PH1122 - Women's Health Flashcards

1
Q

what factors increase the chance of a UTI

A
frequent or recent sexual activity, 
previous episodes of cystitis, 
the use of diaphragms or spermicidal agents, 
advancing age (e.g., postmenopausal), 
pregnancy, and 
diabetes can be risk factors.
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2
Q

how common is recurrent cystitis and what is the time frame for it ?

A

Recurrent cystitis (usually defined as three or more episodes in the past 12 months or two episodes in the past 6 months) is relatively common

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3
Q

What are reasons to refer with symptoms associated with cystitis ?

A

Duration Symptoms that have lasted longer than 5–7 days should be referred because of the risk that the woman might develop pyelonephritis.
Age of the patient Cystitis is unusual in children and should be viewed with caution. This might be a sign of a structural urinary tract abnormality. Referral is needed.
Older female patients (> 70 years) have a higher rate of complications associated with cystitis and are therefore best referred.
Presence of fever Referral is needed if the woman presents with fever associated with dysuria, frequency and urgency because fever is a sensitive indicator of an upper urinary tract infection.
Vaginal discharge If a patient reports vaginal discharge, the likely diagnosis is not cystitis but a vaginal infection.
Location of pain Pain experienced in the loin area suggests an upper urinary tract infection.

blood present in the urine requires further investigation

Suprapubic discomfort not associated with passing urine might also be present but is not common should also be referred.

Children <16 years Cystitis unusual in this age group
Patients with diabetes More likely to develop complications from a UTI
Duration >7 days Does not suggest an uncomplicated UTI
Vaginal discharge May indicate vaginitis
Women >70 years More susceptible to complicated UTIs and pyelonephritis; also, symptoms may be indicative of atrophic vaginitis
Pregnancy Pressure on the urinary tract caused by an infant makes management of UTIs more difficult and can increase the risk of pyelonephritis
Haematuria Blood may indicate a stone or a tumour
Immunocompromised More likely to develop complications from a UTI
Patients with associated fever and flank pain Suggestive of a complicated UTI and/or pyelonephritis

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4
Q

what are symptoms of cystitis ?

A

Cystitis is characterized by pain when passing urine and is associated with frequency, urgency, nocturia, and changes to urine’s appearance.
the patient might report only passing small amounts of urine, with pain worsening at the end of voiding urine.
usually SUDDEN ONSET

Suprapubic discomfort not associated with passing urine might also be present but is not common.

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5
Q

what are conditions to eliminate when suspecting cystitis.

A

Pyelonephritis
The most frequent complication of cystitis is when the invading pathogen involves the ureter or kidney by ascending from the bladder to these higher anatomical structures. The triad of flank pain, fever, and nausea and vomiting are typically associated with pyelonephritis. Onset is typically sudden. Pain relief can be offered, but a medical referral is needed to confirm the diagnosis, exclude pelvic inflammatory disease, and initiate appropriate treatment

Sexually transmitted diseases (STDs) can be caused by a number of pathogens; for example, Chlamydia trachomatis (most common but generally asymptomatic) and Neisseria gonorrhoea.
Symptoms are similar to those of acute uncomplicated cystitis in that pain and dysuria are experienced, but symptoms tend to be more gradual in onset and last for a longer period of time. In addition, up to 50% of people experience increased or altered vaginal discharge, and pyuria (pus in the urine) is usually present. Usually more common in younger people.

Oestrogen deficiency
Postmenopausal women experience thinning of the endometrial lining as a result of a reduction in the levels of circulating oestrogen in the blood. This increases the likelihood of irritation or trauma, leading to cystitis-like symptoms. If the symptoms are caused by intercourse, symptomatic relief can be gained with a lubricating product. Referral for possible topical oestrogen therapy would be appropriate if the symptoms recur.

Medicine-induced cystitis
Nonsteroidal antiinflammatory drugs (NSAIDs, especially tiaprofenic acid), allopurinol, danazol and cyclophosphamide have been shown to cause cystitis.

Vaginitis
Vaginitis exhibits similar symptoms to cystitis in that dysuria, nocturia and frequency are common. Bleeding or spotting may also be present. It can be caused by direct irritation (e.g., use of vaginal sprays and toiletries). All patients should be questioned about an associated vaginal discharge. The presence of vaginal discharge is highly suggestive of vaginitis.

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6
Q

what can be used to treat cystitis ?

A

Alkalinizing agents are used to return the urine pH back to normal, thus theoretically relieving symptoms of dysuria. However, they have little trial data to support their use.

Potassium citrate

Sodium citrate (Cymalon, CanesOasis, Cystitis Relief, Care Cystitis Relief)

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7
Q

What non pharmacological advise can be given to a patient with cystitis ?

A

Fluid intake Patients should be advised to drink about 5 L of fluid during every 24-hour period. This will help promote bladder voiding, which is thought to help flush bacteria out of the bladder.

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

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8
Q

what is the dose for medication used to treat cystitis ?

A

All marketed products are presented as a 2-day treatment course and taken three times a day, although potassium citrate can be bought as a ready-made solution (the dosage is 10 mL three times a day, diluted well with water). They have very few side effects and can be given safely with other prescribed medication, although, in theory, products containing potassium should be avoided in patients taking angiotensin-converting enzyme (ACE) inhibitors, potassium-sparing diuretics and spironolactone.

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9
Q

What are key symptoms of thrush that help differentiate it with other conditions ?

A

Symptoms of pruritus, burning and discharge are possible in all three common causes of vaginal discharge; therefore, no one symptom can be relied on with 100% certainty to differentiate among thrush, bacterial vaginosis and trichomoniasis. However, certain symptom clusters are strongly suggestive of a particular diagnosis.

Discharge Any discharge with a strong odour should be referred. Bacterial vaginosis and trichomoniasis are associated with a fishy odour. Discharge in bacterial vaginosis tends to be grey-white and trichomoniasis greenish-yellow. By contrast, discharge associated with thrush is often described as curdlike or cottage cheese–like, with little or no odour. Note that the physiological discharge is clear and odourless but can cause slight staining of underwear.
Age Thrush can occur in any age group, unlike bacterial vaginosis and trichomoniasis, which are rare in premenarchal girls. In addition, trichomoniasis is also rare in women >60 years.
Pruritus Vaginal itching tends to be most prominent in thrush compared with bacterial vaginosis and trichomoniasis, where itch is slight or absent.
Onset In thrush, the onset of symptoms is sudden, whereas in bacterial vaginosis and trichomoniasis onset tends to be less sudden.
The defining feature of thrush is vulval itching. Vulval soreness and irritation are also common. Discharge occurs only in about 20% of patients and, if present, has little or no odour and is described as resembling cottage cheese or is curd-like. Symptoms are generally acute in onset.

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10
Q

What conditions need to be eliminated when suspecting thrush ?

A
Bacterial vaginosis
Many patients are asymptomatic but, when symptoms occur, the condition is characterized by a thin white discharge with a strong fishy odour. Odour is worse after sexual intercourse and may worsen during menses. Itching and soreness are not usually present. The exact cause of bacterial vaginosis is unknown but results from an overgrowth of anaerobic bacteria and reduction in lactobacilli concentration. Gardnerella vaginalis is often implicated.
Certain risk factors include change in sexual partner, multiple sexual partners, low social class and race (more common in African and African American women). It may remit and relapse for several months. OTC products are marketed, such as a product to differentiate between thrush and bacterial vaginosis (Canestest), and works on changes in pH levels (> 4.5 can suggest bacterial vaginosis); Canesbalance is marketed for its treatment because it alters pH back to normal physiological levels. However, this should not be recommended because treatment requires antibiotics (oral metronidazole, 400 mg, twice daily for 5–7 days or local application of metronidazole or clindamycin).

Trichomoniasis
Trichomoniasis, a protozoan infection ( Trichomonas vaginalis ), is primarily transmitted through sexual intercourse. Up to 50% of patients are asymptomatic. If symptoms are experienced, approximately 30% experience a profuse, frothy, greenish-yellow and fishy-smelling discharge. Other symptoms include vulvar itching and soreness, vaginal spotting, dysuria, and lower abdominal pain. Referral for metronidazole (400 mg bd for 5–7 days) is required.

Chlamydia
Most people with chlamydial infection are asymptomatic but, when symptoms are experienced, the patient may complain of purulent or mucopurulent discharge, dysuria, urinary frequency, and intermenstrual or postcoital bleeding.
Cystitis
Dysuria can affect up to one in three women with a vaginal infection. Other symptoms such as nocturia and urgency will be more prominent in cystitis, and discharge is uncommon.
Atrophic vaginitis
Symptoms consistent with thrush in postmenopausal women, especially vaginal itching and burning, may be due to atrophic vaginitis. However, clinically significant atrophic vaginitis is uncommon in postmenopausal women and should be referred to rule out malignancy.
There are also several factors that predispose women to thrush and require consideration before initiating treatment.
Medicine-induced thrush
Corticosteroids, immunosuppressants and medications affecting the oestrogen status of the patient (e.g., oral contraceptives, hormone replacement therapy, tamoxifen, raloxifene), can predispose women to thrush. This is also true with the use of broad-spectrum antibiotics, and it is not unusual to see a patient prescribed an antibiotic and treatment for thrush at the same time.
Diabetes
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.
Pregnancy
Hormonal changes during pregnancy will alter the vaginal environment and have been reported to make eradication of Candida more difficult. Topical agents are safe and effective in pregnancy, but OTC-licensed indications state that patients should be treated by a doctor or midwife; therefore, these patients should be referred to the doctor.

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11
Q

How should you treat someone suffering from recurrent thrush ?

A

After treatment, a minority of patients will present with recurrent symptoms (four or more episodes per year). This may be due to poor adherence, misdiagnosis, resistant strains of Candida, undiagnosed diabetes, or the presence of a mixed infection. Such cases are outside the remit of community pharmacy and have been shown to be difficult to treat. Often, specialist care is needed through a genitourinary medicine clinic.

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12
Q

When would you refer a patient with symptoms related to thrush ?

A

Discharge that has a strong smell- Thrush has no or little odour and therefore this suggests other causes, such as bacterial vaginosis or trichomoniasis

Women <16 and >60 years-Thrush is unusual in these age groups

Patients with diabetes-Might suggest poor diabetic control

OTC medication failure
Patients predisposed to thrush
Recurrent attacks- Suggests underlying problem or misdiagnosis

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13
Q

What OTC medication can be used to treat thrush ?

A

Topical imidazoles and one systemic triazole (fluconazole) are available OTC to treat vaginal thrush. They are potent and selective inhibitors of fungal enzymes necessary for the synthesis of ergosterol, which is needed to maintain the integrity of cell membranes.
Imidazoles and triazoles have proven and comparable efficacy, with clinical cure rates between 85% and 90%. Additionally, cure rates between single- or multiple-dose therapy and multiple-day therapy show no differences

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14
Q

What are some common side effects and drug interactions of imidazoles and fluconazole ?

A

Imidazole - Vaginal irritation
Drug interaction - NONE
Fluconazole- GI disturbances, headache, rash
Drug interactions- Anticoagulants, ciclosporin, rifampicin, phenytoin, tacrolimus

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15
Q

How should people be advised to use a pessary for thrush ?

A

Because the dosage is at night, patients should be advised to use the pessary when in bed.
• 1.
Wash your hands.
• 2.
Pull out the plunger from the applicator.
• 3.
Remove the pessary from the packaging and place firmly into the applicator (the end of the applicator needs to be gently squeezed to allow the pessary to fit).
• 4.
Lying on your back, with knees drawn towards the chest, insert the applicator as deeply as is comfortable into the vagina.
• 5.
Slowly press the plunger of the applicator until it stops.
• 6.
Remove and dispose of the applicator.
• 7.
Remain on your back for as long as possible.

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16
Q

How should people be advised to administer vaginal cream ?

A

• 1.
Wash your hands.
• 2.
Pull out the plunger from the applicator.
• 3.
Remove the tube of cream and one applicator from the box (if the applicator is prefilled, skip to point 6).
• 4.
Squeeze the cream from the tube until it reaches the dose level on the applicator.
• 5.
Remove the tube from the end of the applicator.
• 6.
Lying on your back, with knees drawn towards the chest, insert the applicator as deeply as is comfortable into the vagina.
• 7.
Slowly press the plunger of the applicator until it stops.
• 8.
Remove and dispose of the applicator.
• 9.
Remain on your back for as long as possible.

17
Q

What is good general advise for people suffering from thrush ?

A

General advice to help prevent infection- Avoid tight clothing, such as underwear, jeans.
Use simple nonperfumed soaps when washing.

Symptom resolution- The symptoms of thrush (burning, soreness or itching of the vagina) should disappear within 3 days of treatment. If no improvement is seen after 7 days the patient should see their GP.

18
Q

What further information is important when recommending imidazoles ?

A

they may damage latex condoms and diaphragms. Consequently, the effectiveness of such contraceptives may be reduced.
Topical imidazoles have a number of product license restrictions, which should be observed when recommending these products:
Product license restrictions: Imidazoles
Product license restriction < 16 or > 60 years of age
Suspected rationale: Thrush less common in these age groups
Has systemic symptoms Suggests infection from a cause other than thrush
Has symptoms that are not entirely consistent with a previous episode (e.g., discharge is coloured or malodourous; ulcers or blisters present) Suspect bacterial vaginosis or trichomoniasis
Has had two episodes in 6 months, and has not consulted her GP about the condition for more than 1 year Good practice because repeat infection may be due to misdiagnosis or predisposing risk factors
May be pregnant or is breastfeeding Safe in both pregnancy and breastfeeding, although thrush is more common during pregnancy; it is also important to rule out gestational diabetes
Has had a previous STD (or her partner has) Rule out STD
Has had abnormal menstrual bleeding or lower abdominal pain Symptoms not suggestive of thrush
Does not experience complete resolution of symptoms after 7 days of treatment Imidazoles are highly effective; continuing symptoms point to a misdiagnosis

19
Q

what further information is required for fluconazole ?

A

Fluconazole is a single oral dose treatment that can be taken at any time of the day. Fluconazole is generally well tolerated but side effects of nausea, abdominal discomfort, diarrhoea, headache and rash are most commonly experienced. There are a number of established clinically important drug interactions with fluconazole, including anticoagulants, ciclosporin, rifampicin, phenytoin and tacrolimus.

20
Q

what is Primary dysmenorrhoea ?

A

“period pain”

primary dysmenorrhoea (PD) is defined as menstrual pain without organic pathology
Overproduction of uterine prostaglandins E 2 and F 2 α are major contributory factors in causing painful cramps. 

Prostaglandin production is controlled by progesterone and, before menstruation starts, progesterone levels decrease, allowing prostaglandin production to increase; if overproduced, cramps occur.

21
Q

what is key info about the age, nature of pain, severity of pain and onset of pain with primary dysmenorrhoea ?

A

Age-PD is most common in adolescents and women in their early 20s. Secondary dysmenorrhoea usually affects women many years after the menarche, typically after the age of 30 years.

Nature of pain-A great deal of overlap exists between PD and secondary dysmenorrhoea, but generally PD results in cramping, whereas secondary causes are usually described as dull, continuous, diffuse pain.

Severity of pain- Pain is rarely severe in PD; the severity decreases with the onset of menses. Any patient presenting with moderate to severe lower abdominal pain should be referred.

Onset of pain- PD starts very shortly before or within 24 hours of the onset of menses and rarely lasts for more than 3 days. Pain associated with secondary dysmenorrhoea typically starts a few days before the onset of menses(bleeding).

22
Q

What are some clinical features of primary dysmenorrhea

A

A typical presentation of PD is of lower abdominal cramping pains shortly before (6 hours) and for 2 or possibly 3 days after the onset of bleeding. Commonly associated symptoms include fatigue, back pain, nausea and/or vomiting and diarrhoea. Pain may radiate to the back and inner thigh. It is typically associated with young women who have recently (6–12 months) started having regular periods. However, there may be a gap of months or years between menarche and the onset of symptoms. This is due to as many as 50% of women being anovulatory in the first year (and still 10% of women 8 years after the menarche). This is important to know because anovulatory cycles are usually pain free.

Anovulation is the lack or absence of ovulation (the release of an egg).

23
Q

Which OTC medication is best for treating Primary dysmenorrhea?

A

Nonsteroidal antiinflammatory drugs
The use of NSAIDs would be a logical choice because raised prostaglandin levels cause PD. In multiple clinical trials, they have been shown to be effective in 80% to 85% of women. A Cochrane review (Marjoribanks et al., 2015) concluded that NSAIDs were significantly more effective in relieving pain associated with PD compared. However, there was little evidence of superiority of any individual NSAID.

Low-dose combined oral contraceptives
Although not available OTC, oral contraceptives have been reported to be beneficial in treating PD. A Cochrane review (Wong et al., 2009) identified 10 trials and found improvements in pain compared with placebo (odds ratio [OR], 2.01; 95% CI, 1.32–3.08); therefore, if standard OTC treatment is not controlling symptoms adequately the patient should be referred, because contraceptives provide an alternative treatment option.

NSAIDs (ibuprofen or naproxen) should be used as first-line therapy unless the patient is contraindicated from using an NSAID. A trial of two to three cycles should be long enough to determine whether NSAID therapy is successful. If NSAIDs are ineffective or poorly tolerated, paracetamol should be offered.

24
Q

What contraindications would mean you shouldn’t give NSAIDs?

A
  • You have stomach problems, including heartburn.
  • You have high blood pressure, heart disease, liver cirrhosis, or kidney disease.
  • You have asthma.
  • You take a diuretic medication.
25
Q

What non pharmacological advise can be given to those suffering from primary dysmenorrhea?

A

Hot water bottles The application of warmth to the lower abdomen may confer some relief of the pain.

Exercise may be effective, although this is based on low- to moderate-quality evidence

possibly try:electrical nerve stimulation (TENS),

26
Q

What is menorrhagia

A

“heavy menstrual bleeding”

excessive menstrual blood loss over several consecutive cycles, which interferes with a woman’s physical, social, emotional and/or material quality of life.

27
Q

what are some reasons to refer when suspecting dysmenorrhea

A

Heavy or unexplained bleeding- Possibly dysfunctional uterine bleeding

Pain experienced days before menses
Pain that increases at the onset of menses
Women >30 years with new or worsening symptoms Possibly secondary dysmenorrhoea

Accompanying systemic symptoms, such as fever and malaise Suggests possible infection or pelvic inflammatory disease

Vaginal bleeding in postmenopausal women Suggests potentially more sinister cause, such as carcinoma Urgent same-day

28
Q

What is menorrhagia ?

A

Heavy menstrual bleeding or
is excessive menstrual blood loss over several consecutive cycles, which interferes with a woman’s physical, social, emotional and/or material quality of life.

29
Q

What are some key symptom specific questions to investigate with mennorhagia?

A

Timing of bleeding Symptoms that might suggest structural or pathological abnormality include bleeding at times other than at menses.

Effect on quality of life An assessment should be made to determine what effect menstrual bleeding is having on the patient.

Symptoms in relation to normal cycles Patients will show cycle to cycle variation in the amount of blood loss. It is important to discuss this normal variation with the patient and to determine from the patient whether the patient thinks that blood loss is within the normal range.

30
Q

What would be a reason to refer when suspecting Menorrhagia?

A

Intermenstrual bleeding, postcoital bleeding, pelvic pain Possibly a sign of cervical or endometrial cancer Urgent same-day referral

Treatment failure May indicate alternative diagnosis or more serious pathology As soon as practicable

31
Q

Which medications could cause Menorrhagia ?

A
Anticoagulants
Monoamine oxidase inhibitors
Phenothiazines
Steroids
Tamoxifen
Thyroid hormones
32
Q

What is the dose and possible side effects of tranexamic acid ?

A

Tranexamic acid (Cyklo-f) should be taken once bleeding starts. The dosage is two tablets three times a day for a maximum of 4 days. The dosage can be increased to two tablets, four times a day, with very heavy menstrual bleeding. The maximum dose is eight tablets (4 g) daily. Common side experienced are mild nausea, vomiting and diarrhoea.

As an OTC product, it is restricted to women with a history of heavy bleeding who have regular (21- to 35-day) cycles that show no more than 3 days of individual variability in cycle duration.

Treatment failure (National Institute for Health and Care Excellence guidance) If there is no improvement in symptoms within three menstrual cycles, the use of NSAIDs and/or tranexamic acid should be stopped.

33
Q

if both menorrhagia and menhorrhoea are present what would be the best course of action ?

A

If menorrhagia and HMB coexist with dysmenorrhoea, the use of NSAIDs should be preferred to tranexamic acid.