C P E Program [VAGINAL AND VULVOVAGINAL DISORDERS]

Continuing pharmaceutical education

(CPE) program

Alexandria Syndicate of pharmacists

Vaginal disorders & non-

hormonal contraceptives
Prepared by :
Ph/Esraa Refaii
Ph/Esraa nader
Ph/Omnia Abdelrahman
Ph/Salma Abbas

Revised by:
Dr.Heba Attia

Presented by:
Ph/Omnia Abdelrahman
Alex syndicate of pharmacists Page 1
C P E Program [VAGINAL AND VULVOVAGINAL DISORDERS]

Vaginal and Vulvovaginal Disorders

Needed medical background:
The vagina is an elastic fibro-muscular tube lies between the vulva &
the cervix.
Its functions include receiving the erect penis & semen during coitus &
ejaculation & serving as a passageway for fetus & menses to the
outside of the body.
Its pH is acidic (4 - 4.5), this in addition to normal vaginal flora
(Lactobacilli mainly) protect the vagina from infection with other
bacteria.
Lactobacilli mainly responsible for the vaginal acidity by converting
glycogen (in the lining of vagina) to lactic acid.
Production of lactic acid as well as hydrogen peroxide by
lactobacillus both protect vagina from infections.
After menopause, estrogen decreases, thinning of the vaginal lining
occurs, glycogen levels decrease & so the pH rises.
Various factors affecting the vaginal flora & pH, including hormonal
fluctuations of the menstrual cycle, aging (with decreasing estrogen level,
thinning of the vaginal lining occurs, the lactobacilli decline, and the pH rises &
higher levels of estrogen can cause increased vaginal discharge, leaving your
vagina damp and moist, yeast and bacteria are given prime conditions in which
to grow.), certain diseases (e.g. uncontrolled diabetes mellitus as
hyperglycemia can enhance production of protein surface receptors on
Candida albicans which hinders phagocytosis by neutrophils which make its
elimination more difficult ), use of various medications (e.g. contraceptive
preparations, hormones, antibiotics; antibiotic can significantly reduce the
population of friendly organisms allowing the unfriendly forms, which may be resistant to
the antibiotic therapy) & douching with feminine hygiene products(that
can change both the acid-base balance (pH) of the vagina as well as remove
the protective mucus in the vagina).
Repopulation the intestinal tract with friendly organisms by eating
yogurt with active bacteria (lactobacillus) in between taking the
antibiotics (if needed) is recommended.
The healthy vagina is cleansed daily by secretions that lubricate the
vaginal tract.

Alex syndicate of pharmacists Page 2

C P E Program [VAGINAL AND VULVOVAGINAL DISORDERS]

Normal vaginal discharge (leukorrhea) is odorless, clear or white, and

viscous or sticky.
An increase in vaginal secretions is normal during ovulation, during
pregnancy following menses, and with sexual excitement or
emotional flares.
An alteration in vaginal secretions may also occur in response to
vaginal irritants (e.g., feminine hygiene deodorant products as wipes
or spray, vaginal douches and other cleaning products),
contraceptive products and devices, or use of tampons(products
inserted into the opening of the vagina to absorb menstrual flow) .

Differentiation of common vaginal infections

There are three common vaginal infections; bacterial vaginosis (BV),
vulvovaginal candidiasis (VVC) and trichomoniasis.

VVC BV Trichomoniasis
Infection type Fungal Polymicrobial Protozoal infection.
infection. infection with
(yeast is common a reduction of
in vagina but the normal
excess growth
vaginal
make infection)
lactobacillus.

Etiology
Candida Imbalance in Trichomonas vaginalis.
albicans normal
(mainly). vaginal flora.

Epidemiology - Common by - Mostly - Sexually transmitted

age 18 years of affects young disease.
age and older. sexually
- Uncommon active
prior to women.
menarche.

Causes
-No identical -New sexual -New sexual partner
cause. partner. -Presence of other sexually
-May be: -Use of IUD. transmitted disease .
Alex syndicate of pharmacists Page 3
C P E Program [VAGINAL AND VULVOVAGINAL DISORDERS]

Pregnancy, -Douching. -Non-use of barrier

high dose -smoking. contraceptives.
estrogen oral -Prior to
contraceptives pregnancy.
and estrogen
replacement
therapy (ERT).
-High vaginal
pH
(menstruation
and after
menopause).
-Diabetes
mellitus(as
urinary sugar is
rich medium
for microbes) .
-Broad
spectrum
antibiotics,
corticosteroids,
anti-
neoplastics
and immuno-
suppressants.
- Use of IUD.
- Food that
increase
urinary sugar.

Differentiating - Strong vaginal -Less frequent. -As VVC but less strong.
irritation. =========== ====================
symptoms -itching. -white -malodorous with a green-
-erythema. discharge yellow discharge.
-vulval edema with strong
& soreness of fishy odor.
vulval lips.
-dysuria‫ﻋﺳر اﻟﺑول‬.
Alex syndicate of pharmacists Page 4
C P E Program [VAGINAL AND VULVOVAGINAL DISORDERS]

============
-Thin white
cheesy
discharge with
no odour &
normal pH(4.5).

Non-infectious conditions that may be confused

with vaginal infections
 Vulvo-vaginal irritation or pruritus caused by allergy to latex,
spermicides, vaginal lubricants containing potential irritants (e.g.,
propylene glycol), or anesthetics (used by males to delay
ejaculation) .
 Irritation secondary to Douches, feminine hygiene products,
soaps/detergents, or frequent use of panty liners ‫اﻟﻔوط اﻟﺻﺣﯾﺔ ﻟﻼﺳﺗﺧدام‬
‫اﻟﯾوﻣﻰ‬or sanitary napkins ‫اﻟﻔوط اﻟﺻﺣﯾﺔ ﻟﻼﺳﺗﺧدام اﺛﻧﺎء اﻟدورة اﻟﺷﮭرﯾﺔ‬.
 Urethral irritation and dysuria resulting from vulvovaginits may be
mistaken for a urinary tract infection.

1.Vulvovaginal candidiasis(VVC)
General advices
 Avoid tight or damp ‫ رطﺑﺔ‬clothing.
 Dry vaginal area well after bathing.
 Wear cotton underwear because synthetic one increases the moisture
and decreases breathing of the area.
 Use pads and not tampons.
 Avoid douching(unless your physician tells you to do) because it
removes healthy bacteria lining the vagina & decrease acidity that
protect against infection.
 Use unscented ‫ ﻏﯾر ﻣﻌطر‬soap.
 If significant irritation of vulva is present, use sodium bicarbonate sitz
bath because it decreases irritation by neutralizing the excess acidic
pH.
 Decrease simple sugars and refined carbohydrates in your diet (as

Alex syndicate of pharmacists Page 5

C P E Program [VAGINAL AND VULVOVAGINAL DISORDERS]

urinary sugar is rich medium for microbes specially fungi if very high
level of sugar) and try eating yogurt specially if you are on antibiotics

Cases of referral
 First episode of symptoms
 Pregnant woman
 Girls younger than 12 years old(Uncommon prior to menarche).
 Recurrent vaginal infection (>3 infection per year) or infection in the
past few months.
N.B.: Repeat infections that occur immediately after treatment, or a yeast
infection that does not respond to any treatment, may be an early sign
that a person is infected with HIV.

 Medications that can predispose VVC (corticosteroids, anti-

neoplastics and immuno-suppressants) as they make immune system
impaired.
 Disease that can predispose VVC (diabetes mellitus and HIV infection)
 Discharge of fishy odor (bacterial vaginosis) or thin, malodorous
purulent discharge (trichomoniasis).
 If severe symptoms or symptoms don't improve within 3 days or not
gone within a week.

Questions to be asked are about:

 Age
 Symptoms
 History
 Medications
 Diseases

Medications of VVC:
1. Topical & systemic imidazoles antifungal

a. Clotrimazole
Market: Canesten® (Vag. Tab.), Candistan® (Vag. Tab.), Locastan®
(Vag. Supp.)

Alex syndicate of pharmacists Page 6

C P E Program [VAGINAL AND VULVOVAGINAL DISORDERS]

Probable adverse effects: irritation

b. Miconazole
Market: Gynodaktarin® (Vag. Supp., Vag. Cream), Gynozol® (Vag.
Supp., Vag. Cream), Gynoconazol® (Vag. Cream), Micoban® (Supp.),
Monicure® (Supp.), Monicure plus® (Supp.), Mykotral® (Vag. Supp),
Candicure (ovules).

c. Econazol
Market: Gynopevaryl® (Vag. Cream), Gynoryl® (Vag. Tab., Vag.
Cream).

d. Tioconazole
Market: Mipazol® (Vag. Ovules), Topzol -v® (Vag. Cream),
Gynotrosyd® (Vag. Tab., Vag. Cream), Gytro® (Vag. Tab.)

Dose:
Single dose for 1 day, 3 days or 7 days up to 14 days depending on case
severity.

e. Fluconazole
Market: flucoral®(2 cap.), diflucan®(1 cap., 7 cap.,syp, vial) ,
fungican®(1 cap.)

Dose: 150 mg single dose for 1 day repeated when needed.

Probable adverse effects: GI disturbances

N.B.: Oral ketoconazole and fluconazole can be used for recurrent VVC
.Unfortunately, hepatotoxicity has been reported with ketoconazole and
it is recommended that patients on long term treatment have their liver
function tests checked monthly similarly Patients taking fluconazole long
term are recommended to have liver function tests after 6 months.
Alex syndicate of pharmacists Page 7
C P E Program [VAGINAL AND VULVOVAGINAL DISORDERS]

Moreover, Side effects especially cardiac ones must be carefully

monitored.

N.B. : nystatin anti-fungal may be added to one of

imidazoles in the same preparation.

For topical imidazoles antifungal:

Counseling points:
- Complete the course of therapy even if symptoms improve, don't
skip any day even during menstrual flow.
- Avoid sexual intercourse and avoid using tampons during therapy.
- Avoid condoms and diaphragm use for 72 hrs after therapy is
completed (The oil-based nature of these agents in cream and
suppository form could potentially weaken latex condoms and
diaphragms).
- Safe anti-fungals in pregnancy: clotrimazole (category B) &
miconazole _ used when physician recommend that (category C).

Adverse drug reactions:

Vulvovaginal burning and irritation with initial application.

Interaction:
Concurrent use of systemic imidazoles and warfarin may decrease
clearance of warfarin leading to bleeding or bruising.
Management
Decreasing the dose of warfarin to avoid increase in the international
normalized ratio and possibility of bleeding, but it’s preferable to replace
imidazoles by other drugs that can be used for the same purpose.

How to apply vaginal antifungal products

1. Start treatment before going to bed to reduce leakage.

2. Wash vaginal area with mild soap and water, and dry completely.
3. Vaginal cream: (if prefilled applicators, skip to step 4.). Attach the

Alex syndicate of pharmacists Page 8

C P E Program [VAGINAL AND VULVOVAGINAL DISORDERS]

applicator to the tube. Squeeze until the applicator is completely

filled. Remove the applicator from the tube.
Vaginal tablets/suppositories: Place the product into the end of the
applicator.
4. While standing with your feet slightly apart and your knees bent, as
shown in drawing A, or while lying on your back, as shown in
drawing B, gently insert the applicator into the vagina as far as it will
go comfortably.
5. Push the inside piece of the applicator in and place the cream as
far back in the vagina as possible.
6. Remove the applicator from the vagina.
7. Remain in the supine position.
8. Clean the applicator with soap and water.
9. If desired, wear a sanitary pad to absorb leakage.

2. Alternative therapy and herbal products

a. Yogurt
Eating one cup of yogurt (which contains Lactobacillus acidophilus
bacteria) daily is helpful in preventing recurrent VVC

b. Garlic
One crushed clove of garlic wrapped in unbleached gauze inserted
vaginally at bedtime for 6 nights.

Alex syndicate of pharmacists Page 9

C P E Program [VAGINAL AND VULVOVAGINAL DISORDERS]

Adverse drug reactions:

It may cause burning sensation if irritation is present because of vaginitis;
in this case use a whole uncut clove of garlic.

Now it’s obsolete.

c. Tea tree oil

It has antiseptic, antibacterial, antifungal, and antiviral action

E.g.: Gena-ex® solution

d. Gentian violet
For resistant infections.

Dose and method of application:

A tampon can be soaked in the dye, inserted into the vagina and left for
several hours or overnight up to 5 consecutive days.

Side effects:
It can stain fabrics and skin.

Now it’s obsolete.

e. Boric acid
Is useful for non-C. albicans infections which are more resistant to azole
antifungals.

Warning!!
It can be toxic and teratogenic, so capsule should not be ingested,
shouldn't be used if there are cuts or breaks in the vaginal wall and
pregnant women should not use it.

Now it’s obsolete.

Alex syndicate of pharmacists Page 10

C P E Program [VAGINAL AND VULVOVAGINAL DISORDERS]

3. Products to relieve itching and irritation

a. Benzocaine
Market: Equate vagicane® (Cream)

Counseling point:
Applied externally only.

b. Hydrocortisone (local)

N.B. systemic corticosteroids may cause or increase infection

market: Daktacort®, Micosone®, Monicort®, Mycocort®, Mykotral-H®,

Dermozol cort®, Hydrocortisone®, Micort® (Cream)

Counseling points:
-Applied externally only and avoid prolonged use.
-Ointment is not preferred as it is hard to be washed.

c. Povidone-iodine
market: Betadine® (Vag. Ovules, Vag. douche, Supp.), Iodosept®
(Ovules), Povidone-iodine® (Vag. Supp.).

Dose: insert one supp. every 12 hrs and for douche use one measure in
1L of warm water.

Treatment outcome: symptoms should disappear within 3

days of treatment, if no improvement is seen after 7 days the patient
should be referred to the physician.

Alex syndicate of pharmacists Page 11

C P E Program [VAGINAL AND VULVOVAGINAL DISORDERS]

2-Bacterial Vaginosis(BV)
General advices:
 Don't Douche as possible as you can.
 Don't smoke.
 Wash diaphragms & other reusable birth control devices
thoroughly after use.
 Avoid moisture of the vagina.

Medications of BV:
1. Oral metronidazole 500mg
market: Amrizole® (Tab.), Dumozol® (Tab.), Flagyl® (Tab.), Flagicure
Forte® (Tab.), Gedazole® (Tab.)
Dose: 1 Tab. twice daily for 7 days or single 2g single dose.

OR
Oral clindamycin 300mg
market: Clinacyn® (Cap.), Clindacine® (Cap.), Clindam® (Cap.),
Dalacin-C® (Cap.), Mepaclind® (Cap.).
Dose: 1 Tab. twice daily for 7 days.

2. Topical metronidazole
market: Amrizole® (Vag. Supp.), Amrizole-N® (Vag. Supp.), Flagicure®
(Vag. Tab.), Krema-Rose® (Supp.), Metrozole® (Vag. Tab., Vag, Ovules),
Metronal® (Vag. Tab.).
Dose: one supp. or one tab. inserted daily for two weaks.

OR:
Topical Clindamycin
market: Dalacin® (Vag. Cream), Vagiclind® (Vag. Cream).
Dose: 5gm inserted daily for 7 days.

Alex syndicate of pharmacists Page 12

C P E Program [VAGINAL AND VULVOVAGINAL DISORDERS]

3. Povidone-iodine

N.B.: Safe drugs in pregnancy: metronidazole & clindamycin (category B)

but Povidone-iodine (cat. D)

3-Trichomoniasis
General advices:
 Both partners should be treated at the same time to eliminate the
parasite.
 Persons being treated for trichomoniasis should avoid sex until they
and their sex partners complete treatment and have no symptoms.
 Latex male condoms, when used consistently and correctly, can
reduce the risk of transmission of trichomoniasis.

N.B.: pregnant woman who are infected by trichomoniasis may have

premature or low-birth weight babies.

Medications
1.Oral Metronidazole

 Dose: 2gm as single dose or 500mg twice daily. for 7 days.

 Safe in pregnancy (category B).

2.Tinidazole
 For metronidazole resistant infections.
 Dose: 2g as single dose.

Alex syndicate of pharmacists Page 13

C P E Program [VAGINAL AND VULVOVAGINAL DISORDERS]

4. Atrophic vaginitis
Definition
It is inflammation of the vagina due to thinning tissue and decreased
lubrication, over time there may be narrowing & shrinkage of the vaginal
opening & vagina itself. It is related to reduced estrogen levels (Estrogen
is very important in keeping the tissues of the vagina lubricated and
healthy).

Causes
Decrease in estrogen level during menopause, the postpartum period
and breast-feeding (in the last 2 cases atrophic vaginitis is temporary &

Alex syndicate of pharmacists Page 14

C P E Program [VAGINAL AND VULVOVAGINAL DISORDERS]

less severe), decrease in ovarian estrogen production (e.g., radiation

therapy, chemotherapy) in women taking anti-estrogenic medication
such as clompihene, medroxprogesterone, tamoxifen, raloxifene.

Signs and symptoms of atrophic vaginitis

Decrease in vaginal lubrication, vaginal irritation, dryness, burning,
itching, leukorrhea, and dyspareunia ‫ﻋﺳر اﻟﺟﻣﺎع‬.
Thin, watery (occasionally bloody), or yellow malodorous discharge.
Sexual activity may result in vaginal bleeding or spotting.

General advices
- Sexual arousal ‫ اﻻﺳﺗﺛﺎرة‬and intercourse can improve symptoms.
- Avoid products that may aggravate vaginal symptoms (irritants and
allergens such as powders, perfumes, spermicides, and panty liners).

Questions to be asked:
- Symptoms (including association with sexual intercourse) and
severity?
- Are you pregnant, lactating or have you recently given birth?
- Are you premenopausal or postmenopausal?
- Do you use any vaginal or feminine hygiene products? (As they
may cause or worsen irritation and dyspareunia).

Cases of referral
- Symptoms of severe vaginal dryness, dyspareunia or bleeding.
- Systemic symptoms.
- If OTC lubricants don’t produce adequate relief of symptoms of
vaginal dryness or dyspareunia.

Alex syndicate of pharmacists Page 15

C P E Program [VAGINAL AND VULVOVAGINAL DISORDERS]

Medications of atrophic vaginitis

1- Vaginal lubricants

They are water-soluble products temporarily moisten vaginal tissues

and provide short-term improvement in symptoms such as relief from
burning and itching, they also provide adequate vaginal lubrication to
facilitate sexual intercourse.

Counseling points:
- Vaseline should not be used because it is difficult to remove from the
vagina.
- These products provide an improvement in symptoms for less than 24
hours.
- If you are treating dyspareunia, the lubricant should be applied to
both the vaginal opening and the penis.
- Don’t use water insoluble lubricants if you are using latex condom or
diaphragm as they cause damage of latex.
- For generalized vaginal dryness, some relief appears initially, optimal
effect requires regular use of product for several weeks.

Market:
Dormant® (solution), Gena-ex® (solution)

2- Vaginal estrogen products

Market:
Oestrgel®(vag.Gel), Premarin®(vag.cream), fiminosan®(tab.)

Alex syndicate of pharmacists Page 16

C P E Program [VAGINAL AND VULVOVAGINAL DISORDERS]

VAGINAL DOUCHING

Potential Adverse Effects of Douching

- Frequent douching has been associated with an increased risk for

pelvic inflammatory disease (PID) (inflammation of the uterus, fallopian
tubes, and/or ovaries as it progresses to scar formation with adhesions to nearby
tissues and organs. This may lead to infections), reduced fertility, ectopic
pregnancy, vaginal infections (e.g., bacterial vaginosis), sexually
transmitted infections, low birth weight, and cervical cancer.
- Irritation or sensitization from douche ingredients and disruption of
normal vaginal flora and pH.
- Local irritation, sensitization and contact dermatitis are also possible
with many antimicrobial agents found in douches.

Types of douches

1- Non-medicated douches
*They are prepared from water-vinegar solution.
*They have little to no effect on lactobacilli, but inhibit some vaginal
pathogens.
2-Douches containing antiseptics
They inhibit all vaginal flora, reduce total bacteria, but may allows
pathogenic species to proliferate.
Market:
Funny®(v.douch),Monto®(Douch),Osmify®(v.douch),
Rosmine®(v.douch), Rosadine®(douch), Rowasan®(v.douch), Sam
lady®(v.douch).

Intravaginal povidone-iodine may be systemically absorbed, so ….

Contraindicated in:
- Individuals allergic to iodine-containing products.
- Pregnant women: repeated applications may result in iodine-
induced goiter and hypothyroidism in the fetus.
Alex syndicate of pharmacists Page 17
C P E Program [VAGINAL AND VULVOVAGINAL DISORDERS]

Administration Guidelines for Douches

1- Bulb Douche Syringe Method:

- Choose a douching position comfortable for you.
- Gently insert the nozzle about 7.5 cm into your vagina.
- Squeeze bottle gently, letting the solution cleanse the vagina and
then flow freely from the body.
2- Douche Bag Method:
- Fill the douche bag with the prescribed solution or with a warm water
and vinegar solution.
- Lie back with knees bent.
- Place the douche bag about 30 cm above the height of your hips.
- Do not place it higher because this will increase pressure of fluid
entering the vagina.
- Insert the nozzle up and back toward the small of the back, release
the clamp slowly to allow fluid to enter the vagina until the vagina
feels full, and hold the fluid in the vagina out: repeat until the douche
bag is empty.
- Wash the nozzle with mild soap and water.

Patient education for douching

- Keep all douche equipment clean.
- Use warm water to dilute products.
- Follow the appropriate instructions of douching.
- Do not douche until at least 8 hours after intercourse during which a
diaphragm, cervical cap, or contraceptive jelly, cream, or foam was
used.
- Do not douche for at least 3 days after the last dose of vaginal
antifungal medication.
- Do not douche for 48 hours before any gynecologic examination.
- Do not douche during pregnancy unless under the advice and
supervision of a primary care provider.
- Do not douche more often than twice a week, except on the advice
of a primary care provider.
- If vaginal dryness or irritation occurs, discontinue use of the douche.

Alex syndicate of pharmacists Page 18

C P E Program [VAGINAL AND VULVOVAGINAL DISORDERS]

For unmarried girls:

 They must use only external products.
 Early treatment of candida or other infections is needed not to be
disseminated infections & reach fallopian tubes & obstruct them
because this may affect fertility.
 Use cleansers once or twice weekly maximum as preventive
hygiene.

Alex syndicate of pharmacists Page 19

C P E Program [VAGINAL AND VULVOVAGINAL DISORDERS]

Non-hormonal Contraceptives
Entrance:
 The goal of contraceptive use to prevent unintended pregnancy
and sexually transmitted infections (STIs) in persons at risk with a
minimum of adverse effects.
 No method of birth control is perfect.
 Major points to consider in selecting a contraceptive method
should include safety, effectiveness, accessibility, and acceptability
of the method to each sexual partner as it is vital for correct and
consistent use of the method.
 The primary safety factor to consider in choosing a method of
contraception is the risk of side effects, including the potential for
adverse effects on future fertility and on fetus, if unintended
conception occurs.
 The effectiveness of a contraceptive method depends on either
method itself or the use of this method & degree of compliance.

1} Non-prescription contraceptive
products:
1. Spermicidal products
They are composed of an active agents, which immobilizes or kills
sperm, and an inert base (e.g.: foam, cream, jelly, gel, tablet, or
suppository) which localizes the spermicidal chemical in proximity to
the cervix, from which two forms (gels and foams) act as a physical
barrier against sperm.
These agents work by disrupting the sperm membrane and by
decreasing the ability of sperm to metabolize fructose (sperm cells
use fructose in cellular respiration).
They block the cervix, so sperm cannot reach an ovum & immobilize
sperm, so they cannot join with an ovum.
They are inserted deep into the vagina shortly before intercourse

Alex syndicate of pharmacists Page 20

C P E Program [VAGINAL AND VULVOVAGINAL DISORDERS]

They can be used alone, or with other birth control methods to

make them more effective (always used with the diaphragm and
cervical cap that will be discussed later) however spermicidal
contraceptives are not generally recommended for use with
condoms, as there is no evidence of any additional protection
compared with non-spermicidal lubricants.
The active ingredient includes nonoxynol -9 which is considered
safe and effective by the FDA.
Pregnancy: category B.
Lactation: There are no data on the excretion of nonoxynol 9
topical into human milk. Use of vaginal spermicides has not been
reported to cause problems in nursing babies.
Adverse effects:

Less Frequent:
Genital Organ Pruritis, Rectal Irritation, Vaginal Burning, Vaginal
Discharge, Vaginal Dryness, Vaginal Irritation.

Contraindications:

Most Significant: Sensation Disturbance of Genitals

Possibly Significant: Contact Dermatitis

Its role in STIs:

This product does not protect against HIV/AIDS or other STDs and
may increase the risk of getting HIV from an infected partner.
Do not use if you or your sex partner has HIV/AIDS. If you do not
know if you or your sex partner is infected, choose another form of
birth control.

Dosage forms:

(1) Creams, jellies, and gels are used with a diaphragm.

The concentration of spermicide is less than the necessary 8% to be
employed as a single contraceptive method.
(2) Foams disperse better into the vagina and over the cervical opening
but provide less lubrication than creams, jellies, and gels. They usually
Alex syndicate of pharmacists Page 21
C P E Program [VAGINAL AND VULVOVAGINAL DISORDERS]

contain a higher concentration of spermicide ( i.e. , the optimal

concentration of 8% or higher ) .
(a) It should be shaken vigorously before use.
(b) It should be inserted intravaginally about two thirds the length of
the applicator, and the contents should be discharged.
(c) Foam should be reapplied during prolonged intercourse (i.e.,
lasting > 1 hour) and before every subsequent act of intercourse.

(d) To ensure efficacy, the patient should wait at least 8 hours before
douching to avoid diluting the spermicide effect or forcing sperm into
the cervix.

(3) Suppositories and foaming tablets.

These agents are both small and convenient. Although solid at room
temperature, suppositories melt at body temperature (e.g. Contraseed®
, Sendocin® ,12 vaginal supp. and contains nonoxynol-9 100 mg),
whereas foaming tablets effervescence (e.g. Neosampoon® ,12 foaming
vaginal tablets and contains Menfegol 60 mg).

(a)The tablets should be wetted before insertion, which may create a

sensation of warmth.

(b) The tablet or suppository should be inserted high into the vagina, 10-
15 minutes before intercourse.

(c) Intercourse must occur within 1 hour or the dose must be repeated.

(d) Another tablet or suppository should be inserted before each

repeated act of intercourse.

(e) To ensure efficacy, the patient should wait 6-8 hr after the last act of
intercourse before douching.

(4)Film

Comes as small paper, thin sheets that contain nonoxynol

-9 spermicide(e.g.: VCF®).

Alex syndicate of pharmacists Page 22

C P E Program [VAGINAL AND VULVOVAGINAL DISORDERS]

It is inserted on the tip of the finger into the vagina and placed at the
cervical opening 5-15 min before intercourse.

(5)Sponge
It is a doughnut shaped polyurethane device containing the spermicide
nonoxynol -9; it is inserted into the vagina before sexual intercourse.
Efficacy is approximately comparable to that of a cervical cap. It is
believed to act as a contraceptive in three ways: (1) mechanically
blocking the cervical entrance, (2) absorbing semen, and (3) providing a
spermicide.

It can remain in place for 24 hour.

Concerns are a higher risk for TSS (toxic shock syndrome).

Its effectiveness is higher in women who have never given birth.

2.Condoms

1) Male condoms

Types:

 Natural latex

Latex has outstanding elastic properties.

While the advantages of latex have made it the

most popular condom material, it does have some
drawbacks.

Latex condoms are damaged when used with oil-based substances as

lubricants, such as petroleum jelly, cooking oil, baby oil, mineral oil, skin
lotions, suntan lotions, cold creams, butter or margarine.

Alex syndicate of pharmacists Page 23

C P E Program [VAGINAL AND VULVOVAGINAL DISORDERS]

Contact with oil makes latex condoms more likely to break or slip off due
to loss of elasticity caused by the oils. Additionally, latex allergy precludes
use of latex condoms and is one of the principal reasons for the use of
other materials.

In May 2009 FDA granted approval for the production of condoms

composed of Vertex (latex that has been treated to remove 90% of the
proteins responsible for allergic reactions).

An allergen-free condom made of synthetic latex (polyisoprene) is also

available.

 Synthetic

The most common non-latex condoms are made from polyurethane.

Polyurethane is also the material of many female condoms.

Polyurethane can be considered better than latex in several ways:

Condoms may also be made from other synthetic materials, such as AT-
10 resin, and most recently polyisoprene.

#It conducts heat better than latex.

#It is not as sensitive to temperature and ultraviolet light (and so has less
rigid storage requirements and a longer shelf life).

#Can be used with oil-based lubricants.

# Less allergenic than latex, and does not have an odor.

Polyurethane condoms have gained FDA approval for sale in the United
States as an effective method of contraception and HIV prevention, and
under laboratory conditions have been shown to be just as effective as
latex for these purposes.

However, polyurethane condoms are less elastic than latex ones, and
may be more likely to slip or break than latex, and are more expensive.

Alex syndicate of pharmacists Page 24

C P E Program [VAGINAL AND VULVOVAGINAL DISORDERS]

Polyisoprene is a synthetic version of natural rubber latex. While

significantly more expensive, it has the advantages of latex (such as
being softer and more elastic than polyurethane condoms) without the
protein which is responsible for latex allergies.

 Lambskin
Condoms made from sheep intestines, labeled "lambskin", are also
available, although they have been clinically shown not to necessarily
keep out STDs compared to latex because of pores in the material, which
are thought to be large enough to allow infectious agents to pass
through; sperm is still blocked.

Lambskin provides more sensation and are less allergenic than latex, but
because of their comparatively less-safe nature, other hypoallergenic
materials such as polyurethane are recommended for latex-allergic users
and/or partners.

Lambskin condoms are also significantly more expensive than other

types, similar to polyurethane's comparative expense to latex.

2) Female condom

It is a disposable polyurethane sheath that fits

into the vagina and provides protection from
pregnancy and STDs.

The sheath resembles a plastic vaginal pouch and

consists of an inner ring, which is inserted into the vagina
near the cervix much like a diaphragm, whereas the
outer ring remains outside the vagina, covering the labia.

The condom is pre-lubricated, and additional lubricant

(e.g. K-u y Gel®) is provided for use if needed.

The polyurethane sheath is stronger and probably less

likely to tear or break than the latex sheath of male condoms.

Alex syndicate of pharmacists Page 25

C P E Program [VAGINAL AND VULVOVAGINAL DISORDERS]

It should be removed immediately after intercourse (before the woman

stands up).

It may be inserted up to 8 hr before intercourse.

If it is used properly, it provides the woman with a method of preventing

the transmission of STDs.

Some women complain that it interferes with sensation and that it makes
unpleasant noises during use.

2}prescription contraceptive
products:
1. Diaphragm
A contraceptive device that is self - inserted into the
vagina to block access of sperm to the cervix.

It must be used in conjunction with a nonprescription spermicide to seal

off crevices between the vaginal wall and the device.

There are four types of diaphragms: the coil spring, the flat spring, the
arcing spring, and a wide-seal rim.

The tone of vaginal muscles as well as the position of the uterus and
adjacent organs usually determine the type of diaphragm necessary.

Sizes of the diaphragm range from 50 to 95 mm in diameter, in 5-mm

gradations.

Application method: The diaphragm is held in place by the spring tension

of a wire rim encased by rubber.
When positioned properly, the diaphragm forms a flexible dome to
cover the cervix, the sides pressing against the vaginal muscle wall and
the pubic bone.

Alex syndicate of pharmacists Page 26

C P E Program [VAGINAL AND VULVOVAGINAL DISORDERS]

Application instructions:
(1) The diaphragm plus spermicide can be inserted as long as 6 hour
before coitus.
The device should be left in place for 6-8 hr after intercourse, but no
longer than 24 hr.
Additional spermicide is required for repeated intercourse.
(2) Before inserting the diaphragm, 5- 8 cm ribbon of spermicidal cream
or jelly should be spread over the inside of the rubber dome.
(3) Also, spermicide should be spread around the rim to permit a good
seal between the diaphragm and the vaginal wall. (For added
protection, it can be applied outside the dome).

Proper care
(1) The diaphragm should be washed with soap and water, rinsed
thoroughly, and dried with a towel.
(2) It should be dusted with cornstarch and kept in its original container
(away from heat).

2. Cervical cap
A prescription rubber device smaller than a diaphragm
that fits over the cervix like a thimble. It is more difficult
to fit than the diaphragm.

It remains effective for more than one episode of

intercourse, without adding more spermicide.

The cap should be filled one third full of spermicide cream or jelly; the
spermicide is then applied to the rim.

The cervical cap may be left in place for a maximum of 48 hr and should
be left in place for at least 8 hr after intercourse.

3. Intra-uterine devices (IUDs)

IUDs are small, "T-shaped" devices made of flexible plastic.

They are one of the most effective forms of birth control

Alex syndicate of pharmacists Page 27

C P E Program [VAGINAL AND VULVOVAGINAL DISORDERS]

methods available.

A health care provider inserts an IUD into a woman's uterus.

IUDs affect the way sperm move, preventing them from joining with an
egg. There are two types of IUDs: the copper –containing IUD and an IUD
that slowly releases progesterone. Both types also alter the lining of the
uterus.

IUDs includes Copper T 380® (380 mm square of copper) ,Multiload 375 ®

(polyethylene loop) , Nova-T® (the vertical portion of T is
wound round with thin copper wire stabilized with a silver core
,107-140 mg copper and 11-29 mg silver).

Progestin works by keeping a woman's ovaries from

releasing eggs & also prevents pregnancy by thickening
a woman's cervical mucus. The mucus blocks sperm and
keeps it from joining with egg.

IUD doesn't protect against sexually transmitted

infections.

Use latex or female condom along with the IUD reduces the risk of
infection.

Application:

An IUD can be inserted at any time of the month. But it is usually more
comfortable if woman has it inserted in the middle of her menstrual
cycle. That is when the cervix — the opening to the uterus — is the most
open.

An IUD can be inserted after a pregnancy or abortion.

IUD can be inserted up to 48 hours after giving birth or after waiting at

least four weeks after giving birth or immediately after an abortion.

When the IUD is in place, a string will hang down into the vagina. It will
be about one to two inches long.

Alex syndicate of pharmacists Page 28

C P E Program [VAGINAL AND VULVOVAGINAL DISORDERS]

Woman should have a checkup after her first period.

It is especially important to check every few days for the first few months.

Woman shouldn’t wait longer than 3 months after she gets her IUD to
make sure it is still in place.

Woman should check her pads, tampons, or cups to see if the IUD has
fallen out. If it has, she must check with her health care provider. Until
then, use another form of birth control such as latex or female condoms.

When checking for the string ends the following must be done:

 Washing hands. Then either sitting down.

 Putting index or middle finger up into the vagina until touching the
cervix. The cervix will feel firm and somewhat rubbery, much like the
tip of the nose.

 Feeling for the string ends that should be coming through. If finding
them, it means that the IUD is in place and working. Woman should
not attempt to put the IUD back in place herself. Using another form
of birth control until it is put back in place.

 Pulling the string ends might make the IUD move out of place or
even come out.

Woman should tell the health care provider immediately when:

Finding the length of the string ends to be shorter or longer than

they were at first, when feeling for them with the fingers.
No ability to feel the string ends when she checks.
Feeling the hard plastic bottom of the "T" part of the IUD against the
cervix, when she checks.
Thinking that she might be pregnant.
Having periods that are much heavier than normal or last much
longer than normal.
Having severe abdominal cramping, pain, or tenderness in the
abdomen.
Having pain or bleeding during sex.

Alex syndicate of pharmacists Page 29

C P E Program [VAGINAL AND VULVOVAGINAL DISORDERS]

Having unexplained vaginal bleeding.

Having unexplained fever and/or chills.
Having flu-like symptoms, such as muscle aches or tiredness.
Having unusual vaginal discharge.
Having a missed, late, or unusually light period.

Woman should not use an IUD if she:

Have had a pelvic infection following either childbirth or an

abortion in the past three months.
Have or may have a sexually transmitted infection or other pelvic
infection.
Thinks she might be pregnant.
Have cervical cancer that hasn't been treated.
Have cancer of the uterus.
Have unexplained bleeding in her vagina.
Have pelvic tuberculosis.
Have a uterine perforation during IUD insertion.
The unique size, shape, or condition of a woman’s uterus does not
allow correct placement of an IUD.

Positive points

 IUDs may improve her sex life.

 IUDs can be used during breastfeeding.

 The ability to become pregnant returns quickly once the IUD is

removed.

Overall, most women who get an IUD are satisfied with their choice.

Be careful!!!!!
 The IUD can sometimes slip out of the uterus. Sometimes it comes all
the way out. Sometimes it only comes out a little. This is more likely to
happen to women who are younger and who have never had a
baby. If the IUD slips out of place, pregnancy can happen. If it
comes out only part of the way, it has to be removed.

Alex syndicate of pharmacists Page 30

C P E Program [VAGINAL AND VULVOVAGINAL DISORDERS]

Ectopic pregnancy is a serious & can be life-threatening; it is

a complication of pregnancy in which the pregnancy implants outside
the uterine cavity.

Most ectopic pregnancies occur in the Fallopian tube.

Symptoms of an ectopic pregnancy include

Irregular vaginal bleeding.

Pain in the abdomen or tip of the shoulder.
Sudden weakness or fainting.

Women who use IUDs are much less likely to have an ectopic pregnancy
than women who are not using birth control.

But if a woman does become pregnant while using an IUD, it is more likely
to be ectopic than if she was not using the IUD.

If she has any of these symptoms while using an IUD, she should get
medical care immediately.

References:
 Handbook of non-prescription drugs
 Comprehensive pharmacy review 7
 http://women.webmd.com
 http://www.medscape.com
 www.medlineplus.com
 www.safefetus.com
 http://online.lexi.com
 http://www.thomsonhc.com
 http://www.racgp.org.au/afp/200503/200503sheary.pdf )
 Community pharmacy handbook
 Symptoms In The Pharmacy Fifth Edition
 BNF 57
 www.fda.gov

Alex syndicate of pharmacists Page 31