Self-medication with vaginal antifungal drugs: physicians' experiences and women's utilization patterns

Managing recurrent vulvovaginal thrush from patient and healthcare professional perspectives: A systematic review and thematic synthesis

OBJECTIVE

This systematic review aims to identify what is known about patient and healthcare professional experiences of managing recurrent vulvovaginal thrush by synthesising published findings.

METHODS

Five databases were searched for studies on patient and healthcare professional experiences managing recurrent thrush. Two reviewers independently screened and quality assessed qualitative, quantitative, and mixed-methods studies. Findings from eligible studies were thematically synthesised.

RESULTS

720 papers were identified, and 29 were included. Four descriptive themes were developed to depict the repeated management of recurrent thrush. These themes were: (re)experiencing impacts, (re)identifying recurrent thrush, (re)considering consultations, and (re)trying treatments. An analytic high-order frame of 'interwoven and reoccurring uncertainties' was used to understand these themes.

CONCLUSIONS

Patients and healthcare providers face uncertainties when managing recurrent thrush. The inconsistencies raised across papers suggests an unaddressed gap in knowledge about patient experiences and their informational and support needs; this includes insights about this condition's diagnosis, management, treatment, impacts, and meaning.

PRACTICE IMPLICATIONS

This review has implications for patient education, health promotion, and communication between patients and providers. Our interpretations suggest the need for more research and resources to help support patients and clinicians in managing this condition to promote more understanding, communication, and collaborative care.

Management of recurrent vulvovaginal candidosis: Narrative review of the literature and European expert panel opinion

Recurrent vulvovaginal candidosis (RVVC) is a chronic, difficult to treat vaginal infection, caused by Candida species, which affects women of all ages and ethnic and social background. A long-term prophylactic maintenance regimen with antifungals is often necessary. In most clinical practice guidelines, oral fluconazole is recommended as the first-line treatment. Although clinical resistance to antifungal agents remains rare, overexposure to azoles may increase the development of fluconazole-resistant C. albicans strains. In addition, non-albicans Candida species are frequently dose-dependent susceptible or resistant to fluconazole and other azoles, and their prevalence is rising. Available therapeutic options to treat such fluconazole-resistant C. albicans and low susceptibility non-albicans strains are limited. Ten experts from different European countries discussed problematic issues of current RVVC diagnosis and treatment in two audiotaped online sessions and two electronic follow-up rounds. A total of 340 statements were transcribed, summarized, and compared with published evidence. The profile of patients with RVVC, their care pathways, current therapeutic needs, and potential value of novel drugs were addressed. Correct diagnosis, right treatment choice, and patient education to obtain adherence to therapy regimens are crucial for successful RVVC treatment. As therapeutic options are limited, innovative strategies are required. Well- tolerated and effective new drugs with an optimized mechanism of action are desirable and are discussed. Research into the impact of RVVC and treatments on health-related quality of life and sex life is also needed.

Women's preferences and acceptance for different drug delivery routes and products

To use or not to use, that is the first decision to take regarding a drug product. This mandatory step for adherence dictates product efficacy. The determinants for such decision do not only rely on the priority of the therapeutic or preventive strategy, but are related to a complex network of perceptions, preferences, personal and cultural backgrounds, and results from previous experiences. Women's preferences for dosage forms and even for drug delivery routes have been mainly studied in the fields of contraception and HIV prevention (and their related multipurpose approaches). Much less attention has been devoted to other therapeutic or preventive strategies. In a time when patient-centred approaches and shared decisions are increasingly valued, considering women's preferences and their main determinants is essential for product development and selection. Such products will be more likely to be chosen and used as intended, increasing efficacy, and reducing the overall costs related with these treatments. This knowledge shall be integrated in early stages of product development. This article reviews the state of the art related with women's preferences and acceptance for different dosage forms and drug delivery routes involved in women's health. The methodologies used for collecting these data and their major drawbacks are discussed. Results obtained from acceptability studies and the main determinants for selection of preventive and treatment drug products are discussed as tools for new developments in the field.

Clinical Evaluation of a Self-Testing Kit for Vaginal Infection Diagnosis

Vaginitis is a common disorder among women of varying ages that arises from a change in the normal pH balance of vaginal bacteria or an infection. Characteristic symptoms of itching, irritation, and odor cause considerable discomfort and increase the risk of contracting other sexually transmitted infections. Because of the sensitive and personal nature of the condition, some women may be reluctant to seek treatment. This behavior not only fails to solve the problem but may also delay medical treatment and result in additional medical complications. The pH changes associated with vaginitis and vaginosis, which are characterized by the presence or absence of inflammation, respectively, are well known but can vary. For example, bacterial vaginosis and trichomoniasis infection will raise vaginal pH above 4.5, while vulvovaginal candidiasis does not result in any measurable change to pH. Nonetheless, diagnostic tools relying on pH measurement are a valuable approach from which additional testing and treatment may be launched. Here, we focused on the use of a vaginal self-test tool and tested 50 patients, including pregnant women. When used according to the instructions, the Hygeia Touch Self-Testing Kit for Vaginal Infection demonstrated over 88% accuracy compared to a clinical diagnostic workup, with a sensitivity of 87% and a specificity of 89% in the patients where the swab was correctly interpreted. This study demonstrated an effective self-test method with high acceptability among women that provided them with greater autonomy regarding health management.

Public knowledge about dosage forms, routes of drug administration and medication proper storage conditions in Riyadh District, Saudi Arabia

Objectives

The purpose of this study was to assess public knowledge on the safety, efficacy, proper storage conditions and other physiochemical properties of different dosage forms.

Methods

This study was based on a cross-sectional design. A structured quantitative survey, which included five sections, was used as an instrument for data collection. The first section addressed the demographic characteristics of the sample, whereas the second section assessed public knowledge on medications. The third section inquired about participants’ preferred dosage forms. The fourth section was related to the perceived effects of physiochemical properties of medicines on their safety and efficacy. The fifth section addressed participants’ thoughts on appropriate ways for medications usage and storage. A total of 752 participants completed the questionnaire. Data were analysed using SPSS (20.0) software.

Key findings

Although our study findings pointed out some knowledge gaps based on participants’ answers, most of the participants (87%) reported that physicians or pharmacists were the main sources of their medicine-related information. There was a great variation in participants’ responses regarding perceived onset of action, proper storage conditions and other properties of different dosage forms.

Conclusion

The study findings demonstrated the need to educate the public about basic information related to different dosage forms of medications.

Patients' Health Information Practices and Perceptions of Provider Knowledge in the Case of the Newly Discovered Alpha-gal Food Allergy

BACKGROUND

Alpha-gal food allergy is a life-threatening, newly discovered condition with limited presence in authoritative information sources. Sufferers seeking diagnosis are likely to encounter clinicians unfamiliar with the condition.

OBJECTIVE

To understand information practices of individuals diagnosed with alpha-gal allergy, how they obtained diagnosis, and their perceptions of health-care providers' awareness of the condition.

METHODS

Semistructured interviews with open- and closed-ended questions were completed with a chronological systematic sample of 28 adults (11% of alpha-gal clinic patients at the time) diagnosed with alpha-gal allergy and treated at University of North Carolina Allergy and Immunology Clinic.

RESULTS

The majority of patients determined they had alpha-gal allergy through nontraditional health information channels. Three-quarters of patients rated their primary care provider as having little to no knowledge. In 25 specialists' encounters, 23 were rated as having little to no knowledge.

CONCLUSION

With new conditions, information is often available through informal networks before appearing in the vetted medical literature. In this study, social connections were the primary pathway to successful diagnosis. Health practitioners need to develop mechanisms to understand that process.

Global burden of recurrent vulvovaginal candidiasis: a systematic review

Recurrent vulvovaginal candidiasis is a debilitating, long-term condition that can severely affect the quality of life of affected women. No estimates of the global prevalence or lifetime incidence of this disease have been reported. For this systematic review, we searched PubMed, Embase, and Web of Science databases for population-based studies published between 1985 and 2016 that reported on the prevalence of recurrent vulvovaginal candidiasis, defined as four or more episodes of the infection every year. We identified 489 unique articles, of which eight were included, consisting of 17 365 patients from 11 countries. We generated estimates of annual global prevalence, estimated lifetime incidence and economic loss due to recurrent vulvovaginal candidiasis, and predicted the number of women at risk to 2030. Worldwide, recurrent vulvovaginal candidiasis affects about 138 million women annually (range 103-172 million), with a global annual prevalence of 3871 per 100 000 women; 372 million women are affected by recurrent vulvovaginal candidiasis over their lifetime. The 25-34 year age group has the highest prevalence (9%). By 2030, the population of women with recurrent vulvovaginal candidiasis each year is estimated to increase to almost 158 million, resulting in 20 240 664 extra cases with current trends using base case estimates in parallel with an estimated growth in females from 3·34 billion to 4·181 billion. In high-income countries, the economic burden from lost productivity could be up to US$14·39 billion annually. The high prevalence, substantial morbidity, and economic losses of recurrent vulvovaginal candidiasis require better solutions and improved quality of care for affected women.

Safety and efficacy of a new imidazole fungicide, Sertaconazole, in the treatment of fungal vulvo-vaginitis: a comparative study using Fluconazole and Clotrimazole

Background: Sertaconazole is a new imidazole fungicide introduced for vulvo-vaginal candidiasis. It has an azole group with benzothiophene that inhibits biosynthesis of ergosterol and brings about a massive leak of cytoplasm with consequent fungal cell death. Objective: Assess the safety and efficacy of Sertaconazole in the treatment of fungal vulvo-vaginitis for comparison with Fluconazole and Clotrimazole. Subjects and methods: One-hundred eighty-eight outpatients with fungal vulvo-vaginitis were recruited at Siriraj Hospital, Thailand between August 31, 2004 and January 30, 2006. The patients were given Sertaconazole, Fluconazole, or Clotrimazole, and received vaginal swab and culture for fungus at seventh and 28th days after treatment. Results: Out of 188 cases, 177 cases were followed-up completely. Sertaconazole group included 66 cases where 35 cure, 20 fail, and 7 recurrent cases. Fluconazole group included 60 cases and had 37 cure, six fail, and 20 recurrence cases. Clotrimazole group included 55 cases and had 32 cure, nine fail and 11 recurrent cases. There were risk factors of fungal vulvo-vaginitis, including frequent micturition and small toilet shower flushing. Conclusion: Sertaconazole had similar effectiveness and less side-effect as compared with Fluconazole and Clotrimazole. It appeared to work well with lowest recurrence.

Inappropriate self-medication among adolescents and its association with lower medication literacy and substance use

BACKGROUND

While self-medication is common, inappropriate self-medication has potential risks. This study assesses inappropriate self-medication among adolescents and examines the relationships among medication literacy, substance use, and inappropriate self-medication.

METHOD

In 2016, a national representative sample of 6,226 students from 99 primary, middle, and high schools completed an online self-administered questionnaire. Multiple logistic regression analysis was used to examine factors related to inappropriate self-medication.

RESULTS

The prevalence of self-medication in the past year among the adolescents surveyed was 45.8%, and the most frequently reported drugs for self-medication included nonsteroidal anti-inflammatory drugs or pain relievers (prevalence = 31.1%), cold or cough medicines (prevalence = 21.6%), analgesics (prevalence = 19.3%), and antacids (prevalence = 17.3%). Of the participants who practiced self-medication, the prevalence of inappropriate self-medication behaviors included not reading drug labels or instructions (10.1%), using excessive dosages (21.6%), and using prescription and nonprescription medicine simultaneously without advice from a health provider (polypharmacy) (30.3%). The results of multiple logistic regression analysis showed that after controlling for school level, gender, and chronic diseases, the participants with lower medication knowledge, lower self-efficacy, lower medication literacy, and who consumed tobacco or alcohol were more likely to engage in inappropriate self-medication.

CONCLUSION

Lower medication literacy and substance use were associated with inappropriate self-medication among adolescents.

Vaginal semisolid products: Technological performance considering physiologic parameters

Vaginal semisolid products are frequently used to treat vaginal infections and atrophy-related symptoms of menopause. Formulations composition and the methods for their characterization, especially those developed concerning the target epithelia, are key tools to predict in vivo results at early stages of product development. However, recent studies on this subject have been almost exclusively focused on anti-HIV preparations. The aim of this work consists on improving traditional characterization methods by using physiological parameters in order to construct predictive tools to characterize a new ideal vaginal semisolid formulation whatever target it may have. Ten vaginal antimicrobial and hormonal products already available in the market were studied (Gino-Canesten®, Sertopic®, Dermofix®, Gyno-pevaryl®, Lomexin®, Gino Travogen®, Dalacin V®, Ovestin®, Blissel®, Colpotrophine®). Furthermore, Universal Placebo gel and Replens® were used for comparison. Products were characterized in terms of: pH and buffering capacity in a vaginal fluid simulant (VFS); osmolality - directly and upon dilution in VFS; textural parameters (firmness, adhesiveness and bioadhesion) using vaginal ex vivo porcine epithelium; and viscosity (including VFS dilution at 37°C and after administration on an ex vivo model). Interestingly, the majority of the tested commercial vaginal formulations did not present technological characteristics close to the ideal ones when tested under target biological conditions. The inclusion of such methodologic adaptations is expected to optimize cost-efficiency of new formulations development by predicting efficacy and safety profiles at early stages of product development.

Biotherapeutic agents and vaginal health

Treatment of vaginal infection requires different drugs although the recurrence rate post treatment remains high due to adverse effects on the beneficial microbiota. Thus, there are clear clinical advantages for the use of biotherapeutic agents (prebiotics and/or probiotics) for treating these infections. Pre- and probiotic beneficial effects can be delivered topically or systemically. In general, both approaches have the potential to optimize, maintain and restore the ecology of the vaginal ecosystem. Specific carbohydrates provide a therapeutic approach for controlling infections by stimulating the growth of the indigenous lactobacilli but inhibiting the growth and adhesion of pathogens to the vaginal epithelial cells. Overall, little evidence exists to promote the prevention or treatment of vaginal disease with prebiotic carbohydrates in formulations such as pessaries, creams or douches. However, recent reports have promoted prebiotic applications in ecosystems other than the gut and include the mouth, skin and vagina. This review focuses on the utilization of pre- and probiotics for vaginal health.

An overview about the medical use of antifungals in Portugal in the last years

Despite the introduction of new antifungal agents, the frequency of invasive and mucocutaneous fungal infections as well as resistance to antifungal drugs continues to increase. Over 300 million persons are infected annually with fungi. Resistance to antimicrobials is one of today's major health threats. Can the possible causes of fungal antimicrobial resistance be understood and prevented to minimize risks to public health. We provide an overview of antifungal drug use in European countries, particularly Portugal. We reviewed prescriptions for and over-the-counter sales (OTC) of azoles in Portuguese pharmacies and in alternative shops. We conclude that in Portugal, azole antifungal sales, as well as medical prescribed azoles are very high. The Portuguese population consumes more antifungal drugs per capita than others in Europe.

What do portuguese women prefer regarding vaginal products? Results from a cross-sectional web-based survey

Therapeutic outcomes of vaginal products depend not only on their ability to deliver drugs to or through the vagina but also on acceptability and correct use. Women's preferences, in turn, may vary according to age and cultural backgrounds. In this work, an anonymous online survey was completed by 2529 Portuguese women to assess their preferences for physical characteristics and mode of application of vaginal products, according to age. Additionally, intention to use and misconceptions about these issues were assessed. The majority of women of all age groups would use vaginal products to treat or prevent diseases, upon medical prescription. Women preferred vaginal products to be odorless and colorless gels, creams and ointments composed by natural origin drugs/excipients and applied by means of an applicator. Although the majority of women would prefer not to insert any product in the vagina, intention to use for self and recommendation to use for others was associated with previous experiences with vaginal products. General concerns and misconceptions related to use of vaginal products were rare. These data may contribute to the development of products that women are more prone to use.

Recurrent vulvovaginal candidosis among young women in south eastern Nigeria: the role of lifestyle and health-care practices

This work was carried out to study the association between lifestyle, health-care practices and incidence of recurrent vulvovaginal candidosis (RVVC) among young women in south eastern Nigeria. It was a multicentre case-control study of 176 women aged between 20 and 35 years recruited from the designated health facilities. Lifestyle and health-care practice structured questionnaires were used to survey the participants. Clinical examination was performed and vaginal swabs were taken from participants for microscopy, culture and sensitivity. The germ tube test was performed for identification of Candida albicans. The results of this study showed that frequent douching with water or other fluids (odds ratio [OR](adjusted) = 2.41, 95% confidence interval [CI] = 1.25-4.66, P = 0.000), wearing tight nylon/synthetic underwear (OR(adjusted) = 4.76, 95% CI = 2.28-9.95, P = 0.000), alternative medical treatment for repeated or recalcitrant cases (OR(adjusted) = 4.84, 95% CI = 2.94-15.91, P = 0.000), were significantly associated with higher odds for RVVC and self-diagnosis and use of over-the-counter antifungal medications (OR(adjusted) = 4.61, 95% CI = 2.29-9.32, P = 0.000) were associated with RVVC. Results of the fungal cultures showed that C. albicans and non-C. albicans were isolated from 83.7% and 16.3% of participants, respectively. Our results supported the association between some of the hypothesized risk factors and the occurrence of RVVC.

Hormonal contraceptive users' self-reported benefits, adverse reactions, and fears in 2001 and 2007

BACKGROUND

Hormonal contraceptives (HCs) are the most common contraceptive method in western countries. The fears and problems experienced by users of HCs can have an impact on their quality of life, and lead to abortions and unwanted pregnancies.

OBJECTIVE

To investigate whether experiences and perceptions of HC users in Finland have changed from 2001 to 2007.

METHODS

Data were collected using questionnaire surveys of women using HCs in 2001 and 2007. In Finland, HCs are available with a physician's prescription, and are only supplied in community and university pharmacies. University pharmacies in 12 large cities across Finland were selected to distribute the questionnaires. The response rate was 53% (n = 264) in 2001 and 55% (n = 436) in 2007. The average age of the respondents was 26 years in both surveys. The surveys measured self-reported benefits and adverse reactions, preconceptions, fears, knowledge, and opinions.

RESULTS

The number of HC users reporting fears increased from 2001 to 2007 (p = 0.002), whereas the number of HC users reporting adverse reactions decreased (p = 0.013). In both surveys, the most common fear was infertility after HC use (17% vs 26% for 2001 and 2007, respectively). In both surveys, the most common benefits were efficacy and regular menstrual cycle, and the most common adverse reactions were mood swings, lowered libido, and weight gain.

CONCLUSIONS

Our study suggests that, although women using HCs were convinced about their benefits, and the number of users reporting adverse reactions had decreased from 2001 to 2007, the number of users reporting fears had increased. Healthcare professionals need to provide counseling in order to alleviate women's fears and to correct false perceptions of HCs.

Oral ingestion of a topical benzydamine hydrochloride-containing gynaecological preparation in association with television advertising in Italy: analysis of cases managed by a National Poison Control Centre

Objective To evaluate the impact of a television advertising campaign on the risk of oral ingestion of a topical non-prescription gynaecological preparation containing benzydamine hydrochloride. Design An interrupted time series design with data routinely collected. Setting A National Poison Control Centre. Participants 215 cases of hazardous exposure to the preparation under study occurred in Italy from January 2005 to December 2010. Primary and secondary outcome measures Mean daily rate of cases of exposure by gender in three different periods, that is, pre-advertisement period, before the advertisement was broadcast (from 1 January 2005 to 19 December 2009), advertisement period, when the advertisement was repeatedly launched (from 20 December 2009 to 27 February 2010), post-advertisement period (from 28 February 2010 to 6 March 2010); observed/expected ratios of cases, with expected cases based on data from the pre-advertisement period, adjusted for estimated variations in the number of users. Comparison of the distribution of the main characteristics of cases in the three different periods by means of Pearson's χ(2) test or Fisher's exact test. Results The adjusted observed/expected ratio of cases in women was 7.48 (95% CI 5.76 to 9.56) in the advertisement period and 2.97 (95% CI 2.24 to 3.85) in the post-advertisement period. Regarding the characteristics of cases, there was an increased proportion of cases of exposure due to confusion about the correct administration route in the advertisement and post-advertisement periods (81% and 55%, respectively, compared to 16% for the pre-advertisement period.) and of individuals with clinical effects (55%, 52% and 27%, respectively). Conclusions In Italy, an advertisement for a non-prescription medicine seems to have confused consumers regarding the administration route. This effect was observed even after the advertisement had stopped being broadcast. These results highlight the need for the monitoring of medication errors and adverse effects before, during and after advertising.

Information sources used by women in Finland who use hormonal contraceptives

OBJECTIVE

The aim of this study was to examine information sources used by women who use hormonal contraceptives (HCs), and how information source affected women's attitudes and perceptions in 2001 and 2007.

SETTING

The questionnaires were distributed from university pharmacies in 12 large cities across Finland.

METHOD

The data were collected with two questionnaire surveys among women who used hormonal contraceptives in 2001 and 2007. In the 2001 survey the response rate was 53% (n = 264) and in the 2007 survey 55% (n = 436).

RESULTS

The number of respondents who considered professional information sources the most important information sources was markedly bigger in 2007 than in 2001 (P = 0.005). The most common source of information concerning the benefits of hormonal contraceptives was a physician (2001: 43%, 2007: 53%). The most common source of information concerning the risks of hormonal contraceptives was friends and relatives (43%) in 2001 and physician in 2007 (35%). Only a few percent of the respondents considered a pharmacy the most important information source both the 2001 and 2007 surveys.

CONCLUSION

The importance of health care professionals as sources of information concerning hormonal contraceptives has increased. However, role of pharmacists as information source was surprisingly small. Women who use hormonal contraceptives need more information from professional sources to alleviate possible fears associated with use.

Vaginitis: making sense of over-the-counter treatment options

Background. The FDA approved over-the-counter (OTC) use of vaginal antifungals in 1990. Subsequently, a plethora of OTC products have become available to women on drugstore shelves. Objectives. The purpose of this study was to determine the availability of OTC products marketed for the treatment of vaginitis and to determine if their efficacy had been confirmed by published prospective randomized control trials (RCTs). Materials and methods. The authors chose four retail locations frequented by women seeking vaginitis treatment. All products deemed a viable treatment option were purchased. Results. All intravaginal imidazoles purchased, regardless of treatment duration or active ingredient, were found to be of proven efficacy. We were unable to find an RCT confirming the effectiveness of vaginal anti-itch creams and homeopathic treatments for vaginitis. Conclusion. 45% of products available to women in the feminine hygiene section of the stores surveyed could not be confirmed to be effective for treating infectious vaginitis.

Customers’ and physicians’ opinions of and experiences with generic substitution during the first year in Finland

Medicine expenditures have continuously increased in Finland over the past 25 years. Generic substitution was introduced in Finland in the beginning of April 2003 with the aim of curbing the rise in the medical expenses of society and individuals. Pharmacists are obligated to substitute the cheapest or close to the cheapest medicine for prescribed medicine unless the customer refuses or the physician forbids substitution, which the physician can do for medical or therapeutic reasons. In this study, we explored how customers and physicians view the 2003 reform via two customer questionnaires and by interviewing physicians. The first questionnaires were handed out in 15 pharmacies in 5 geographical areas (hospital districts) in Finland to customers (n=1243, response rate 44%) who had refused generic substitution, and the second in 18 pharmacies in 6 geographical areas to customers (n=453, response rate 47%) who had accepted substituted medicines at least once. The physician interview study was directed to psychiatrists, geriatrists, internists and general practitioners (n=49). Most customers and physicians think generic substitution is a good reform measure. The main reason mentioned for substitution was to save money. The most important reason given for refusing substitution was the customers' positive experiences with medicines they had used previously. About half of the physicians thought not all interchangeable medicines are effective and safe.

Do Finnish women using hormone replacement therapy need more information about risks

OBJECTIVE

In 1998, the Women's Health Initiative (WHI) in 2002 and the Million Women Study (MWS) in 2003 have shown a need for re-evaluation of the benefits and adverse reactions of hormone replacement therapy (HRT). Consequently the authorities in Europe and USA have issued new recommendations against the use of HRT. The aim of this study was to examine women's perceptions of HRT since the publication of the Women's Health Initiative study and the Million Women Study, and the kind of sources women use to obtain information about HRT.

METHOD

The data was collected with questionnaire survey in the autumn 2003 among 315 women using HRT.

RESULTS

One third of the respondents (35%) had experienced fears concerning HRT use, and more than half (52%) reported that the debate in the media had markedly influenced them; they have experienced fears or worries, considered discontinuation or discussed with the physician. Whereas the most common source of information concerning the benefits of HRT was the physician (74%), the most common source of information concerning the risks of HRT was the media (78%).

CONCLUSION

This study shows that women using HRT should get more information about the risks from health care professionals. Physicians and pharmacists have an opportunity to alleviate fears and to help women to critically evaluate the information they get from the media. Such discussions are also important to women who have been using HRT for years.

What over-the-counter preparations are pregnant women taking? A literature review

AIM

This paper presents an overview of current literature relating to over-the-counter and herbal preparations use, with a focus on pregnancy.

BACKGROUND

Internationally, there has been a shift towards self-medication through over-the-counter release of many prescription-category drugs and wider acceptance and use of herbal preparations. The general community perception that these preparations are safe may lead to inappropriate use, especially during pregnancy.

METHOD

A range of databases was searched to identify papers addressing 'over-the-counter preparations/medications', 'non-prescription medications', 'herbal preparations' and 'pregnancy', including Medline, Cumulative Index to Nursing, Allied Health Literature, Proquest and Sciencedirect. Midwifery, nursing and scientific papers published from 2000 onwards were included, along with a small number of scientific papers published from 1995 onwards, and some key textbooks to clarify the definitions.

FINDINGS

Pregnant women use a range of over-the-counter preparations, including analgesics, antihistamines, antacids and a variety of herbal preparations. However, in many cases, it is unclear whether their use is actually safe in the short- or long-term for mother or baby, owing to an inadequate evidence-base to support the use of these preparations during pregnancy.

CONCLUSION

While there is extensive literature on the use of over-the-counter preparations generally, less is available about their use in pregnancy. Further research is needed to explore the prevalence of use and effects of these preparations in pregnancy and neonatal outcomes, and to support midwives and nurses in harm minimization through the promotion of informed risk-avoidance behaviours.

Consumers appropriately self-treat based on labeling for over-the-counter hydrocortisone

BACKGROUND

Over-the-counter (OTC) topical corticosteroids, such as hydrocortisone cream (HC), are commonly used for the treatment of minor dermatological conditions. The safety and efficacy of such products are well documented, but details on patterns of use and self-treatment with HC in the OTC environment remain scarce.

OBJECTIVE

We sought to determine compliance with label directions of OTC HCs by examining self-reported patterns of OTC HC use in adults and children.

METHODS

A random digit-dialed telephone survey was conducted with 2000 US adults. Following identification of users of OTC HC in the last 6 months, respondents were asked questions about the conditions being treated with OTC HC and the frequency and duration of use in both adults and children.

RESULTS

Of adults completing the survey, 20% (n = 396) had used OTC HC. In 83% of cases, the conditions treated were consistent with the OTC label. Use was limited; HC was applied < or =4 times daily in 98% of adult users and lasted < or =7 days in 92%. Patterns of pediatric use were similar and almost always consistent with the labeling. Of households with children, 25% (n = 168) had used OTC HC to treat pediatric dermatological conditions. Of child users, 93% were 2 years of age or older, treatment was limited (97% applied HC < or =4 times daily and 94% of treatments lasted < or =7 days), and the conditions treated were appropriate in 86% of cases.

LIMITATIONS

This telephone survey relied on respondents' recall and self-reporting. Our data on pediatric use of OTC HC are skewed toward treatment of younger children.

CONCLUSION

The data suggest that OTC HC products are used for self-treatment in a limited and appropriate fashion that is likely to be safe in both adults and children.

Vulvar susceptibility to contact irritants and allergens: a review

Vulvar tissue differs from cutaneous epithelia in structure, morphology and biophysical characteristics. For example, the skin of the labia majora exhibits elevated hydration, occlusion and frictional properties, which may increase susceptibility to irritants and contact sensitizers. Furthermore, the nonkeratinized vulvar vestibule is likely to be more permeable than keratinized regions. These differences heighten vulvar susceptibility to topical agents. This reviews the structure and properties of vulvar tissue, emphasizing their impact on susceptibility contact irritants and allergens.

Trends in prescribing for vulvovaginal candidiasis in the United States

PURPOSE

To describe trends in visits to office-based physicians in the United States by females 15-64 years of age for vulvovaginal candidiasis and related antifungal prescribing. Since January 1991, intravaginal antifungal medications have been available over-the-counter in the United States to treat vulvovaginal candidiasis.

METHODS

Data from the 1985 through 2001 National Ambulatory Medical Care Surveys (NAMCS) were examined. NAMCS is an annual national probability sample survey that collects data on the utilization of services provided by office-based physicians.

RESULTS

The average annual visit rates for symptoms of vaginitis and a diagnosis of vulvovaginal candidiasis decreased by 55 and 72%, respectively. The intravaginal antifungal prescribing rate for vulvovaginal candidiasis declined by 41%. No trend was found for total antifungal prescribing; however, during the late 1990s, fluconazole was prescribed at approximately one-third of visits with a diagnosis of vulvovaginal candidiasis.

CONCLUSION

These data suggest an increased trend in self-diagnosis and use of over-the-counter intravaginal antifungal medications. The shift from prescribing intravaginal antifungal preparations to fluconazole raises concern about the possible development of azole drug resistance. Educational efforts are needed to counter potential misuse of these medications that may contribute to increased infection with innately azole resistant non-albicans Candida species and chronic infection.

Women's Sexual Pain and Its Management

INTRODUCTION

Approximately 15% of women have chronic dyspareunia that is poorly understood, infrequently cured, often highly problematic, and distressing. Chronic dyspareunia is an urgent health issue.

AIM

To provide recommendations/guidelines concerning state-of-the-art knowledge for the assessment and management of women's sexual pain disorders.

METHODS

An international consultation, in collaboration with the major sexual medicine associations, assembled over 200 multidisciplinary experts from 60 countries into 17 committees. One six-member committee focused on women's sexual pain disorders, developing recommendations over a 2-year period.

MAIN OUTCOME MEASURE

Expert opinion was based on grading of evidence-based medical literature, widespread internal committee discussion, public presentation, and debate.

RESULTS

There is increasing evidence for the role of neuropathic pain mechanisms in the pathophysiology of sexual pain disorders. Empirical literature has demonstrated the comorbid presence of clinical psychopathology. With regard to the pathophysiologic role of the pelvic floor and sexual pain disorders, studies reveal that (i) differentiation between vaginismus and dyspareunia using clinical tools is difficult; (ii) vaginal spasms have not been identified; (iii) physical therapists can differentiate vaginismic women from matched controls based on muscle tone/strength differences; (iv) the traditional treatment of vaginismus with vaginal "dilatation" plus psycho-education, desensitization, and so forth is not evidence-based; (v) pelvic floor muscle tone/strength measures for women suffering from vulvar vestibulitis syndrome are intermediate between those of women with vaginismus and no-pain controls; and (vi) the pelvic floor musculature is indirectly innervated by the limbic system and highly reactive to emotional stimuli and states. Pelvic floor therapies for dyspareunia may be effective.

CONCLUSION

Recommendations include (i) revising the definitions of vaginismus and dyspareunia; (ii) integration of treatment approaches; (iii) validation of nonspecific treatment effects; (iv) controlled studies to test interventions; and (v) sexuality education to help prevent sexual pain.

Factors influencing women's decisions to self-treat vaginal symptoms

PURPOSE

To review the research on women's self-treatment of vaginal symptoms, describe factors influencing this phenomenon, identify evidence-based interventions, and suggest strategies for nurse practitioners (NPs) to promote safe and effective self-treatment decisions by women.

DATA SOURCES

Research articles identified through Medline and CINAHL databases.

CONCLUSIONS

The primary factors influencing women's decisions to self-treat vaginal symptoms were personal (attitudes, beliefs, values, knowledge and experience, and emotions) and environmental (culture, social networks and norms, media, and life context).

IMPLICATIONS FOR PRACTICE

Women's self-diagnostic skills and decision making for self-treatment can be improved through education and support from NPs. The traditional office visit may not provide an opportunity to teach women appropriate self-care because many women do not access providers for advice or information. Different methods of providing information to large numbers of women through consumer publications need to be developed and evaluated.

Usage of antifungal drugs for therapy of genital Candida infections, purchased as over-the-counter products or by prescription: I. Analyses of a unique database

OBJECTIVES: To present sales figures of antifungal drugs for treatment of genital Candida infections in females, which had been purchased in the Swedish county of Skåne (with approximately 1.2 million inhabitants) during the 1990s. To study the relative proportions of the drugs sold by prescription and as over-the-counter (OTC) products. METHODS: Sales figures of antifungal drugs for therapy of vulvovaginal candidiasis (VVC) and such recurrent infections (RVVC), for the years 1990--99, were collected from the 'ACS' database of the National Corporation of Swedish Pharmacies. RESULTS: The study showed an increase in sales of the type of drugs studied from 45,000 packages in 1990 until mid-93/94, when approximately 70,000 packages were sold (mainly azoles for topical use and fluconazole for oral intake). Thereafter there was a decrease until the end of November 1999, when 54,000 packages were purchased. Of the total sales, 93% were OTC products. Sales of clotrimazole and econazole (for vaginal installation) in 1993--1994 were equal to 85-90 packages/1000 women in the age group 15-45 years. Extremely high sales volumes of fluconazole and itraconazole, for one single year each, could be explained by marketing-related activities directed to the medical community. CONCLUSIONS: As many women with RVVC are not cured by iatrogenic initiatives and women consider themselves able to diagnose episodes of genital Candida infection, affected women generally turn to self-medication with antifungal OTC products. This stresses the role of pharmacy counseling. Short-term marked alterations in sales volumes may be due to marketing factors rather than changes in the epidemiology of genital Candida infections.

Usage of antifungal drugs for therapy of genital Candida infections, purchased as over-the-counter products or by prescription: 2. Factors that may have influenced the marked changes in sales volumes during the 1990s

BACKGROUND: The epidemiology of vulvovaginal candidiasis (VVC) and such recurrent infections (RVVC) has been difficult to study as the majority of episodes of these conditions are self-treated by the women affected. In Sweden, all pharmacies are owned by the state and all prescriptions and over-the-counter (OTC) products, such as antifungals, are registered in a database, which offers unique possibilities to study the epidemiology of VVC/RVVC. OBJECTIVES: To analyze all prescriptions and OTC products purchased for therapy of VVC/RVVC and to establish reasons for any observed variation in the sales figures. METHODS: Sales figures in the Swedish county of Skåne of antifungal drugs for therapy of VVC/RVVC were analyzed by the aid of the 'ACS' database of the National Corporation of Swedish Pharmacies for the years 1990--1999. The size of the female population in the county is approximately half a million. RESULTS: The study showed that 93% of all antifungal drugs for VVC/RVVC were sold as OTC products. An increase in sales of the drugs occurred until mid- 1993/94, followed by a decrease until end of the study period in 1999. Demographic factors (e.g. the number of female inhabitants in the county, pharmacies and health-care units), the pregnancy rate and pharmacy-dependent factors (such as the introduction of shelves for self-selection of antifungal products) did not explain the observed variations in sales. Distinct short-term variations in the number of prescriptions of fluconazole and itraconazole could be explained by drugs company sales campaigns and logistics factors in drug distribution. The sales volumes in the 33 municipalities in the county correlated with the density of the population, which was not the case for the total number of prescriptions made in the county during the 1990s. The variation in antifungal drug sales was similar to that of hormonal intrauterine devices, but this was not the case for oral contraceptives. The total Swedish usage of antibiotics showed a similar variation to that of the antifungal drugs analyzed. CONCLUSION: The study stresses the limited impact on the treatment of VVC/RVVC by the medical community. Behavior-related factors in the female population are the most likely explanation for the marked variations found in the usage of drugs for the two conditions.

Improving appropriate use of antifungal medications: the role of an over-the-counter vaginal pH self-test device

Objectives: To determine whether patients can understand and use the vaginal pH device in the diagnosis of vaginitis. To compare whether vaginal pH readings determined by patients and healthcare providers are similar. To determine whether vaginalpHcan reduce inappropriate over-the-counter (OTC) antifungal medication use and improve the correct diagnosis of vaginitis.

Methods: One hundred and fifty-one women indicated their belief about the cause of their vaginal infection, read the instructions of the vaginal pH device package insert, used the device and interpreted the findings. The patient interpretations were compared with results obtained by healthcare providers, blinded to patient findings.

Results: Over 96% of patients stated that they could easily read the instructions, use the vaginal pH device and interpret the readings. They obtained the same readings as healthcare professionals (Kappa = 0.9). Restricting the use of OTC antifungal medications to those individuals with vaginitis symptoms and vaginal pH ≤ 4.5 significantly reduced inappropriate use by approximately 50%, Fisher's exact test,p-value = 0.018. Conversely, seeking healthcare provider assessment with vaginal pH > 4.5, leads to correct diagnosis of vaginitis.

Conclusions: The vaginal pH device can be used as an OTC diagnostic tool by consumers when a vaginal infection is suspected. Vaginal pH readings would direct patients whether to purchase an antifungal medication or seek professional diagnosis from a healthcare provider. Understanding and use of this vaginal pH device could reduce inappropriate use of OTC antifungal medications by approximately 50% and improve the correct diagnosis of vaginitis.

The potential for probiotics to prevent bacterial vaginosis and preterm labor

Infections of the urogenital tract in women represent a major burden on the quality of life of women and on the health care system of Canada and other countries. Complications arising from bacterial vaginosis (BV) include increased risk of sexually transmitted diseases including human immunodeficiency virus and elevated risk of preterm birth (PTB). Pharmaceutical interventions, such as antibiotics, have been suboptimally effective and have failed to reduce the incidence of PTB. The absence of lactobacilli in the vagina, a specific feature of BV, raises the question as to whether restoration of lactobacilli, by probiotic therapy, can restore the normal flora and improve the chances of having a healthy term pregnancy. The rationale for probiotic use in pregnant women is quite strong. Certain lactobacilli strains can safely colonize the vagina after oral and vaginal administration, displace and kill pathogens including Gardnerella vaginalis and Escherichia coli, and modulate the immune response to interfere with the inflammatory cascade that leads to PTB. Additional attributes of probiotics include their potential to degrade lipids and enhance cytokine levels, which promote embryo development. In a society that focuses on disease rather than health and drug therapy rather than natural preventive measures, it will take some effort to get remedies such as probiotics into mainstream care. Perhaps the escalating health care budgets and emergence of "superbugs" will provide the incentives to put in place clinical trials designed to evaluate how best to use the commensal organisms that, after all, make up more of our body than human cells, and without which none of us would survive.

The development of evidence-based guidelines for over-the-counter treatment of vulvovaginal candidiasis

OBJECTIVE

The purpose of this study was to develop evidence-based guidelines for over-the-counter (OTC) treatment of vulvovaginal candidiasis with non-prescription anti-fungal medicines purchased from community pharmacies.

METHOD

A multidisciplinary guideline development group was recruited from the locality where the guidelines were to be tested. A Nominal Group Technique (NGT) was used to achieve formal consensus within the group regarding the issues that the guidelines would address. Guideline recommendations were developed from the results of two systematic literature reviews that assessed which symptoms were predictive of vulvovaginal candidiasis (using data from epidemiological studies) and estimated the relative effectiveness of oral and intra-vaginal anti-fungals using data from randomised controlled trials.

MAIN OUTCOME MEASURES

Evidence-based guideline recommendations. The guideline statements were linked to the evidence using a standard hierarchy.

RESULTS

The guideline development group met four times. The use of NGT was an effective way of achieving consensus on guideline content. Two systematic reviews carried out as part of the guideline development process identified evidence for the guidelines on the efficacy of OTC treatments and symptoms suggestive of vulvovaginal candidiasis. The guideline recommendations were presented as a booklet and a laminated algorithm. In summary, the guidelines highlighted symptoms suggestive of vulvovaginal candidiasis, and symptoms associated with other vaginal conditions that should be referred to the GP. The guidelines stated that oral treatment and intra-vaginal treatment are equally effective, and that selection of an anti-fungal should be based upon safety, cost and patient preference. Many of the recommendations were influenced by OTC license restrictions of each antifungal product. Contra-indications to, and special precautions with, antifungals were also listed. In addition, the guidelines stated that the male sexual partner does not require treatment unless symptomatic.

CONCLUSION

There is sufficient evidence available to develop evidence-based guidelines for the treatment of vulvovaginal candidiasis in the community pharmacy setting. The NGT is a useful component in the guideline development process.

Usage patterns of over-the-counter phenazopyridine (pyridium)

OBJECTIVES

Little is known about how the public uses formerly prescription medications that are available over-the-counter (OTC). This study examines whether consumers inappropriately use and substitute a recently widely distributed OTC urinary analgesic, phenazopyridine, for provider care.

DESIGN/SETTING

We conducted a cross-sectional survey of a stratified cluster random sample of OTC phenazopyridine purchasers (N = 434) in 31 Los Angeles retail pharmacies over 5 months. Recruited by shelf advertisements, participants were 18 years or older who purchased a phenazopyridine product. Each completed a 25-item self-administered anonymous questionnaire. Inappropriate use was defined as 1) having medical contraindications to phenazopyridine, or 2) not having concurrent antibiotic and/or provider evaluation for the urinary symptoms.

RESULTS

The survey response rate was 58%. Fifty-one percent of the respondents used OTC phenazopyridine inappropriately, and 38% substituted it for medical care. Multiple logistic regression analyses revealed that inappropriate use was correlated with having little time to see a provider (odds ratio [OR], 1.57; 95% confidence interval [95% CI], 1.26 to 1.96), receiving friend's or family's advice (OR, 1.25; 95% CI, 1.05 to 1.47), having prior urinary tract infections (OR, 0.49; 95% CI, 0.30 to 0.80), having used prescription phenazopyridine, (OR, 0.40; 95% CI, 0.25 to 0.63), and having back pain (OR, 0.34; 95% CI, 0.16 to 0.74). Similar correlates were found in those who substituted OTC phenazopyridine for provider care. Respondents with incorrect knowledge about phenazopyridine's mode of action had 1.9 times greater odds of inappropriate use and 2.2 times greater odds of substitution than those who had correct knowledge about this drug.

CONCLUSION

Inappropriate use of OTC phenazopyridine appears common. Increasing the public's knowledge about reclassified drugs may help to mitigate this problem.

Benefits and risks of self medication

Self medication is becoming an increasingly important area within healthcare. It moves patients towards greater independence in making decisions about management of minor illnesses, thereby promoting empowerment. Self medication also has advantages for healthcare systems as it facilitates better use of clinical skills, increases access to medication and may contribute to reducing prescribed drug costs associated with publicly funded health programmes. However, self medication is associated with risks such as misdiagnosis, use of excessive drug dosage, prolonged duration of use, drug interactions and polypharmacy. The latter may be particularly problematic in the elderly. Monitoring systems, a partnership between patients, physicians and pharmacists and the provision of education and information to all concerned on safe self medication, are proposed strategies for maximising benefit and minimising risk.