Women's health COMMUNITY PHARMACY - PowerPoint Presentation

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Women's health

COMMUNITY PHARMACY Lecture 12

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Cystitis

Cystitis literally means inflammation of the bladder  in practice urethra and bladder.In men cystitis is uncommon because of the longer urethra, which provides a greater barrier to bacteria entering the bladder; fluid from the prostate gland also confers some antibacterial property.This is especially so in men under the age of 50. After 50 years of age urinary tract infections in men become more common due to prostate enlargement.

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Prevalence and epidemiology

Certain factors do increase the risk of a UTI: In young women, frequent or recent sexual activity. Previous episodes of cystitis. The use of diaphragms or spermicidal agents (contraceptive methods).Advancing age. Diabetes (can indicate poor diabetic control).Cystitis also affects pregnant women

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Recurrent cystitis

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

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Aetiology

The most common bacterial organisms implicated in cystitis are Escherichia coli (>80% of cases), Staphylococcus (up to 10%) and Proteus.Infection is caused, in the majority of cases, by the patient's own bowel flora that ascend the urethra from the perineal and perianal areas. Bacteria are thus transferred to the bladder where they proliferate. However, several studies have shown that up to 50% of women do not have positive urine cultures according to traditional criteria (> 105 bacteria per mL of urine), although they do have signs and symptoms of infection. These patients with 'low count bacteriuria' are classed as having a urinary tract infection.

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Arriving at a differential diagnosis

The majority of patients who present in the community pharmacy will have acute uncomplicated cystitis and accurately made a self-diagnosis. (Occurs in women who have normal structure and function of the genitourinary tract, with no risk factors, and a Community-Acquired M.O) The pharmacist's aims are to confirm a patient self-diagnosis, rule out upper urinary tract infection (pyelonephritis) and identify patients who are at risk of complications

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Clinical features of acute uncomplicated cystitis

Pain when passing urine and causes frequency, urgency, nocturia and haematuria. Patient might report only passing small amounts of urine, with pain worsening at the end of voiding urine. Symptoms usually start suddenly.Suprapubic discomfort is NOT common.Haematuria, although common, should be viewed with caution because it might indicate stones or a tumor. Such cases are best referred.

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Conditions to eliminateLikely conditions

PyelonephritisThe 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 patient will show signs of systemic infection such as fever, chills, flank or loin pain and possibly nausea and vomiting.

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Unlikely causes

Sexually transmitted diseases.Oestrogen deficiency (atrophic vaginitis).

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1- Sexually transmitted diseases

STD can be caused by a number of pathogens, for example Chlamydia trachomatis and Neisseria gonorrhoea. Symptoms are similar to acute uncomplicated cystitis but they tend to be more gradual in onset and last for a longer period of time. Pyuria (pus in the urine} is usually present.

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2- Oestrogen deficiency (atrophic vaginitis)

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 symptoms.

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Very unlikely causes

Medicine induced cystitisVaginitis

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1- Medicine induced cystitis

Non-steroidal anti-inflammatory agents (NSAIDs), allopurinol, danazol and cyclophosphamide have been shown to cause cystitis.

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2- Vaginitis

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

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medication

Alkalinising agentsCranberry juice

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1- Alkalinizing agents

Current OTC treatment is limited to products that contain alkalinising agents, namely sodium citrate, sodium bicarbonate and potassium citrate.Alkalinising agents are used to return the urine pH back to normal thus relieving symptoms of dysuria.

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2- Cranberry juice

Cranberry juice is a popular alternative remedy to treat and prevent urinary tract infections.Widespread use of cranberry juice has resulted in the identification of a possible interaction with warfarin,

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Women's healthVAGINAL DISCHARGE

COMMUNITY PHARMACY Lecture 13

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Background

Patients of any age can experience vaginal discharge. The three most common causes of vaginal discharge are bacterial vaginosis, vulvovaginal candidiasis (thrush) and Trichomoniasis. As THRUSH is the only condition that can be treated OTC, the text concentrates on differentiating this from other conditions.

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Prevalence and epidemiology

It has been reported that sexually active women have a 75% chance of experiencing at least one episode of thrush during their childbearing years, and half of these will have more than one episode. Most cases are acute attacks but some women will develop recurrent thrush defined as 4 or more attacks each year. The condition is uncommon in prepubertal girls unless they have been receiving antibiotics. In adolescents it is the second most common cause of vaginal discharge after bacterial vaginosis.

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Aetiology of thrush

The vagina naturally produces a watery discharge (physiological discharge), the amount and character of which varies depending on many factors, such as ovulation, pregnancy and concurrent medication. At the time of ovulation the discharge is greater in quantity and of higher viscosity. Normal secretions have no odour. The epithelium of the vagina contains glycogen, which is broken down by enzymes and bacteria (most notably lactobacilli) into acids. This maintains the low vaginal pH, creating an environment inhospitable to pathogens.

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Aetiology of thrush (continued)

The glycogen concentration is controlled by oestrogen production; therefore any changes in oestrogen levels will result in either increased or decreased glycogen concentrations.If oestrogen levels decrease glycogen concentration also decreases, giving rise to an increased vaginal pH and making the vagina more susceptible to opportunistic infection such as Candida albicans; 95% of thrush cases are caused by C. albicans. The remaining cases are caused by C. glabrata although symptoms are indistinguishable.

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Arriving at a differential diagnosis

Many patients will present with a self-diagnosis and the pharmacists' role will often be to confirm a self-diagnosis of thrush. This is very important as studies have shown that misdiagnosis by patients is common and can have important consequences because other conditions can lead to greater health concerns.

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Arriving at a differential diagnosis (continued)

For example, bacterial vaginosis has been linked with pelvic inflammatory disease (PID) and the preterm delivery of low-birth-weight infants and C. trachomatis can cause infertility. Symptoms of pruritus, burning and discharge are possible in all three common causes of vaginal discharge. Therefore no one symptom can be relied upon with 100% certainty to differentiate between thrush, bacterial vaginosis and trichomoniasis. However, certain symptom clusters are strongly suggestive of a particular diagnosis. Asking symptom specific questions will help the pharmacist to determine if referral is needed.

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Clinical features of thrush

The dominant feature of thrush is vulval itching. This is often accompanied with discharge (in up to 20% of patients}. The discharge has little or no odour and is curd- like (almost like cottage cheese). Symptoms are generally acute in onset.

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Conditions to eliminate

1- BACTERIAL VAGINOSISThis is the commonest cause of vaginal discharge, in a community pharmacy setting; it must be eliminated as a cause of symptoms, as treatment requires antibiotics (metronidazole 400 mg twice daily for 5 to 7 days). 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. Odour is worse after sexual intercourse and may worsen during menses. Itching and soreness are not usually present. CERTAIN RISK FACTORS include multiple sexual partners, low social class and race (more common in black women).

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Unlikely causes

1- Trichomoniasis2- Cystitis3- Atrophic vaginitis4- Medicine-induced thrush5- Diabetes6- Pregnancy7- Chemical and mechanical irritants

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Unlikely causes (continued)

1- TRICHOMONIASISTrichomoniasis, a protozoan infection 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, greenish-yellow and malodorous discharge accompanied by vulvar itching is typical. Other symptoms can include vaginal spotting, dysuria and urgency. Referral for metronidazole (400 mg bd for 5 to 7 days) is required.

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2- CYSTITISDysuria can affect up to one in three women with vaginal infection. However, the patient will often be able to sense that it is an external discomfort, rather than an internal discomfort located in the urethra or bladder that occurs with urinary tract infections.

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Unlikely causes (continued)

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3- ATROPHIC VAGINITISSymptoms 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 that require consideration prior to instigating treatment.

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Unlikely causes (continued)

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4- MEDICINE-INDUCED THRUSHBroad-spectrum antibiotics, corticosteroids, immunosuppressants and medication affecting the oestrogen status of the patient (oral contraceptives, Hormone replacement therapy (HRT), tamoxifen and raloxifene) can predispose women to thrush. It is therefore not unusual to see a patient prescribed at the same time as receiving antibiotics.

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Unlikely causes (continued)

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5- DIABETESPatients 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.

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Unlikely causes (continued)

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6- PREGNANCYHormonal 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 ore licensed indications do not allow sale to pregnant women and therefore these patients must be referred to the GP.

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Unlikely causes (continued)

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7- CHEMICAL AND MECHANICAL IRRITANTSIngredients in feminine hygiene products, for example, bubble baths, vaginal sprays and douches can precipitate attacks of thrush by altering vaginal pH. Condoms have also been found to irritate and alter the vaginal pH.

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Unlikely causes (continued)

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Recurrent thrush (four or more episodes per year)

After treatment a minority of patients will present with recurrent symptoms. This may be due to poor compliance, misdiagnosis, resistant strains of Candida, undiagnosed diabetes or the patient having a mixed infection. Such cases are outside the remit of community pharmacy and have shown to be difficult to treat. Often specialist care is needed through genitourinary medicine clinics.

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Evidence base for over-the-counter medication

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. Treatment choice will therefore be driven by patient acceptability and cost.

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Women's healthPrimary dysmenorrhoea (period pain)

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COMMUNITY PHARMACY

Lecture 14

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Primary dysmenorrhoea (period pain)

Menstruation spans the years between menarche to menopause.Typically this will last 30 to 40 years, starting around the age of 12 and ceasing around the age of 50.The menstrual cycle usually lasts 28 days but this varies and it can last anything between 21 and 45 days.

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Primary dysmenorrhoea (period pain)

Menstruation itself lasts between 3 and 7 days. Individuals can also exhibit differences in menstrual cycle length and blood flow.Dysmenorrhoea is usually categorised as primary or secondaryPrimary dysmenorrhoea (PD) is defined as menstrual pain without organic pathology Secondary dysmenorrhoea an identifiable pathologic condition can be identified.

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Prevalence and epidemiology

PD is very common in adolescents but exact prevalence rates vary due to differing definitions of dysmenorrhoea used in studies. However, it is likely to affect over 50% of women, and 7 to 15% of these women report symptoms severe enough to cause school and work absence.

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Aetiology

Overproduction of uterine prostaglandins E 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, and if overproduced cramps occur.

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Aetiology

Ovulation inhibition can also improve symptoms (by using the oral contraceptive pill) as it lessens the endometrial lining of the uterus Reducing menstrual fluid volume Reducing prostaglandin production.

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Arriving at a differential diagnosis

The main consideration of the community pharmacist is to exclude conditions that have a pathologic cause (secondary dysmenorrhoea).It is essential to take a detailed history of the patient's menstrual history as PD is a diagnosis based on exclusion.

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Clinical features of PD

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. There may be a gap of months or years between menarche and onset of symptoms as anovulatory cycles are usually pain free. 50% of women being anovulatory in the first year (and still 10% of women 8 years after the menarche).

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Conditions to eliminate Likely causes

Secondary dysmenorrhoea (e.g. endometriosis)Endometriosis simply means presence of endometrial tissue outside of the uterus.Reports suggest it may occur in up to 50% of menstruating women but many are asymptomatic.

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Secondary dysmenorrhoea (continued)

Any person over the age of 30 either presenting for the first time with dysmenorrhoea or has noticed worsening symptoms should be viewed with caution.Patients experience lower abdominal pain (aching rather than cramping), that usually starts 5 to 7 days before menstruation begins and can be constant and severe.

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The pain often peaks at the onset of menstruation. Referred pain into the back and down the thighs is also possible.

Secondary dysmenorrhoea (continued)

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Unlikely causes

Pelvic inflammatory diseaseDysfunctional uterine bleeding

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1- Pelvic inflammatory disease

PID is an important cause of infertility and ectopic pregnancy with many women being asymptomatic and only diagnosed during infertility investigation. It most commonly occurs in sexually active women aged between 15 and 24 years old.

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1- Pelvic inflammatory disease (continued)

Symptomatic cases show variable clinical presentation but it is associated with dull bilateral lower abdominal pain and dysmenorrhoea (with pain greatest premenstrually).Other symptoms such as fever, malaise, vaginal discharge, irregular menses and dyspareunia are often present.

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2- Dysfunctional uterine bleeding

Dysfunctional uterine bleeding is a non-specific medical term defined as abnormal uterine bleeding that is not due to structural or systemic disease and includes conditions such as amenorrhoea (lack of menstruation) and menorrhagia (heavy periods); with the majority of cases attributable to menorrhagia. The pharmacist should ask the patient if their periods are different than usual.

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Treatment

Non-steroidal anti-inflammatoriesHyoscine butylbromide (Buscopan)Low-dose combined oral contraceptivesOther treatment options

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1- Non-steroidal anti-inflammatories

The use of NSAIDs would be a logical choice because raised prostaglandin levels cause.IbuprofenNaproxenDiclofenac PotassiumGastric irritation is possible and ibuprofen can cause peptic ulcers or bronchospasm in asthmatics who have a history of hypersensitivity to aspirin or NSAIDs.NSAIDs (ibuprofen or naproxen) should be used as first line therapy unless the patient is contraindicated from using an NSAID.

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2- Hyoscine hydrobromide

Anticholinergic antispasmodic that relaxes the uterine smooth muscle (there is a lack of published evidence regarding its efficacy). Contraindicated in patients with narrow-angle glaucoma and myasthenia gravis Care should be exercised in patients whose conditions are characterized by tachycardia (for example, hyperthyroidism and cardiac problems).

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2- Hyoscine hydrobromide (continued)

Anticholinergic side effects such as dry mouth, visual disturbances and constipation can be experienced. Side effects are potentiated if it is given with tricyclic antidepressants, antihistamines.

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3- Low-dose combined oral contraceptives

oral contraceptives have been reported to be beneficial in treating PD. (Although not available OTC)Therefore, if standard OTC treatment is not controlling symptoms adequately the patient is best referred as contraceptives provide an alternative treatment option.

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4- Other treatment options

A number of alternative treatments have been tested in PD, most notably transcutaneous electrical nerve stimulation (TENS), acupuncture, exercise and dietary supplements. Of these, high frequency TENS appears to have the strongest body of evidence to support its use (wide range of dietary intervention is frequently recommended and includes vitamin B and E, fish oils and magnesium.

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COMMUNITY PHARMACY Lecture 15

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WOMEN'S HEALTH

PREMENSTRUAL SYNDROME (

PMS

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AND

HEAVY

MENSTRUAL BLEEDING

(MENORRHAGIA)

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Premenstrual syndrome

Premenstrual syndrome (PMS) is a broad term that encompasses a wide range of symptoms - both physical and psychological. Symptoms range from mild to very severe;severe symptoms, especially mood symptoms, affect approximately 5% of patients and can interfere with day to-day functioning and relationships. Most women tend to be over 30 years old.

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Aetiology

The precise pathophysiology of PMS is still unclear.A number of theories have been put forward, for example excess oestrogen, a lack of progesterone or ovarian function.Most researchers now believe PMS is a complex interaction between ovarian steroids and the neurotransmitters serotonin and GABA.

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Conditions to eliminate

Primary dysmenorrhoea:Key distinguishing features between PMS and primary dysmenorrhoea are the lack of behavioral and mood symptoms in primary dysmenorrhoea and the difference in timing of symptoms in relation to the menstrual cycle.

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Mental health disorders

Depression and anxiety are common mental health disorders, which often go undiagnosed and can be encountered by community pharmacists. Patients with PMS might experience symptoms similar to such conditions, namely low or sad mood, loss of interest or pleasure and prominent anxiety or worry.

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Other symptoms may include disturbed sleep and appetite, dry mouth and poor concentration.The symptoms are not cyclical and are not associated with other symptoms of PMS such as breast tenderness and bloatedness.

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medication

Vitamin or mineral supplementation, only calcium supplements have good evidence of effectiveness vitamin B6 have shown that overall symptoms of PMS improve over a period of 2 to 6 months and also help with behavioural/mood symptoms such as depression

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medication

CalciumVitamin B6 (pyridoxine)

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Calcium

Calcium supplementation should provide at least 1200 mg of elemental calcium per day.Calcium supplements can cause mild gastrointestinal disturbances such as nausea and flatulence. If the patient is taking tetracycline antibiotics or iron then a 2-hour gap should elapse between doses to avoid decreased absorption of the antibiotic or iron

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Vitamin B6 (pyridoxine)

There is no definitive dose of vitamin B6 required to alleviate symptoms of PMS. However, doses of up to 100 mg daily have been shown to help reduce symptoms. Side effects are extremely rare with doses at this level, although at higher doses it can cause numbness and peripheral neuropathy.

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Heavy menstrual bleeding(menorrhagia)

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menorrhagia

excessive menstrual blood loss which interferes with a woman's physical, social, emotional and/or material quality of life, and which can occur alone or in combination with other symptoms'.Excessive menses in an otherwise normal menstrual cycle that are associated with clots.

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Aetiology

Identifiable causes can result from uterine and pelvic pathology (e.g. fIbroids, polyps and carcinoma), systemic disorders (e.g. hypothyroidism) and iatrogenic factors (e.g. medication and intrauterine devices).

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Clinical features of HMB

The key symptom will be blood loss that is perceived to be greater than normal. The patient's bleeding pattern should be the same as during normal menses but heavier.

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Conditions to eliminate

Medicine-induced menstrual bleedingEndometrial and cervical carcinoma

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Medicine-induced menstrual bleeding

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Endometrial and cervical carcinoma

Characterized by inappropriate uterine bleeding, and usually occurs in postmenopausal women. Bleeding starts as slight and intermittent but over time becomes heavy and continuous. Discharge and pain are rare. Irregular bleeding between periods, is extremely significant and suggests pre-cancerous/cancer of the cervix.

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Practical prescribing and product selection

Tranexamic acid is an antifibrinolytic and stops the conversion of plasminogen to plasmin - an enzyme that digests fibrin and thus brings about dot dissolution. If the patient history suggests no abnormalities then drug treatment can be given.

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Tranexamic acid

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. Maximum dose is eight tablets (4 g) daily. Side effects are unusual (mild nausea, vomiting and diarrhoea).

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Tranexamic acid

The causal relationship of thromboembolic events and tranexamic acid is unclear and NICE guidance states that no increase in the overall rate of thrombosis has been identified with those taking tranexamic acid. Women at high risk of thrombosis have been excluded from pharmacy supply.

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