema) Surgery - laparoscopic ovarian drilling (LOD) = ovaries are surgically treated using heat or a laser to destroy the tissue that's producing androgens (male hormones).  Adenomyosis Adenomyosis is where the lining of the womb (uterus) starts growing into the muscle in the wall of the womb. Adenomyosis is more commonly diagnosed in women over the age of 30. Symptoms: painful periods heavy bleeding pelvic pain (pain in the lower part of the tummy) bloating, heaviness or fullness in abdomen pain during intercourse (dyspareunia) Treatment as for painful/ heavy periods, in extreme cases may need a hysterectomy Adenomyosis Endometriosis  Endometriosis Endometriosis is where cells similar to those in the lining of the womb (uterus) grow in other parts of the body. Endometriosis usually grows in areas around the womb, i.e. the ovaries and fallopian tubes. It can also affect organs such as the bladder and bowel. Symptoms: Severe period pain, affects normal activities/ daily life Heavy periods Pain when you poo or pee Pain in the lower tummy and back (pelvic area) Pain during or after intercourse Extreme tiredness (fatigue) Treatment: Treatment as for painful/ heavy periods (painkillers/ contraceptives), in extreme cases may need a hysterectomy  Fibroids Fibroids are non-cancerous growths that develop in or around the womb (uterus). The growths are made up of muscle and fibrous tissue. They're sometimes known as uterine myomas or leiomyomas. Cause: The exact cause of fibroids is unknown, but they have been linked to the hormone oestrogen. Symptoms: Many women are unaware they have fibroids because they do not have any symptoms. Heavy periods or painful periods Tummy (abdominal) pain Lower back pain Frequent need to urinate Constipation Pain or discomfort during sex Treatment: Treatment as for painful/ heavy periods (painkillers/ contraceptives) Fibroids often shrink after the menopause, and your symptoms will usually either ease or disappear completely. shrink fibroids = Ulipristal acetate and Gonadotropin releasing hormone analogues (GnRHas) e.g. Goserelin can be prescribed by specialists.  Pelvic inflammatory disease (PID) Pelvic inflammatory disease (PID) is characterised by inflammation of a woman's reproductive organs (uterus, fallopian tubes and ovaries), which is caused by infection. Most cases occur by sexually transmitted bacteria that travel from the vagina to the cervix and up into the uterus, fallopian tubes and ovaries. Caused by the bacteria from sexually transmitted infections (STIs) - Chlamydia trachomatis (chlamydia), and and Neisseria gonorrhoeae (gonorrhoea). Acute PID: Acute pelvic inflammatory disease is characterised by sudden or severe inflammation of the female reproductive organs (uterus, fallopian tubes, ovaries) due to infection. Chronic PID: Chronic pelvic inflammatory disease is characterised by persistent inflammation for a long time, which can lead to severe complications. Symptoms: Lower abdominal or pelvic pain Vaginal discharge (yellow, green or fishy odour). Abnormal vaginal bleeding Dyspareunia (painful intercourse) Pain in the upper right abdomen Increased temperature Painful urination Bleeding and spotting after intercourse Treatment: Antibiotics  Women's’ health – differential diagnosis Is it …. ? How to differentiate between Adenomyosis Endometriosis Fibroids Irritable bowel syndrome (see nutrition lecture) Heavy (menorrhagia) Painful periods (dysmenorrhea) Pelvic inflammatory disease Polycystic ovary syndrome (PCOS)  Referring Women with Menstrual Problems Severe symptoms Older patients complaining of painful/ heavy periods for the first time Pain getting worse with each period Abnormal discharge/ bleeding/ fever Irregular periods Bleeding in between cycles Heavy periods despite having contraceptive coil fitted Pregnant/ breastfeeding  Emergency hormonal contraception (EHC)​ Over-the-counter (OTC) there are two options for EHC : 1. Levonorgestrel = Levonelle ~ £25 2. Ulipristal acetate = ellaOne ~ £35 Generics are available for both (often cheaper than the brands) Must be over 16 years of age to buy EHC over-the-counter, under 16s will need a prescription. The emergency contraceptive pill needs to be taken within 3 days (Levonelle) or 5 days (ellaOne) of unprotected sex for it to be effective – the sooner it is taken, the more effective it'll be. General information/ counselling for patients: The emergency contraceptive pill can make your next period earlier, later or more painful than usual. If patient is sick (vomit) within 2 hours of taking Levonelle or 3 hours of taking ellaOne, they should see their GP, pharmacist or genitourinary medicine (GUM) clinic, as they will need to take another dose or have an IUD fitted. There are no serious side effects of using emergency contraception. Side –effects = nausea, headache, vomiting, changes to next period (earlier, later or heavier). Emergency contraception doesn't cause an abortion. EHC doesn't continue to protect you against pregnancy – if you have unprotected sex at any time after taking the emergency pill, you can become pregnant.  Emergency hormonal contraception (EHC)​ Most women can use the emergency contraceptive pill. This includes women who can't use hormonal contraception, e.g. combined pill. Can’t take emergency contraceptive pill if: Patient is allergic to anything in it Patient has severe asthma or Patient takes any medicines that may interact with it, such as: St John's Wort (herbal medicine) Medicines used to treat epilepsy, HIV or tuberculosis (TB) Antacids e.g. omeprazole Antibiotics e.g. rifampicin and rifabutin ellaOne can't be used if you're already taking one of these medicines, as it may not work. Levonelle may still be used, but the dose may need to be increased. You can also read the patient information leaflet that comes with your medicine for more information. Breastfeeding Levonelle is safe to take while breastfeeding. Although small amounts of the hormones in the pill may pass into breast milk, it's not thought to be harmful to the baby. The safety of ellaOne during breastfeeding isn't yet known. The manufacturer recommends that you don't breastfeed for one week after taking this pill.  Emergency hormonal contraception (EHC)​ Levonorgestrel 1500 mcg tablet = Levonelle. Mode of action of levonorgestrel = a synthetic (man-made) version of the natural hormone progesterone produced by the ovaries. It stops or delays the release of an egg (ovulation). It has to be taken within 72 hours (3 days) of sex to prevent pregnancy. It doesn't interfere with regular method of contraception. It's most effective if taken within 12 hours of having unprotected sex.  Emergency hormonal contraception (EHC)​ Ulipristal acetate 30mg tablet = ellaOne Mode of action = selective progesterone receptor modulator = stops progesterone working normally. Stops or delays the release of an egg. It has to be taken within 120 hours (5 days) of sex to prevent pregnancy. It's most effective if taken as soon as possible after having unprotected sex.  Emergency hormonal contraception (EHC)​ EHC for Free ? Some pharmacies (patients aged 13-18 under a patient group direction (PGD)) Contraception clinics/ Brook centres/ sexual health or genitourinary medicine (GUM) clinics Most NHS walk-in centres and minor injuries units Most GP surgeries Some hospital accident and emergency (A&E) departments??? – never a first choice  Menopause Menopause marks the natural end of fertility and occurs 12 months after your last menstrual period. It marks the permanent end of menstrual cycles due to the cessation of the production of reproductive hormones from the ovaries.  Menopause Symptoms Changes to periods = irregular, eventually stop Phycological symptoms: Mood changes Low mood/ depression Anxiety Low self-esteem Brain fog Physical symptoms: Hot flushes Vaginal dryness and Pain, itching or discomfort during intercourse Insomnia difficulty sleeping Palpitations Headaches and migraines that are worse than usual Muscle aches and joint pains Changed body shape Weight gain Skin changes including dry and itchy skin Reduced libido Recurrent urinary tract infections (UTIs) Sensitive teeth, painful gums or other mouth problems Management Menopause Lifestyle: Eat well (hydration, fruit, fibre, protein, calcium etc) Exercise Rest, sleep well Mood changes – try relaxing activities, may need cognitive behavioural therapy (CBT) or medication Vaginal dryness = use lubricants and vaginal moisturisers Hot flushes = ventilate areas, light cotton clothes Weak bone protection = calcium rich foods, vit D supplements (sunlight is important) Consider supplements and herbal remedies: Black cohosh = hot flushes and mood swings Valerian = relaxation and sleep Flax seed = improves mood and libido Red clover = improves sleep, mood, libido St John’s wort = anxiety/ mild depression Sage = sweats and hot flushes Chamomile = helps sleep and is calming  Menopause Treatment Hormone replacement therapy (HRT) = uses oestrogen to replace what the body is no longer producing. -available as tablets, patches, gel, spray, vaginal rings, pessaries or creams Progesterone is included in some HRT for women with a womb to reduce effects of oestrogen on the womb. Testosterone used to increase libido Vaginal dryness = Oestrogen gel for vaginal dryness Mood changes = antidepressants Hot flushes = medication e.g. clonidine or gabapentin  Women’s Health Things to consider Who is the patient? – age, pregnant/breastfeeding Age – treatment appropriate, product licensed? Symptoms – severity, onset? Treatment already tried – OTC treatment failure? Other medical conditions – e.g. diabetes, asthma Other medication taken – caution/ contra-indications/ interactions  Recommended Reading FASTtrack: Managing Symptoms in the Pharmacy - Alan Nathan Community Pharmacy, 3rd Edition - Symptoms, Diagnosis and Treatment - Paul Rutter Symptoms in the Pharmacy: A Guide to the Management of Common Illness -Wiley-Blackwell