In the management of women requiring treatment for vaginal atrophy, women's health nurse practitioners are responsible for provision of the primary service, prescription of medication as required and review three months after commencement of treatment.
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Anticipated outcomes
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Women's health nurse practitioners will provide:
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- consistency in assessment and management of vaginal atrophy
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- optimal care in the management of vaginal atrophy
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- secondary referral as required
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Eligible women are women who:
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- complain of vaginal discomfort and demonstrate signs of vaginal atrophy
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- demonstrate signs of vaginal atrophy and experience pain during the bimanual or speculum examination
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- return a Pap test advising vaginal oestrogenisation prior to repeat Pap test
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History
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Women's health nurse practitioners should document the relationship of present signs and symptoms to any contributing factors resulting in a low oestrogen environment such as menopausal status or whether currently lactating. They should also ascertain whether other contributing factors are present such as contact irritants, and exclude sexually transmissible infections as appropriate.
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Assessment
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Signs and symptoms of atrophic vaginitis include:
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- thin, pale and dry vaginal epithelium
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- friable vaginal epithelium
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- generalised vulvovaginal itching
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- pain from splitting caused by friction
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Management
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Non-prescription management
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The women's health nurse practitioner will ensure the client is aware of a range of options including vaginal moisturisers (Replens™), vaginal lubricant (Senselle™ and Silk™) and or sexual lubricant (Wet Stuff™).
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This management may be used in conjunction with pharmacological management.
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Prescription management
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Women's health nurse practitioners should check the client's medical history, medication history and history of allergies when prescribing medications. They should also ensure the patient understands the drug regimen, and inform them of possible adverse reactions.
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All relevant fields on the medication order chart should be completed. This includes the name of the prescriber, the commencement date, the dose, the frequency, the date and time of prescribing, and the prescriber's name.
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Women's health nurse practitioners should utilise the current prescribing information regarding the following medication and ensure the patient is aware of appropriate storage required for the medication:
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Prescribing information
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Prior to repeat pap test
| Oestriol (eg Ovestin Vaginal Cream™) 1mg/1g 15 g tube
| 1 applicator (0.5g) intravaginally at bedtime nightly for 1-2 weeks; cease therapy 3 days prior to Pap test
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| For treatment of symptomatic vaginal atrophy
| Oestriol (eg Ovestin Vaginal Cream™) 1mg/1g 15 g tube
| Initially 1 applicatorful (0.5g) intravaginally at bedtime nightly for 2-3 weeks, maintenance 0.5g twice weekly. Reassess every 3 months by ceasing therapy for 4 weeks
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| Oestriol (eg Ovestin Ovula Pessaries™) 0.5mg (15)
| Initially 1 pessary intravaginally at bedtime for 2-3 weeks; maintenance 1 pessary 1-2 times weekly. Reassess every 2-3 months by ceasing pessaries for 4 weeks
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| Oestradiol (eg Vagifem™) 25 mcg (15) applicators
| Initially: 1 pessary intravaginally at bedtime for 2 weeks; maintenance 1 pessary intravaginally twice weekly. Reassess every 3 months by ceasing therapy for 4 weeks.
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Links to consumer information
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Clients should be advised that if they experience irregular or atypical bleeding they will need to see a doctor.
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Follow up and referral
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Symptomatic women demonstrating vaginal atrophy and not requiring a repeat Pap test and who have been prescribed topical hormonal oestrogen medication should be seen by the women's health nurse practitioner three months after commencement of treatment. Any woman not responding to treatment and requesting further investigations or medications should be referred to the medical practitioner.
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Royal Women's Hospital Clinical Practice Guidelines (CPGs) are intended to provide guidance to health care professionals, based on a thorough evaluation of research evidence, on the practical assessment and management of specific clinical issues or situations. The guidelines allow some flexibility on the part of the health care professional based on the needs of the specific patient for whom they are caring.
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