“Many women present to the pharmacy with symptoms of irritation in the vulvo-vaginal area. Itching, soreness, dryness and discharge can be caused by a number of issues including, but not exclusively, thrush, bacterial vaginosis or genitourinary syndrome of the menopause.”
Vulvovaginal candidiasis (thrush)
Vulvovaginal candidiasis, or thrush, is the most common cause of vaginitis (inflammation of the vagina) and vulvovaginitis (inflammation of the vulva and vaginal region). Candidiasis is typically caused by an overgrowth of the fungal yeast Candidia albicans. The National Institute of Healthcare Excellence (NICE) states that C.albicans accounts for 80-92% of cases with a number of other fungal yeasts accounting for the remaining cases.
Candidiasis is very common, with 70-75% of women experiencing the condition at least once and 40-50% of women reportedly experiencing it two or more times throughout their lives. It is estimated that Candida species could be isolated from 20% of vaginal swabs form otherwise healthy, asymptomatic women of reproductive age at any one time.
The lactic acid producing Lactobacillus species causes the acidic pH range of the vagina, although the vaginal microbiome is diverse. The composition of the vaginal microflora is dynamic and increased change occurs during menstruation and sexual activity.
The majority of women are thought to be colonised with Candida species without symptoms at some point in their lives thus it is thought that the dynamic nature of the vaginal microbiome is a critical factor that leads to colonization by Candida, as well as contributing to it becoming pathogenic. There are a number of risk factors that have been identified as leading to colonization and/or symptomatic candidiasis:
• Hormonal changes (e.g. pregnancy, combined oral contraceptive pill/ hormone replacement therapy, menstruation.
• Immunosupression (e.g. HIV, corticosteroids)
• Antibiotics (particularly broad spectrum)
• Sexual activity (e.g. sexual intercourse, orogenital contact)
• Diabetes (particularly when poorly controlled as high blood sugar levels lead to better conditions for the yeast to grow)
• Changes in vaginal pH
• Vulvardermatosis
• Genetics
There are a number of typical symptoms and signs of thrush:
• Pruritis
• Cheesy discharge
• Irritation (redness, swelling)
There are a range of OTC products available in pharmacies that pharmacists can recommend after establishing that a woman has presented with symptoms of thrush. Azole creams and pessaries inhibit Candida yeast cells from transforming into hyphae and are available OTC. Oral treatments are available on prescription only.
Pregnancy can increase the chances of women developing thrush. It is not harmful to the baby and can be treated with topical treatments and pessaries. Pregnant women should be advised to return if their symptoms have not resolved within 7-14 days.
Various lifestyle factors may contribute to the development of thrush and the discomfort associated with symptoms. Women should be advised to wear loose-fitting, cotton underwear, to use fragrance-free and soap-free cleansers and to have showers rather than baths. Advise women to keep their genitals clean and dry as Candida species, like most fungi, thrive in moist, warm environments. Dietary changes such as reduced sugar intake and use of probiotics have been noted to increase the rate of clinical cure and reduce short-term relapse. The effectiveness of probiotics is however, strain dependent.
Bacterial vaginosis (BV) Bacterial vaginosis is a common cause of abnormal vaginal discharge in women of reproductive age. It is characterized by a white, nonirritating, malodorous vaginal discharge. This discharge commonly smells ‘fishy’ and this odour is often more noticeable after sexual intercourse. Women who experience repeated episodes of Bacterial Vaginosis may benefit from using lactic acid vaginal gels to facilitate the restoration of the normal vaginal flora. Repeated episodes are more frequent in women who practice vaginal douching.
The diagnosis is made clinically on the basis of the description and appearance of the discharge. Typically, the normal pH of the vagina increased from <4.5 to above 4.5 and up to 6.0 reflecting the replacement of normal lactobacilli with anaerobic organisms.
Patients diagnosed with BV should be advised to avoid contributing factors including vaginal douching, use of shower gel in the genital area, and use of antiseptic agents or shampoo in the bath. Patients should also be counselled on smoking cessation and safe sex practices to reduce instances of BV. Goals of treatment include relief of symptoms, reduction in postoperative infection, and reduction of STIs.
Without treatment, BV resolves spontaneously in up to one-third of non-pregnant and one-half of pregnant individuals. Nonpregnant women who are symptomatic or those undergoing gynaecological procedures or surgeries that involve the vagina should be offered treatment. Non-pregnant women with asymptomatic BV do not usually require treatment.
Screening for BV is not recommended as part of regular antenatal care, however if a pregnant woman is incidentally found to have asymptomatic BV, the woman’s obstetrician should be consulted as to whether treatment is appropriate. Pregnant women diagnosed with BV who are symptomatic should be treated. Nitroimidazole antibiotics are usually prescribed orally to treat BV. Lincomycin is prescribed orally and/or topically. There is no benefit in treating male partners.
Genitourinary syndrome of the menopause (GSM)
Genitourinary syndrome of the menopause (GSM) or vulvovaginal atrophy, results from estrogen loss and is often associated with vulvovaginal complaints e.g. dryness, burning, dyspareunia (pain during sexual activity) and even pain and sensitivity when wiping post urination. Urinary frequency and bladder infections may also occur.
It is important to consider the age of a women when she presents to the pharmacy with symptoms such dryness, excessive watery discharge, burning or pain during sexual activity. Advise on soap free cleansers, vaginal moisturisers and lubricants may be beneficial. These products are widely available OTC in pharmacies.
The use of locally applied estrogen (either cream, gel or pessaries) in perimenopausal or post-menopausal women can considerably reduce symptoms of GSM. For some women oral or transdermal hormone replacement therapy (HRT) will be required.
Many women with GSM (up to 80%) do not seek medical care or advise so it is important that when a woman presents to the pharmacy that the appropriate questions are asked and that she is referred to her GP when appropriate.
Women’s intimate healthcare is a large and very relevant topic and one where Pharmacists can make a positive and lasting impact on the health of the women they are dealing with every day.
By virtue of their patient access, community pharmacists can provide front-line health education and screenings to female patients. Pharmacists can identify women at increased risk for various diseases and help in early detection of disease.
