Week 23 - womens health

Question 1

Cystitis

Answer 1

Upper Urinary Tract Infection (UTI):
-Pyelonephritis -> infection/inflammation of
kidney(s)
Ureteritis -> infection/inflammation of
ureter(s)
Lower Urinary Tract Infection
(UTI):
-Cystitis -> infection/ inflammation of bladder
-Urethritis -> infection/inflammation of
urethra

Question 2

Cystitis overview

Answer 2

Terms ‘cystitis’ and ‘UTI’ often used interchangeably
‘Cystitis’ is used to describe a collection of urinary symptoms including dysuria (pain on urinating), frequency and urgency
Occurs when bacteria pass up along urethra and enter and multiply within the bladder-> causing inflammation
50% cases- no cause identified
->usually caused by bacteria from the GI tract, most commonly E.coli
Common in females, less common in males
->1 in 2 women affected in lifetime - shorter urethra than in males –> easier for bacteria to reach bladder

Question 3

Causes (cystitis)

Answer 3

-Side effect of some medication
-Post-menopausal changes to
vaginal lining
-Irritation from chemicals /
toiletries
-Sexual intercourse
-Wiping front to back after bowel motion
-Previous infection not clearing
-Uncontrolled diabetes

Question 4

Normal symptoms (cystitis)

Answer 4

-Signs of impending attack: itching or pricking sensation in urethra
-More frequent desire to pass urine
-Urgent need to pass urine throughout day and night
-Can only pass few burning, painful drops of urine (dysuria)
-Bladder may not feel completely empty after urinating
-Cloudy and strong-smelling urine: sign of bacterial infection

Question 5

Symptoms needing referral (cystitis)

Answer 5

-Haematuria (blood in urine)- may just be severe UTI, but could be kidney stone (blood with pain) or potentially bladder/kidney cancer (blood but no pain)
-Symptoms suggestive of upper UTI- pain in lower back, loin pain and tenderness, systemic symptoms such as fever, nausea and vomiting
-Abnormal vaginal discharge- local fungal or bacterial infection
-Cystitis symptoms & alteration in vaginal discharge & lower abdominal pain = potential chlamydia

Question 6

Cystitis – self-management (& preventing recurrence)

Answer 6

->Avoiding irritants -> no need to clean vagina with douches or deodorants- it self-cleans
-> Drink plenty of water -> traditional advice to drinks loads to encourage urination to flush out the bacteria, but this will cause discomfort -> best to drink normally to ensure hydration
->Empty bladder fully -> wait 20 seconds after passing urine then strain to empty final drops ->Leaning back may help, rather than the usual sitting posture
->Wipe front to back after a bowel motion
->Urinate after sexual intercourse
Will get better on its own in 3 days

Question 7

Alkalising agents - potassium citrate (cystitis)

Answer 7

Potassium citrate:
->Only to take stated dose of product - some cases of severe hyperkalaemia reported
->Contraindicated in patients taking medication which may also cause hyperkalaemia
->Potassium-sparing diuretics (e.g. spironolactone), ACE inhibitors
->Available as potassium citrate mixture- unpleasant taste, so dilute well with cold water
->Available as potassium citrate granules

Question 8

Cystitis - OTC management

Answer 8

Pain relief -> paracetamol and/or ibuprofen for up to 2 days - help with dysuria and any discomfort felt
Alkalising Products:
Potassium citrate or sodium citrate
Idea is that they make urine more alkaline to help with dysuria -> will cause symptomatic relief but not treat the cause (infection)

Question 9

Alkalising agents - sodium citrate (cystitis)

Answer 9

->Only take stated dose of product
->Contraindicated in patients with hypertension, heart disease or are pregnant
->Available as granules

Question 10

Cystitis - antibiotics

Answer 10

Some community pharmacies involved in a pilot scheme to test and treat UTIs within the pharmacy:
->Only able to treat uncomplicated UTIs in women aged 16-65 years
->Offer treatment if urine dipstick positive, or if symptoms strongly suggestive of UTI
Options:
Trimethoprim or Nitrofurantoin for 3 days -> would likely see these antibiotics on a prescription for UTIs too

Question 11

Cystitis - who to refer to GP

Answer 11

-Children
-Males
-Pregnant females
-Post-menopausal women- could be vaginal atrophy
-Catheterised patients
-Upper UTI symptoms
-Symptoms of systemic infection- fever/nausea/vomiting
-Haematuria or abnormal vaginal discharge
-Symptoms lasting longer than 2 days
-Recurrent cystitis- could be diabetes
-Failed treatment

Question 12

Vaginal candidiasis

Answer 12

Common yeast infection, known as thrush -> caused by Candida albicans
-Usually harmless, but can be uncomfortable and recurrent
NOT a sexually-transmitted infection (STI) -> however if infected the patient’s partner may also have it and need
treatment too

Question 13

Vaginal candidiasis - symptoms

Answer 13

-Itch (pruritis) around the vagina
->Intense and burning in nature
->Skin may be excoriated and raw from scratching if severe
->Check this is not due to using any new toiletries- could be dermatitis not thrush
-Vaginal discharge
->Normal= thin and watery, no smell
->Candidiasis= white/cream-coloured, thick like cottage cheese, sometimes an
unpleasant smell but not always
->Bacterial infection= yellow/green-coloured, strong foul odour
-Vaginal soreness
-Dysuria (pain on urination)
-Dyspareunia (painful sexual intercourse)

Question 14

Vaginal candidiasis - risk factors

Answer 14

-The yeast likes to grow in warm, moist conditions and develops if the balance of vaginal bacteria changes
-Age -> most common in women of childbearing age due to low vaginal pH and presence of glycogen
-Recently taken a course of antibiotics -> ‘good’ bacteria killed, allows opportunistic infections to grow like thrush
-Pregnancy - attributable to hormonal changes causing an increase of glycogen
-Diabetes (especially if poorly controlled)
-Weakened immune system
e.g., because of HIV or chemotherapy

Question 15

Prevention / self-help advice (vaginal candidiasis)

Answer 15

-Dry area properly after washing
-Avoid tight/nylon tights or underwear -> wear cotton underwear instead as more airy
-Avoid perfumed soaps and shower gels, vaginal douches and deodorants, and foam baths ->these strip away protective lining of vagina
-Wipe front to back after bowel motions
-Candida may be transferred from bowel

Question 16

Vaginal candidiasis - management

Answer 16

Manged with azole antifungals:
1. Topical vaginal cream
2. Pessary
3. Oral capsule
No one option better than other- all equally effective in managing
infection
->Usually decided based on patient preference
->Some OTC products available as a mixture of formulations -> to treat infection and provide symptomatic relief
->Offer treatment for free via Common Ailments Scheme

Question 17

CAS – vaginal candidiasis treatment

Answer 17

Option 1: External Vaginal Cream e.g., Clotrimazole 2% cream (Canesten®)
Option 2: Internal Vaginal Cream e.g., Clotrimazole 10% cream (Canesten®)
Option 3: Pessary e.g., Clotrimazole 500mg pessary (Canesten®)
Option 4: Oral capsule e.g., Fluconazole 150mg capsule (Canesten®)

Question 18

1 - External Vaginal Cream e.g., Clotrimazole 2% cream (Canesten®)

Answer 18

-Symptomatic relief of symptoms -> will need repeated applications to continue to get
relief, will need long course to cure infection fully
-Patient must be motivated to use
-Affects barrier contraception, so will need additional measures for 5 days

Question 19

2 - Internal Vaginal Cream e.g., Clotrimazole 10% cream (Canesten®)

Answer 19

-One-off dose –> at night for better retention
-Convenient, local Tx
-Formulation may be unacceptable for some
-Advice on how to administer with applicator
-Affects barrier contraception, so will need additional measures for 5 days; not to use on
period!

Question 20

3 - Pessary e.g., Clotrimazole 500mg pessary (Canesten®)

Answer 20

-One-off dose – at night (can repeat in 7 days)
-Convenient
-Formulation may be unacceptable for some
-Advice on how to administer with applicator
-Affects barrier contraception, so will need additional measures for 5 days; not to use on
period

Question 21

4 - Oral capsule e.g., Fluconazole 150mg capsule (Canesten®)

Answer 21

-One-off dose at any time of day
-Easy & acceptable formulation, but can take 24-48h to see benefit
-Several significant drug interactions
-Warfarin, statins, phenytoin, rifampicin, ciclosporin and theophylline
-No additional precautions needed

Question 22

Side effects

Answer 22

Clotrimazole products:
-Sometimes mild itching/burning sensation
-Rare: allergic reaction – stop using and seek Dr
Fluconazole:
-Mild and transient
-Likely GI side effects

Question 23

Candidiasis symptoms in males (candidal balanitis)

Answer 23

Male may catch infection from a female partner
-May be asymptomatic
Symptoms may include:
-Irritation, burning and redness around the head of the penis and under the foreskin
-White/cream-coloured discharge, thick in consistency like cottage cheese
-Discharge which may or may not have an unpleasant smell
-Difficulty pulling back the foreskin
-Will only usually treat partner if they are symptomatic (area up for debate)
-Management: Azole external cream BD for 6 days or oral fluconazole STAT

Question 24

Candidiasis - when to refer to GP

Answer 24

-First occurrence of symptoms- to confirm diagnosis
-Allergic to antifungals
-Pregnant or breast feeding
-Immunocompromised
-More than 2 thrush attacks in previous 6 months
-Previous exposure to STI or partner with STI
-Women aged under 16 or over
60
-Abnormal/irregular vaginal bleeding
-Blood-stained vaginal discharge // Foul smelling discharge
-Vulval or vaginal sores/blisters/ulcers
-Associated lower abdo pain or dysuria
-Adverse effects related to treatment(redness/ irritation/ swelling)
-No improvement within 7 days of treatment
->OTC licensing of candidiasis products reflect these referral criteria

Question 25

Periods

Answer 25

2 issues can be managed OTC: 1)Dysmenorrhoea 2)Menorrhagia

Question 26

Dysmenorrhoea

Answer 26

-Period pain Symptoms: -Cramping lower abdominal pain beginning day before bleeding starts ->If cramping pain is mid-cycle this is ovulation pain not period pain ->1 in 2 women suffer while 1 in 10 have severe symptoms requiring time off work / school -Peak incidence: 17-25 years of age -Usually few years after initially starting period (menarche) as ovulation doesn’t happen within first few months/years of menstruation

Question 27

Menorrhagia

Answer 27

-Heavy menstrual bleeding ->Technically classed as over 60mL blood loss per cycle (normal is 30-40) ‘heavy’ is subjective and determined by patient

Question 28

Primary dysmenorrhoea - management

Answer 28

->Non - drug management ->Drug managment

Question 29

Non-drug management

Answer 29

-Exercise (endorphins help) -TENS machine (alters ability to receive/perceive pain signals) -Acupuncture -Locally applied low-level heat (heat pads or even warm bath) -Supplements like fish oil or vitamin B- evidence is patchy

Question 30

Drug management

Answer 30

-Simple analgesia (NSAIDs best) -Hyoscine butylbromide (antispasmodic)– evidence is patchy -Caffeine (enhance analgesic effect)

Question 31

Dysmenorrhoea- NSAIDs

Answer 31

-Pain of dysmenorrhoea linked to increased prostaglandin activity -NSAIDs block synthesis of prostaglandins -> why they are effective in treating period pains

Question 32

Dysmenorrhoea- NSAIDs

Answer 32

-Ibuprofen: 200-400mg TDS with food -Naproxen: 500mg initially then 250mg 6-8 hours later if needed. Max 3 days! -> treatment can be supplied OTC Not appropriate if allergy (incl. aspirin), asthma or GI bleeds ->Could offer these patients paracetamol - doesn’t work on prostaglandins but may have some benefit Take painkillers regularly for 2-3 days each period -> not just PRN

Question 33

Menorrhagia- tranexamic acid

Answer 33

Type of antifibrinolytic drug Inhibits fibrinolysis -> increased clot formation -> reduced blood loss Only take once heavy bleeding has started (not before) Two x 500mg tablets TDS until symptoms alleviated -> for a maximum of 4 days OTC If bleeding very heavily can increased to a maximum of eight tablets a day (4g daily) Can repeat for each menstrual cycle

Question 34

Menorrhagia – when to refer to GP

Answer 34

-Women under 18 or over 45 years -Treatment failure -Breastfeeding -Obese or diabetic patients (could be PCOS) -Signs of iron-deficiency: fatigue, pallor -Signs of endometrial cancer: irregular/prolonged bleeding, bleeding in between periods -Signs of cervical cancer: bleeding between periods/after sex/after menopause -Contraindications to tx: Hx of clots, convulsions, on warfarin, on COC

Question 35

Oral contraception

Answer 35

Majority of oral contraceptives are POM -P med: desogestrel 75mg tablets (Lovima® and Hana®) -Type of progesterone-only pill (POP) ->Can be 99% effective in preventing pregnancy

Question 36

Must only sell:

Answer 36

-As a form of contraception (i.e. no other indication) -To women of childbearing age (under 18s to be supplied based on clinical judgement as no info on safety or efficacy in SPC) ->Dose: 1 tablet daily (no break between packs)

Question 37

Contraindications (oral contraceptive)

Answer 37

Blood clots, cancer, soya/peanut allergy (Lovima® contains soya bean oil, so avoid in both allergy types)

Question 38

Interactions (oral contraceptive)

Answer 38

Refer anyone with clinically relevant interaction (e.g. antiepileptics)

Question 39

When to start taking

Answer 39

Take on Day 1 of period, otherwise will need additional barrier contraception if starting on days 2-5 ->RPS has guidance on when to start in other situation, e.g. after EHC, after childbirth, after miscarriage, if switching between contraceptives

Question 40

Missed pills (oral contraceptive)

Answer 40

Under 12 hours: take ASAP and continue as normal ->Over 12 hours: protection lost, take ASAP and use barrier methods for 7 days -> may need EHC

Question 41

Side effects (oral contraception)

Answer 41

Common: irregular periods, altered mood, headaches, nausea, weight changes ->If vomits within 3-4 hours, follow missed pill rules

Question 42

Oral contraceptives -> supply

Answer 42

First supply - up to 3 months can be supplied ->Repeat supply - up to 12 months can be supplied ->Women under 18 - up to 3 months can be supplied Only OK to supply if: -Not pregnant -No bleeding between period/after sex -No health conditions -No allergies -Not taking other meds ->Otherwise, refer

Question 43

Emergency Hormonal Contraception (EHC)

Answer 43

Also known as the morning after pill ->Need to handle queries for EHC sensitively in a private area 2 products licensed OTC: ->Levonorgestrel 1500 microgram tablet (Levonelle®) ->Ulipristal acetate 30mg tablet (Ella One®)

Question 44

Emergency hormonal contraception - OTC

Answer 44

Can sell OTC to patients aged 16+ ->Some areas have PGDs where it can be supplied for free under locally agreed protocol (usually from 13 years Next period may be sooner, later or on time -> if lighter, shorter or 3 days later than usual, need to take pregnancy test

Question 45

EHC- What do you need to know to supply safely?

Answer 45

-What happened? -When did it happen? -Is there a chance that they’re they already pregnant?

Question 46

What happened? (EHC)

Answer 46

-Failure of barrier contraceptive method (e.g. condom splits) -Missed contraceptive pills (exact number of missed days varies between pill types- refer to FFPRGC 2006 guidance) -Unprotected sex

Question 47

When did it happen? (EHC)

Answer 47

-Careful when wording this question & explain why asking -EHC most effective the sooner it is taken after unprotected sex -The answer will influence what you can supply them

Question 48

Is there a chance that they’re they already pregnant? (EHC)

Answer 48

If so, EHC won’t work and they need referral -Was last period normal / lighter / later? -Any other episodes of unprotected sex during this cycle?

Question 49

Ulipristal acetate

Answer 49

When to use? ->Within 120 hours (5 days) of unprotected sexual intercourse What if patient weights over 70kg? ->Can still supply What to do if vomits after dose? ->If occurs within 3 hours, can take another one ASAP Clinical conditions: ->Avoid in severe liver impairment and severe asthma using glucocorticoids Interactions: ->Avoid in those taking enzyme inducers (e.g. carbamazepine, phenytoin, rifampicin, St John’s wort) Breastfeeding: ->Do not breast feed for 7 days after dose Contraception: ->Can reduce efficacy of contraceptive pill, so use barrier method of contraception until next period

Question 50

Levonorgestrel

Answer 50

When to use? ->Within 72 hours (3 days) of unprotected sexual intercourse What if patient weights over 70kg? ->May be less effective -> must inform patient of risk - offer alternative - some evidence for double-dosing -> this is off- label and not recommended What to do if vomits after dose? ->If occurs within 3 hours can take another one ASAP Clinical conditions: ->Avoid in severe liver impairment, inflammation of fallopian tubes and severe malabsorption syndromes (e.g. Crohn’s) Interactions: ->Avoid in those taking enzyme inducers (e.g. carbamazepine, phenytoin, rifampicin, St John’s wort) -> may also increase level of ciclosporin - avoid Breastfeeding: ->Not harmful - but take immediately after breast feed Contraception: ->Can continue with regular contraceptives

Question 51

EHC if cannot supply

Answer 51

If cannot sell / not suitable to do so -> refer to local sexual health clinic for insertion of copper intrauterine device (IUD) – effective for up to 5 days after unprotected sex (most effective method)

Question 52

EHC - other points to consider

Answer 52

Supply to a patient representative -> can be supplied if deemed a genuine request and treatment is clinically appropriate (should telephone patient if rep can’t fully answer questions needed to make a safe supply) Moral beliefs -> should not refuse supply based on your own religious or moral beliefs, need to put patient first, especially as referrals not always possible Advance supply of EHC -> can be supplied in advance of unprotected sex or in case barrier fails, need to ensure that it’s still clinically appropriate, that patient is competent and is going to use it appropriately Long-term contraception and sexual health -> meant for emergency use, not as a long-term contraception, may be appropriate to discuss long-term contraception options at point of supply EHC doesn’t protect against STIs -> may need referring to sexual health clinic

Question 53

EHC – other points to consider

Answer 53

Vulnerable adults and children -> cannot sell product to under 16s, but may fall under local PGD ->Should be aware of issues such as non-consensual intercourse, child protection issues, vulnerable adults, consent and confidentiality ->RPS and Dept of Health have guides with practical advice on managing vulnerable adults, e.g. if domestic abuse is suspected Also have advice on how to report safeguarding concerns -> children under 13 deemed too young to consent and should be reported to social services

Question 54

Menopause

Answer 54

Biological state when woman has not had period for 12 consecutive months ->Ovaries stop maturing eggs & secreting oestrogen + progesterone ->Menstruation stops + can’t conceive -Vasomotor symptoms: hot flushes, sweats -Musculoskeletal symptoms: joint and muscle pain -Urogenital symptoms: vaginal dryness, urinary frequency, UTIs -Other symptoms: low mood, reduced libido

Question 55

Menopause - self-management

Answer 55

Hot flushes & night sweats: ->Keeping cool- light clothing, cool showers, using fans ->Keep bedroom cool at night ->Avoid triggers- caffeine, spicy food, smoking, alcohol ->Exercise & lose weight if overweight Mood changes: ->Plenty of rest, take exercise, relaxing activities such as yoga Weak bones (low oestrogen = increases risk of osteoporosis) ->Regular weight-bearing and resistance exercise, healthy diet with sources of calcium, getting some sunlight ->Stop smoking, less alcohol & calcium/vit D supplements

Question 56

Menopause – OTC management

Answer 56

Options are limited – usually POM ->Only thing that can be managed OTC is vaginal atrophy Symptoms of vaginal atrophy: vaginal dryness, soreness, itching, burning, irritation, painful sexual intercourse Symptomatic relief: Vaginal dryness- OTC vaginal moisturisers and lubricants (Vagisil®,Vagisan®) Treatment: Gina® (estradiol) intravaginal tablets

Question 57

New! Estradiol tablets (P medicine)

Answer 57

Brand: Gina® Form: 10 microgram vaginal tablets -> use applicator to insert into vagina -> DO NOT TAKE ORALLY!! Dose Initiation: 1 tablet inserted intravaginally daily for two weeks Dose Maintenance: 1 tablet inserted intravaginally twice a week -> try to use for shortest effective duration Manage expectations: takes 8-12 weeks to feel full benefit Common side effects: headache, stomach pain, vaginal bleeding / discharge / discomfort STOP immediately if: signs of allergy, blood clot, jaundice, hypertension symptoms

Question 58

Menopause – when to refer to GP?

Answer 58

-Contraindications to treatment -Experienced side effects -Symptoms don’t sound like vaginal atrophy -Hx of endometriosis -Already on systemic HRT / using a different local HRT -Anyone who doesn’t fit selling criteria (e.g. women under 50, last period was less than 1 year ago etc) -If symptoms worsen/don’t improve after 7 weeks Tx Red flag symptoms: -Vaginal – undiagnosed bleeding, smelly/unusual discharge,severe itching -Vulva – changes to look / texture / colour, soreness, rashes, lumps, swelling -Pain – pelvic, when passing urine -Lower abdominal – pain, bloating, swelling

Question 59

Selling Estradiol OTC

Answer 59

When can you sell: treatment of vaginal atrophy symptoms due to oestrogen deficiency- ->In postmenopausal woman aged over 50 who haven’t had a period for at least one year ->Can be used in woman who have or don’t have a womb Quantity: no limits, but good practice for patient to be reviewed every 3 months if taking these Contraindications: liver disease, current/recent heart attack or ischaemic stoke, breast / ovarian / endometrial cancer, DVT/PE, untreated vaginal infections -> treat vaginal infection first if possible

Question 60

What about herbal remedies?

Answer 60

NICE guidelines actually suggest the use of herbal remedies to help with vasomotor symptoms: ->Black cohosh ->Isoflavones But states that the following should be explained: ->Some evidence for it, but not robust ->Multiple preparations are available and their safety is uncertain ->Different preparations may vary ->Interactions with other medicines have been reported