Womens health - Tx of vulvovaginal candidiasis, menstruation disorders, pregnancy and STI prevention

Vulvovaginal candidiasis (VVC)

Thick, white discharge (cottage cheese)

No odor

No change to vaginal pH (4-4.5)

Vaginal itching (primary symptom, sometimes even before discharge), irritation, erythema, dysuria

Organism: Candida albicans, candida galbrata, candida tropicalis, candida parapsilosis, candida krusei

bacterial vaginosis

NOT a candidate for self-care

Thin, white/grey discharge (water, foamy)

Fishy odor

Vaginal pH > 4.5

Vaginal irritation, dysuria may occur, but less than with VVC or trich

Imbalance of normal vaginal flora

Trichomaniasis

NOT a candidate for self-care

Frothy, yellow-green discharge

Has an odor

PH > 4.5

Vaginal itching, may have irritation, 50% may be asymptomatic initially

STI (Partner(s) MUST be treated)

Caused by trichomonas vaginalis

Risk factors for VVC

Pregnancy, uncontrolled diabetes, antibiotic use, immunosuppressive agent use, HIV infection, receptive oral sex, vaginal sponge use, COCs and estrogens may impact vaginal pH and susceptibility to candida

VVC: candidates for self-care

Uncomplicated disease

Infrequent episodes (3 or less per year, none in past 2 months)

Mild to moderate symptoms

At least 1 episode in the past diagnosed by a provider

VVC: self-care EXCLUSIONS

Age < 12 years

Pregnancy

Fever or pain in pelvic area/lower abdomen/back/shoulder

Use of corticosteroids, antineoplastics

Uncontrolled diabetes or HIV infection

Recurrent VVC (> 3/year, or 1 infection in last 2 months)

First VVC episode (without prescriber consultation)

VVC: treatment goals

Relief of symptoms

Eradication of infection

Reestablishment of normal vaginal flora

VVC: assessment

Symptom history

Medical history

Optional: self-testing of vaginal pH

- testing cannot occur until: 72 hours after use of vaginal preparations (spermicides, anti fungal), 48 hours after sexual intercourse or douching, 5 days after end of menses

PollEv: Which one of the following best describes symptoms and signs consistent with VVC?

Thick, white discharge with a vaginal pH of 4.2

VVC self-care: nonpharmacologic treatment

Eating yogurt containing live cultures

Discontinuing medication that may increase risk (if possible)

VVC self-care: intravaginal imidazoles

Preferred treatment: alter fungal cell membrane permeability

ADEs: vulvovaginal burning, itching, irritation

Interactions: unlikely due to low systemic absorption, warfarin interacts with miconazole vaginal suppositories

Also use anti-itch products as supportive care

OTC imidazoles for VVC: clotrimazole

1% cream: 1 applicatorful intravaginally at bedtime for 7 days

2% cream: 1 applicatorful intravaginally at bedtime for 3 days

OTC imidazoles for VVC: Miconazole

2% cream: 1 applicatorful intravaginally at bedtime for 7 days

4% cream: 1 applicatorful intravaginally at bedtime for 3 days

100mg vaginal suppository: 1 suppository intravaginally at bedtime for 7 days

200mg vaginal suppository: 1 suppository intravaginally at bedtime for 3 days

1200mg vaginal suppository: 1 suppository intravaginally at bedtime once

OTC imidazoles for VVC: Tioconazole

6.5% ointment: 1 applicatorful intravaginally at bedtime once

OTC imidazoles for VVC: side effects

Vulvovaginal burning (May be dose related)

Less common side effects: burning sensation experienced by sexual partner, polyuria, purity’s vulgar, vaginal discharge, vulvar pain/swelling

patient counseling for OTC imidazoles

Medical attention if symptoms: continue past 1 week beyond end of treatment, reoccur within 2 months, occur more than 3x in a year

Symptom relief may occur in2-3 days, but can take up to a week

Review instructions, side effects

No douching

Avoid tampons, intercourse, other vaginal preparations (if possible) while using

May weaken integrity of latex condoms and diaphragms

OTC options for external (vulvar) itching

May use imidazoles creams externally to help with itching

May consider anti-itch products (Vagisil, but potential risk of methemoglobinemia with benzocaine products)

PollEv: A patient reports with sx consistent with VVC. She has not had an infection in the past 6 months. She reports last time she was treated she found the Tx really painful. She used Monistat 1-day. Which one of the following is best to recommend today?

Clotrimazole 2% cream x3 days

Complementary treatment of VVC

lactobacillus use: probiotics, yogurt with live culture

Sodium bicarbonate sits bath

Tea tree oil vaginal suppository (for resistant infections)

Gentian violet (for resistant candida infections)

Boric acid(non-candida albicans)

dysmenorrhea

Painful menstruation

Primary: pain at the time of menstruation (develops 6-12 months after monarch)

Secondary: typically associated with pelvic pathology (symptoms 2+ years after menarche or pain occurs at times other than menses)

Causes of primary dysmenorrhea

Exact cause unknown

Prostaglandins and leukotrienes play significant roles

Ovulation →increases progesterone →increases arachidonic acid → prostaglandins and lekotrienes

Prostaglandins 2-4x higher in those with dysmenorrhea

Exclusions for self-care of dysmenorrhea

Severe dysmenorrhea and/or heavy bleeding

Symptoms inconsistent with primary dysmenorrhea (2+ years from menarche, pain at other times than onset of menses)

History of pelvic inflammatory disease, infertility, irregular menstrual cycles, endometriosis, ovarian cysts

Use of IUD

Allergy to aspirin or NSAIDs, NSAIDs intolerance

Use of warfarin, heparin, lithium

Active GI disease (PUD, GERD, UC)

Bleeding disorder

PollEv: Which of the following patients is not a candidate for self-care?

25 year-old reporting difficulty concentrating at work, bloating, and irritability. She is unsure when exactly t starts each month

Dysmenorrhea Treatment goals

Resolve/improve symptoms

Minimize disruption of usual activities

Dysmenorrhea Self-care: non-pharm treatment

Heat therapy

Sleep

Exercise

Smoking cessation/avoiding secondhand smoke

Dysmenorrhea self-care:pharmacological treatment

Aspirin

APAP

NSAIDs: Ibuprofen and naproxen

Start at onset of menses or pain (or 1-2 hours prior) schedule doses for first 48-72 hours of menses

OTC medications for dysmenorrhea: dosing

APAP: 650-1000mg q4-6h (max 4g/24h)

Aspirin: 650-1000mg q4-6h (max 4g/24h)

Ibuprofen: 200-400mg q4-6h (max 1200mg/24h)

Naproxen: 220-440mg, then 220mg q8-12h

Dysmenorrhea: Dietary supplements and complementary therapy

Fish oil, fenugreek, ginger, valerian, vitamin B1, vitamin D, zataria, zinc sulfate may be beneficial

- fish oil and vitamin D have the most robust evidence

- increased consumption of fish rich in omega 3 fatty acids may reduce symptoms (tuna, salmon, sardines, may also use supplements)

Vitamin D 600 units per day

Transcutaneous electrical nerve stimulation (TENS) decreases acute pain

Dysmenorrhea patient counseling

Avoid aspirin in children/adolescents recovering from chickenpox or influenza

Breast/chest feeding: avoid high dose aspirin

Educate on dysmenorrhea: primary is normal (don’t downplay pain), when to seek medical attention, NSAIDs preferred, how to use agents

Not all patients will respond to initial treatment

Excessive blood loss needs evaluated

“Typical”premenstrual symptoms

Mild physical or mood changed before menses that do not interfere with normal life function

Breast tenderness, bloating, backache, irritability

Premenstrual syndrome (PMS)

One physical or mood symptom during 5 days prior to menses. Resolves by about day 5 of cycle

Symptoms cause distress or impact Norma daily functioning

Premenstrual dysphoric disorder (PMDD)

5+ symptoms (physical mood)during last week of cycle

Symptoms: depression, anxiety, affective liability, or anger. Interferes with work, school, social activities, relationships.symptoms resolve after menses

Exclusions for self-care of PMS/PMDD

SeverPMS/PMDD

Uncertain pattern of symptoms (Unsure when they occur in relationship to menses)

Onset of symptoms coincident with use of oral contraception or MHT

Contraindications to dietary symptoms

PMS treatment goals

Increase understanding premenstrual disorders

Improve or resolve symptoms

- reduce impact on activities and relationships

- target: reduce symptoms by 50% or more

Non-pharm Tx of PMS

Aerobic exercise

Complex carbohydrates

Cognitive behavioral therapy

Limit sodium

Avoid caffeine

Avoid alcohol

Pharm Tx of PMS

Pyridoxine

Calcium and vitamin D

Magnesium

Vitamin E

NSAIDs

Diuretics

PMS: Pyridoxine

80-100mg daily

Targets mood

PMS: calcium

1000-1300 mg daily (dietary intake optimal)

Prevents development of symptoms; moo and physical symptoms

PMS: magnesium

360mg daily

Dietary intake optimal - Swiss chard, spinach, nuts, legumes whole-grain cereals

Targets mood

PMS: vitamin E

100mg daily

Targets Physical and mood symptoms

PMS: NSAIDs

Ibuprofen 200-400mg q4-6h

Naproxen 220-440mg BID

Targets physical symptoms but may also improve mod

Diuretics for PMS

Pamabrom (Aqua-ban, diuretic max): 50mg QID (q6h)

Caffeine (Diurex ultra): 100-200mg q3-4h

Diuretics for PMS: combination products

Pamabrom 25mg/APAP 500mg/pyrilamine maleate 15mg (pamprin multi-symptom)

Caffeine 50mg/magnesium saicylate 162.5mg (diurex water pills + pain relief)

Caffeine 65mg/APAP 250mg/aspirin 250mg (pamprin max)

Pamabrom 25mg/APAP 500mg (midol caffeine-free)

PMS: complementary therapy

Chasteberry may be helpful for mild-moderate symptoms (especially breast tenderness and mild mood symptoms)

- nausea, headache most common ADEs

- avoid if pregnant/lactating: caution with hormone-sensitive cancers

St John’s Wort may reduce anxiety: not really used, MANY interactions

ginkgo may improve breast pain, anxiety, irritability, depression

Saffron extract may reduce mood and physical symptoms

PMS: Pt counseling

PMS does not occur after menopause

Breast/chest feeding = avoid herbal products, diuretics

Encourage tracking of symptoms and cycle

Begin management 7-14 days before menses

May take several cycles to see improvement

Monitor impact on daily life

Contraceptive barrier methods

pregnancy and STI prevention: external condom, internal condom (Rx only)

Pregnancy prevention only: spermicide, sponge, diaphragm (Rx only), cervical cap (Rx only)

Polyisoprene condom

STI protection: yes

Degraded by oil-based lubricants/meds: yes

Use if latex allergy exists: yes

Contraceptive barrier methods: treatment goals

Prevent unintended pregnancy

Prevent STIs

Reduce risk of side effects

Latex condoms

STI protection: yes

Degraded by oil-based lubricants/meds: yes

use if latex allergy exists: NO

Lamb cecum condom

STI protection:NO

Degraded by oil-based lubricants/meds: NO

use if latex allergy exists: yes

Condoms: notes

Latex have best evidence for STI protection; recommend latex UNLESS and allergy exits (or oil-based lubricant/vaginal preparation used)

May be used with spermicide

Expiration date:3-5 years

Internal condoms

Prescription only

FC2 = available product

Outer ring, sheath/pouch that fits over vaginal mucosa, inner ring that secures sheath (fits over cervix)

Breakage rate lower than external, but slippage may be higher

May be inserted up to 2 hours before intercourse (works immediately)

Do not use with external condoms

Spermicide

Nonoxynol-9 available in US

Immediate onset except for suppository/film (about 15 minutes)

Duration = 1 hour

Vaginal foams distribute more evenly, but provide less lubrication

When used alone, insert full dose near cervix

Diaphragm/cap: fill device 1/3 full with spermicide

Reapply for each coital act

Low effectiveness when used alone

Vaginal sponge

Today sponge

Permeated with nonoxynol-9

May fit poorly in women with previous vaginal births

May insert up to 24 hours before intercourse

Must remain in place for 6 hours after intercourse

Do not use during menses

Avoid 6 weeks after giving birth

Do not. Use with sensitivity, anatomic abnormalities of vagina, or history of TSS

Diaphragm

Rx only

Use spermicide

Requires fitting by a clinician, except Cayla

Insert up to 2 hours before intercourse

Must leave in place for at least 6 hours after intercourse

- reapply if intercourse occurs within 6 hours of initial insertion; leave device in place

- take device out if >6h since initial insertion, reapply spermicide and reinsert

Cervical cap

Rx only

Reusable (Up to 1 year)

Each cap can be used for up to 48 hours

Use with spermicide

Dome and strap side face down, long brim goes into vagina first

May insert up to 6 hours before intercourse

May keep in place for at least 6 hours after intercourse

- may leave in for up to 48 hours

- reapply spermicide with each coital act

Other OTC contraceptives

Levonorgestrel emergency contraception pill (plan B)

Norgestrel progestin-only pill (Opill)

Fertility Awareness based (FAB) Methods (FABM)

Many options exist

Use a variety of techniques to determine fertile phase of menstrual cycle

Can be used to avoid pregnancy or determine optimal time for intercourse to try and become pregnant

Calendar method

Use menstrual cycle length to calculate fertile period

Record 6-12 cycle to predict range of fertile days

First fertile days = subtract 18 from number of days in shortest cycle

Last fertile day = subtract 11 from number of days in longest cycle

Best for cycles 26-32 days in length

Cervical mucus method

Detect changes in cervical mucus

Billings and TwoDay are examples

Cervical mucus becomes more prevalent, clear, stretchy(last day of detection of clear, stretchy mucus occurs within 1 day of ovulation)

Mucus thick and sticky or absent after ovulation

Fertile window:fist day mucus detected until 4 days after peak symptom

Symptothermal method

Combines cervical mucus tracing with basal body temperature (BBT) monitoring (cervical mucus detects onset of fertile window, BBT determines end)

BBT monitoring:

- chart temp upon waking, before getting out of bed

- at least 3 hours of uninterrupted sleep

- oral, rectal, vaginal temp: use same site every day

Natural Cycles FDA approved app

OTC contraception: patient counseling

No method of contraception is 100%effective

Every decision should be focused on the patient’s goals and desires

Know where accessible STI testing is available in your area

Pharmacists in many states can prescribe contraception

Can provide connections to many other resources

Knowledge of preventative are and other services is essential

Ovulation prediction (not for pregnancy prevention)

Ovulation predictor kits (OPK)

- detect LH surge

- urinary excretion detected

- LH increases 8-40 hours prior to ovulation

transdermal ovulation detection

- biosensor detects and measures Chloride ion fluctuation (Cl in sweat peaks 5 days before ovulation)

- another tracks skin temp, resting pulse rate, HR variability ratio, skin perfusion, breathing rate, movement, sleep

- wear devices when sleeping

Pregnancy test

Detect presence of hCG in urine

- detectable in urine 10-12 days of fertilization, but may take up to 21 days

False positives: miscarriage, given birth in last 8 weeks, hCG injections

False Negatives: testing too soon,ectopic pregnancy,molar pregnancy

Polyurethane condoms

STI production: yes

Degraded by oil-based lubricants/meds: no

Use if latex allergy exists: yes