Update-toolkit-womens-health

Women’s
health
Authors
Katharine Gascoigne MRPharms
Dr Sharmila Chauhan PhD MRPharmS
Doreen Cochrane MRPharmS
▶Click here to continue

Women’shealth
▶ Menstrual problems
● The changes caused during the menstrual cycle
● The treatments for menorrhagia available in
the pharmacy
● The causes of amenorrhoea
● Common drugs that can interfere with the
menstrual cycle
▶ Practical Approach 1
What is SPD in pregnancy and how is it treated?
▶ Treating endometriosis
● The incidence, prevalence and symptoms
of endometriosis
● How endometriosis is diagnosed and pain is managed
● The hormonal and surgical options available for
treatment
● The answers to common questions on fertility
Which LARC products will suit this patient?

▶ Management of lupus
● The pattern of disease in lupus and the organs
commonly affected
● The key diagnostic signs you should know
● The different treatment options considered in lupus
● Lifestyle and management advice pharmacists
can offer patients.
Bleeding and depression with an IUD
Click here to continueThis toolkit is made up of three Update modules previously published in C+D magazine in August 2012 and online at chemistanddruggist.co.uk/update ▶
Contents Click on the green arrows to navigate directly to chapters or pages

Menstrual
problems
Katharine Gascoigne MRPharmS
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Asha Fowells MRPharms
Menstrual problems are one of the four most
common reasons women of reproductive age
visit their GP. This article gives an overview of
the menstrual cycle, examining the roles played
by the different hormones involved. It discusses
three menstrual problems – menorrhagia
(heavy periods), amenorrhoea (absent periods)
and dysmenorrhoea (menstrual pain) – and how
pharmacists can help sufferers manage their
symptoms.
Menorrhagia
Menorrhagia is menstrual blood loss that interferes
with a woman’s physical, emotional, social and
material quality of life. It can occur alone or in
combination with other symptoms. It is usually
considered to be a monthly menstrual blood loss in
excess of 80ml.
Around a third of women describe their periods
as heavy, but only around 10 per cent are classed
as having menorrhagia. In general, if the bleeding
is such that the woman has to use tampons and
towels together, is experiencing flooding, passing
clots and is finding that the bleeding is impacting on
her daily life, menorrhagia should be considered.
In 40 to 60 per cent of cases there is no obvious
cause of the heavy bleeding; this is termed
dysfunctional uterine bleeding. About 20 per cent
of cases are associated with anovulatory cycles and
menorrhagia is most common at the beginning and
end of a woman’s reproductive life.
Other causes include:
● fibroids
● pelvic inflammatory disease
● endometriosis
● cervical or uterine polyps
● polycystic ovary syndrome (PCOS)
● hypothyroidism
● cancer.
A full blood count is usually performed to establish
whether the woman is anaemic and, if necessary,
iron tablets are prescribed.
Assuming there is no serious underlying cause,
the first-line treatment for menorrhagia is the
levonorgestrel-releasing intra-uterine system (LNG-
IUS). It should be used for a minimum of 12 months
and reduces blood loss by 71 to 96 per cent. Possible
side effects are irregular bleeding for six months
or more, breast tenderness, acne, headache and
amenorrhoea.
If the LNG-IUS is not acceptable, for example
because the woman does not want long-acting
contraception, tranexamic acid can be prescribed,
or is available as a P medicine for menorrhagia over
several cycles in women with regular, 21 to 35-
day cycles. It is a plasminogen-activator inhibitor,
preventing the dissolution of thrombosis that leads
to menstrual flow. It is taken for the three to four
days of heaviest bleeding and can reduce blood
loss by up to 58 per cent. Usually two tablets are
taken three times a day for a maximum of four days,

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although the dose may be increased up to 4g daily
for very heavy menstrual bleeding. Treatment should
not be initiated until menstrual bleeding has started,
and should be stopped if there is no improvement
after three months.
NSAIDs are another choice: mefenamic acid,
naproxen and ibuprofen are most commonly used
and have been shown to reduce blood flow by 20
to 50 per cent. They should be taken throughout
menstruation and work by reducing uterine
prostaglandin levels. This also leads to a reduction
in dysmenorrhoea but, if blood flow is not reduced
within three months, treatment should be ceased.
The combined oral contraceptive (COC) is also
used to treat menorrhagia, but has a number of
significant side effects and is only an option if
contraception is desired.
The third-line treatment for menorrhagia is
norethisterone, at a dose of 5mg three times a day
from day five to day 26 of the menstrual cycle. Side
effects include weight-gain, bloating, headaches and
acne. It works quickly and can stop heavy bleeding
within 48 hours. Injected medroxyprogesterone
acetate is also sometimes used.
If drug treatment is not effective, the next step
is surgery according to whether the cause of
menorrhagia is due to the presence of fibroids.
There are no specific lifestyle changes that can
reduce menorrhagia.
The menstrual cycle
Menstruation is the shedding of the
endometrium (lining of the uterus) accompanied
by bleeding. It occurs roughly once a month
throughout a woman’s reproductive life, except
during pregnancy. Girls start to menstruate at
an average age of 12 (at menarche) and continue
until they reach menopause, usually between 50
to 55 years.
Each cycle normally lasts 25 to 36 days. Around 35
to 40ml of blood is typically lost over an average
of five days.
The menstrual cycle is divided into three phases:
1. The follicular phase begins on day one of
the menstrual cycle, classed as the first day of
bleeding. At the beginning of this phase the
endometrium is thick with fluids and nutrients,
ready to receive a fertilised egg. If this does not
happen, the levels of oestrogen and progesterone
fall, causing the top layers of the endometrium
to break down. As they are shed, menstrual
bleeding occurs.
At this time the pituitary gland increases its
production of follicle-stimulating hormone
(FSH), which stimulates the growth of between
three and 30 egg-containing follicles. The level
of FSH then decreases, leaving just one follicle to
continue to grow. This follicle starts to produce
oestrogen and the other follicles break down.
This phase lasts an average of 13 to 14 days. It is
the phase that varies most in length and tends to
become shorter near menopause. The follicular
phase ends when there is a surge in the level of
luteinising hormone (LH).
2. The ovulatory phase then begins, lasting just
16 to 32 hours. It starts with a huge increase in
the level of LH produced by the pituitary gland.
LH stimulates the dominant follicle to bulge then
rupture from the surface of the ovary, releasing
the egg. The level of FSH also increases at this
time. As the egg is released, the ovulatory phase
ends.
3. The luteal phase begins after ovulation
and lasts about 14 days. During this phase
the ruptured follicle closes after releasing
the egg and forms the corpus luteum. This
structure produces increasing quantities of
progesterone, which makes the endometrium
thicken in preparation for receiving a fertilised
egg. Progesterone also causes the mucus in
the neck of the cervix to thicken and the body
temperature to increase slightly. The level of
oestrogen is high during this phase and also
causes thickening of the endometrium.
If the egg is not fertilised, the corpus luteum
degenerates after 14 days. Progesterone is
no longer produced and levels of oestrogen
decrease, resulting in the start of the next
menstrual cycle.

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Asha Fowells MRPharms
Amenorrhoea
Amenorrhoea is the absence of menstruation and is
classed as either primary or secondary.
Primary amenorrhoea is defined as the failure of
menstruation by the age of 16 years in the presence
of normal secondary sexual characteristics, or 14
years in the absence of other evidence of puberty.
Primary amenorrhoea is not common, and the
causes can range from delayed periods to abnormal
development of the reproductive system.
Secondary amenorrhoea is defined as the absence
of periods for at least six months in a woman who
has previously had regular periods, or 12 months if
she has previously had oligomenorrhoea (bleeds less
frequently then six-weekly).
The prevalence of amenorrhoea not due to
pregnancy, lactation or menopause is around 3 to
4 per cent in women of reproductive age and its
treatment depends on the cause. Complications of
amenorrhoea can include osteoporosis (prophylaxis
may be required), cardiovascular disease, infertility
and psychological distress, depending on its cause.
One in three cases of secondary amenorrhoea is
caused by PCOS, other symptoms of which include
hirsutism, fertility problems and weight gain.
Treatment options include:
● weight loss and exercise
● COC or anti-androgen therapy
● metformin
● clomifene and laparoscopic ovarian drilling.
Hypothalamic amenorrhoea can be caused by
stress, excessive weight loss, excessive exercise or
systemic illness and treating the cause should result
in a restoration of menses; amenorrhoea due to
hypothyroidism should cease after several months
of treatment with levothyroxine.
Hyperprolactinaemia can cause amenorrhoea and
can be drug-induced, in which case stopping the
causative drug could be considered.
Patients should be made aware that a small number
of women with secondary amenorrhoea will
become pregnant, so contraception should still be
considered.
Dysmenorrhoea
Dysmenorrhoea is pain in the lower pelvis
associated with menstruation. It is thought to be
caused by prostaglandins and leukotrienes in the
menstrual fluid creating vasoconstriction in the
uterine vessels, leading to uterine contractions
and pain. It is very common, affecting 40 to 70
per cent of women at some time. Risk factors for
dysmenorrhoea include long duration of menses,
early menarche, smoking, alcohol and obesity.
Primary dysmenorrhoea occurs in adolescent girls
with no underlying pathology. The pain often
starts shortly before menstruation and lasts for
up to 72 hours, improving as menses progresses.
Nausea, vomiting, migraine, bloating and emotional
symptoms may be experienced. ▶

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Secondary dysmenorrhoea is when menstrual pain –
which often persists after menstruation has finished
– appears after several years of painless periods and
is associated with some forms of pelvic pathology
.
Causes of secondary dysmenorrhoea include:
● fibroids
● adenomyosis (uterine thickening caused by
endometrial tissue moving into the outer muscular
walls of the uterus)
● endometriosis
● pelvic inflammatory disease
● cervical or uterine adhesions
● developmental abnormalities.
Having a hot bath or applying warmth to the area
usually eases the discomfort of dysmenorrhoea, as
does massage to the abdomen and/or back or lying
down flat on the back. Acupuncture or the use of a
TENS machine may be of benefit.
The most commonly used drugs for dysmenorrhoea
are NSAIDs due to their inhibition of prostaglandin
synthesis. If there is no benefit after three cycles,
then a COC can be considered; these are thought to
reduce prostaglandin release during menstruation.
Other treatments less commonly used include
depo-medroxyprogesterone acetate, LNG-IUS,
danazol and, rarely, leuprolide acetate.
Red flag menstrual symptoms
● Persistent bleeding outside menstruation
● Post-coital bleeding
● Pain during sexual intercourse
● Rectal pain or bleeding
Drugs that can interfere with the
menstrual cycle
● NSAIDs, if taken regularly, can interfere with
ovulation.
● Steroids and immunosuppressants in high
doses can prevent the pituitary gland from
producing enough FSH and LH for ovulation to
occur, resulting in irregular menstrual cycles.
● Some antipsychotics, antiepileptics and
antidepressants (other than SSRIs) may cause
hyperprolactinaemia, which can cause missed
or irregular periods.
● Carbimazole and propylthiouracil can cause
hypothyroidism, which in turn can cause
amenorrhoea.
Further information
● For women requesting advice on menstrual
problems, the following websites are good sources
of information and support:
▶ nhs.uk
▶ womens-health-concern.org
▶ pms.org.uk
▶ womens-health.co.uk
▶ endometriosis-uk.org

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▶ Return to contentsReturn to contents
Tips for your CPD entry on menstrual problems
Reﬂect
What happens during the luteal phase of the
menstrual cycle? What is the first-line treatment
for menorrhagia? What causes secondary
amenorrhoea?
Plan
This article gives an overview of the menstrual
cycle and the roles played by hormones. It also
discusses the causes, symptoms and treatment of
menorrhagia, amenorrhoea and dysmenorrhoea.
Act
Read the article and the suggested reading below
then take the 5 Minute Test.
● Find out more about menorrhagia on the Patient
UK website
▶ tinyurl.com/menstrual11
● Read the brief decision aid about heavy menstrual
bleeding management options
● Revise your knowledge of the OTC supply of
tranexamic acid from Manx Healthcare
● Read more about amenorrhoea on the NHS
Choices website
● Find out more about PCO
● Update your knowledge of dysmenorrhoea
Evaluate
Are you now confident in your knowledge of
the causes and symptoms of menorrhagia,
amenorrhoea and dysmenorrhoea? Could you give
advice to patients about their treatment?
Take the 5 Minute Test
Click here to check what you’ve learnt
by taking our short MCQ test and get
a CPD log sheet if you pass
(Internet connection required)

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Practical Approach
■ Test yourself and your team with this scenario based on pharmacy practice
A woman comes in the pharmacy, clutching her
pregnancy notes and with tears running down
her face.
Fearing the worst, you usher her into the
consultation room so that she can have some
privacy.
“I’ve just had my 24-week appointment with the
midwife,” she says. “Everything is fine with the
baby, but I’m having some pain when I walk and
it’s starting to stop me doing things, like sitting
on the floor to play with my four-year-old.
“The midwife was running late so she didn’t say
much, other than that it would get worse as I got
bigger but it would go away once the baby comes.
She told me it was pretty common and nothing to
worry about, but it’s really uncomfortable.
“I’ve got months to go until the baby is born.
What am I going to do?”
You glance at her pregnancy notes and next to
today’s date see that the midwife has written
“SPD”.
● What does SPD stand for?
SPD stands for symphysis pubis dysfunction (also
known as pelvic girdle pain, or PGP), and affects up
to one in four pregnant women. There are various
theories as to why it happens:
● higher than normal levels of the hormone relaxin
causing the pelvic ligaments to loosen too much and
too early, causing movement in the normally stable
pelvis
● one of the three joints in the pelvis becoming
stuck, causing asymmetric movements and leading
to inflammation
● separation of the symphysis joint in the pelvis.
continued ▶

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Practical Approach
(continued)
● What are the symptoms?
The condition can start at any point during
pregnancy (usually in the second trimester) and
is progressive due to the increasing weight of the
growing baby. Pain, which often starts as a dull
ache or an occasional stabbing sensation but rapidly
worsens, can occur in the pubic region, the inside of
the thighs, the hips and the buttocks. It can cause a
clicking sensation or sound.
Any activity that puts strain on the pelvis can cause
the pain to increase, including walking, climbing
stairs, turning over in bed and lifting or pushing
heavy objects. This means that the condition has
a huge impact on everyday life, as well as causing
sufferers to feel isolated and low.
● What are the possible treatment options,
both in the pharmacy and from specialist
teams?
Getting help early can make a huge difference. A
specialist obstetric physiotherapist will measure and
fit a pelvic support belt that limits the movement of
the joint and keeps the pelvis aligned, and provide
some hands-on treatment.
Suitable analgesia includes paracetamol, heat
therapies and TENS. Resting and avoiding activities
that trigger the pain can slow progression, but some
women may need crutches or even a wheelchair as
their pregnancy continues.
Small adjustments can make a big difference, such
as sitting on a carrier bag to make getting in and
out of the car easier, going up the stairs on hands
and knees, and sleeping with a pillow between
the legs to keep the pelvis in line. However, the
biggest difference will occur when the baby is born,
hormones start to return to pre-pregnancy levels
and the pressure on the pelvis is relieved.
● More information is available at:
▶ nhs.uk/conditions/pregnancy-and-baby/
pages/pelvic-pain-pregnant-spd.aspx
▶ pelvicpartnership.org.uk
If you identify a gap in your knowledge, consider
making a CPD entry.

Treating
endometriosis
Dr Sharmila Chauhan PhD MRPharmS
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Endometriosis affects 10 to 15 per cent of all
menstruating women aged 25 to 44 years. The
condition can range from mild to severe and can
be both physically and emotionally debilitating.
Currently around 1.5 million women in the UK
suffer from endometriosis and a significant
number remain undiagnosed.1
Endometriosis is characterised by the presence of
endometrial-like cells outside the uterus. These are
most commonly found inside the pelvis, around
the ovaries and fallopian tubes, on the ligaments,
intestines, bladder, vagina and the rectum. In rarer
cases, these ‘misplaced’ cells also grown into the
muscle layer of the uterus (adenomyosis), the skin,
eyes, spine, lungs and the brain.
The precise cause is unclear. Research has suggested
a number of contributing factors, including
endometrial cells travelling back up the fallopian
tubes and onto the ovaries during menstruation,
endometrial cells replacing other cells in tissues
outside the uterus, transportation of endometrial
cells to other parts of the body via the blood or
lymphatic system, and immune dysfunction.
Abdominal wall
Intestines
Peritoneum
Appendix
Fallopian tubes and ovaries
Uterus
Cervix
Bladder
Rectum
Vulva
The organs inside a woman’s abdomen. Possible sites where endometriosis can develop are indicated in blue

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Endometriosis is an inherited condition and
common in first-degree relatives of women with
the condition. It is most common in menstruating
women and generally becomes remissive after the
menopause. It is more common in women who
have:
● their first baby after age 30 years
● never had a baby
● short menstrual cycles (less than 27 days)
● certain structural abnormalities of
the uterus.
The condition is less common in women who
have had several pregnancies, use low-dose oral
contraceptives, or who exercise.
Symptoms
Like their uterine counterparts, endometrial cells
outside the uterus are also under the influence
of sex hormones during menstruation, and will
undergo proliferation and swelling under the
influence of oestrogen before a period. However,
since there is nowhere for them to be shed, they
accumulate and cause inflammation, pain and,
eventually, the formation of scar tissue.
Bands of fibrous tissue (adhesions) may form
between the structures in the abdominal cavity,
causing neighbouring organs to stick together,
leading to further complications.2,3
Typical symptoms include:2,3
● severe dysmenorrhoea
● pain in lower abdomen between menstrual cycles
(this may not be as painful as period pain but may
be more constant)
● painful sexual intercourse
● menstrual irregularities
● bowel or bladder symptoms (eg need to urinate
frequently, pain during urination, constipation, rectal
bleeding during menstruation).
Adhesions on the ovaries can form a cyst that bleeds
Patient questions on endometriosis
1. Will I be able to have a baby?
The majority (60 to 70 per cent) of women with endometriosis have no problems getting pregnant. If a
woman wants conceive in the future, she should discuss this with her doctor, since this will play a role in
the management of the condition. Pharmacological treatment for endometriosis should be avoided for
women who are trying to conceive.3
2. What are the options if I want to have a baby and have difficulty conceiving?
Data on the benefits of intrauterine insemination (IUI) in women with endometriosis are unclear, although
IVF can be considered. Pregnancy rates, however, are lower in women with endometriosis than those with
tubal infertility.3
3. Will having a baby ‘cure’ my endometriosis?
Pregnancy is not a ‘cure’ for endometriosis, although some women may experience temporary benefit
while pregnant. In most cases, symptoms return after giving birth and the menstrual cycle resumes.1
4. Can I use any alternative medicines?
Systemic reviews indicate that a variety of alternative medications have been shown to relieve
dysmenorrhoea, including: high frequency TENS, acupuncture, vitamin B1 and magnesium. One
randomised controlled trial provided evidence that vitamin E may relieve primary dysmenorrhoea and
reduce blood loss. The efficacy of these treatments in endometriosis-associated dysmenorrhoea is unclear.
into itself each month, often called a ‘chocolate cyst’.
In severe cases of endometriosis, the adhesions
may block the fallopian tubes, impairing fertility.
Infertility has also been reported in women with
mild cases of the disease but the mechanism by
which this occurs is not understood. Between 25
and 50 per cent of women who are infertile have
endometriosis.2,3
Endometriosis has a number of psychological
effects and women with the condition may report
depression, isolation and anxiety.

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Diagnosis
Diagnosis of endometriosis cannot be made on
symptoms alone, and in many women can be
delayed by up to 12 years. This is because of a lack
of awareness among women, lack of specialists,
the asymptomatic nature of the condition and
reluctance of women to ask for help until the
condition is severe.
The diagnosis of endometriosis is all too often a
consequence of a different medical investigation,
for example, during investigation of fertility issues.1
Improved awareness of the condition together with
provision of resources to enable diagnosis may help
to improve prognosis of women with the condition.
Diagnosis requires specialist investigation. Currently
the gold standard is laparoscopy, which allows
the pelvis to be visually inspected and the size and
location of adhesions in the abdominal cavity to be
assessed.
Treatment
Management of endometriosis currently includes
symptomatic treatment, hormonal intervention, and
surgery.
First-line treatment usually includes non-steroidal
anti-inflammatory drugs (NSAID), such as ibuprofen,
naproxen, mefenamic acid, or diclofenac. These are
usually prescribed to women who are experiencing
a lot of pain, those who do not wish to use hormonal
treatments, and those who are awaiting referral
from their GP to a specialist. However, the Royal
College of Obstetricians and Gynaecologists (RCOG)
states “that although NSAIDs may be effective
in endometriosis-associated pain, there are too
few randomised controlled trials to assess their
effectiveness”.3
Patients who cannot take NSAIDs (eg those with
stomach ulcers or asthma) can be prescribed
paracetamol, and studies suggest regular use of
the drug may be more effective than as-required
use. In patients in whom adequate pain relief is not
achieved, codeine may be added to paracetamol
and/or an NSAID.
Hormone therapy
Hormonal treatments are used to interfere
with oestrogen production and/or activity at its
receptors, thereby shrinking the adhesion size.
These treatments can also be used to treat the
pain and bleeding disorders associated with
endometriosis.
Combined oral contraceptives (COCs) are
considered the first-line hormonal treatment, and
may be taken continuously without a break, or in
a tricycling (taking three packs without a break)
regimen to control endometriosis. Women taking
a COC may report beneficial effects such as lighter
and less painful periods. Other symptoms such as
painful sex and pain in the pelvic area may also
improve.
Progesterone agents act by decidualisation
and atrophy of the endometrium. In studies,
medroxyprogesterone has been shown to be
effective in pain suppression. Adverse effects of this
type of drug include weight gain, fluid retention,
depression, and breakthrough bleeding.
Long-acting progesterones can be used in patients
with compliance issues and also in women who
are uncomfortable with a daily tablet intake.
They may be more acceptable in patients who are
familiar with depot or intrauterine devices
for contraceptive use.
Women should be reassured that long-acting
devices are effective and studies show that the
levonorgestrel intrauterine system (LNG-IUS)
can reduce endometriosis-associated pain and, if
inserted during laparoscopic surgery, can reduce the
recurrence of dysmenorrhea.
Androgens (eg danazol) act through an inhibition
of the midcycle follicle-stimulating hormone (FSH)
and luteinising hormone (LH) surges as well as
prevention of steroidogenesis in the corpus luteum.
Although studies show danazol is as effective as
the newer agents, its adverse effects reduce its
acceptability. These include acne, oily skin, weight
gain, deepening of the voice, and facial hirsutism.
It also has a number of side effects related to low
oestrogen levels: hot flushes, emotional lability,
vaginal dryness, and reversible breast atrophy.
The usual dose is 200 to 800mg daily in up to four

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divided doses, adjusted to achieve amenorrhoea,
usually for three to six months. These can bring on
an ‘artificial menopause’ as they reduce oestrogen
and progesterone production.
GnRH analogues (eg buserelin, goserelin, nafarelin,
leuprorelin, and triptorelin) inhibit pituitary
gonadotrophin release. Preparations are taken as
a nasal spray or injection. Goserelin and leuprorelin
are the most commonly used agonists and have
been shown in studies to reduce pain associated
with endometriosis.
Reports suggest that as many as 85 to 100 per cent
of women experience pain suppression following
GnRH therapy and that these benefits may persist
for between six to 12 months after treatment
cessation. Research also shows GnRH treatment can
also relieve the pain and bleeding associated with
extrapelvic distant endometriosis.
Adverse effects of GnRH agonists include hot
flushes, vaginal dryness, reduced sex drive,
headaches, reduced bone density, insomnia
and amenorrhoea, some of which disappear on
cessation. Pharmacists should remind patients that
they may experience flare up in symptoms during
the first few days of treatment.
Manufacturers recommend a single course of six
months duration, although some specialists may
prescribe a repeated or extended course. There is
limited data regarding the safety and efficacy of this
approach. Alternatives include using a three-month
course or repeated shorter courses. The latter may
offer sustained beneficial effect combined with
lower impact on bone mineral density and fewer
hypo-oestrogenic adverse effects.
There is debate as to whether oestrogen/
progesterone “add-back” therapy should be used
to prevent osteoporosis and hypo-oestrogenic
symptoms experienced by women receiving GnRH
therapy for endometriosis. Low-dose hormone
replacement therapy (HRT) has been shown
to prevent loss in bone density and to relieve
vasomotor symptoms without compromising the
efficacy of GnRH regimens; these data suggest that
inclusion may be beneficial for many women.
Surgical treatment
The RCOG guidelines3
outline the ideal treatment
of endometriosis as diagnosis followed by surgical
removal of adhesions.
There are three types of surgery:
● Conservative – reproductive potential is
maintained
● Semiconservative – reproductive ability is
diminished but ovarian function is retained
● Radical – when the uterus and ovaries are
completely removed.
Surgery usually includes removal of adhesions and
correction of any related anatomical distortions.
The former are ablated using either laser energy or
electrosurgical techniques.
Laparoscopic uterine nerve ablation (LUNA) involves
the destruction of a small segment of ligament that
carries nerve fibres within the pelvis. However, it has
not been shown to be efficacious and therefore is
not advised for this patient group.
When deciding on the type of surgery, the patient’s
age, desire for children and their current quality of
life should all be considered.
Dr Sharmila Chauhan is a pharmacist
and medical writer with a PhD in clinical
pharmacology
References
1. Endometriosis UK Available at: http://www.
endometriosis-uk.org/information/whatisit.html
Accessed June 2012
2. Endometriosis Merck Manuals. Available at:
http://www.merckmanuals.com/home/womens_
health_issues/endometriosis/endometriosis.html.
Accessed June 2012
3. The Investigation and Management of
Endometriosis. Royal College of Obstetricians and
Gynaecologists. 2006

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For more information
▶ fpa.org.uk/helpandadvice/contraception/
longactingreversiblecontraceptionlarc
▶ guidance.nice.org.uk/CG156
▶ fsrh.org/pages/clinical_guidance.as
● Endometriosis UK for women with endometriosis
▶ endometriosis-uk.org
● Endometriosis SHE trust
▶ shetrust.org.uk
● RCOG
▶ rcog.org.uk/womens-health
● The Pain Society
▶ britishpainsociety.org

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Reﬂect
What are the main symptoms of endometriosis?
What are the adverse effects associated with GnRH
analogues? How does endometriosis affect fertility?
Plan
This article discusses endometriosis and includes
information about causes, symptoms and diagnosis.
It also describes the hormonal and surgical
treatments available and answers common
questions that patients with endometriosis might
have about fertility.
Act
Read the article and the suggested reading below
● Read more about endometriosis on the Patient
UK website
▶ tinyurl.com/endometriosis11
● Find out about the advice you could give to
patients who are suffering from long term pain on
the NHS Choices website
▶ tinyurl.com/endometriosis12
● Research self-help organisations and websites
for women who suffer from endometriosis. Find
out about local groups and print out any useful
information leaflets.
● Consider carrying out training with your
pharmacy staff so that women who prefer to talk to
a female or older or younger person can be made to
feel more at ease.
Evaluate
Are you now confident in your knowledge of
the symptoms and treatment of endometriosis?
Could you and your staff confidently give advice to
patients?
Tips for your CPD entry on treating endometriosis

▶
▶
Practical Approach
A young woman visits the pharmacy and
requests a consultation for emergency
hormonal contraception (EHC). You head into
the consultation room and, after ensuring it is
appropriate, decide to provide her with EHC.
As you come back, the woman looks anxious.
“It’s really embarrassing, but this is the second
time I’ve had to have this in the last few months,”
she says. “My husband and I have two children
and we really don’t want anymore. He’s thinking
about having a vasectomy, but using condoms
clearly isn’t working for us while he makes up his
mind!”
You ask if she’s considered oral contraception.
“I don’t think that will work. I wasn’t very good at
remembering to take the pill when I was younger,
so is there something else I can do?”
● What are the four methods of long-acting
reversible contraception? What are their
effectiveness and benefits?
There are four methods of long-acting reversible
contraception (LARC), any of which may be suitable
for this woman, and all of which are deemed by
NICE to be more cost-effective than combined oral
contraceptives even at one year of use and have
more than 99 per cent effectiveness:
● The progesterone-based contraceptive injection
needs administering every eight or 12 weeks
depending on the product used. It is associated
with menstrual disturbances and weight gain, and it
can take up to a year for fertility to return once it is
stopped.
● The implant also contains progesterone and
works for three years, though it can be removed
sooner if required. It has been associated with
irregular menstrual bleeding, acne and discomfort
on insertion and removal, and fertility returns to
normal as soon as it is removed. ▶

▶
▶
Practical Approach
(continued)
● The intrauterine system (IUS) releases
progesterone over five years (though it can be
removed sooner at the woman’s request), and is
more than 99 per cent effective. Disadvantages
include discomfort on insertion and removal,
and it can cause irregular bleeding, acne and
mood changes, though many women enjoy the
amenorrhoea it can cause. The risk of ectopic
pregnancy is lower than if no contraception is being
used, but if the woman becomes pregnant with the
IUS in situ, the risk jumps to one in 20 (this is also
the case for IUDs). Fertility returns to normal upon
removal.
● Intrauterine devices (IUDs) containing copper
have been widely superseded by the IUS but are still
an option for woman who prefer a non-hormonal
method of contraception. They need replacing every
five to 10 years, though fertility returns to normal
as soon as they are removed. The most common
side effects are vaginal bleeding and pain, and pelvic
inflammatory disease and uterine perforation are
much less common than perceived (and are the
same as for the IUS).
This woman should be provided with information on
all the options available and offered the opportunity
to ask any questions she may have in order to
choose a method that she will then be able to
use effectively. Not all methods will be available
from her GP surgery as some require specialist
training, but she will be able to access her preferred
contraception locally due to referral pathways.
making a CPD entry.

Management
of lupus
Doreen Cochrane
MRPharmS
▶
▶

▶
▶
Lupus is an autoimmune rheumatic condition
and about 90 per cent of cases are in women.
The disease has peak onset during the
child-bearing years. In the UK, lupus affects
about one in 750 Caucasian women, rising to
one in 250 Asian and African-Caribbean women.
People from an Asian or African-Caribbean
background tend to have severe forms.
Pharmacists can help raise awareness of the
condition, support patients with medicines and
provide healthy lifestyle interventions to help
prevent cardiovascular disease.
What is lupus?
Lupus is a complex illness that can affect many
organs, most commonly the muscles and joints or
tendons; nervous system; lungs; heart; kidneys;
serous membranes and components of the blood.
In lupus the body’s immune system becomes
hyperactive, forming antibodies that attack normal
tissues and organs. It tends to be characterised by
periods of illness – called flares or exacerbations –
and periods of remission.
About 70 per cent of cases are catergorised as
systemic lupus erythematosus (SLE), among which
about half of patients have non-organ threatening
disease. These patients have normal life expectancy
and it is unlikely they will develop major organ
involvement after the first five years of developing
lupus. If the disease affects the major organs
(heart, lungs, kidneys or liver), it may become life
threatening.
Drug-induced lupus, which accounts for about 10
per cent of all cases, is a side effect of long-term
use of certain medications. It tends to be mild
and is usually reversible when the medicine is
stopped. Potential causative drugs include isoniazid,
hydralazine and procainamide. A further 10 per cent
of patients have cutaneous, or discoid, lupus.
Systemic lupus
erythematosus (SLE)
rash on the skin of the
face in a female patient,
an autoimmune disease
where the immune
system attacks the
body’s connective tissue,
mainly in the skin, joints
and kidneys.

▶
▶
Some patients have a genetic predisposition to
developing SLE. Many of the clinical manifestations
of SLE are mediated by deposition of immune
complexes in organs such as the kidney, resulting in
lupus nephritis.
One or more environmental factors may trigger
disease in genetically predisposed individuals. These
factors include:
● previous viral infections, especially with the
Epstein-Barr virus
● excessive ultraviolet light exposure
● changes in the sex hormones, especially
oestrogen.
Other environmental factors have been implicated
in the pathogenesis of the disease. Autoantibodies
may be present for many years before the clinical
onset of lupus, and there may be increasing
numbers of antibodies just before symptoms
develop.
The development of clinical lupus results from
abnormalities in B cells and T cells, defects in cell
signalling, impairment of cell-surface protective
mechanisms and failure in T-regulatory cells to
prevent inflammation. If this process is interfered
with chronically, this will result in tissue and organ
damage.
The prognosis from patients with lupus ultimately
depends on the amount of permanent scarring or
irreversible organ dysfunction accrued over the
course of the illness. Treatment therefore aims to
eliminate inflammation and thrombosis, minimise
organ damage and prevent cardiovascular disease.
Diagnosis
Exhaustion is one of the most common and
persistent features of SLE. Lupus may start with
flitting joint pains in the small joints of the hands
and feet, and skin rashes – especially malar rash (a
characteristic red or purple, mildly scaly facial rash)
– which may be worse when exposed to strong
sunlight. There may be swollen glands and mild
hair loss. Raynaud’s phenomenon (whitening of the
fingers) may occur. Depression is also an important
symptom in lupus and patients may develop
frequent mouth ulcers.
Patients presenting with these symptoms should
be referred to their GP. A diagnosis of lupus or a
related connective tissue disorder is often apparent
after clinical assessment, urinalysis, and basic
investigations such as full blood count (often
showing anaemia or cytopenia), and renal and liver
function tests; results indicating a high erythrocyte
sedimentation rate (ESR) with a normal C reactive
protein concentration are characteristic.
A blood test for anti-nuclear antibodies and anti-
double-stranded DNA antibodies are the usual
starting points when considering referral to
specialist care. This will lead to more extensive
testing, including detailed assessment of organ
involvement and further autoantibody testing.
Raynaud’s phenomenon
(whitening of the
fingers) is one of the
symptoms which may
occurr.

▶
▶
Treatment of lupus
● Antimalarials such as chloroquine and
hydroxychloroquine are effective in treating skin
rashes, aches and pain and fatigue and reducing
flares of the disease. They may protect against renal
insufficiency and the occurrence of thrombotic
events, diabetes, and reduced bone mineral density.
They have a beneficial effect on lipid profiles,
especially among patients treated with steroids.
Hydroxychloroquine may be used alongside
mycophenolate mofetil in the treatment of lupus
nephritis.
The dose used at initiation of treatment with
hydroxychloroquine for adults may be as
high as 400-800mg daily, with an average
maintenance dose of 200-400mg daily; the usual
recommendation is for a daily dose of 1-3mg/
kg daily to avoid retinal toxicity. Because of its
long half-life, patients should be advised that it
takes two to eight weeks to achieve effectiveness.
Hydroxychloroquine is considered to be safe in
pregnancy and breastfeeding.
● Immunosuppressants are commonly used to
treat the condition. Azathioprine is widely used
to suppress the immune response in SLE, but also
affects other dividing cells – including white blood
cells. It is often used if lupus is affecting the kidneys
(lupus nephritis) and as a steroid-sparing agent.
The usual dose is 1-2.5mg/kg body weight daily
(usually 100-150mg daily). For most patients the
drug is well tolerated but requires blood monitoring
at least every three months. About five per cent
of patients cannot tolerate this medication due
to immediate onset of nausea and altered liver
function. Treatment with azathioprine should not be
initiated during pregnancy but may be used during
breastfeeding if its benefits outweigh the risks to
the newborn.
Mycophenolate mofetil is an effective and safe
alternative for many patients who cannot tolerate
azathioprine. Initially mycophenolate was used
in cases of lupus nephritis and to effect disease
remission. It has now gained a place in other aspects
of lupus including patients with muscle disease, low
platelet counts and skin disease. The most common
side effects are nausea and loose stools. It is not
safe in pregnancy or breastfeeding and blood counts
must be monitored monthly during treatment.
Methotrexate is used at a low dose, usually 7.5mg
weekly, increasing if necessary depending on
response and the side effects experienced by the
patient. In view of the significant toxicity associated
with methotrexate, patients should have a full blood
count and renal and liver function tests checked
before starting treatment, and at least every two to
three months during maintenance therapy. Patients
must be educated to report all signs and symptoms
suggestive of infection and pulmonary toxicity
immediately.
● Corticosteroids can be used, with the dose
dependent on the severity of the patient’s illness.
The most common side effects of corticosteroids are
weight gain; ‘moon-face’; increased blood pressure;
osteoporosis; lowered resistance to infection and
mood disturbances. Problems associated with the
use of corticosteroids are minimised by using the
lowest possible dose for the shortest period of time.
Steroid-sparing drugs, such as azathioprine and
mycophenalate mofetil, may be used to reduce the
dose of corticosteroid. The patient’s blood pressure,
glucose levels and lipid profile should be monitored
during corticosteroid therapy, which is considered
safe for use during pregnancy and breastfeeding.
Cyclophosphamide, cyclosporine, monoclonal
antibodies and immunoregulators are used in the
treatment of patients with severe disease.
Ongoing mananagement of lupus
Education is critical for patients, their carers
and friends, and pharmacists can help them to
access information about lupus and medicines
used in its treatment to encourage concordance.
Often, patients are concerned about the effects
of the illness on their future physical mobility
and employment. Because of the emotional and
psychological consequences of the diagnosis and
the role of depression in the illness, the hospital
lupus team usually offers support from a specialist
nurse counsellor. Patients are encouraged to
alternate periods of activity with periods of rest to
reduce symptoms of tiredness, and physiotherapists
can support patients with a graduated exercise
programme. ▶

▶
▶
Pharmacists can help patients choose effective
sun-blockers to reduce ultraviolet exposure.
Patients should be advised to use a sunblock of
factor 25 or greater, and that sunblock products
are also available on prescription. Some OTC
medications, such as sleep aids containing
diphenhydramine, should be avoided by patients
with thrombocytopenia due to haematological
involvement. Many herbal treatments available in
the pharmacy, including echinacea, are best avoided
by patients with lupus.
In recent years, the treatment for lupus has
broadened to include lifestyle factors, especially
smoking cessation and reduction of cholesterol
levels to prevent strokes and coronary artery
disease; inflammation is associated with LDL
lipoprotein levels. Management of related problems
such as blood pressure, and prevention of conditions
such as osteoporosis is important.
A balanced, healthy diet containing fish or fish oil
supplements is encouraged. Alfalfa shoots, which
are rich in the amino acid L-canavanine, trigger
flares and should be avoided. Some patients avoid
other foods which make their symptoms worse.
The risks associated with live viral vaccinations
must be individually assessed for all patients taking
immunosuppressive medicines, and some patients
can experience a flare of symptoms following
vaccinations for illnesses such as influenza.
Pregnancy presents particular challenges for
the patient with lupus, especially if the mother
has hypertension or reduced renal function. The
pregnancy should be planned well in advance
wherever possible to minimise the risks to both
the mother and foetus. Factors included in the
pre-assessment for pregnancy in lupus include
the manifestations of underlying disease, the past
history of flares and past and current medications.
With proper management the majority of patients
with lupus now lead full and active lives. Disparities
continue to exist in the course of disease based on
ethnicity and socioeconomic status and these are
current areas of research.
Useful further information
▶ arthritisresearchuk.org
▶ lupus.org.uk
▶ thelupusinitiative.org
▶ sagepub.com
Search for Lupus (An International Journal)

▶
▶
Reﬂect
In which ethnic groups is lupus likely to be more
severe? Which treatments for lupus are safe for use
in pregnancy and breastfeeding? What are the side
effects of mycophenolate mofetil?
Plan
This article describes the autoimmune rheumatic
condition lupus and includes information about
symptoms, diagnosis and treatment. Lifestyle advice
and the challenges of lupus and pregnancy are also
discussed.
Act
Read the article and the suggested reading below,
● Read more about lupus on the NHS Choices
website
tinyurl.com/lupus111
● Find out more about discoid lupus erythematosus
from the British Association of Dermatologists
website
● Read more about how lupus is diagnosed on the
Arthritis Research UK website
● Find out more about how lupus can affect the
mouth on the Lupus UK website
● For lifestyle advice you could give to patients with
lupus, see the Arthritis Research UK website
Evaluate
Are you now confident in your knowledge of the
symptoms and treatment of lupus? Could you give
lifestyle advice to patients about this condition?
Tips for your CPD entry on managment of lupus

▶
▶
Practical Approach
Bleeding and depression with an IUD
1. Pamela Allen, a woman in her 30s asks to speak
to pharmacist Verity Smith in private about two
problems.
Verity leads her to the consultation room where
the woman starts to explain.
“I had a Mirena coil fitted for contraceptive
purposes after my daughter was born and it was
brilliant,” she says.
“The best thing of all was that it stopped my
periods. When it ran out after five years, I had
another one fitted straight away. That was four
and a half years ago.
“In the past few months, I have started to get
some spotting and in recent weeks. I seem to be
bleeding all the time. My other problem is that I
am feeling quite depressed for no reason. It’s just
not like me.
“Can being depressed give you periods? Or is the
continual spotting making me depressed? The
two things seemed to happen about the same
time.”
2. Pamela returns to the pharmacy about four
weeks later, early on Saturday morning, and again
asks to speak to the pharmacist in private.
She is clearly in distress and Verity can see that
she appears pale and is sweating.
She tells Verity that she saw her GP who believed
that the Mirena had ‘run out’ even though the
five years weren’t up. The GP said this wasn’t
uncommon and could be causing Pamela’s
problems.
The GP took the coil out and Pamela opted to
have it replaced at once.
However, the procedure did not go smoothly.
The doctor had great difficulty getting the
replacement coil in, using Nitrolingual Pumpspray
on Pamela’s cervix to facilitate the insertion. ▶

▶
▶
Practical Approach
Bleeding and depression with an IUD (continued)
Pamela tells Verity that she was left feeling
profoundly unwell and hadn’t really recovered.
“I went into shock, which my GP said can happen
if something comes into contact with your cervix
like that.
“Anyway, that was four weeks ago and I’ve had
problems ever since. Since then, I’ve been back to
the practice and seen a different GP.
“I told her I have been suffering from cystitis
and soreness down below and she gave me
antibiotics and some thrush cream, but it’s made
no difference,” she says.
“Last night I started to get stomach ache, a
horrid, disabling, cramping pain, which came and
went, just like being in labour. I’m bleeding great
clots and I feel sick and I’m sweaty and shivery.
“I took some paracetamol last night and it helped
a bit, but I just don’t know what to do now.”
1. Can the intra-uterine device cause depression?
What action should Verity take about the
irregular bleeding?
Verity looks at the BNF entry for Mirena and sees
that depression (sometimes severe) is listed as a side
effect and a history of depression is a caution for use
of the device.
Irregular bleeding is common in the first six months
of using an intra-uterine device, but is a sign for
referral if it occurs after this time, as in Pamela’s
case. Verity has no hesitation in referring Pamela to
her GP.
2. What could be happening, and what should
Verity do?
Verity remembers that there can be some period-
like pain early on after insertion, but she thinks this
is more serious. She is concerned that Pamela may
either have an ectopic pregnancy, that the coil
is being expelled, or the insertion has perforated
Pamela’s womb. She rings the emergency doctor on
Pamela’s behalf and Pamela’s partner drives her to
the surgery.
Pamela returns to the pharmacy the following
week, looking considerably better. The Mirena was
indeed being expelled. Verity has discovered that
this happens in about 6 per cent of Mirena users
in the first year of use. Fortunately, there was no
perforation (which occurs in about one in 1,000
women). The doctor removed the coil giving Pamela
almost instant relief. She is going back to discuss
possible future contraception in a week’s time.
making a CPD entry based on the article.

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