Women’s Health Issues

CHAPTER 23 Women’s Health Issues



I. Osteoporosis

Osteoporosis is a condition in which bones have decreased density and altered structure; the weakened bones are prone to fractures. Osteoporosis is considered a silent disease because bone loss itself is gradual and painless. There are usually no symptoms until the bones weaken to the point of fracture.


A. Incidence

The incidence of osteoporosis increases with age and is more common among individuals with slender frames, such as Asians and Scandinavians. Africans and African Americans genetically have denser bones and it takes longer for denser bone mass to decrease to the level of osteoporosis. Osteoporosis can occur at any age, in all ethnic groups, and in both sexes, although it is much more common in women. Because vitamin D and calcium are essential for healthy bones, malnourished individuals, including those with eating disorders, may develop osteoporosis.


B. Pathophysiology
1. In normal bones, there is a regulated balance between the activity of cells that create bone and those that break it down, a process called bone remodeling. There are three main cell types that compose bone:
a. Osteoblasts are the cells primarily responsible for new bone formation and its mineralization.

b. Osteoclasts are responsible for breaking down old bone in a process called resorption.

c. Osteocytes are calcified osteoblasts that comprise the hard part of the bone structure.

2. Healthy bone remains stable because osteoblasts and osteoclasts are working at a similar rate, allowing bone to continuously remodel and heal when damaged. If osteoclast activity outpaces osteoblast activity, bones become weakened. In other words, if resorption is greater than formation, bone loss occurs.

3. By the mid-30s, most men and women gradually begin to lose bone strength. When bones become less dense and structurally weaker, this condition is known as osteopenia. Osteopenia refers to mild bone loss that is not as severe as osteoporosis. Individuals with osteopenia are at increased risk of developing osteoporosis. As the condition progresses, bones lose calcium, phosphorus, boron, and other minerals and they become lighter, less dense, and more porous. If untreated, osteopenia can progress painlessly to osteoporosis, increasing likelihood of fracture. Although any bone is susceptible to fracture, the most common fractures due to osteoporosis occur at the spine, wrists, and hips. Spine and hip fractures in particular may lead to chronic pain, long-term disability, and even death.

4. Extracellular levels of calcium, vitamin D, and parathyroid hormone (PTH) are key regulators in maintaining bone remodeling. PTH enhances the release of calcium and stimulates bone resorption and formation. Estrogen is thought to have a direct effect on bone cells. It enhances bone formation by stimulating the estrogen receptors, which are located on the osteoblasts. There is a direct link between the estrogen loss after menopause and the development of osteoporosis. Low hormone levels that occur in early menopause can significantly increase the risk of osteoporosis. Using anti-inflammatory corticosteroids may also significantly affect bone health. Corticosteroids are commonly taken by women greater than 55 years of age for conditions such as arthritis but are known to directly lead to bone loss. It is estimated that 20% of all osteoporosis cases may be attributed to corticosteroid use.

C. Risk factors
1. Sex (women are twice as likely to break/fracture bones than men)

2. Age (elderly)

3. Ethnicity (caucasian)

4. Family history

5. Frame size (small boned)

6. Smoking

7. Estrogen levels: longer exposure to estrogen equals less chance of developing osteoporosis

8. Other hormone-related diseases: hyperthyroidism, hyperparathyroidism, Cushing’s syndrome

9. Chronic use of corticosteroids

10. Other medications (e.g., > 2 years of use of medroxyprogesterone (Depo-Provera) for birth control)

D. Signs and symptoms

The early stages of bone loss are often not accompanied by any symptoms. Once bones have been weakened by osteoporosis, signs and symptoms may include back pain, which can be severe if a vertebra has fractured or collapsed; loss of height with an accompanying stooped posture; and fractures (commonly wrists, hips, or vertebrae). Although some fractures (such as in the wrist or hip) are obvious, spinal fractures can be more difficult to diagnose. Spinal fractures may be painless; even if pain occurs from a vertebral fracture, it might be attributed to another cause besides a fracture. More obvious signs of spinal fractures are reduced height and kyphosis, which is the curved upper spine that is sometimes called a “dowager’s hump.”


E. Diagnostic tests
1. Bone mineral density (BMD)

2. Dual-energy x-ray absorptiometry (DEXA) (Table 23-1)

3. Peripheral dual-energy x-ray absorptiometry (pDEXA)

4. Dual photon absorptiometry (DPA)

5. Quantitative ultrasound

6. Quantitative computed tomography (QCT)

7. X-rays

F. Treatment
1. Lifestyle and nutrition

2. Adequate intake of calcium
a. Everyone older than age of 8 years, minimum calcium intake of 1000 mg/day

b. Individuals older than age of 50 years, minimum calcium intake of 1200 mg/day

c. Pre-teens and teens (9 to 18 years old), minimum calcium intake of 1300 mg/day

3. Adequate intake of vitamin D needed to help with absorption of calcium and maintain muscle strength
a. Until age 60 years: 400 international units (IU) of vitamin D per day

b. After age 60 years: 600–800 IU of vitamin D per day

4. Weight-bearing exercises
a. Weight-lifting, jogging, hiking, stair-climbing, step aerobics, dancing, racquet sports, other activities that require muscles to work against gravity

5. Medications
a. Therapies that increase BMD and prevent fractures
(1) Calcium
(a) Important for attaining peak bone mass and preventing osteoporosis, antiresorptive, beneficial effects enhanced with other therapies and exercise

(b) 1200–1500 mg of elemental calcium daily

(c) Adverse effects: constipation, gas, and kidney stones (rare)

(d) Caution needed with concomitant use with certain antibiotics (e.g., ciprofloxacin)

(2) Vitamin D supplements
(a) Promote calcium absorption

(b) 400–800 IU per day

(c) Active form of vitamin D is calcitriol (1, 25-dihydroxycholecalciferol)

(d) Consider use in kidney dysfunction

(e) Not approved for osteoporosis treatment

(f) Adverse effects: hypercalcemia (weakness, headache, somnolence, nausea, cardiac rhythm disturbance), hypercalciuria

b. “Bone-building” treatments

Table 23-1 DEXA Result Interpretation















  T-score
Normal > −1
Osteopenia −1 to −2.5
Osteoporosis < −2.5

Without adequate calcium and vitamin D, the following treatments cannot improve bone architecture. Calcium and vitamin D are therefore prerequisites to the following therapies.


(1) Bisphosphonates
(a) Mechanism of action: bisphosphonates adsorb to the bone, preventing osteoclasts from adhering to the same bone surfaces, thereby inhibiting osteoclast activity.

(b) For the prevention and treatment of osteoporosis in postmenopausal women

(c) Provide the greatest BMD increases, effect is dose-dependent, combination therapy with estrogen/hormone replacement therapy (HRT) results in greater increases in BMD

(d) Examples
(i) Alendronate (Fosamax) taken orally once a week

(ii) Risedronate (Actonel) taken orally once a week

(iii) Ibandronate (Boniva) taken orally once a month; can also be given IV, once every 3 months

(iv) Zoledronic acid (Reclast) given IV once a year

(e) Adverse effects: nausea, dyspepsia, abdominal pain, diarrhea; esophageal, gastric, or duodenal irritation, perforation, ulceration or bleeding, acid reflux; osteonecrosis of jaw

(f) Considerations, if patient is taking medication orally
(i) Take on an empty stomach, with plain water only, first thing in the morning before having anything to eat or drink.

(ii) Patient must not lie down, eat, drink, or take other medications for at least 30 minutes. If patient wants to lie down after 30 minutes, the patient must eat breakfast first. These directions are necessary to avoid irritation of esophagus

(iii) Caution: Use of bisphosphonates in women who are pregnant or breastfeeding is not well studied.

(2) Hormone replacement therapy
(a) Estrogen alone or estrogen plus progestin
(i) Mechanism of action: The bone-protective effects of estrogen may involve suppression of inflammatory chemicals called cytokines, as discussed previously. There are estrogen receptors on osteoblasts and osteoclasts. Estrogens decrease osteoclast recruitment and activity, inhibit PTH peripherally, increase calcitriol concentrations and intestinal calcium absorption, and decrease renal calcium excretion. Estrogens also decrease cytokine levels.

(ii) Consideration: The progestin component is added only in women with an intact uterus to prevent endometrial overgrowth and endometrial cancer.

(iii) Caution: Use is contraindicated in active/suspected estrogen-dependent cancer, abnormal vaginal bleeding, severe liver disease, and active vascular thrombosis. Relative contraindications include migraines, thromboembolic disease, hypertriglyceridemia, uterine fibroids, endometriosis, gallbladder disease, family history of breast cancer, and chronic hepatic dysfunction.

(3) Selective estrogen receptor modulators (SERM)
(a) Mechanism of action: mimic the positive effects of estrogen on bones without side effects such as breast cancer and stroke; raloxifene (Evista) decreases spine fractures in women and is approved for use only in women at this time.

(b) Examples: raloxifene (Evista), tamoxifen (Nolvadex)

(c) Adverse effects: hot flashes, leg cramps, thromboembolic events

(d) Consideration: Avoid in patients with history of blood clots.

c. Medications that increase BMD only
(1) Calcitonin (Miacalcin)
(a) Mechanism of action: inhibits activity of osteoclasts; thought to increase spine BMD. May also lessen pain from spinal fractures.

(b) Available as injection and nasal spray; nasal spray more commonly used.

(c) Adverse effects
(i) Intranasal: rhinitis, epistaxis, and nasal irritation

(ii) Subcutaneous: GI symptoms, injection-site pain, and flushing

d. Medications that increase bone formation
(1) Teriparatide (Forteo)
(a) Mechanism of action: a form of PTH that helps stimulate bone formation

(b) Side effects: dizziness/syncope, chest pain, rash, nausea, rhinitis, fatigue, leg/muscle cramps, arthralgia

(c) Considerations
(i) If patient’s PTH levels are elevated or if the patient has ever had radiation therapy, may not be able to take this medication

(ii) Daily injection given subcutaneously and can be taken for a maximum of 2 years

6. Surgery
a. Vertebroplasty

b. Kyphoplasty

G. Prevention
1. Smoking cession

2. Alcohol in moderation

3. Maintain healthy body weight

4. Sunlight (some exposure necessary for adequate vitamin D)

5. Diet

6. Adequate calcium and vitamin D are essential for the prevention of osteoporosis in general, including postmenopausal osteoporosis. Postmenopausal women are especially susceptible to fractures of the hip, wrist, and spine; therefore, it is recommended by healthcare professionals for postmenopausal women to have about 1200–1500 milligrams of calcium and 800 IU of vitamin D daily.

7. Exercising regularly (e.g., strength training, weight-bearing activities, walking, jogging)

8. Avoiding hazardous falls

II. Vaginitis due to Yeast Infection
A. A yeast infection is a fungal infection called vulvovaginal candidiasis (VVC). It is rare before menarche. Incidence is likely after age 20, and 50% of women who have had a yeast infection before will have another yeast infection.

B. Yeast is part of the normal flora in the vagina. Usually, changes in the patient’s vaginal environment triggers the infection. Changes include hormonal changes, such as in pregnancy, or the use of antibiotics, which disrupt the normal flora in the vagina.

C. The major pathogen is Candida albicans. With increasing use of over-the-counter (OTC) products, short-course therapies, and the increased use of preventive or long-term maintenance therapy, there is an increased incidence of non-albicans candidiasis (e.g., Candida glabrata). A diagnosis for a yeast infection or VVC entails a positive vaginal culture for Candida.

D. Yeast infections can be sporadic or recurrent. They could also be defined as uncomplicated sporadic infections, which most likely, will be susceptible to all forms of antifungal therapy regardless of the duration of treatment. Complicated or recurrent VVC occurs in immunocompromised patients or those who have uncontrolled diabetes. Therapy in these populations requires longer duration (10–14 days), regardless of the route of administration.

E. Risk factors
1. Sexually active, but VVC is not an STD

2. Oral-genital contact

3. Diaphragm with spermicide

4. Contraceptive sponge

5. Intrauterine device (IUD)

6. Oral contraceptives (OC), especially of higher dose

7. Antibiotic use

8. Diet (particularly excessive carbohydrates)

9. Douching

10. Tight-fitting clothing

11. African American women appear to be at higher risk for VVC compared with white women.

F. Symptoms generally worsen during menstruation because the hormonal changes provide a better environment for fungal growth.
1. Itching

2. Watery or curd-like vaginal discharge that is white in color

3. Vaginal erythema (reddening of the skin)

4. Pain during sexual intercourse (dyspareunia)

5. Painful urination

6. Swollen labia and vulva

7. Vaginal lesions

G. Treatment
1. Nonpharmacological
a. Avoiding harsh soaps and perfumes to reduce irritation

b. Keeping the genital area clean and dry by avoiding tight clothing

c. Avoiding frequent or prolonged exposure to hot tubs

d. Using cool baths to soothe the skin

e. Eating yogurt containing Lactobacillus acidophilus

2. Prescription antifungal suppositories/vaginal creams (Table 23-2)
a. Vaginal yeast infections are treated with antifungal medications that are inserted directly into the vagina as suppositories or as cream-filled applicators.

b. Adverse effects: minimal, include vaginal burning, stinging, or irritation

3. Common OTC vaginal medications
a. Selection of product is based on patient’s preference for the preparation used and the duration of treatment.

b. Adverse effects: minimal, include vaginal burning, stinging, or irritation

4. Prescription oral antifungals (Table 23-3)
a. Oral azole antifungal agents may also be used to treat vulvovaginal candidiasis or yeast infection as an alternative to using antifungal creams.
(1) Fluconazole (Diflucan): 150 mg PO for 1 day

(2) Ketoconazole (Nizoral): 200 mg PO bid for 5 days

(3) Itraconazole (Sporanox): 200 mg PO bid for 1 day

(4) Adverse effects: nausea, vomiting, or headache

D. Resistance
1. When persistent positive yeast cultures fail to respond to therapy despite patient adherence to therapy. Often occurs with Candida glabrata.

2. Treatment
a. Boric acid

b. Initial 600 mg intravaginal capsule daily for 14 days

c. Maintenance: 1 capsule intravaginally twice weekly

d. Caution: toxic if administered orally

e. Requires extemporaneous compounding by pharmacist.

3. 5-Flucytosine
a. 1000-mg cream inserted vaginally nightly for 7 days; product not commercially available in the United States; requires extemporaneous compounding.

III. Menopause

Table 23-2 Prescription Antifungals for Vaginal Conditions


















Active Ingredient Duration
Terconazole (Terazol, Zazole) 0.4% cream 7 days
  0.8% cream or 80 mg suppository 3 days
Nystatin 100,000 unit vaginal tablet 14 days

Table 23-3 OTC Medications for Vaginal Candidiasis







































Active Ingredient   Duration
Butoconazole (Femstat) 2% cream 3 days
Clotrimazole (Gyne-Lotrimin, Mycelex, Canesten) 1% cream or 100-mg tablet 7 days
  2% cream or 200-mg tablet 3 days
  10% cream or 500-mg tablet 1 day
Miconazole (Monistat, Vagistat-3, Monistat-1 Ovule Pak) 2% cream or 100-mg suppository 7 days
  200-mg suppository 3 days
  1200-mg ovule 1 day
Tioconazole (Vagistat-1) 6.5% ointment or 300-mg ovule 1 day

Menopause is when a woman’s menstrual periods stop completely. It signals the end of the ovaries releasing eggs for fertilization. Menopause begins naturally when the ovaries start making less estrogen and progesterone, the hormones that regulate menstruation.


A woman is said to have completed menopause when her menses have stopped for an entire year. Menopause generally occurs between the ages of 45–55 years, although it can occur as early as the 30s or as late as the 60s. Progesterone (the hormone that prepares the body for pregnancy) levels drop and fertility declines. In the 40s, changes in menstrual patterns are experienced. The woman’s period may become longer or shorter, heavier or lighter, and more or less frequent. Eventually, the ovaries cease to function and there are no more periods.


All women will experience menopause. Menopause is not considered a disorder and most women do not need treatment for it. However, if symptoms are severe, medications may be used to help alleviate symptoms.


A. Risk factors associated with early menopause
1. Smoking
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Jun 21, 2016 | Posted by in PHARMACY | Comments Off on Women’s Health Issues

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