Reproductive Health PDF

REPRODUCTIVE HEALTH Dr. Lemay PHP 315 TOPICS TODAY Opill Emergency Contraception – Plan B Vaccines to Prevent STIs Vaginal Infections Urinary Tract Discomfort Dysmenorrhea  OTC ORAL CONTRACEPTIVE OPILL ...

REPRODUCTIVE HEALTH Dr. Lemay PHP 315 TOPICS TODAY Opill Emergency Contraception – Plan B Vaccines to Prevent STIs Vaginal Infections Urinary Tract Discomfort Dysmenorrhea  OTC ORAL CONTRACEPTIVE OPILL  5 https://www.fda.gov/news-events/press-announcements/fda-approves-first-nonprescription-daily-oral-contraceptive  Opill is a progestin-only oral contraceptive (mini-pill) containing norgestrel 0.075mg Does not contain estrogen Approved by the FDA for OTC use on July 13th, 2023 Can be used by any menstruating person  Not age restricted Useful for individuals unable to take estrogen Preferred hormonal contraceptive for breast-feeding patients  Must be taken at the same time every single day Perfect use effectiveness = 98% Relevant Drug-drug interactions Effectiveness reduced by drugs like phenytoin, carbamazepine, barbiturates, rifampin, efavirenz, and Saint John’s Wort Available in stores and online $18 for 28-day supply  Progestin-only contraception should not be initiated in women with: Current or history of breast cancer Known or suspected pregnancy Unexplained vaginal bleeding COUNSELING POINTS Same time every day Administer continuously with no interruption between packs May be started on any day of the month Use non-hormonal backup for first 48 hours Or if vomiting/diarrhea occur within 4 hours of a dose OCP do not protect against STIs  WHAT’S NEXT? Cadence will be seeking FDA-approval on an OTC combination pill called Zena (levonorgestrel 0.1mg/ethinyl estradiol 0.02mg) OVER-THE-COUNTER EMERGENCY CONTRACEPTION EMERGENCY CONTRACEPTION HOW DO WE HELP OUR PATIENTS? WHAT DO THEY NEED TO KNOW? MECHANISM OF ACTION Levonorgestrel is a synthetic form of progesterone Progesterone inhibits ovulation from occurring Other mechanisms Interfering with fertilization Immobilizing sperm by altering uterine pH Preventing implantation by disrupting the uterine lining Thickening cervical mucus MECHANISM OF ACTION Work primarily by preventing ovulation May also prevent fertilization of a released egg or attachment of a fertilized egg to the uterus Concern to some pharmacists and patients If BMI is 26 or greater, effectiveness of the nonprescription EC products may be reduced, but do not withhold products  SIDE EFFECTS Nausea (25%)* Vomiting (5%)* Breast tenderness Abdominal pain/cramping Headache Menstrual changes Tiredness Diarrhea Dizziness * more nausea/vomiting with oral contraceptive tablets, may pre- treat with an antiemetic 30-60 minutes before 1st dose  COUNSELING POINTS Do not use if allergic to levonorgestrel Does not protect against HIV/AIDS or other STIs Do not use if already pregnant Will not terminate an existing pregnancy Do not use for regular birth control Is most efficacious in the first 72 hours after unprotected intercourse (*self care labeling*), but can be used up to 120 hours after Repeat dose if patient vomits within 1-2 hours after taking initial dose ULIPRISTAL ACETATE (ELLA) Approved August 13, 2010 Prescription-only for emergency contraception One (30 mg) tablet taken within 120 hours (5 days) after contraceptive failure, or no contraception used Progesterone agonist/antagonist Side effects: headache, nausea, abdominal pain, fatigue, and dizziness Debate over similarity to RU-486 Pregnancy category X  PHARMACIST PRESCRIBING HORMONAL CONTRACEPTIVES What do you think?  PHARMACIST PRESCRIBING HORMONAL CONTRACEPTIVES  Let’s Practice! #2 #1 9-VALENT HPV VACCINE HEPATITIS B VACCINES  2024 CDC VACCINE SCHEDULES https://www.cdc.gov/vaccines/hcp/imz- schedules/adult-age.html (ADULTS) https://www.cdc.gov/vaccines/hcp/imz- schedules/child-adolescent-age.html (KIDS) VAGINAL YEAST INFECTIONS & DISORDERS  VAGINAL INFECTIONS Bacterial Vaginosis (BV) Thin, watery, off-white, green, gray, tan discharge, may have a fishy odor and foamy discharge NOT self care Rx clindamycin or metronidazole Trichomoniasis Malodorous, yellow-green discharge, pruritis, or no symptoms NOT self care Rx metronidazole or tinidazole Vulvovaginal candidiasis (VVC) SELF CARE What are the “classic” characteristics _____________ ?  VULVOVAGINAL CANDIDIASIS (VVC) “YEAST INFECTION” Second most common vaginal infection (20-25% of cases) after BV VVC is uncommon prior to menarche By age 25, 50% of women will have had 1 or more episodes of VVC Recurrent infections occur in < 5% of women 4 or more infections within one year  VVC PRESENTATION 80-92% of cases caused by C.albicans Pregnancy, high-dose estrogen oral contraceptives, estrogen replacement therapy (ERT) may increase risk by increasing glycogen Elevated pH during menstruation may predispose  VVC PRESENTATION Women with Diabetes with poor glycemic control at risk After treatment with broad-spectrum antibiotics Immunosuppressive therapy or conditions (HIV) may increase frequency Increased frequency with onset of sexual activity Often, no known cause Male partners are not generally treated  VVC TREATMENT Goals: Relief of symptoms Eradication of the infection Reestablishment of normal vaginal flora Generally, a single course of therapy is adequate to achieve treatment goals Self-treatment of VVC is appropriate for patients: Vaginal symptoms are infrequent (no >3/yr and none w/in the past 2 months) At least 1 previous episode of VVC was medically diagnosed Mild-to-moderate symptoms and consistent with those of VVC, particularly nonmalodorous discharge If measured, vaginal pH should be 4.5 or lower  VVC TREATMENT Exclusions for Self-Care Pregnancy AFAB < 12 years old Concurrent symptoms Fever or pain in the lower abdomen, back, or shoulder Predisposing medications Corticosteroids, antineoplastics Predisposing medical conditions DM, HIV Recurrent VVC > 3 vaginal infections per year or vaginal infection in past 2 months  WHICH PRODUCT SHOULD WE RECOMMEND? A non-prescription, FDA-approved imidazole product is the recommended initial therapy Products are available as vaginal creams, suppositories, and tablets Patient preference Imidazoles have been found to be equally effective ~ 80-90% Butoconazole 1 dose vs. miconazole 7 day = nonsignificant differences Miconazole 1 day vs. 3 day vs. 7 day overall similar Similar results daytime vs bedtime dosing  PRODUCTS FOR SELF CARE VCC TREATMENT Trade Name Primary Ingredient Dosage Butoconazole Nitrate Products Mycelex-3 Cream Butoconazole nitrate Insert cream into vagina qd for 3 2% days; apply to vulva bid prn for itching Clotrimazole Products Gyne-Lotrimin 7 Clotrimazole 1% Insert cream into vagina qd for 7 Cream days; apply to vulva bid prn Mycelex-7 Cream for itching Mycelex-7 Tablet: clotrimazole Insert tablet into vagina qd for 7 Combination Pack 100 mg days; apply cream to vulva Cream: clotrimazole bid prn for itching 1% Gyne-Lotrimin 3 Clotrimazole 2% Insert cream into vagina qd for 3 Cream days; apply to vulva bid prn for itching  Miconazole Nitrate Products Monistat 1 Cream: mic. Insert suppository into Combination Pack nitrate 2% vagina qd for 1 day; apply Supp: mic. nitrate cream to vulva bid prn for 1200mg itching Monistat 1 Daytime Suppository: Insert suppository daytime Ovule miconazole nitrate or nighttime daily for 1 day 1200mg Monistat 3 Cream Miconazole nitrate Insert cream into vagina qd 4% for 3 days; apply to vulva bid prn for itching Monistat 3 Cream: mic. Insert suppository into Combination Pack nitrate 2% vagina qd for 3 days; apply M-zole 3 Supp: mic. nitrate cream to vulva bid prn Combination Pack 200mg itching  Miconazole Nitrate Products Monistat 7 Miconazole nitrate Insert suppository into vagina Suppository 100 mg qd for 7 days Monistat 7 Cream Miconazole nitrate Insert cream into vagina qd for Femizole-M Cream 2% 7 days; apply to vulva bid prn for itching Monistat 7 Cream: mic. nitrate Insert suppository into vagina Combination Pack 2% qd for 7 days; apply cream to M-zole 7 Supp: mic. nitrate vulva bid prn itching Combination Pack 100mg Vagistat-3 Miconazole supp. Insert supp into vagina qd for Combination Pack 200mg each 3 days; apply cream to vulva Miconazole cr 2% bid prn itching  Tioconazole Products Vagistat-1 Tioconazole Insert ointment into Ointment 6.5% vagina qd for 1 day 1-Day Ointment Monistat 1- Tioconazole Insert ointment into Day 6.5% vagina qd for 1 day VVC COMPLEMENTARY THERAPIES Lactobacillus preparations Douches Tea tree oil Gentian violet Boric acid  APPLYING VAGINAL ANTIFUNGAL PRODUCTS Start at bedtime Wash and dry vaginal area before applying product Gently insert applicator into the vagina as far as it will comfortably go Push inside piece of the applicator to apply cream, vaginal tablets, vaginal suppositories Remove applicator  APPLYING VAGINAL ANTIFUNGAL PRODUCTS Recap cream and clean applicator May wish to wear sanitary pad after application Side effects: vulvovaginal burning, itching, and irritation Drug interactions unlikely Warfarin What would you do as the pharmacist? Vagisil? Benzocaine VAGISIL SCREENING KIT Detects pH of vaginal secretions pH of 4.5 + symptoms suggests yeast pH ≥ 5 + symptoms suggest bacterial vaginosis or trichomoniasis  VVC CASE Bella presents to your pharmacy with complaints of vaginal itchiness and white discharge. She is an 18 year old high school senior and occasional thrill-seeker. She is in a committed relationship with a fellow “senior” and is still a virgin. What are some questions you would ask her? What information do you need to obtain? Will you recommend OTC treatment for her infection? URINARY TRACT DISCOMFORT Suspected urinary tract infections should be treated by a primary care provider  URINARY TRACT DISCOMFORT Self care exclusions Strong, persistent need to urinate, yet only pass a small amount Burning sensation when urinating Urine is cloudy or contains blood Strong odor Pain in the back or lower abdomen Nausea, vomiting and/or patient feels ill PHENAZOPYRIDINE Use: relieving pain, burning, urgency, frequent urination, and discomfort caused by irritation of the lower urinary tract Brands: Azo, Uristat, Prodium Should only be used for up to 2 days or 12 tablets, then contact MD Side effects: GI upset, urine may appear orange/red Directions: 2 tablets 3 times a day (w/ meals to reduce GI upset); max 2 days  METHENAMINE AND SODIUM SALICYLATE Use: relief of pain from urinary tract discomfort; acts as analgesic and antibacterial Brand name: Cystex 2 tablets by mouth 4 times a day Not meant to treat urinary infections, still need to contact clinician  50 OXYTROL FOR WOMEN First nonprescription therapy for overactive bladder (OAB) in women, 18 and older Indicated for symptoms of urge incontinence, urgency and frequency Each patch provides relief for 4 days  DYSMENORRHEA Difficult or painful menstruation Prevalence highest in adolescence (up to 93%) Primary Abnormal uterine activity without pelvic disease Affects mostly those in their teens and early 20s Secondary Endometriosis, Pelvic inflammatory disease (PID), fibroids, etc. 26% report dysmenorrhea-related school/work absenteeism 50% with severe pain SIGNS AND SYMPTOMS Cramping lower abdominal pain Sharp, throbbing, dull, nauseating, burning or shooting Nausea, vomiting, dizziness, diarrhea, fatigue, headache Usually begins within 12 hours or on 1st day Duration of 24-72 hours SELF CARE EXCLUSIONS Severe dysmenorrhea or profuse bleeding Dysmenorrhea began after age 25 Pain >24 hours before menses Use of an intrauterine contraceptive (IUC/IUD) History of PID, infertility, ovarian cysts, endometriosis Pelvic pain in absence of menstrual period Irregular menstrual periods Active GI disease or a bleeding disorder Intolerance or non-response to NSAIDs  SELF CARE TREATMENT Heat Therapy Regular Exercise Smoking Cessation Rest  PHARMACOLOGIC TREATMENT NSAIDs Analgesic Combos NOT “as needed” Diuretics (caffeine, Magnesium pamabrom) Pyrilamine Omega 3-fatty acids Vitamin D3 Fenugreek Estrogen Valerian Ginger Contraceptives THANK YOU FOR YOUR ATTENTION QUESTIONS ARE ALWAYS ENCOURAGED! 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