Case 1—Hot Flashes:
LM is a 53-year-old woman who comes to the pharmacy complaining of hot flashes. She says she just began menopause and the hot flashes come out of nowhere, suddenly drenching her in sweat. She as a professor and says these sweating episodes can be extremely embarrassing. She says estrogen replacement is not an option for her because she has heard it has horrible side effects. Instead, LM is looking for a more natural treatment. She is particularly interested in buying some black cohosh, which she says has worked wonders for her friend. What recommendations would you make for LM?
Since LM is clearly having hot flashes related to menopause, it is important to educate her about lifestyle changes. She should use fans or air conditioning to keep her surroundings cool. When she is lecturing, she should wear light cotton clothing and use relaxation techniques to keep calm. Since LM has expressed interest in black cohosh, it is important to tell her that evidence about the substance’s effectiveness is mixed. Some studies have suggested that it significantly reduces menopausal symptom indices and hot flash frequency, but most of the clinical trials are short-term and lack safety data.1-3
There have also been case reports of hepatitis and myopathy associated with black cohosh.4,5
In addition, its package labeling recommends that it not be used for longer than 6 months, so you should advise LM not to use black cohosh long term in any case. If she insists on using it, the evidence favors using a specific commercial extract, such as Remifemin or PhytoPharmica. You can also inform LM that other prescription non-estrogen drug classes, such as antidepressants, may help improve her symptoms. She should speak to her physician about taking an agent such as venlafaxine to help with her hot flashes as well as how she can better manage her hot flashes.
Case 2—Ovulation Predictor Tests:
SG is a 32-year-old woman who comes to the pharmacy looking for an ovulation predictor test. She says she has been trying to conceive a baby with her husband for almost 10 months. She says she is very frustrated because she planned on having a summer baby and now that summer is here, she still is not pregnant. She says a few of her friends got pregnant using ovulation kits and wants to know if you can recommend a specific test for ovulation prediction. What would you recommend for SG?
Since SG is 32 years old, she should try to conceive for a full year before seeing a reproductive endocrinologist. For her current needs, there are many available ovulation predictor tests. These tests are typically not recommended for use for longer than 3 months. SG can start by charting her basal body temperature to observe when ovulation occurs. Resting basal body temperature is typically below 97.5 degrees F; after ovulation, it rises to near 98.6 degrees F. It is important to tell SG to take her temperature at the same time each morning. She should be sure to get at least 5 hours of sleep and should avoid talking, moving, drinking, eating, or smoking before she takes her temperature. If monitoring her basal body temperature does not work, SG can try a urinary hormone test such as Clearblue or First Response. These tests detect a surge in luteinizing hormone, indicating that ovulation should occur in the next 48 hours. Another product to consider is the fertility microscope, which detects fertility patterns in saliva caused by a surge in estrogen. Finally, there is the OV watch, which predicts ovulation based on fluctuations of chloride ions. All of these products require careful compliance with instructions in order to avoid incorrect results. SG should also be counseled that use of many fertility medications and hormonal contraceptives can lead to false positive results.
Case 3—Heartburn and Calcium Supplementation:
ML is a 54-year-old woman who comes to the pharmacy with a prescription for Nexium 40 mg. She says she has had heartburn for years despite significantly modifying her diet and that Nexium really helps to control it. She is also looking for an OTC product to prevent osteoporosis. Her girlfriend was just diagnosed with it and had to start prescription medication. ML says her mother also has osteoporosis and broke her hip last year, leading to a painful recovery that required multiple surgeries. ML’s bone mineral density is normal, but seeing her mom suffer has made her worry about what will happen to her as she gets older. Her doctor has advised her to take calcium daily, but she was overwhelmed by the range of supplement choices at the pharmacy and has been lazy about calling her doctor to ask which she should take. What would you recommend to ML regarding her choice of calcium supplement?
The recommended daily allowance for women 50 and older is 1200 mg of calcium and 800-1000 IU of vitamin D.6
Available supplements contain 2 forms of calcium: calcium carbonate and calcium citrate. Either is recommended, but patients who are taking medications for heartburn that reduce levels of stomach acid can absorb calcium citrate more easily. Since ML is taking Nexium, she should take calcium citrate. She should also be counseled to take her daily dose in 2 separate portions. The percentage of calcium absorbed depends on how much is ingested at one time, and absorption is highest in doses <
Therefore she can take a supplement with calcium citrate 600 mg twice daily, with or without food. Patients who take calcium carbonate should take it with food to help aid absorption. It is also important to assess a patient’s calcium intake from other food sources, such as yogurt and milk, to ensure that they do not get too much.
Case 4—Vaginal Infection:
GR is a 36-year-old woman who comes to the pharmacy looking for something to treat an infection. Upon questioning, she says her vaginal discharge is thick and white. She says it looks like cottage cheese, but has no odor. She says it appeared the previous day and now she is very itchy. She works for an advertising company and has been extremely busy for the past few weeks working 14-hour days to launch a new product, so she needs something quick and hassle-free. She says she has no medical conditions, is not on any medications, and has no fever or pain. What would you recommend for GR?
GR appears to have vulvovaginal candidiasis. The goal of therapy is typically to provide symptom relief and eliminate the infection. Since GR does not have any exclusion to self-treatment (eg, pregnancy, age under 12 years, or fever or pain in the lower abdomen, back, or shoulders) and she doesn’t have any medical disorders and is not taking medications, she is a candidate for self-treatment. A nonprescription FDA-approved imidazole product is the recommended initial therapy for uncomplicated vulvovaginal candidiasis and relief of external vulvar itching and irritation associated with the infection. These drugs include butoconazole, clotrimazole, miconazole, or tioconazole.8
Since GR is extremely busy, it might be appropriate to start her on the Monistat 1 Combination Pack. She should apply the cream to her vulva twice daily as needed for itching and insert the suppository into her vagina at bedtime, leaving it in for 1 day. Comparisons of miconazole single dose and 7-day treatments have found similar overall cure rates, with significantly faster rates of symptom relief by day 3 in the single-dose group.9
In addition, GR might benefit from consuming yogurt containing live cultures. Yogurt can help decrease vulvovaginal candidiasis, particularly in women who experience recurrent infections. She might also benefit from decreasing her intake of sugar.
Dr. Mansukhani is a clinical pharmacist in South Plainfield, New Jersey, and clinical assistant professor, Ernest Mario School of Pharmacy, Rutgers University. Dr. Bridgeman is an internal medicine clinical pharmacist in New Brunswick, New Jersey, and clinical assistant professor, Ernest Mario School of Pharmacy, Rutgers University.
Liske E, Hanggi W, Henneicke-von Zepelin HH, Boblitz N, Wüstenberg P, Rahlfs VW. Physiological investigation of a unique extract of black cohosh (Cimicifugae racemosae rhizoma): a 6-month clinical study demonstrates no systemic estrogenic effect. J Womens Health Gend Based Med. 2002;11:163-174.
Osmers R, Friede M, Liske E, Schnitker J, Freudenstein, J, Henneicke-von Zepelin HH. Efficacy and safety of isopropanolic black cohosh extract for climacteric symptoms. Obstet Gynecol. 2005;105:1074-1083.
Nappi RE, Malavasi B, Brundu B, Facchinetti F. Efficacy of Cimicifuga racemosa on climacteric complaints: a randomized study versus low-dose transdermal estradiol. Gynecol Endocrinol. 2005;20:30-35.
Whiting PW, Clouston A, Kerlin P. Black cohosh and other herbal remedies associated with acute hepatitis. Med J Aust. 2002;177:440-443.
Minciullo PL, Saija A, Patafi M, Marotta G, Ferlazzo B, Gangemi S. Muscle damage induced by black cohosh. Phytomedicine. 2006;13:115-118.
Calcium and vitamin D: what you need to know. National Osteoporosis Foundation website. www.nof.org/aboutosteoporosis/prevention/calcium. Accessed May 5, 2013.
National Institute of Health: Office of Dietary Supplements. http://ods.od.nih.gov/factsheets/calcium. Accessed May 5, 2013.
Vaginal and vulvovaginal disorders. In: Krinsky DL, Berardi RR, Ferreri SP, et al, eds. Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care. 17th ed. Washington, DC: American Pharmacists Association; 2011:124.
Upmalis D, Cone FL, Lamia CA, et al. Single dose miconazole nitrate vaginal ovule in the treatment of vulvovaginal candidiasis: two single-blind, controlled studies versus miconazole nitrate 100 mg cream for 7 days. J Womens Health Gend Based Med. 2000;9:421-429.