Women's Health Part II 2023-24 FINAL PDF

Women's Health 4-Emergency hormonal contraception Dealing with requests for emergency hormonal contraception (EHC) requires sensitive interpersonal skills from the pharmacist, privacy for the consultation and careful question wording. (1). Assessment A-Age: E...

Women's Health 4-Emergency hormonal contraception Dealing with requests for emergency hormonal contraception (EHC) requires sensitive interpersonal skills from the pharmacist, privacy for the consultation and careful question wording. (1). Assessment A-Age: EHC can be supplied OTC for women aged 16 years and over in UK. For women under 16 years the pharmacist can refer to the doctor (1). 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). C-When unprotected sex/contraceptive failure occurred: 1-Ulipristal needs to be started within 120 h (5 days) of unprotected intercourse and levonorgestrel within 72 h (3 days). The sooner EHC is started, the higher is its efficacy (1). 2-If hormonal EHC is unsuitable for the woman, she can be referred to have copper intrauterine device (Cu-IUCD) fitted as a method of emergency contraception, provided this is done within 120 h of unprotected intercourse (1). D-Could the woman already be pregnant? If pregnancy is suspected [if the period is different from normal (lighter) or 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: Women taking some medications (or have taken them in the previous 4 weeks) like (carbamazepine, rifampicin, griseofulvin) should be referred (1). Treatment timescale EHC must be started within 120 h of unprotected intercourse for ulipristal or 72 h for levonorgestrel (1). Treatment 1-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). 2-Ulipristal has been demonstrated to be more effective than levonorgestrel for emergency contraception (1). 1 Mode of action: 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. -After 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). Side-effects 1-The most frequently reported side effects were headache (around one in five women) and nausea (around one in eight women) (1). 2-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 1-Both drugs should not be taken by a woman who is pregnant (because it will not work), or has severe hepatic dysfunction (1). 2-Levonorgestrel should not be taken by a woman who 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. 9th edition. 2023. 2-American pharmacists association. Handbook of Non-prescription drugs: An Interactive Approach to Self-Care. 20th edition. 2020. 3-Nathan A. fasttrack. Managing Symptoms in the Pharmacy. Pharmaceutical Press. 2008 4-Paul Rutter. Community Pharmacy. Symptoms, Diagnosis and Treatment. 5th edition. 2021. 5-Menorrhagia (Heavy menstrual bleeding) Heavy menstrual bleeding (HMB) may be defining as 'excessive menstrual blood loss which interferes with a woman's physical, social, or emotional quality of life' (1). 2  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 -1: Medication that can alter menstrual bleeding (1). B-Timing of bleeding Anticoagulants Symptoms that might suggest structural or Cimetidine pathological abnormality include bleeding at Monoamine oxidase inhibitors times other than at menses (1). Phenothiazines Irregular bleeding between periods especially if Steroids associated with postcoital bleeding is extremely Thyroid hormones significant and suggests pre-cancerous/cancer of the cervix (1). (Endometrial and cervical When to refer carcinoma are usually occurs in postmenopausal -Presence of abnormal vaginal women) (1). discharge (2). C-Menstrual cycle -Intermenstrual and/or postcoital 1-If a patient’s period was previously regular and bleeding (2). this has changed, pathology should be ruled out -Pelvic pain (2). and referral is indicated (2). -Pain on intercourse (dyspareunia) (2). - Pelvic pain (2). 2-If the periods have been heavy over several -Presence of fever (2). months or more, then blood loss may have given -Treatment failure (1). rise to iron deficiency anemia (referral) (2). D-Medications 1-Occasionally, medicines can change menstrual bleeding patterns (Table -1). If an adverse drug reaction is suspected then the pharmacist should contact the prescriber and discuss other treatment options (1). 2-The incidence of menstrual pain is higher in patients who have had an 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). 3 3-Tranexamic acid (cyklokapron® 500 mg tablet) is effective medicine in decreasing menstrual blood loss. It reduces blood loss by up to 50% (1). 4-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). 5-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). 6-Side effects are unusual. Those reported include mild nausea, vomiting and diarrhea (affecting between 1% and 10% of patients) (1). 7-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. 5th edition. 2021. 2-Alison Blenkinsopp, Paul Paxton and John Blenkinsopp. Symptoms in the pharmacy. A guide to the managements of common illness. 9th edition. 2023. 3- Anna Livshits and Daniel S. Seidman. Role of Non-Steroidal Anti-Inflammatory Drugs in Gynecology. Pharmaceuticals. 2010; 3: 2082-2089. 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 -2). Thrush is the only condition that can be treated OTC (1). Table -2: 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 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, 4 greenish-yellow and malodorous discharge accompanied by vulvar itching and soreness is typical (1). 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) -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. Regular washing with warm water is all that needed to keep the vagina clean and to maintain healthy vaginal environment (2). 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). 5 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 hyperglycaemia can enhance production of protein surface receptors on C. albicans organisms. This hinders phagocytosis by neutrophils, thus making thrush more difficult to eliminate (1). F-Sexually Transmitted Diseases When to refer (STDs): -First occurrence of symptoms (2). Women who have previous history -Known hypersensitivity to imidazoles or other of STDs should be referred (with vaginal antifungal products (2). previous history of STDs the current -Pregnancy or suspected pregnancy (2). condition may not be thrush or may -More than two attacks in the previous 6 include dual infections with other months (2). organisms) (2). -Previous history of STD (2). G-Medication: -Exposure to partner with STD (2). What treatment had the patient tried -Patient under 16 or over 60 years (2). before seeking our advice (failed -Abnormal or irregular vaginal bleeding (2). medication required referral) (2). -Any blood staining of vaginal discharge (2). -Vulval or vaginal sores, ulcers or blisters (2). Broad spectrum antibiotics, -Associated lower abdominal pain or dysuria (2). corticosteroids, cancer -Adverse effects (redness, irritation or swelling chemotherapy, and medication that associated with treatment) (2). affecting the estrogen status of the -No improvement within 7 days of treatment (2). patient [oral contraceptives, -Patients with diabetes (1). hormone replacement therapy (HRTt), tamoxifen] can predispose women to thrush. 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). 6 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). The difference between single-dose fluconazole and continuous therapy in relation to interactions is not clear. Theoretically, single-dose use is unlikely to cause problems, but in a small study of women taking warfarin, the prothrombin time was increased (2). 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). 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). 7 3-Treatment of husband: Men may be infected with candida without showing any symptoms. Treating husband without symptoms remains an area of debate. 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 7 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). 5-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. 4th edition. 2021. 2-Alison Blenkinsopp, Paul Paxton and John Blenkinsopp. Symptoms in the pharmacy. A guide to the managements of common illness. 9th edition. 2023. 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. 20th edition. 2020. 6-Nathan A. Non-prescription medicines. 4th edition. London: Pharmaceutical Press. 2010. 8