Case 1: Emergency Contraception
ML is a 15-year-old female who comes to the pharmacy looking frantic. She is near the contraceptives aisle looking for something specific. Upon questioning, she states she is looking for emergency contraception. She says she has been sexually active with her boyfriend of 2 years. They always use protection, but last night, she realized that the condom was not intact after they had intercourse. She is concerned about getting pregnant and wants to know if there is anything available over the counter. She says she does not want to use her insurance because she is concerned about her parents finding out. What recommendations would you give ML?
In June 2013, the FDA announced that Plan B One-Step (levonorgestrel) can be used as a nonprescription product by all women of childbearing potential. Before this, the product was marketed over the counter for patients 17 years and older. Currently, 2 options are available for emergency contraception: Plan B One-Step does not have an age restriction, but Next Choice is restricted to women 17 years and older. To purchase Next Choice, presentation of identification is required. Plan B One-Step and Next Choice contain levonorgestrel.
ML meets the criteria for emergency contraception because her unprotected intercourse occurred within the past 72 hours. Studies have shown that emergency contraception can be effective if given within 5 days (120 hours). However, it is most effective when used immediately.
The side effects associated with Next Choice and Plan B One-Step include nausea and vomiting. Patients not using a routine form of contraception should be educated on the various methods available. Because ML is 15 years of age, her only option is Plan B One-Step. ML should be informed that it will not protect her from sexually transmitted diseases such as HIV/AIDS.
Case 2: Osteoporosis
NM is a 58-year-old female who comes to the pharmacy looking for an OTC vitamin. She says her doctor recommended that she get a bone density test, and her T-score showed that she is close to having osteopenia. She does not want to take prescription medications to prevent bone loss because she heard they have terrible side effects. Because she does not have osteoporosis yet, her doctor recommended that she start taking a calcium supplement. NM does not exercise, and she smokes 1 pack of cigarettes per day. Many OTC options are available. What can you recommend to NM?
Osteoporosis is a disease in which bones become fragile and more likely to fracture. Osteoporosis can be prevented before fractures occur. Treatment using calcium can help prevent bone loss. The best way to receive an adequate amount of calcium is through the diet. NM should be encouraged to incorporate calcium-containing products into her diet. Women 51 years and older should take 1200 mg of calcium per day divided into at least 2 doses. NM should also be encouraged to take vitamin D 800 IU per day to help with calcium absorption.1
Because she does not exercise, she should be encouraged to engage in weight-bearing and strengthening exercise to improve her strength and balance. Exercise will also decrease her risk of falls. NM should also be encouraged to quit smoking because smoking increases the risk of osteoporosis. Smoking cessation products can be recommended if NM is interested.
Two forms of OTC calcium are available: calcium carbonate and calcium citrate. Both are recommended, but individuals who have heartburn and take medications to decrease stomach acid can absorb calcium citrate more easily. Calcium carbonate requires more stomach acid and it is therefore recommended that it be taken after meals or with a glass of juice to aid in absorption. Because NM does not have heartburn, either supplement could help her.
Case 3: Douche
SN is a 28-year-old female who comes to the pharmacy looking for douching products. She says she notices an odor from her vagina and wants to clean it with a douching product. Upon questioning, she says she has been douching 6 to 8 times every month for the past 2 years. She claims she has multiple sexual partners and feels like cleaning her vagina regularly. She says she feels that the douche keeps her safe from syphilis and gonorrhea. She typically douches immediately after intercourse. She also heard that eating a lot of yogurt can help prevent infections, so she has been eating a cup of yogurt daily for 1 year. She has not had any symptoms related to infection. She denies smoking or drinking alcohol. She is currently taking a multivitamin daily. What recommendations do you have for SN regarding douching products?
SN should be educated that douching does not safeguard against sexually transmitted diseases. The best way for her to reduce her risk of syphilis and gonorrhea is to use contraception products such as condoms. Many women use douche products frequently. Women tend to mistakenly believe that douching regularly cleans the vagina, rinses away blood after menstruation, helps get rid of odor, and prevents infections. However, repeated douching has been associated with pelvic inflammatory disease, reduced fertility, vaginal infections, and cervical cancer. Regular douching should be discouraged for all women. The most common product contains water and vinegar (acetic acid) solution.
SN should be informed that douching is not recommended for cleaning her vagina and will not eliminate the odor. It increases her risks and does not provide much benefit. It is recommended that if she uses vaginal spermicide, she should wait at least 6 to 8 hours after sexual intercourse before douching. If she is concerned about keeping her vagina clean, she should be encouraged to gently wash it with lukewarm water and mild soap when she is in the shower.
Case 4: Menopause
MG is a 56-year-old female who is complaining of hot flashes. She says she is going through menopause and wants to know what she can take that is natural. She is concerned about taking estrogen replacement prescription products because there have been so many problems associated with them. She heard natural products such as soy and black cohosh work well. She wants to know if you have heard anything about these products and if there is one you prefer for treating menopause symptoms. Upon questioning, she states she is not taking any medications and smokes 1 pack of cigarettes per day. What recommendations do you have for MG?
Many women like MG are concerned about the safety of hormone replacement therapy during menopause, and some are turning to natural products to help alleviate some of their symptoms. It is important to remind patients that many herbal products work similarly to estrogen replacement, so their safety profile may be similar as well.
Soy has the most data to support its use in treating menopause symptoms. A few studies have shown that 20 to 60 g of soy protein per day can decrease the frequency and severity of hot flashes in menopausal women. However, the use of soy is controversial because some data have shown no benefit. If a patient enjoys including soy in her regular diet, it may be beneficial. Black cohosh is very popular for treating menopause symptoms and has some estrogen-like effects. However, MG should be informed that black cohosh has been associated with liver damage. Because soy currently has the most evidence to support its use, MG should consider trying it to see if it is beneficial for her.
Other lifestyle modifications may also help control her menopause symptoms. Women who are overweight are more likely to experience hot flashes; therefore, a good exercise and weight-loss regimen may help. Another beneficial lifestyle modification for MG would be decreasing the number of cigarettes she smokes per day or, preferably, quitting completely.
Dr. Mansukhani is clinical assistant professor at Ernest Mario School of Pharmacy, Rutgers University, and transitions of care clinical pharmacist at Morristown Medical Center in Morristown, New Jersey. Dr. Bridgeman is clinical assistant professor at Ernest Mario School of Pharmacy, Rutgers University, and internal medicine clinical pharmacist at Robert Wood Johnson University Hospital in New Brunswick, New Jersey.
Clinician’s guide to prevention and treatment of osteoporosis. National Osteoporosis Foundation website. http://nof.org/files/nof/public/content/file/2791/upload/919.pdf. Accessed May 13, 2014.