Women's Health

 

01 Introduction

Introduction

Women's Health - An Introduction

 

 

On average a woman will visit a pharmacy 18 times a year, compared to just four times a year for men. Women are more likely to seek help for medical problems and, as ‘custodians’ for family health, they will use the opportunity to pick up something for their family as well as themselves.

 

And with the increasing availability of over the counter products for women’s health, there is real potential to make a difference to your patients.

 

Understanding women’s health and women as customers will help you to understand your biggest patient group. 

Learning outcomes

Learning outcomes

 

 

As a result of doing this training you will be able to:

 

  • Advise on common women’s health problems including thrush, cystitis and period pain

 

  • Recommend appropriate treatment for these conditions and refer where required

 

  • Know when to refer customers to the pharmacist

 

 

This module will take you approximately 20 minutes to complete.

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What you already know

What you already know

 

 

 

Do you know which of these statements are true and which are false? Have a think and then hover over each statement to find out the answer.

 

 

Cystitis is more common in men 

 

 

Advice for cystitis includes drinking lots of water 

 

 

The antifungal fluconazole 150mg (e.g. Canesten Oral Capsule) is taken as one capsule three times a day.

 

 

EHC (emergency contraception, e.g. Levonelle) can be sold by medicine counter assistants 

 

 

If Chlamydia is left untreated it can cause infertility 

 

02 Refresher

Cystitis

Cystitis

 

Cystitis is the word used to describe an inflammation of the bladder.

 

It is more common in women than men as the tube that passes urine from the bladder (the urethra) is shorter in women and also closer to the anus (back passage). This may contribute to the spread of bacteria into the bladder.

 

Up to 15% of women have cystitis each year and about half of women have at least one bout of cystitis in their life.

 

Causes

These include:

  • Infection in the bladder
  • Irritation or damage (e.g. during sex)
  • Some medications

 

Symptoms

These include:

  • Pain on passing urine
  • Needing to pass urine more frequently
  • Bloody or cloudy urine
  • High temperature

 

Ref: NHS Choices, Patient UK

Vaginal infections

Vaginal infections

 

Thrush

Thrush is caused by a fungal yeast infection called Candida albicans, which lives naturally in the body including in the vagina. ‘Friendly bacteria' in the vagina help keep the environment acidic and so keep the fungus in check. When the pH balance is disrupted and the vagina becomes less acidic, there is an overgrowth of Candida albicans which results in thrush.

 

Thrush can be passed on during sex.  Symptoms of thrush in a man include redness, swelling and irritation of the head of the penis; thick, lumpy discharge under the foreskin; and an unpleasant odour. Partners may need to get treated at the same time to prevent reinfection.

 

Bacterial vaginosis 

Bacterial vaginosis (BV) is a bacterial infection caused when the balance between good and bad bacteria inside the vagina becomes disrupted. Triggers that may cause an inbalance of organisms in the vagina include:

 

  • Pregnancy and menopause
  • Scented soaps or bubble baths
  • Vaginal deodorants
  • Tight clothing (such as tight jeans) or synthetic clothing (such as nylon underwear) that prevents air circulation to the area

Period pain

Period pain

 

Dysmenorrhoea

About 1 in 10 women have painful periods (also known as dysmenorrhoea). Period pain is common in teenagers and young adults; periods tend to become less painful as women get older.

 

When the lining of the uterus is preparing to shed, prostaglandin hormones are released. These trigger the muscles in the uterus to contract and shed the lining out of the body. Some people have higher levels of this hormone, making the contractions harder leading to cramp and period pain.

 

Symptoms

Symptoms can start a few days before bleeding begins and continues for 2-3 days afterwards. They can also vary from period to period, with some periods feeling worse than others.

 

  • Crampy pain in lower abdomen
  • Pain in lower back, top of the legs

 

Menorrhagia

Excess bleeding, also called menorrhagia, can cause staining of clothing, soaking of bedclothes, passing clots and can restrict normal daily activities. Patients who bleed a lot may also have a lot of pain and may often need to use double sanitary protection.

 

Endometriosis

It’s important to distinguish period pain from other conditions which need different treatment. Patients who suffer from a lot of pain (with or without excessive bleeding) may also have a condition called endometriosis. This is where the endometrium (tissue that lines the uterus) is found outside the uterus in the pelvic area and lower abdomen and causes pain and complications. This requires specialist care.

 

Advice

Advice

 

Here is some information to help you advise your customers.

 

Advice for cystitis

  • In most cases cystitis resolves by itself over 4-9 days
  • Drink lots of water (around 1.2 litres or 6-8 glasses a day) as this is thought to help ‘flush out the infection’
  • Avoid alcohol and caffeine, since they can dehydrate the system
  • Take painkillers if needed
  • Avoid sex during an attack as this can worsen cystitis

 

Advice for thrush/bacterial vaginosis

  • Wear loose clothing and cotton underwear – avoid synthetic underwear, nylon tights and tight trousers
  • Stay cool – when you feel hot or after exercising, try showering or bathing the area
  • Keep it simple use non-fragranced soaps and shower gels
  • Avoid friction – rubbing in the vaginal area can cause candida to thrive and also disrupt the natural flora. This can happen in situations such as over zealous scrubbing of the area using sponges, brushes or flannels; and sexual intercourse in some cases, as this can often be due to vaginal dryness (a lubricant may help)
  • Tampons can sometimes irritate the area
  • Avoid stressful situations stress can cause a thrush attack

 

Advice for period pain

  • Exercise and keeping active can help to reduce pain and get endorphins (chemicals produced by the brain which induce feelings of well being) going which can help you feel better
  • A hot water bottle or bean bag can help to soothe a sore back or stomach
  • As well as feeling good, a bath or shower can also help relax muscles that may be causing pain
  • Gentle, light circular massage around the lower abdomen and back can help
  • Yoga and pilates or simple stretching can help relaxation and help patients cope with pain better
  • Transcutaneous electronic nerve stimulation (TENS) machines can help to reduce pain by interfering with pain pathways.

 

Ref: NHS Choices, Patient UK

Treatment Choices

Cystitis

Treatment choices

 

Cystitis

 

Painkillers

Paracetamol or ibuprofen can help to reduce the associated pain and discomfort. These can be taken during the course of the condition.

 

Urine alkalising agents

These can help to reduce the acidity of the urine which causes the irritation and pain associated with cystitis. They come in sachets and the dose is one sachet taken in water three times daily over 2 days. Examples include:

 

  • Sodium citrate (e.g. CanesOasis). It should not be taken by patients with diabetes, heart disease, hypertension, history of renal disease or those on a low salt diet. The product should also not be used during pregnancy and breastfeeding.
  • Potassium citrate (e.g. Cystopurin). Refer to the pharmacist anyone taking other medication e.g. blood pressure tablets, immunosuppressants and antibiotics.

Thrush

Treatment choices

 

Thrush

 

Thrush can be easily treated using antifungal agents (e.g. clotrimazole, fluconazole). These work by slowing down and controlling the growth of fungi (fungistatic). Customers should have had thrush previously diagnosed by a GP before you make a recommendation.

 

Topical treatments

Antifungal vaginal preparations containing clotrimazole (e.g. Canesten), are the mainstay of treatment. These are found in a variety of formulations:

  • Vaginal pessaries – inserted into the vagina at night. Available as 500mg tablet or gel pessary as a single treatment
  • External cream – double strength clotrimazole 2% is used 2-3 times a day.
  • Vaginal internal cream – inserted into the vagina at night. It especially useful for women who find pessaries difficult to use. 

 

Oral treatments

The antifungal fluconazole 150mg (e.g. Canesten Oral Capsule) is taken as a single treatment. Oral treatments are suitable for women (aged 16-60) who find it uncomfortable to use vaginal preparations. Fluconazole capsules are also used for the treatment of thrush in men. Check on pack details for further advice for people taking other medication or with long-term medical problems.

BV

Treatment choices

 

Bacterial vaginosis 

 

Treatment used to be only antibiotics, however nowadays OTC products are available which help to restore the balance of vaginal bacteria.

 

Lactic Acid

This restores the normal pH of the vagina.  An example is Balance Activ which comes as single use tubes, the contents of one tube should be inserted into the vagina daily at bedtime for seven days. It also has glycogen which provides nutrients for the lactobacilli (friendly bacteria). For prevention of BV during a course of antibiotics, the product can be used as above for 4-5 days after the antibiotic course.

 

Another product is Canesbalance Bacterial Vaginosis Vaginal Gel.

 

Period pain

Treatment choices

 

Period pain

 

Advise patients to take the first dose of their painkiller as soon as the pain starts, or as soon as the bleeding begins.

 

It might even be advisable to take the painkiller the day before the period is due. Painkillers should also be taken regularly, for 2-3 days each period, rather than 'now and then' when the pain builds up. If one painkiller doesn’t work, consider a stronger type (e.g.  naproxen) or one that includes codeine.

 

Paracetamol and Non Steroidal Anti-Inflammatories (NSAIDS) are the two main types of painkillers for period pain:

 

  • Paracetamol - (e.g. Panadol)  take four times a day.
  • Ibuprofen - (e.g. Nurofen Express Period Pain) take three times a day. Care should be taken when using NSAIDs, particularly the stronger ones. Refer to pack information for more details.
  • Naproxen – (e.g. Feminax Ultra) is the strongest NSAID available OTC for women with period pain aged 15-50. On the first day 2 tablets (500mg) should be taken to start with and then one tablet (250mg) after 6 to 8 hours later that day if needed. On the second and third day, if needed, one tablet (250mg) should be taken every 6 to 8 hours. Not more than 3 tablets to be taken per day. The maximum duration of continuous treatment in any one cycle (period) is 3 days.

 

Refer to the OTC Expert Pain module for more information on these painkillers.

Excess bleeding

Treatment choices

 

Excess bleeding

 

Tranexamic acid (e.g. Cyclo-F and Femstrual) is an anti-fibrinolytic drug which means it stops clots breaking down and by doing so, reduces the amount of blood during heavy periods. It is recommended for those aged 18-45 years, have had heavy menstrual flow over several cycles and have a regular cycle of 21 to 35 days (and a cycle that does not vary by more than three days each month).

 

The usual dose is two tablets taken 3 times a day (e.g. in the morning, afternoon, and evening) for up to 4 days. For heavy bleeding take 2 tablets 4 times daily for up to 4 days. Do not take more than 8 tablets each day.Refer to pack information for details on the conditions and medication where tranexamic acid should be avoided.

 

Other treatments

Treatment choices

 

Other treatments

 

There are other things to consider for women’s health. Here is an overview but you need to refer to further sources of information and training on these before getting involved.

 

Emergency hormonal contraception (EHC)

It is an OTC treatment to prevent pregnancy and is also known as the ‘morning after pill’. It can be used after unprotected sex, for instance if no contraception was used or if the contraception failed e.g. condom split.

 

There are two types of EHC products availableLevonelle One Step (main ingredient is a hormone called levonorgestrel) can be used for up to 72 hours after unprotected sex or contraceptive failure but the sooner it is taken the more effective it is. A newer product is ellaOne (contains ulipristal acetate 30mg) which should be taken as soon as possible, but no later than 120 hours (5 days) after unprotected sexual intercourse.

 

EHC can only be sold under the guidance of a pharmacist so always refer patients asking for treatment to your pharmacist.  

 

Clamelle

Chlamydia is a bacterial infection and is one of the most common sexually transmitted infections (STIs) in the UK. In women if chlamydia is left untreated it can cause pelvic inflammatory disease (PID), which can lead to infertility, miscarriage and ectopic pregnancy.

 

Chlamydia can be treated OTC with the antibiotic azithromycin (e.g. Clamelle Tablets) if the patient or partner first tests positive for the infection. They can do this at a sexual health clinic or by buying a testing pack from the pharmacy (e.g. Clamelle test kit).

 

Incontinence pads

Bladder weakness or incontinence affects around one in four people at some time. In women, bladder weakness can arise as a result of pregnancy, after childbirth, and after the age of 40. Bladder weakness is treated by the doctor but women can use incontinence pads such as Tena Lady and may also need advice about pelvic floor exercises which can help to strengthen the muscles in the area.

03 Customer Experience

WWHAM cystitis

WWHAM cystitis

 

 

Who?

Ask if the patient is someone below the age of 16 or over 60. Reason for asking: some products may not suitable.

 

What?

Check which symptoms the patient is suffering from. Reason for asking: if the main symptoms are just urinating frequently, the patient may not need painkillers or urine alkalisers and could just ‘watch and wait’ to see if it goes away by itself.

 

How long?

Check how long the patient has had their symptoms for. Reason for asking: the advice you give may differ based on their severity and length of time suffered e.g. patients who have had cystitis for a day or so, can try drinking lots of water to see if the condition resolves by itself. But, if they have had it for longer (2-4 days), they should try an OTC treatment such as a painkiller or alkalising agent (or both) before referral to GP.

 

Action already taken?

Check what action they have taken already. Reason for asking: so you can recommend the best product e.g. if the patient has only tried a painkiller, try an alkalising agent. Also check that they are drinking lots of water.

 

Other Medicines or Medical Conditions?

If recommending an alkalising agent or a painkiller, check whether they have allergies to the ingredients and if they are on other medication. Reason for asking: alkalising agents may not be suitable if people are taking blood pressure medication for example; also painkillers such as ibuprofen  are not appropriate for people who have asthma and stomach ulcers.  

 

 

WWHAM thrush

WWHAM thrush

 

 

Who?

Check if the customer could be pregnant or breastfeeding. Reason for asking: thrush is common in pregnancy and these women should be referred to their doctor or midwife. If the patient is uncomfortable using vaginal products consider oral preparation instead.

 

What?

You can ask where the customer is suffering symptoms. Reason for asking: this can help you decide whether it's thrush or something else  like bacterial vaginosis (BV); it can also help you recommend the best products for the symptoms e.g. if the main symptoms are external, consider using a cream, however be aware that this could be embarrassing for the customer to discuss so be discreete.

 

How long?

Ask how long the customer has suffered the symptoms for. Reason for asking: if the symptoms have been present for over seven days, refer as the customer may need to see their GP. Patients who have recurring infections (more than four episodes in the last year) should also be referred since they may have an underlying problem e.g. reinfection by their partner, diabetes or even immunosuppression.

 

Action already taken?

Check what action they have taken. If the patient has already used thrush medication and it hasn’t worked then double check that the patient finished the course. Reason for asking: if they did use the treatment as they should, check for BV symptoms and suggest a treatment for that if appropriate.

 

Other Medicines or Medical Conditions?

Find out if the customer is taking other medication. Reason for asking: oral capsules of fluconazole should not be taken by patients already taking certain prescribed medication e.g. the cholesterol-lowering drug simvastatin.

 

 

WWHAM period pain

WWHAM period pain

 

 

Who?

Find out the age of the patient. Reason for asking: heavy, painful periods are common in adolescent girls but some stronger medications (e.g. naproxen and tranexamic acid) cannot be used for this age group.

 

What?

Ask the customer if they are suffering with symptoms beyond pain. Reason for asking: women with heavy bleeding might do better with tranexamic acid if suitable. Also the pain may be due to more serious conditions such as endometriosis which needs referral.

 

How long?

Check how long they suffer symptoms for each month. Reason for asking: if symptoms are there throughout the month or accompanied by other symptoms, they will need further investigation.

Remind teenage girls that painful periods are more common in their age group and should get better with time.

 

Action already taken?

Check which products they have tried already and how they took them. Reason for asking: if painkillers are not effective ensure the patient is taking them correctly or recommend a stronger one. Also some self-help measures, such as hot water bottle and exercise, may help.

 

Other Medicines or Medical Conditions?

Check if the patient has any medical conditions or takes any medication. Reason for asking: some medications aren’t suitable e.g NSAIDs (e.g. ibuprofen) for asthmatics and those with stomach ulcers.

When to refer

When to refer

 

There may be other occasions when it is necessary to refer a customer to the pharmacist but here are a few examples when it will be necessary.

 

Cystitis

  • Difficulty in passing urine
  • Blood in urine
  • Strong smelling urine
  • Cloudy or dark urine
  • Abdominal/loin/back pain with cystitis
  • Temperature with cystitis
  • Cystitis resistant to OTC treatment
  • Cystitis for over five days
  • A man or child with cystitis
  • An elderly person with cystitis

 

 

Thrush/bacterial vaginosis

  • Have had more than two episodes of thrush in the past six months
  • Experiencing pain or bleeding
  • Are suspected of thrush but allergic to antifungal treatments
  • Are pregnant
  • Have tried a treatment but the symptoms are still present a week later
  • Have severe symptoms
  • Have symptoms that may suggest a sexually transmitted infection (STI) e.g. lower pelvic pain, sores around the vagina
  • Pregnant or breastfeeding women must consult their doctor or midwife before using any treatment for thrush or BV

 

Period pain

  • Anyone with a change in usual pattern of pain  e.g. if periods become more painful
  • Bleeding between periods
  • Irregular periods
  • Pains between periods
  • Changes in bleeding patters  (e.g. becomes heavier)
  • Vaginal discharge
  • Pain during sex

 

Signposting

Signposting

 

 

Additional information and resources to signpost customers to.

 

Wellbeing of Women

Gives information and general health advice including pelvic floor exercises.

 

www.wellbeingofwomen.org.uk

 

Women’s Health Concern

Provides advice on gynaecological, urological and sexual health conditions.

 

www.womens-health-concern.org

 

NHS Choices

General advice on health issues affecting women.

 

www.nhs.uk

Added value

Added value

 

 

Added value advice

 

Remember many women’s health issues can be quite private. Always offer to carry on a sensitive conversation in a quieter part of the pharmacy or consultation room.

 

Added value product

 

Don’t forget to recommend add-on products when it is appropriate, for example:

 

  • Cystitis – bottled water
  • Period Pain - hot water bottles, sanitary products

 

Added value pharmacy

 

  • Promote your self-care service to your customers and promote any women’s health services e.g. sexual health, contraceptive health
  • Get involved in local or national women’s health awareness campaigns e.g. safe sex campaigns
  • Use promotions effectively – be aware of new launches and ad campaigns
  • Use point of sale material to prompt customers to ask your advice especially around embarrassing issues
  • Stock up your leaflet stand and be prepared with contact details for self-help groups and charities to sign-post customers to
  • Make sure your shelves are clean, tidy and well stocked – think about how you display or link associated products (e.g. treatments for thrush near sanitary products).

04 Case Study

Recommend or refer

Recommend or refer

 

Which of the customers would you recommend a treatment/product for and which would you refer to the pharmacist? 

 

A. An eighteen year old woman says she is experiencing pain when having sex.

 

B. A 36 year old woman experiencing stinging when she passes urine.

 

Click on each person below and see if you were right.

Case study 1a

Over the next few screens, you'll see an example of a good consultation and a bad consultation.

 

A woman in her 30’s approaches the counter to buy a product for cystitis.

Tracy : Hi, I’m after those sachet things that help with making urine burn less

 

Sam: Have you used them before?

 

Tracy: Yes, I used them about 10 months ago

 

Sam: As you've had it before you need to see a GP

 

Tracy: Oh really?  Ok, well I’ll grab the sachets to help until I see a GP.

 

Sam: No I can’t sell them to you.

Now take a minute to think about what went wrong. When you're ready go to the next screen.

Case study 1b

What went wrong

 

 

  • Sam gave Tracy incorrect advice about needing to see a GP

 

  • Sam didn’t find out what symptoms Tracy had

 

  • Sam didn’t find out how long Tracy had suffered with symptoms this time

 

  • Sam didn’t offer any lifestyle advice such as increasing water intake

 

  • Sam didn’t offer any other products such as painkillers

 

Now click on to see examples of good dialogue.

Case study 2a

Tracy : Hi, I’m after those sachet things that help with making urine burn less

 

Sam: Are they for yourself?

 

Tracy: Yes, I had the same symptoms about 10 months ago

 

Sam: Can you describe those symptoms? Do you have a temperature?

 

Tracy: No temparature. I woke up this morning with it, it burns when I pee

 

Sam: OK, these sachets will last 2 days, if you still have the symptoms after that please see your GP.  Also increase your water intake to help relieve the stinging.  If you need to, you can take painkillers on top.

 

Tracy:  Thanks, I didn’t know about the water.  Apologies I need to head back to work now.

 

Sam:  One last question, do you take any other medication or have any medical conditions? 

 

Tracy:  No nothing

 

Sam: Great, if you want any other information pop back or go onto the NHS Choices website

Now take a minute to think about what went right before clicking on to the next screen

Case study 2b

What went right

 

 

  • Sam used WWHAM to gather all the information to make a recommendation

 

  • Sam offered lifestyle advice

 

  • Sam let Tracy know that painkillers

 

  • Sam recognised that Tracy was in a hurry, and helped by saying he only had one further question

 

  • Sam mentioned the NHS Choices website to Tracy so she can gain further knowledge


 

Take action

Take action

 

 

  • Help customers recognise the type of symptoms they are suffering so that you can recommend the best treatment for them

 

  • Give advice on how customers can help themselves. Lifestyle advice is very important to either help with symptoms or reduce the chance of the condition occurring again

 

  • Ensure all WWHAM questions are covered

 

  • Show empathy to your customers. Some customers will find it embarrassing to discuss these intimate problems

 

End

To take the Quiz, close the module (click X) and return to the course page.

Reviewed: Nicola Hart, pharmacist and lecturer at King’s College London who has held positions as manager within Learning and Development at community pharmacy multiples.

Date of review: March 2016.

 

This material has been prepared to support your practice. Use of this material is not intended to replace the need to refer to the latest product information and other established sources of information. Information correct at time of publication. Whilst every effort is made to ensure the accuracy of information, Mediapharm does not accept responsibility for any errors or omissions. Mediapharm is not responsible for the content of any external websites mentioned.

© 2016 Mediapharm Ltd.

 

Well done you have completed this module.