combined self care exam 2 cards

True/False: vaginal symptoms can be present with anyone with vaginas REGARDLESS OF

• sexual orientation (straight, homosexual)

• sexual activity (active or not)

• menopause status

true

Approximately 65% of people experiencing vaginal symptoms have either

1. bacterial vaginosis (BV)

2. vulvovaginal cadidiasis (VVC)

3. trichomonaisis

can infections be polymictobial?

yes

What are some NORMAL bacteria/ fungus that live in the vagina, what makes them beneficial?

• lactobacillus —> beneficial bc/ maintains pH at 4 to 4.5 protecting vagina from infection from other bacteria

• gardnerella vaginalis

• prevotella

• bacteroids

• moviluncus (imbalance in this flora can lead to disease states)

• candida albicans (fungi)

how do decreased estrogen (can be caused by menopause) levels effect the normal bacteria in the vagina?

decreased estrogen —> changes vag flora —> inc pH —> vaginal atrophy

Normal Vaginal Discharge (leukorrhea): protects against bacteria

• odorless

• clear/ white

• viscous or sticky

• NORMAL increases can occur during ovulation, pregnancy, after menstruation

• normally discharge does NOT lead to irritation, itching, or burning?

• vary w vag irritants, barrier contraceptive products, tampons

bacterial vaginosis

polymicrobial infection due to vaginal flora imbalance

• inc

  • gardnella vaginalis

  • anaerobes

  • mycoplasma hominis

• dec

  • lactobacillus

responsible for 30% of vaginal symptoms

risk factors for bacterial vaginosis

• multiple/new sexual partners (can happen even w/o sex)

• sex

• IUD

• prev pregnancy

• douching (washing w water)

• tobacco

does your partner ALSO need to be treated if YOU have bacterial vaginosis?

NO

Bacterial Vaginosis: signs/symptoms

• ph over 4.5 (normally 4-4.5)

• discharge thin, white/grey, foamy w fishy odor —> gets worse after sex or menstruation

  • (IF NO ODOR THEN NOT BACTERIAL)

  • fishy odor is a must

• unlikely: vaginal irritation / dysuria (painful pee)

  • more in VVC & trichomoniasis

bacterial vaginosis complications

• pelvic inflammatory dx (PID)

  • pathogens go up repro tract into uterus

  • different treatment from uncomplicated bacterial vaginosis

• preterm birth

• transmission of HIV

can bacterial vaginosis be treated OTC or do you have to have a prescription?

MUST be prescription CANNOT treat OTC

• clindamycin

• metronidazole

• topical or oral (5g q night for 5 days)

• not mandated for partners

Trichomonas- STI caused by vaginosis parasite

• responsible for 15-20% of vaginal infections

• most commonly in

  • black and hispanic communities

  • low socioeconomic

  • hx of incarcerations

trichomoniasis risk factors

• multiple/new sex partners

• not using barrier contraceptives

• other STIs

Trichomonias Signs/ Symptoms:

• pH over 4.5

• FROTHY, yellow-green (discolored), smelly discharge

• dysuria/vaginal irritation

• symptoms usually not right away- most people feel symptoms after 6 months if they feel any at all

  • most men DO NOT feel symptoms but are reservoirs for infections

Hallmark = strawberry cervix- little polyps in cervix

trichomoniasis complications

• PID

• easier transmission of HIV

• low-birth-weight infants

• tubal infertility (relating to fallopian tube dysf)

Can trichomoniasis be treated OTC or does it HAVE to be prescription?

NO OTC products, MUST be treated with prescription

What are the prescription treatments that are available for treating trichomoniasis?

• metronidale

• tinidazole

Should partners of patients with trichomonias also be treated with either metronidazole or tinidazole?

YES (individuals should avoid sexual intercourse until they and all partners have completed treatmenrt and are asymptomatic)

How are metronidazole and tinazole taken for trichomoniasis?

metronidazole = 1st line = 500mg oral 2x a day for 7 days

tinazole = one time dose

Vulvovaginal Candidaisis (20-25% of vag infections (nearly 75% have at least one VVC inf)

• yeast or monilasis infection- fungal, specifically candida

  • albicans- uncomplicated

  • glabrata- comp

  • topicalis- comp

  • parapsilosis- comp

  • krusei)- comp

tx depends on type of candida

What are some risk factors for vulvovaginal candidiasis (VVC)?

• pregnancy

• drugs (antibiotics, immunosupressants, estrogen)

• diabetes

• tight fitting, nonabsorbent clothing or pantyhose

Vulvovaginal Candidiasis (VVC) s/s

• normal pH

• dysuria common

hallmark= thick, white ‘cottage cheese’ discharge w (bready) or without odor

is vulvovaginal candidiasis (VCC) treatment available by prescription, or can it also be given OTC?

CAN TREAT OTC if

• mild-moderate classic symptoms

• infrequent vaginal symptoms

• antibiotic associated VVC

after tx OTC, medical eval should be done within 1 week or if recurrence within 2 mo

refer if any of these self-care exclusions

• pregnancy

• less than 12y

• diabetes

• HIV inf

• taking corticosteroids or antineoplastics (predisposing)

• warfarin

• recurrent (over 3 infections/yr or prev inf 2 months ago)

• first VVC episode

• concurrent:

  • fever

  • pain in pelvic area/lower abdomen/back/shoulder

what are the goals of treating Vulvovaginal candidasis?

• relieve symtpoms

• eradicate infection

• re-estbalish normal flora

non-pharmacologic tx of Vulvovaginal candidiasis?

dietary modification

• decrease sugar + refined carbohydrates —> stop feeding fungi and pathogens

• eat yoghurt containing live cultures (provides good bacteria + restores normal flora)

pharmacologic tx VVC

imidazole antifungals- ORAL only

• alter fungal MEMBRANE (dec ergosterol synthesis)

• inhibit CYP450 enzymes in the fungal membrane

• oral- fluconazole 150 mg one time

  • q72h if complicated

• creams/ointments/suppositories

  • 
    

NOT likely to have drug interactions, but be careful w/ warfarin, corticosteroids, and antineoplastics)

What are examples of creams/ointments that are available for Vulvovaginal Candidasis?

1. Clotrimazole 1% cream

2. Clotrimazole 2% cream

3. Miconazole nitrate 2% (Monistat 7)

4. Miconazole nitrate 4% (Monistat 3)

5. Tioconazole 6.5% (Vagistat 1 + Monistat -1 Day)

How often do you take the following Vulvovaginal candidasis creams?

3. Clotrimazole 1% cream

• into vagina for 7 days + vulva twice daily PRN for itching

1. Clotrimazole 2% cream

• for 3 days

3. Miconazole nitrate 2% (Monistat 7)

• into vagina for 7 days + vulva twice daily PRN for itching

3. Miconazole nitrate 4% (Monistat 3)

• qd for 3 days

• apply to vulva BID prn for itching

5. Tioconazole 6.5% (Vagistat 1 + Monistat -1)

• insert ointment into vag qd for 1 day

What are the combo packs available for Vuvlovaginal Candidiasis?

1. Monistat 1 combo (day or night)

• miconazole 2% cream + miconazole 1200mg suppository

• suppository for 1 day + cream twixe daily prn for up to 7 days

1. Monistat 3 or Vagistat 3:

• miconazole 2% cream + miconozole 200mg suppositories

• suppository for 3 days + cream twixe daily prn for up to 7 days

suppositories application

Vaginal Application

1. Wash hands

2. Open pouch containing suppository

3. Insert the suppository in wider end of the applicator

4. Insert applicator into vagina as far as it will comfortably go (standing or lying down)

5. Push the plunger all the way in as far back into the vagina as possible

6. Remove applicator from the vagina

7. can applicators be reusable- yes, after washing w warm soap & water

8. lie down as soon as possible after inserting the suppository

Vulva Application (External) ٫ for creams that come in combination packs

1. Wash hands

2. Squeeze a small amount from the tube

3. Apply to itchy/irritated areas up to 2x daily

do miconazole single dose and 7 day treatments have similar cure rates? yes

which one has faster symptoms relief?- single dose

are there similar results between miconazole, clotrimazole, and ticonazole?- yes

WHICH treatment is recommended by CDC for pregnancy and diabetes?- 7 day

YES

single day

yes

7 DAY IS RECOMMENDED FOR DIABETES AND PREGNANCY

General Counseling for vulvovaginal candidiasis treatment":

• Start treatment at any time of day or before bed (preferred)

• lying down will reduce leakage of product from the vagina

• burning may occur

• Should you continue to use product for the full extent even if your symptoms have improved?- yes, to 3 or 7 day

• Should you continue to use product even during menstruation?- yes

• Consider avoiding tampons to avoid impaired absorption

• Avoid sex

• Can antifungals irritate partners- Yes

• Antifungal vaginal formulations may damage latex condoms

• spermicides/diaphragms may irritate the local area

What are some complementary/ alternative therapies alongside miconazole/ tioconazole / clotrimaziole for vulvovaginal candidiasis?

Nonspecific

• adjunctive for specific symptoms

• not typically recommended

• contains benzocaine, hydrocortisone, povidone-iodine (not recommended)

alternative therapies

• lactobacillicus preparations (probiotics)

• tea tree oil supp

• sodium bicarbonate sitz bath

• gentian voilet soaked tampons

• boric acid - 600mg vaginal capsule x 14 days (used in those who do not respond with antifungals BUT avoid in pregnancies)

Vulvovaginal Candidasis Monitoring:

• symptoms could lessen within 2~3 days and resolve in 1wk

• length of treatment DOES NOT correspond w resolution time

• patient should call health care provider if different symptoms occur

Atrophic Vaginitis:

• vaginal atrophy due to decreased estrogen

• 45% of postmenopausal individuals experience symptomatic atrophic vaginitis

• occur during menopause, postpartum period, and breastfeeding (vaginal epithelium thins and lubrication declines)

• may occur in individuals w decreased ovarian estrogen production (radiation + chemotherapy)

what are some medications that can cause atrophic vaginitis?

• antiestrogenic drugs

• aromatase inhibitors

• gonadotropic-releasing hormones

What are signs and symptom of atrophic vaginitis?

• dyspareunia - painful sex bc/ of lack of lubrication

• vaginal irritation - dryness, burning, itching

• thin watery bloody, yellow discharge- smelly

• spotting/blood (go to doctor to make sure its not cancer)

what are the goals of therapy for atrophic vaginitis?

• reduce or eliminate symptoms

• provide lubrication to vaginal tissue if dryness is the cause of pain

What are some non-pharmacological treatments for atrophic vaginitis?

AVOID IRRITANTS

• powders/perfumes

• spermicides

• panty liners

VAGINAL LUBRICANTS:

• temporarily moisten vaginal tissues

• only water-soluble lubricants can be used with latex condoms/diaphrams

• applied intravaginally, vulva, or partners penis

What are two kinds of lubricants that are out there? Which kind should you use and which should you avoid?

1. water/silicone based lubricants - RECOMMENDED

   • Improves symptoms of vaginal dryness

   • relieves burning + itching

   • facilitates intercourse + reduce pain

2. oil/ petrolatum- based - NOT RECOMMENDED

• may damage latex condoms and impair contraceptive methods

What is an example of a home test kit that can be used to test if you are going through a vaginal infection?

pH test (if candidiasis/yeast then NO change in pH —> if change then bacterial vaginosis or trichomoniasis)

AZO test = vaginal pH test

Vaginal Douching:

• maintain hygiene of the vagina

• ADEs

  • disruption of vaginal flora

  • allergic reactions

  • pelvic inflammatory disease (PID) + ectopic pregnancy

You should avoid douching at least __ hrs after sexual intercourse when vaginal spermicide is used

6-8 h

Which infections CANNOT be treated over the counter?

Which CAN be treated OTC?

Who is excluded from OTC treatment for this type of infection?

• bacterial vaginosis + trichomoniasis CANNOT BE TREATED OTC

• vulvovaginal candidasis CAN be treated topically (oral must be prescribed)

• exclusions

  • pregnancy

  • less than 12

  • predisposing drugs (neoplastics + warfarin + corticosteroids)

  • recurrent diseases

  • FIRST episode of VVC

Menstrual Cycle

• what are the phases?

avg menst cycle = 28 days

menstruation = day 0

phases

• follicular phase

  • menstrual phase

  • proliferative phase

• ovulation

• luteal/secretory Phase

estrogen/progesterone levels during period, when uterus sheds lining

both low

the proliferative phase after menstruation

• estrogen rises to release an egg

• uterine lining built

proliferative phase —> ___ released right before ovulation (egg release)

ovary

estrogen

what phase does the body prepare for pregnancy? what hormone is high?

• luteal

• progesterone

Physiology of Menstrual cycle

Hypothalamus- releases GnRH

Anterior Pituitary- LH and FSH

Ovary- estrogen + progesterone

all to stimulate uterus

estrogen sends negative feedback to the AP and hypothalamus

Follicular Phase

menstrual phase

• days 0-5

• endometrium is shed

proliferative phase

• Days 6-14

• Increased FSH —> ovarian follicular growth

• mature follicles secrete ESTRADIOL —> promote endometrial growth —>

• maturation of oocyte and development of dominant follicle

Ovulation

day 14

• surge in LH —> ovulation (final step in ovum maturation

• stimulates prdocution/release of PROSTAGLANDINS and PROTEOLYTIC enzymes needed to release mature ovum

• decreased estradiol levels —> mid-cycle bleeding

• follicular fluid release may cause some pain (mittelschmerz)

Luteal/ Secretory Phase:

• what happens during this phase?

• how does it end?

• once ovum is released from follicle —> follicle turns into corpus leutum —>

• corpus leutum secretes PROGESTERONE, ESTRADIOL, and ANDROGENs

• if pregnant —> embryo releases HCG (human chorionic gonadotropin) to support corpus leutum

• if NOT pregnant —> corpus leteum does not function —> decreased estrogen + progesterone —> endometrial lining shed

ENDS with menstruation

what is dysmenohrrhea?

difficult or painful menstruation

what are the two different types of dysmenhorea (painful periods)?

Primary = cramp-like LOWER abdominal pain

• Highest rate in adolescents

• greatest cause of calling out

Secondary = pelvic pain, later onset

• caused by endometriosis, fibroids, polyps, pelvic inflammatory disease (PID)

What can cause secondary dysmenhorea?

• endometriosis

• fibroids

• polyps

• pelvic inflammatory disease

Which type of dysmenhorea CANNOT be treated over the counter

secondary

What are some signs and symptoms of dysmenhorea?

• cramping pain

• n/v/d

• headache / dizziness

• fatigue

• nervousness

What are the goals of treating dysmenhorea?

• relief of symptoms n

• minimalize dysruption of daily acticity

What is the pathophysiology of dysmenorrhea?

Prostoglandins (released during ovulation):

uterine contractions + cervical narrowing + increased vasopressin —> vasoconstriction

vasopressin has positive feedbak with uterine contractions

Leukotriene:

increased sensitibity of uterine pain fibers

What are the exclusions to self-treatment for patients with dysmenhorrea?

1. SEVERE dysmenorrhea and/or menorrhagia

2. SECONDARY dysmenorhea

3. history of

   1. PID

   2. infertility

   3. irregular menstrual cycles

   4. endometriosisi

   5. ovarian cysts

4. presence of an intrauterine device (IUD)

5. Asprin or NSAID allergy (used to treat dysmenhorea)

6. Use of WARAFRIN + HEPARIN + LITHIUM

7. active GI disease

8. Bleeding disorder

Which medications should you NOT take if you want to be treated for your dysmenhorea over the counter?

warfarin + lithium oxide + heparin

Which medications are availeble OTC to treat PRIMARY dysmenhorea?

1. NSAIDs

2. Acetaminophen

3. Aspirin

What doses of the following medicatiosn can be used to treat dysmenhore?

• NSAIDs

• Acetaminophen

• Aspirin (ASA)

• NSAIDS =

  • ibuprofen = 200-400 mg q 4-6 hours (MAX= 3200mg/day)

  • naproxen = 220-440mg q 12hr (MAX - 660mg/day)

• Acetaminophen =

  • 650-100mg q4-6 hours PRN (MAX = 4000mg/day)

• Asprin =

  • 650- 1000 mg q4-6 hours PRN (MAX = 4000mg/day)

What are some counseling points you would give someone who is using NSAIDs (ibuprophen or naproxen) to treat their dysmenhorea?

• difference in responses depending on person

• GI effects

• dont take in on anticoagulants + antihypertensives + lithium

• relative contraindications

• drink w/ water

What are some counseling points you would give someone who is using acetaminophen to treat their dysmenorrhea?

• avoid alcohol

• be aware of other products that have acetaminophen (max dose = 4000mg/day)

What are some counseling points you would give someone who is using Asprin (ASA) to treat their dysmenorrhea?

• take WITH food

• may INCREASE menstrual flow

• not recommended in younger adolscents

• drug interactions / relative contraindications

What should you counsel patients in GENERAL that are buying OTC meds to manage their dysmenhorea?

• make it clear that symtpoms are common and dont necessarily have to be treated

• ask further questions to see if patient requires refferal

• nonpharmacological treatment is just as appropriate

which is first line in treatement for dysmenhorea? acetaminophen, NSAIDs, or Asprin?

NSAIDs (they are actually stopping the production of what is CAUSING pain - prostoglandins)

What are some non-pharmacological treatments for dysmenorrhea?

• heat

• rest

• loose clothing

• exersize

• massage

• smoking cessation

Premenstrual Syndrome (PMS):

• Cyclic disorder characterized by _____ and _______ changes that occur during the ______ phase of a women’s cycle just before menses

• Which hormonal patterns do you see during this syndrome?

physical and emotional changes

during LUTEAL phase

Premenstrual Syndrome (PMS) Pathophysiology:

• _______ ovarian function and hormonal fluctuations are though to cause a cyclic trigger for symptoms

• decreased _________ levels thought to cause irritability, dysphoria, and food cravings

• normal

• seretonin

What are the main systems of PMS?

behavioral and physical

What are the behavioral symptoms of signs of Premenstrual Syndrome

What are the physical symptoms of signs of Premenstrual Syndrome

PMS: Goals of Therapy

• understand PMS

• resolve/relieve symtpoms and reduce the impact on daily activities

What are exclusions for Self- Treatment?

1. SEVERE PMS or PMDD

2. Atypical timing of symptoms

3. Onset of symptoms related to the use of ORAL CONTRACEPTIVES or HORMONAL REPLACEMENT therapies

4. Contraindications to specific pharmacologic agents

what are some nonpharmacological treatments for premenstrual syndrome?

• physical exersize

• stress management

• diet modification (avoid salty foods, simply sugars, caffeine, and alcohol)

• education on cyclic nature of symptoms

What are some pharmacologic treatments for premenstrual syndrome?

• Vitamin B6 (Pyroxidine)

• Calcium

• Magnesium

• NSAIDs

• Diuretics

• Tocopherol or Vitamin E

Premenstrual Syndrome:

• intiial treatment includes ______, _______, or ________

• _______ or _________ may provide relief for bloating or irritability

• _________ are contraindicatd in patients with a history of ulcer disease or those who are taking _______

• ________ and combination products for that matter should be reserved for women with BOTH PMS and dysmennorhea

• magensium + calcium + pyridoxine

• caffeine + pamabrom (diuretic) —> can help w bloating

• xanthines —> contraindicated if ulcer disease or NSAIDs

• NSAIDS only IF has dysmenorrhea as well

Toxic Shock Syndrome:

• women between ___ and ____ ( )

13 and 19 —> first menses

What are some risk factors for Toxic Syndrome Syndrome (TSS)?

• tampons (greatest risk with HIGHER absorbency tampons)

  • for every 1g increase, risk increases

  • continuous use and not frequently changing (toxins STAY in body + systemic inflammatory response)

• barrier contraceptives

  • diaphrams

  • cervical caps

  • cervical sponges

  • IUDs

Toxic Shock Sydnrome (TSS): Signs and Symptoms

• occurs within ___days of onset of menses

• malaise, myalgias, chills (occurs for __- __ days) before severe symptoms

• approximately ___ - ___ days after onset of TSS, _________ of the skin on the paitents ___ , _____, and ________ (hallmark symptom)

• 2 days of onset of menses

• 2-3 days

• 5-12 days —> desquamation —> face, trunk, extremities

• Is toxic shock syndrome (TSS) a rare or common disease?

• How often should you change tampons at least every ___ hours or according to product instructions?

• Should you alternate between sanitary pads and tampons?

• Can toxic shock syndrome be treated OTC?

• rare

• 6 hours

• yes

• NO

Prevention of Unintended Pregnancies and Sexually Transmitted (STDs):

• ___% of pregnancies are uninteneded

• contraception prevents ____ _______

• A woman may be fertile between ___ days before to the day of ovulation

  • The risk of pregnancy during this time is 5-45% if a woman has unprotected sex during this time

• STIs are aquired through contact with infected genital _____, ____ ______, or ___ _______

• 45%

• EGG FERTILIZATION

• 5

• tissues, mucous membranes, or body fluids

Efficacy of prevention strategies

• NOTHING is 100% (except abstinence)

• _____ use: method- related failure rate (MRFR)

• _____ use: use-related failure rate (URFR)

• perfect

• typical

Male condoms: efficacy

• Most important method for barrier contraception

• What are some risk factors for failure?

• Incorrect placement

• reused condoms

• increased duration, intensity, or frequency of sex

• oil-based lubricant use with latex condoms

What are the types of male condoms?

1. latex

2. nonlatex (polyurethane + lambskin + sheepskin)

You should ONLY use _____- based lubricants when using male condoms

What would happen if you used the other type of lubricant?

• ONLY use water-based

• Oil-based lubricants will BREAK DOWN LATEX

What are some counseling points for male condoms?

• keep in sealed package and protect _____ and excessive _____

light and heat

Female Condoms:

• _____ or ___ intercourse

• made of ______ and ________

• can it come lubricated?

• is it used with water or oil based lubricant?

vaginal or anal

nitrile and polyurethane

prelubricated OR w/ additional lubricant

can be used w water OR oil

Female Condoms:

• can they be washed and reused?

• how long before intercourse can it be inserted

• is it effective immediately upon insertion?

• store at ____ temp unopened

• can you use with male condom?

• What are some complaints?

• NO one time use

• can be put in 8 HOURS before insertion

• IS effective immediately upon insertion

• room

• YES you can use with male condom

• vaginal irritation, increased noise (popping/cracklin), decreased sensation, disconfort

Vaginal Spermicides:

• what are the forms that it comes in?

• does efficacy improve if you use it in combination with condoms or other methods of contraception?

• what is its active agent?

• can it increase the risk of STIs?

• gels, foams, suppositories, films

• NO dont use in combos

• nonoxynol-9-surface-active agent

• YES

Contraceptive Sponge:

• Was it withdrawn by the FDA?

• Do they increase the risk of toxic shock syndrome?

• yes but reapeared in 2005

• yes

small, circular polyurethane spong permeated with spermicide

what is the moa?

contraceptive sponge

• mechanical barrier + spermicide + absorbs semen

Can you use the sponge during menses?

NO

what was the first ever OTC daily oral contracteptive?

• Opill (norgestrel)

What are the contraindictions of Opill (norgesterl)- first OTC daily oral contraceptive?

• History of breast cancer

• Allergy to FD&C Yellow No. 5 (tartrazine)

• Concurrent use of other birth control pill (vaginal ring, patch, implant, injection or IUD)

• Known or suspected pregnancy

• male

Opill (norgestrel) Counseling Points

• Is it an emergency contraceptive?

• Does it protect against STIs?

• Is it effective immediately?

• NO

• DOES NOT protect against STIs

• NO is NOT effective for the first 48 hours