Vaginal Thrush in Practice: Case 1

Julie Parker telephones your pharmacy to ask for advice because she thinks she might have thrush. She tells you she didn’t want to come to the pharmacy as she was concerned that the conversation might be overheard. When you ask why she thinks she may have thrush, she tells you that she was recently prescribed a week’s course of metronidazole. She had her first baby about 6 months ago and has had some skin irritation following an episiotomy. When she went back to the GP after taking the metronidazole, she was prescribed a second course of metronidazole plus a course of amoxicillin for 1 week and a swab was taken. She didn’t hear anything further for about 2 weeks until the surgery rang her and asked if she had been told the results of the swab (she hadn’t). She was asked to go and collect a prescription from the surgery. She hasn’t brought it in yet to be dispensed but it is for a pessary.

The pharmacist’s view

This sort of query is difficult to deal with because the pharmacist does not have access to diagnosis or test results. It sounds as though there may have been a communication problem initially and a delay in the test results being dealt with. I would ask what the name of the pessary on the prescription is and then explain what it’s used for. I would explain that thrush sometimes happens after a course of antibiotics and that the pessary is likely to cure it.

The GP’s view

It would probably be best for Julie Parker to go back and see her GP who has already given her two courses of treatment and taken a swab. She needs to find out exactly what the GP has been treating her for, what the swab result is and to be able to explain to her GP what her current symptoms are. Metronidazole is often prescribed for bacterial vaginosis. It could be that she has also developed thrush especially as she has been taking amoxycillin. It is always important for patients to know how and when they can get their results. Often patients understandably assume that if they don’t hear from their doctors’ surgery, the result is negative or normal. This is potentially dangerous and it is always important for the person taking laboratory samples to explain clearly how and when the results will be available and agree this with their patient. In this situation it is also important for the prescriber to explain the need for the prescription that has been left out at the surgery.

Vaginal Thrush in Practice: Case 2

Helen Simpson is a student at the local university. She asks one of your assistants for something to treat thrush and is referred to you. You walk with Helen to a quiet area of the shop where your conversation will not be overheard. Initially, Helen is resistant to your involvement, asking why you need to ask all these personal questions. After you have explained that you are required to obtain information before selling these products and that, in any case, you need to be sure that the problem is thrush and not a different infection, she seems happier. She has not had thrush or any similar symptoms before but described her symptoms to a flatmate who made the diagnosis. The worst symptom is itching, which was particularly severe last night. Helen has noticed small quantities of a cream-coloured discharge. The vulval skin is sore and red. Helen has a boyfriend, but he hasn’t had any symptoms. She is not taking any medicines and does not have any existing illnesses or conditions. Since arriving at the university a few months ago she has not registered with the university’s health centre and has therefore come to the pharmacy hoping to buy a treatment.

The pharmacist’s view

The key symptoms of itch and cream-coloured vaginal discharge make thrush the most likely candidate here. Helen has no previous history of the condition and, unfortunately, the regulations preclude the recommendation of an intravaginal azole product or oral fluconazole in such a case. An azole cream would help to ease the itching and soreness of the vulval skin. As her boyfriend is not experiencing symptoms he does not need treatment. However, because external treatment alone is unlikely to prove effective in eradicating the infection, it would be best for Helen to see a doctor.

She would be well advised to register at the university health centre. You can explain to her that she can seek treatment on a temporary resident basis but that it would be best to get proper medical cover.

The doctor’s view

The history is very suggestive of thrush and treatment should include an appropriate intravaginal preparation. The case history highlights some of the difficulties of asking personal questions about genitalia and sexual activity. These difficulties are also likely to occur in the doctor’s surgery. It is important for the doctor to carefully explore the patient’s ideas, understanding, concerns and preconceptions of her condition. Many doctors would prescribe without an examination with such a clear history and examine and take appropriate microbiology samples only if treatment fails.

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