Women like to be knowledgeable about their health but can often be confused by misleading articles in newspapers, magazines and on the internet. What can pharmacists do to separate fact from fiction?

 

 

Health stories often hit the headlines and can lead to confusion rather than clarity. Well-informed pharmacy teams can offer women advice and reassurance about issues that affect their health and provide them with much needed, accurate information. Here we look at the evidence behind some of the women’s health issues that have recently hit the headlines.

The link between HRT and blood clots/stroke

The risks and benefits of hormone replacement therapy (HRT) are an ongoing cause of confusion for women. Over the years there have been many negative headlines about the risks of HRT, one of the most recent examples being a scientific review that reported women on HRT are at a small increased risk of blood clots and possibly stroke.¹

The link was made by the international Cochrane group, which looked at clinical trials involving 40,000 women. Researchers estimated that for every 1,000 women taking HRT, six would suffer a stroke and eight would experience a blood clot.

Maureen Talbot, British Heart Foundation senior cardiac nurse, says the risks of taking HRT for an individual have to be balanced against the benefits, which are relief from menopausal symptoms that some women find can have a significant impact on their quality of life.“It is important that women have a full understanding of the risks and benefits of HRT and should talk this through with their pharmacist or GP,” she advises.

NICE guidance says menopausal women at increased risk of blood clots can be prescribed HRT patches, which have a lower risk of venous thromboembolism than oral HRT.²

The risk of cancer and co-morbidities in obese women

More than half (58 per cent) of women are overweight or obese. This is a concern because obesity increases the risk in women of developing a number of chronic diseases and conditions including certain cancers, type 2 diabetes, coronary heart disease, hypertension and stroke, asthma, depression and anxiety, metabolic syndrome, dyslipidaemia, gastro-oesophageal reflux disease, gallbladder disease, reproductive problems, osteoarthritis and back pain, obstructive sleep apnoea, breathlessness and psychological distress. That’s quite a list.

There is a need for women to be educated about the dangers of obesity, says Cancer Research UK. A survey by the charity of more than 3,000 people found that three in four people do not know that obesity causes cancer. Being overweight or obese can cause up to 10 types of cancer, including breast, bowel, oesophageal and pancreatic tumours.

Post-menopausal women are particularly at risk of certain cancers because oestrogen made by fat cells can make cells multiply faster in the breasts and womb, increasing the risk of cancer.

The British Heart Foundation also warns that excess fat in women upsets metabolic processes, raises blood pressure and worsens blood cholesterol, increasing the risk of cardiovascular disease. Being obese also affects the way the body deals with glucose, which can cause type 2 diabetes, another major risk factor for cardiovascular disease. 

Community pharmacists can play a major role in educating and supporting women to lose weight. “Shedding a kilogram of excess adipose tissue does your health as much good if you are only a little overweight as it does if you are grossly overweight or obese,” says Professor Paul Aveyard, professor of behavioural medicine at Oxford University. “The risks from a kilo of extra fat are the same, regardless of how many other kilos you are carrying.”

 

 

Dementia is the leading cause of death in women over 80 years of age

Dementia and Alzheimer’s disease are the leading causes of death for women over the age of 80, according to a report by Alzheimer’s Research UK.³

Dementia affects over 850,000 people in the UK and it is estimated that, of these, 61 per cent are women and 39 per cent men. This statistic is likely to reflect the fact that women live longer than men, as age is the biggest known risk factor for the condition.

The report says that not only is dementia the leading cause of death among British women, but that women are far more likely than men to end up as carers of those with dementia – suffering physical and emotional stress and job losses in the process.

There are currently more than 500,000 women in the UK living with dementia and women over 60 years are now twice as likely to get dementia as breast cancer. “Dementia has a devastating impact on all those whose lives it touches, but the condition is hitting women particularly hard,” says Hilary Evans, director of external affairs at Alzheimer’s Research UK.

Effects of menstruation on quitting smoking

Women may worry that quitting smoking will affect their periods. While few studies have examined this question, it is known that smoking affects the hormones that are responsible for periods. One study has shown that in pre-menopausal women, smokers have elevated levels of oestrogen, progesterone and various androgens.⁴

This issue is important because women experience more severe health consequences from cigarette smoking, including a 25 per cent increased risk of developing coronary heart disease and chronic obstructive pulmonary disease, a higher incidence of lung cancer and an increased incidence of lung cancer-related deaths. Smoking cessation at any age can reduce the risk of tobacco-related diseases and death but there is anecdotal evidence that women have greater difficulty giving up smoking than men. 

A recent study reported that timing smoking cessation with the menstrual cycle might make it easier for women to quit.⁵ Researchers studied the brains of pre-menstrual women who smoked and discovered that they found it harder to quit smoking and were more likely to relapse during the follicular phase of their menstrual cycle (the early days of the cycle prior to ovulation during which the ovaries mature).

Their research was based on a number of animal studies, which have demonstrated that the female hormones oestrogen and progesterone, which fluctuate across the menstrual cycle, can modulate addictive behaviour.

“Understanding how the menstrual cycle phase affects neural processes, cognition and behaviour is a critical step in developing more effective treatments and in selecting the best, most individualised treatment options to help each cigarette smoker quit,” say the researchers.

Benefits of taking aspirin in women over 65 years of age

Taking a low dose of aspirin every other day has a protective effect against bowel cancer and cardiovascular disease in women over 65 years, research has shown.⁶

The study of almost 30,000 women found that the risk of gastro-intestinal bleeding caused by aspirin rose with age, but so did the drug’s impact on lowering the risk of cardiovascular disease and bowel cancer. For women aged 65 and over, the balance appeared to tip in favour of the drug.

Another clinical review of the evidence came to similar conclusions.⁷ This found that if all women aged 50-65 started taking aspirin daily for at least 10 years, there would be a 7 per cent reduction in the number of cancers, strokes and heart attacks overall. The total number of deaths from any cause would also be lower, by about 4 per cent over a 20-year period.

“While there are some serious side-effects that can’t be ignored, taking aspirin daily looks to be the most important thing we can do to reduce cancer after stopping smoking and reducing obesity,” says lead researcher, Professor Jack Cuzick, Queen Mary University of London.

Dealing with women’s sensitive health issues

Most women experience sensitive health issues from time to time, which can range from women of childbearing age experiencing bouts of bacterial vaginosis or thrush to older women suffering recurrent cystitis.

Reena Barai, independent community pharmacist, who works in her family-owned pharmacy in Surrey, says the pharmacy team is well-placed to offer over-the-counter treatment, reassurance and advice for these problems.

“The health concerns of these customers need to be dealt with sensitively because women will find these topics embarrassing. The important thing is to take the customer into the private consultation room and to build some trust and rapport with them so that they feel at ease.

“I always address the issue head on and will say something like ‘Shall we let the embarrassment go out of the window because I need to ask you some sensitive questions?’ Most women are happy with that and will then relax and open up about their symptoms and the things they are worried about,” she says.

 

 

Other common health problems

Bacterial vaginosis
Bacterial vaginosis (BV) is characterised by an overgrowth of predominantly anaerobic organisms and a loss of lactobacilli, causing the vagina to lose its normal acidity. It is the commonest cause of vaginal discharge. Symptoms include a:
• Fishy or unpleasant odour
• Watery discharge
• Greyish/white-looking discharge
• Worsening of the above after sex or during a period.

About half of women will have no symptoms. BV is not a sexually transmitted infection and is not usually associated with soreness, itching or irritation, but it is more prevalent in sexually active women and can be commoner in black women than other ethnic groups.

Bacterial vaginosis isn’t serious for the majority of women but women who are pregnant should be referred to the GP for further tests as it is associated with late miscarriage, pre-term labour, pre-term birth, pre-term premature rupture of membranes, low birthweight and postpartum endometritis.

The symptoms of BV can be similar to other vaginal infections. If unsure, pharmacy staff can offer women a self-testing kit that enables them to determine whether they are suffering from thrush, BV or another infection. BV can be treated with antibiotics, with metronidazole the preferred treatment.

Thrush
Vulvovaginal candidiasis (genital thrush) is caused by a candida yeast although other yeasts are occasionally implicated. Symptoms include:
• Vulval itching (often the defining symptom)
• Vulval soreness and irritation, vaginal discharge (usually white, ‘cheese-like’ and non-offensive)
• Pain or discomfort during sex or when passing urine.

Most women get thrush at some point in their lives, but it is most common in women in their 30s and 40s, and in those who are pregnant.

Treatment of uncomplicated infection involves a short course of an intravaginal antifungal (e.g. clotrimazole) or oral antifungal (fluconazole or itraconazole). Refer to the GP if thrush is recurrent.

Urinary tract infections
Lower urinary tract infections (UTIs) are common in women and are usually caused by bacteria from the gastrointestinal tract, most commonly Escherichia coli. Symptoms include:
• A need to urinate more often than usual
• Pain or discomfort when urinating
• Sudden urges to urinate
• Urine that is offensive smelling, cloudy or contains blood
• Lower abdominal ache
• Feeling generally unwell, aching all over, fever and chills – which may be a sign the infection has reached the kidneys.

Most urinary tract infections clear up on their own within four to five days. Painkillers such as paracetamol can help ease any pain and drinking plenty of fluids may also help. If infections last longer than five days they can be cleared up with a short course of antibiotics. Women should be advised to seek medical attention if they develop a high fever or become systemically unwell, are pregnant or have diabetes.

Bladder weakness
Bladder weakness, also known as urinary incontinence, describes the condition when the bladder leaks involuntarily. The two main types of bladder weakness are:
• Stress incontinence: caused when the bladder is under pressure, such as when coughing or laughing
• Urge incontinence: caused by a sudden urge to pass urine.
The condition is commoner in women due to pregnancy, childbirth, the menopause and ageing.

Your pharmacy should stock a comprehensive selection of specialist incontinence products including disposable and washable pads and pants in a variety of sizes and absorbencies, and staff should be able to advise women which products best suit their needs.

Self-help advice should include:
• Drink normally but cut down on diuretics such as tea and coffee
• Do pelvic floor exercises to strengthen the pelvic floor muscles
• Carry a bag of essentials including spare pants, bladder weakness pads and wet wipes in case of an emergency
• Eat plenty of fibre to avoid constipation, as straining can put additional stress on the pelvic floor.

Vaginal atrophy 
Vaginal atrophy is a common problem for women going through or after the menopause. A reduction in oestrogen causes the vaginal walls to become thin and dry. It can sometimes also be caused in younger women by breastfeeding, childbirth, the contraceptive pill or contraceptive injection.

Symptoms include:
• Vaginal irritation, discomfort, itchiness or a burning sensation
• Discomfort during sex
• A reduced sex drive
• Difficulty getting aroused and reaching orgasm
• The surface of the vagina looks pale and thin
• Narrowing or shortening of the vagina
• Needing to urinate more often than usual
• Repeated UTIs.

Over-the-counter vaginal lubricants and moisturisers can reduce the discomfort of sex. Vaginal oestrogen and HRT may be prescribed.

Being overweight or obese can cause up to 10 types of cancer

<sup>References
1. Boardman HMP, Hartley L, Eisinga A, et al. Hormone therapy for preventing cardiovascular disease in post-menopausal women. Cochrane Database of Systematic Reviews: onlinelibrary.wiley.com/doi/10.1002/14651858.CD002229.pub4/pdf/abstract
2. Menopause: diagnosis and management. NICE November 2015: nice.org.uk/
guidance/ng23
3. Women and dementia, a marginalised majority. Alzheimer’s Research UK: alzheimersresearchuk.org/wp-content/uploads/2015/03/Women-and-Dementia-A-Marginalised-Majority1.pdf
4. Windham G, Mitchell P, Anderson M, Mitchell P. Cigarette smoking and effects on hormone function in premenopausal women. Environmental Health Perspectives doi:10.1289/ehp.7899
5. Wetherill R, Jagannathan K, Hager N, et al. Influence of menstrual cycle phase on resting-state functional connectivity in naturally cycling, cigarette-dependent women. Biology of Sex Differences: bsd.biomedcentral.com/articles/10.1186/s13293-016-0078-6
6. van Kruiisdiik R, Visseren F, Ridker P, et al. Individualized prediction of alternate-day aspirin treatment effects on the combined risk of cancer, cardiovascular disease and gastro-intestinal bleeding in healthy women. Heart (2015) doi:10.1136/heartjnl-2014-306342
7. Cuzick J, Thorat M, Bosetti C, et al. Estimates of benefits and harms of prophylactic use of aspirin in the general population. Ann Oncol (2015) doi.org/10.1093/annonc/mdu225</sup>