1. Gynaecological disorders
Lecture -1
Presented By
Magdy M. Awny, Ph.D.,
2018/2019

2. The course aim and intended learning outcomes are based to:
provide pharmacy students with required knowledge and necessary skills to deliver safe and effective drug therapy interventions.
It addresses the pharmacotherapy of certain disease states in terms of pathophysiology, therapeutic goals, treatment Plan, treatment alternatives and outcomes monitoring as well as patient counseling and education.
Counseling = advising or recommendation

3. Gynaecology Gynae = woman “science of the women”
Is the branch of medicine that dealing with the health of the female reproductive organs (vagina, uterus and ovaries) and the genital tract.
Almost all modern gynaecologists are also obstetricians
Obstetric …obstet = child birth

4. Gynaecological disorders
Are conditions affecting female reproductive organs in
abdomen & pelvic areas , include:-
Vulvodynia and Vaginitis (vulvovaginitis)
Toxic Shock Syndrome [TSS]
Dysmenorrhea
Premenstrual syndrome (PMS)
Endometriosis

5. 1-Vulvodynia
Definition: It is a chronic discomfort or pain in vulva. It occurs in 16% of all women
worldwide
Etiology:
Recurrent yeast infections
Frequent use of deodorants
Allergy to certain soaps & sexual abuse
Oxaluria
Complicated vaginal delivery e.g. tears of vulvar skin
Altered neuropathway of the vulva
Symptoms: burning, itching, stinging, irritation, rawness in vulva
that last from days to years and can lead to depression, also may interfere
with sexual and normal daily activities. (woman suffer from alteration in quality of life).
Vulva: female external genitalia
Management:
Regular washing of vulvar area with warm water (without soap)
Avoid tight & synthetic underwear
Use of estrogen cream to vulvar area & give Ca+2 supplement to ↓ urinary oxalate
Avoiding oxalate rich food [ chocolate , coffee,……]

6. 2-Vaginitis & Vulvovaginitis
1-infectious
Epidemiology: it affects 90% of all women in their reproductive age
2-Non infectious

7. 2-Vaginitis & vulvovaginitis
1- Non infectious vaginitis:
vaginal irritation without infection
There are 2 common forms
1-Allergic Vaginitis:
Due to Allergic reaction of vagina to sprays, douches, perfumed soap, spermicidal products…etc.
2. Hormonal or atrophic (senile) Vaginitis:
-Result from ↓ estrogen (dry, thin vaginal tissues)
secondary to Menopause, Removal of ovaries &
radiation therapy
-Also occur after delivery & during lactation period
Symptoms:
Vaginal itching, burning, and irritation
odorless scanty discharge
Vaginal dryness
Dyspareunia
Pelvic pain during intercourse
Treatment: depends on estrogen preparations (cream or oral tablet)→
restore lubrication &↓irritation and soreness
Premarin® 0.625mg/gm

8. 2-infectious Vaginitis (Vulvovaginitis)
Vaginal infections are one of the most common reasons that seek gynecological care today
Epidemiology:
-at least 1/3 of all women at child bearing age currently have one or more vulvovaginal
infections (VVI) (vaginal discharge, itching and burning).
-The fear, shame, physical discomfort and psychosexual problems as a result of VVI cause
more unhappiness than any other Gynaecological disorder.
Organisms that most frequently cause vaginal infections include:
C. Albicans…………… %
T. vaginalis ………..… %
G. vaginalis (H. vaginalis) in association with anaerobes …40-50% of cases,
causes NSV which has been recently called Bacterial vaginosis
Other organisms; chlamydia trachomatis and mycoplasma hominis
The mere presence of C. albicans in not necessarily consistent with an infection as this organism can be isolated in 15-25% of asymptomatic women harboring yeast species as part of their flora but who do not require therapy.. It is the proliferation of this organism that cause vaginitis and the symptoms observed.

9. Physiology & pathophysiology:
Thick protective vaginal epithelium of women at reproductive age
is maintained by:
Estrogen
maintain cervical mucus
Aerobic organism: coliform, listeria, doderlein’s lactobacilli
Group D & B hemolytic streptococci
Anerobic organism: clostridia, peptostreptococcus
thinning of vaginal epithelium &↓cervical mucus (antibact, contain lysozymes) →↑vaginal infections (yeast, bacteria & mixed flora)
Antibiotic
postmenopause
pH (Neutral or alkaline)
A pH (4.5 – 5.5)
N. Flora
Epithelial cell carbohydrate [glycogen]
lactic acid
Lactobacilli

10. Common forms of infectious Vaginitis
1-Vaginal or [Vulvovaginal] candidiasis [VVC]
2-Trichomonas Vaginitis [Vaginal Trichomoniasis]
3- Bacterial Vaginosis
4- Chlamydia Vaginitis
5-Genital Herpes Vaginitis
6- Human Papilloma Virus Vaginitis

11. 1-Vaginal or [Vulvovaginal] candidiasis [VVC] {20-30% of cases}
Cause: Candida Albicans
Symptoms:
Watery, thick, white (cheese-like or curd-like) vaginal discharge
Red itchy vulva, bright red vagina
Dysuria
Vaginal discharge of pH ≤ 4.5
  ** long thread-like fibers of mycelia with attached conidia buds
Factors predispose to VVC:
1- Antibiotic therapy
2-Uncontrolled diabetes mellitus & poor immunity
3-Corticosteroid therapy
4-Oral contraceptives & pregnancy

12. Recurrent VVC ( > 4 episodes /year) Approx
Recurrent VVC ( > 4 episodes /year) Approx. 75% of women have 1 episode of VVC, 40-45% have 2 or more episodes. < 5% will experience RVVC
Etiology/causes:
Intestinal reservoir [fecal matter]
Poor hygiene
 Sexual transmission by infected male partner [Balanitis]
 Therapy failure due to candidal sporulation in the deep
layers of vaginal epithelium, the re-infection occurs weeks or months later when epithelial cells are normally shed
Treatment of VVC:
Clotrimazole (canesten®) is the CDOC
The one day regimens is as effective as the 3 & 7 days regimens
pt compliance improves as the duration of therapy shortens
Male partners who experience symptomatic balanitis or penile dermatitis should be treated with topical cream for 7 days.
Front-to- Back Washing
(Vagina to anus washing)

13. Treatment of VVC: 3 days regimens
1 Day regimen
Fluconazole (diflucan® ,Treflucan ®, Fungican ®,…)
150 mg oral tablets (1 oral tablet for one day)
NB: two sequential oral doses (second dose 72 hours after initial dose) is recommended.
3 days regimens
Drug Dose/regimen
Clotrimazole (canesten®)
1% vaginal cream…………..1x2x (App 1 p.v. BID for 3 days)
100 mg vaginal tablets …..2x1x3 (2 tabs p.v.h.s for 3days )
Miconazole
(Gynodaktaren®,
Gynozol)
2% vaginal cream………….…1x2x (App 1 p.v. BID for 3 days)
400 mg vaginal pessaries.. 1x1x3 (Pess 1 p.v.h.s for 3days)
Itraconazole
(sporanox®)
100 mg oral tablet………..… 1x2x (tab1 PO BID for 3 day)
Ketoconazole
(Nizoral®)
200 mg oral tab………………....1x2x (tab1 PO BID for 3 day)
NB: vaginal creams and pessaries are oil- based and may weaken latex condoms….pregnancy

14. 7 Days regimens Clotrimazole Drug Dose/regimen (Canesten®)
1% vaginal cream….1x1x (App 1 p.v.h.s for 7 days)
100 mg vaginal tablets .1x1x7 (1 tab p.v.h.s for 7days )
Miconazole
(Gynodaktaren®)
2% vaginal cream….1x1x (App 1 p.v.h.s for 7 days)
400 mg vaginal pessaries 1x1x7 (1 pess p.v.h.s for 7days)
Tioconazole
(Gynotrosyd®)
100 mg vaginal tablets 1x1x (1 tab p.v.h.s for 7days)
Econazole
(Gynopevaryl®)
1% vaginal cream….1x1x (App once p.v.h.s for 7 days)
NB: vaginal creams and pessaries are oil- based and may weaken latex condoms….pregnancy

15. Topical azole (7–14 days) or
Severe VVC
Topical azole (7–14 days) or
Oral fluconazole 150 mg in two sequential doses (72 hr apart
RVVC
Topical therapy for 7–14 days or
Oral fluconazole (150-mg) every third day for a total of 3 doses [day 1, 4, and 7)
Maintenance antifungal regimen: (Oral fluconazole (i.e., 100-mg, 150-mg, or 200-mg dose) weekly for 6 months
Pregnant female
Only topical azole therapies, applied for 7 days, are recommended
Compromised Host
7–14 days of conventional treatment
from Guidelines of sexually by transmitted disease STDs

16. 2-Trichomonas Vaginitis [vaginal trichomoniasis] 20-30 % of cases,
Trichomoniasis: is a disease of the vagina, also occurs in lower male UT
sexually transmitted, newborn infection comes from untreated mothers
Cause:
by protozon Trichomonas Vaginalis
Signs & Symptoms: variable
1-Profuse, bubbly greenish-yellow or gray malodorous vaginal discharge, itching , burning & soreness of the vulva and vagina,
- Dyspareunia
- Burning upon micturation (Dysuria; 10% of pts)
- strawberry vagina or cervix
Diagnosis
2- The vaginal discharge usually have a pH of
3- physical/speculum examination →show strawberry vagina or cervix (10% of pts)
4-microscopical examination of discharge revealed highly motile (flagellated), pear-shaped, unicellular T. Vaginalis

17. Treatment of trichomoniasis: : CDOC is Metronidazole
A-Recommended regimen: 2 grams
Metro 500 mg tablet [4tab PO as a single dose]
B-Alternate regimen:
Metro 500 mg tablet BID for 7 days
*Male sex partners of infected women →
should be treated simultaneously with regimen A or B????
as 80% be culture +ve
*Pregnant pts should be treated with 2 gm of
Metronidazole in a single dose but with great caution especially
in early pregnancy
*For lactating women should use regimen A, with stopping of breast feeding for at least 24 hrs after treatment