prevention of STIs and pregnancy, vvvd, and menstrual disorders

can you treat sti otc

NO — require referral

what are complications of stis

Pelvic Inflammatory Disease (PID)

o Chronic Pelvic Pain

o Pregnancy Complications

o Malignancies

o Infertility

how long is fertile window

6 days

• ovulation = when egg is released

sti non pharm strategies

Abstain from sexual activity

• Avoid intercourse with a known infected partner

• Avoid intercourse with an individual having multiple sex partners

• Use a fresh condom with each episode of intercourse

• Seek a mutually monogamous relationship

with an uninfected partner

• Discuss partner's past sexual experience

Examine partner/self for genital lesions

• Avoid sexual activity involving direct contact with blood, semen, or other body fluids

• Avoid sharing sexual devices that come in

contact with semen or other body fluids

• Choose safe and effective methods to reduce risk of STIs

• Avoid sexual activity if signs/symptoms of an STI are present

• Consider vaccination for persons at high risk for a vaccine-preventable STI

what are the vax for STIs

• HPV—gardasil

• HBV— engerix, recombivax

ind for HPV— gardasil

11-12 yo up to 15 yos

schedule for HPV (gardisal) dosing

2 doses

• 6-12 months apart

ad eff of HPV vax (gardasil)

injection site rxn, malaise, syncope

what are the three HBV shots

engerix

recombivas

heplisav

what vax reduices cervical cancer risk

gardasil

what HPV subtypes most for cervical cancers? which for cervical cell changes?

16 and 18

• 6 and 11

which HBV vax for children

engerix

recombivax

• newborns,kids who didnt get

which HBV vax have 3 dose schedule

engerix

recombivax

• 0, 2 , 6-18 months

which HBV for adults specifcllay

heplisav-B

• 18+

  • if never got or at risk

schedule for heplisav

2 doses at 0 and 4 weeks

ad eff for HBV shots

injection site

what is difference between perfect use and typical use percents

typical use usually higher risk bc not always per box instructions

which things least effective?

fertility awareness, spermicide

whihc most effective?

implant, IUD, sterilzation (in m or w)

ad eff of M condoms

allergy— latex

counseling M condoms

• store in cool dry place

• check expiration date

• space at tip

  • check for tears

which kind of condom is NOT recommended

Nonoxynol-9 (spermicide)

treated condoms are discouraged b/c potential risk of irritation, increasing risk of infection

what lubricant NOT use with m condoms

noooo oils— makes less effective

• also includes lotions

what types of condoms NOT latex recommended

• Polyurethane

• Polyisoprene

• Lamb Cecum

not as effective as latex

do m/f condoms prevent preg and sti?

YES

do lamb cecum condoms prevent stis

NO

what is the one F condom product

FC2 (nitrile)

f condom counseling

Insert the closed end of the condom into the vaginal canal by pinching the closed end

and inserting as far as possible so that the inner ring is placed beyond the pubic bone

and the outer ring is outside the vagina (adjust to avoid twisting of the pouch)

• Removal and insertion of a new condom should follow any issues with use

• To remove the product after intercourse, twist the outer ring and pull gently.

• Discard in the trash can

spermicides MOA/what contain

surface-acting agents (nonoxynol-9 - US) immobilize and kill sperm

spermicides how effect preg/sti risk

• no efficiacy for sti

  • low eff for preg

vaginal spermicides CI

Vaginal anatomic abnormalities that prevent appropriate placement near the cervix

• Persons with known risk factors for STIs (monotherapy)

onset for spermicide gel/foam

immediate to 1 hour

spermicide supp/film onset

10-15 min up to 1 hour after application

• film is up to 3

how long can gel/foam be applied before for spermicide

up to 1 hour

sup/contracep how long before apply for spermicide

10-15 min

• film can be up to 3 hours prior

which spermicide can keep in fridge

suppository

what is the one product for contraceptive sponge

Today Sponge

• off market— online ppl still find it

contraceptive sponge MOA

sponge permeated with nonoxynol-9 serves as both a barrier to sperm entering the cervix as well as a spermicide, incapacitating and immobilizing sperm

does sponge prevent preg/sti?

ind for preg, NOT for sti

CI for contraceptive sponge

Spermicide allergy

• Anatomic abnormalities of the vagina

• History of Toxic Shock Syndrome (TSS)

sponge counseling

Remove from packaging and moisten with water to activate spermicide

• Insert convex side vaginally and place against the cervix

• May be inserted up to 24 hours prior to intercourse

• Retain the sponge in-place for at least 6 hours following intercourse

• Remove the sponge from the cervix and vaginal canal (after no longer than 30 hours total) by inserting a finger through the polyester loop and gently pulling

OPILL moa

suppresses ovulation in approximately half of the cycles in users, thickens the cervical mucus to inhibit sperm penetration, lowers midcycle luteinizing hormone (LH) and follicle-stimulating hormone (FSH) peaks, slows movement of the ovum through the fallopian tubes, and alters the endometrium

what does opill contain

norgestrel 0.075 (progestin)

CI for OPill (female pts)

Pregnancy

• History of breast cancer or other hormone sensitive cancer

• Liver disease

• Undiagnosed irregular vaginal bleeding

• Allergy to components

ad eff OPill

adverse effects: nausea, irregular vaginal bleeding, breast tenderness, headaches

OPill ddi

Antiepileptic therapies

• Rifamycin antibiotics

• Antiretroviral medications

• Bosentan

• St. John’s Wort

what does Opill ncrease risk of

ectopic preg— egg gets stuck in fallopian tube— med emergency

opill counseling— mostly TIME related

Take one pill by mouth at the same time each day

• If a pill is taken > 3 hours from the scheduled dose, a non-hormonal back-up contraceptive method must be used for at least 48 hours

• Any missed dose should be taken IMMEDIATELY, even if that means doubling doses

REFER for opill if…

New onset headaches

✓ Worsening of existing headaches

✓ Concerning vaginal bleeding

✓ Acute abdominal pain

✓ Signs of liver disease (e.g. jaundice

what are the four non-product contraceptive methods

• calendar method— based on cycle

• cerivcal mucus method—

• symptothermal method— basal body termometry is end of fertile period

• lactational amenorrhea method— breastfeeding prevents cycle

Calendar Method

Record cycles for 6-12

months

•First fertile day

calculated by

subtracting 18 from # of

days in shortest cycle

•Last fertile day

calculated by

subtracting 11 from # of

days in longest cycle

Cervical Mucus Method

5-6 days before

ovulation, rises in

estrogen cause cervical

mucus to increase in

quantity, elasticity, and

become clear

•Fertility is considered

high from the first day

of detection until 4

days after stretchy

mucus subsides

Symptothermal Method

Cervical mucus tracking identifies the onset of fertility

•Basal Body Thermometry (BBT) identifies the end of the fertile period

•Requires recording BBT first thing each AM

Lactational Amenorrhea Method

98% protection against pregnancy in the first 6 months following birth for women exclusively breastfeeding their infants and remain amenorrheic

•Not effective for pumping

method failure immediate actions

• apply spermicide (f durp)

• no “douching”

• can use emergency contraconception within 72-120 hours

what is THE OTC emergency conceptrative

Levonorgestrel

Levonorgestrel brands

Aftera, EContra EZ, EContra One-Step, My Choice, My

Way, New Day, Plan B One-Step, Take Action, etc

Levonorgestrel MOA

suppression of ovulation; other potential mechanisms: interference with transportation of sperm or egg, including thickening of cervical mucus

• won’t help if egg already released (=ovulation)

Levonorgestrel dosiing

• 1 tab PO w/in 72 hours— longer you wait lower efficiacy

• effciacy lowered by increased BMI

Levonorgestrel ad efff

nausea (25%), vomiting (5%), headaches, breast tenderness, menstrual changes, dizziness

Levonorgestrel what to do if pt throws up?

If it has been 1-2 hours since the dose was taken, advise th patient to take an OTC anti-emetic, wait an hour, and re-dose the levonorgestrel.

what to do if no cycle 21 days after taking Levonorgestrel

preg test

if pt takes oral contraceptives, when resume after Levonorgestrel taking

day AFTER taking Levonorgestrel

what are other emergency contraceptives

• ulipristal acetate

• copper IUC

• Levonorgestrel IUC

  • “yuzpe”— estrogen+progestin 0.6 mg, 2 doses in 12 hours

what is only VD that can be treated OTC?

Vulvovaginal Candidiasis (VVC)

what is vvc?

Overgrowth of Candida species in the vaginal canal, disrupting normal vaginal flora and

causing discomfort and vaginal discharge

risk factors of vvc?

increased vaginal pH – pregnancy, high dose combined oral contraceptives, estrogen therapy (only if high estrogen pills though)

▪ Poor glycemic control

▪ Antibiotic use— kills normal flora

▪ Immunosuppression – transplant, HIV, corticosteroid/antineoplastic/immunosuppressant use

▪ Sexual activity – onset, receptive oral sex, use of vaginal/intrauterine contraception

symptoms of vvc

• discharge

• irritation

• erythema—redness

• dysuria

vvc symptoms referral

abnormal bleeding

cramping

characteristics vvc

discharge is thick, white, no odor

• normal pH is 4-4.5

charactertiscs of discharge that are referral

Green/Yellow color

• Thin/Watery

consistency

• Fishy odor

• Vaginal pH > 4.5

red flags/limits of pH testing

Cannot use within 72 hours of vaginal products (including spermicides or antifungal products)

• Cannot be used within 48 hours of sexual intercourse or douching

• Cannot be used within 5 days after a menstrual period

history to ask for vvc

• symptoms before

• how frequent?

  • when last symptoms

red flags in history for vvc diagnosis

no history of vaginal symptoms

• > 3 infections/year

• Has had a vaginal infection in the past 2 months

what are onset questions for vvc? what are higher risk for symptoms?

May vary

• At higher risk with menstruation

• At higher risk with new onset of

regular sexual activity

• At higher risk with receptive oral sex

what are location vvc red flags

systemic!

pelvic/back pain

what are aggravating factors to counsel on

tight fitting clothes

non-absorbent clothing—not cotton

high glycemic foods

what is red flag for aggravting factors

intercourse

what can make vvc better (non pharm)

yogurt

sitz bath— Na Hco3— sit in bath 15 min PRN

loose clothing

medss that increase risk of VVC

estrogen therapy or contraccepties (if estrogen higher than 35 mcg)

antiboditics

corticosteriods

IUDs

immunosuppressants

what alleriges are ref for vvc

Azole antifungals

•Topical skin sensitivity

•Applicator materials

what CONDITIONS are referral for vvc

diabetes

organ transplant

HIV

preg

other vvc exclusions to care

• preg

• girls under 12 yo

• concurrent symptoms (ex systemic)

• meds that predispose to vvc

• recurrent (more than 3 infections a year or another infection in past 2 months)

• first episode

what is drug of choice for vvc

imidazole antifungals

imidazole antifungals for vvc moa

inhibit CYP450 enzymes in fungal cell membranes leading to a decrease in synthesis of ergosterol causing structural damage to the fungal cell membrane and increased permeability

imidazole antifungals for vvc ad eff

vulvovaginal burning, itching, irritation

cramps, headache, allergic rxn

imidazole antifungals formulations

creams, suppositories, tablets

list imidiazole formulations

• clotrimazole

• miconazole

  • tioconazole

clotrimazole for vvc general dosing

q day for 7 days; BID PRN

• higher concentrations are used for 3 days

clotrimazole brands

gyne-lotrimin, mycelex

miconazole nitrate brand name

monistat (add whatever — 3 cream, 7 cream, etc)

tioconazole brands

vagistat-1: strongest product

specifically monistat-1 day

when should relief of symptoms for vvc start? when refer?

• 24-48 hours— but keep using until therapy over

• refer after 7

counseling for vvc antifungals

• continue therapy for whole duration

• no tampons for up to 3 days after

• CAN use during cycle

• avoid other products and etc

what other products could use for vvc that don’t treat underlying cause

benzocain products, hydrocortizone, povidone/iodine, homeopathic

natural meds for vvc

• tea tree oil

• gentian violet

• boric acid

lactobacillus preparations— re-establish normal flora- can be like ingesting yogurt type beat

referrals for atrophic vaginitis

• first episode of post-menopausal bleeding

• severe symptoms require referral

  • if lubricant products do not help

s/s of atrophic vaginitis

• Dyspareunia: painful intercourse

• Vaginal irritation, dryness*, burning, itching

• Vaginal discharge

• Spotting

• discharge that is thin, watery, yellow, malodorous

• onset is associated with menopause

when refer for atrophic vaginitis if no improvement

7 days

what are brand lubricants used for atrophic vaginitis

astroglide, K-Y branded things, replens gel