Self-Care for Women's Health

Case 1: Yeast Infection Screening Test

Q: LL is a 36-year-old woman who comes to the pharmacy looking for an at-home test for her yeast infections, of which she has had 5 over the past year. She was concerned, so she went to see her primary care provider (PCP), who wanted to confirm that she is not suffering from recurrent urinary tract infections. Her PCP recommended that she purchase a pH test for the next time she thinks she has a yeast infection. He advised her when to seek medical care based on the test result. Currently, LL has no symptoms of a yeast infection, feels well, and does not have any medical problems or allergies to medications. What recommendations do you have for LL?

A: Yeast infections typically do not alter vaginal pH; however, a higher pH could indicate the presence of another type of infection. One study used pH testing in patients who believed they had a yeast infection, and over half of the patients tested negative.1 Therefore, pH testing may be helpful in preventing the inappropriate use of OTC products and in identifying whether a patient should seek medical care. LL can be educated that the Vagisil Screening Kit can be used to identify vaginal infections; she should be instructed to follow the package directions. The Monistat Complete Care kit is a vaginal swab that identifies vaginal pH via color coding; it also contains Instant Itch Relief Cream. LL should be educated that she cannot use Monistat if she has had sexual intercourse in the past 48 hours. In addition, the product cannot be used during her menstrual period and for up to 5 days after. Vaginal products with spermicide can alter the pH and interfere with the test.²

Case 2: Yeast Infection

Q: SN is a 20-year-old woman who comes to the pharmacy complaining of thick cottage cheese-like vaginal discharge that has no odor. She says she feels no burning or pain during urination. Her symptoms started yesterday, and she has never had them before. Because her physician is not available today, she is wondering whether she should go to an urgent care center or can use an OTC treatment. Otherwise, SN reports feeling well and does not have any medical problems or allergies to medications. What recommendations do you have for SN?

A: SN appears to be suffering from vulvovaginal candidiasis, also known as a yeast infection. The typical sign is a thick white discharge that is typically odorless. First-line treatment of uncomplicated yeast infections is any OTC imidazole product, such as butoconazole, clotrimazole, miconazole, and tioconazole.³ Many OTC formulations are available. SN should be informed that products come as vaginal creams, suppositories, and tablets. She can purchase any of the products in the formulation of her choice. She should follow package directions because the products vary by formulation. SN should be educated that decreasing her intake of carbohydrates and sugars can lessen her chances of having recurrent yeast infections. Yogurt with live cultures may also benefit her.³ If her symptoms remain after treatment, she should see her PCP or go to an urgent care center.

Case 3: Osteoporosis

Q: RG is a 72-year-old woman who comes to the pharmacy with a bottle of women’s vitamins. She is looking for something to help her bones. A few years ago, her PCP told her she had osteopenia, for which she was put on alendronic acid for a few years. Now her PCP says she should discontinue it and take a calcium supplement. She denies daily intake of calcium-rich foods, such as milk and yogurt, and decided to get the multivitamin with calcium because her vitamin D level is also borderline low. She currently takes lisinopril 10 mg daily for her blood pressure and has no other medical conditions. What recommendations do you have for RG?

A: All women, including RG, should be educated to use preventive strategies to decrease their chances of developing osteoporosis. RG should be educated that a multivitamin will not give her adequate calcium, as most women should get 1000 to 1200 mg per day of calcium. In addition, she should take 600 to 1000 IU daily of vitamin D.⁴ Many brands of supplements with calcium and vitamin D are available. Because RG does not suffer from acid reflux, she can take calcium carbonate 500 to 600 mg twice daily. To maximize absorption, she should be educated not to take 2 tablets together. In addition, she could do regular weight-bearing and strengthening exercises to prevent fractures. Women at risk for osteoporosis should also avoid alcohol and cigarette use. Bone mineral density testing should be encouraged in all women 65 years and older. If risk factors for osteoporosis are present, bone mineral density testing should be done at a younger age.⁵

Case 4: Emergency Contraception

Q: DD is a 26-year-old woman who comes to the pharmacy looking for emergency contraception. She says she was having intercourse with her boyfriend last night, and the condom broke. She is concerned about getting pregnant. Her girlfriend told her there is an OTC product that can help prevent pregnancy in situations like this. She denies taking any medications on a daily basis. Upon questioning, she says she has never used emergency contraception before. What recommendations do you have for DD?

A: DD appears to have no contraindications to using emergency contraception. Typically, it should be used within 3 to 5 days after unprotected sexual intercourse. DD could use any OTC product but may benefit from the convenience of a 1-pill formulation, such as Plan B One Step, Next Choice One Dose, or My Way. A 2-dose OTC formulation is also available, but the singledose formulation can help patients remain adherent. All study results have shown that the efficacy of emergency contraception declines as the time after unprotected intercourse passes; therefore, DD should be educated to take the medication immediately. If the 2-dose formulation is used, she should take the second dose 12 hours after the first dose. She should also be instructed that she may experience nausea and vomiting; that if the vomiting occurs within 1 to 2 hours, the dose should be repeated⁶ ; and to follow up with her PCP to be tested for sexually transmitted diseases.

Dr. Mansukhani is a clinical associate professor at the Ernest Mario School of Pharmacy, Rutgers University, and a transitions-of-care clinical pharmacist at Morristown Medical Center in Morristown, New Jersey.Dr. Bridgeman is a clinical associate professor at the Ernest Mario School of Pharmacy, Rutgers University, and an internal medicine clinical pharmacist at Robert Wood Johnson University Hospital in New Brunswick, New Jersey.

References

• Roy S, Caillouette JC, Faden JS, Roy T, Ramos DE. Improving appropriate use of antifungal medications: the role of an over-the-counter vaginal pH self-test device. Infect Dis Obstet Gynecol. 2003;11(4):209-216. doi: 10.1080/10647440300025523.
• Monistat [package insert]. monistat.com/vaginal-complete-care-products/monistat-vaginal-health-test-kit. Accessed April 15, 2017.
• Vaginal and vulvovaginal disorders. In: Krinsky DL, Ferreri SP, Hemstreet B, et al (eds). Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care. 18th ed. Washington, DC: American Pharmacists Association; 2015.
• Calcium Fact Sheet. National Institutes of Health website. ods.od.nih.gov/factsheets/Calcium-HealthProfessional. Accessed April 15, 2017.
• Bone density exam/testing. National Osteoporosis Foundation website. nof.org/patients/diagnosis-information/bone-density-examtesting/. Accessed April 15, 2017.
• Plan B One Step website. planbonestep.com. Accessed April 15, 2017.