OTC Products for Feminine Care

Daily feminine hygiene and care is an important part of good gynecological health. It promotes an overall sense of well-being and confidence in a woman.

Safe Feminine OTC Care

A host of products on the market address many of the issues females face, from yeast infections to the hormonal changes of menopause. Pharmacists should be prepared to answer questions about women’s health issues and help their female patients choose the most appropriate and available OTC products. To ensure proper treatment and avoid complications, they should refer patients for additional medical care from their gynecologist or other health care provider if necessary.

Common Vaginal Infections

The 3 most common yeast infections are bacterial vaginosis (BV), vulvovaginal candidiasis (VVC), and trichomoniasis.¹ Noninfectious issues, such as vaginal irritation or pruritus due to allergic or hypersensitivity reactions, are also typical events. And conditions commonly mistaken for a urinary tract infection include ureteral irritation and dysuria due to vulvovaginitis.¹

Prior to attempting to self-treat symptoms, patients should reach out to their pharmacist, gynecologist, or primary health care provider to confirm a diagnosis and determine the appropriate treatment, especially with OTC products.

Accurately distinguishing the type of infection is critical because many OTC vaginal antifungal products are often used inappropriately when treating mild cases of VVC.¹ Moreover, BV, severe and recurring VVC, and trichomoniasis all require a prescription medication.¹ Results from a study revealed that 2 of 3 women who self-diagnose and use OTC vaginal antifungals do not have VVC, but rather bacterial vaginosis or another type of infection.²

Vulvovaginal Candidias

VVC is the second most prevalent vaginal infection after BV.¹ VVC can be classified as uncomplicated or complicated based on frequency, symptoms, microbiology, and response to treatment.¹ In general, 80% to 92% of infections are caused by Candida albicans, but in the past 2 decades, Candida tropicalis, and Saccharomyces cerevisiae have accounted for 10% of them, which may be due to overuse of OTC antifungals and long-term suppressive therapy with imidazole antifungals.¹

Signs of VVC include a thick, white, odorless, cottage cheese-like discharge, normal pH, itching, soreness, and intense burning and inflammation of the vulva.^1,3 Factors that increase the chances of developing a yeast infection include uncontrolled diabetes, pregnancy, highdose estrogen oral contraceptives, and estrogen replacement therapy.¹ Some women also develop VVC infections during or after broad spectrum antibiotic treatment or use of systemic corticosteroids, immunosuppressant agents, or antineoplastic drugs.¹ Treatment depends on the severity and frequency of the infections. A tell-tale sign for differentiating C albicans from bacterial vaginosis or trichomoniasis is the absence of an offensive odor from the discharge.¹

Four nonprescription, FDA-approved treatment options for uncomplicated VVC are butoconazole, clotrimazole, miconazole, or tioconazole are available in vaginal creams, suppositories, or tablets.¹ These products provide relief for external vulvar itching and irritation. Patients should be advised to adhere to the manufacturer directions and ask questions about any concerns.

Instructions are Paramount

In women with mild, infrequent, and uncomplicated infections, self-treatment with OTC antifungal therapy is appropriate.¹ Recurring episodes may be an indication of an underlying issue; consequently, patients should be encouraged to seek further medical care from their primary health care provider.¹

Before recommending OTC products, pharmacists should assess the appropriateness of self-treatment and evaluate the patient for possible contraindications. Those who are breastfeeding should check with their primary health care provider before using anything over the counter.¹

It is important to remind patients to complete the full course of therapy—even if symptoms appear to improve. Failure to complete therapy for the recommended duration is considered the leading cause of recurring VVC episodes.¹ Patients whose symptoms show no signs of improving or worsen, should seek immediate medical attention. See table 1 for examples of patients who should not self-treat for VVC. Examples of key talking points to cover with patients¹ :

• Always wash hands before and after application. • Symptoms typically improve 24 to 48 hours after initiation of therapy.

• Insert antifungal product once daily, ideally at bedtime since lying down may minimize product leakage.

• Complete the full course of therapy, even during menstrual flow.

• Do not use tampons or douche when using vaginal antifungals.

• Refrain from intercourse during treatment with vaginal antifungals.

• Seek medical care if symptoms persist or worsen.

Table 2: Examples of OTC Vaginal Antifungal Agents

Gyne-Lotrimin 7 Vaginal Cream

Clotrimazole (1%)

Gyne-Lotrimin 3 Vaginal Cream

Clotrimazole (2%)

Monistat 1 Complete Therapy Less Mess Ovule

Miconazole nitrate (1200 mg) (vaginal insert), miconazole nitrate (2%) (external cream)

4 cool wipes

Monistat 1 Cure & Itch Relief Less Mess Ovule

Miconazole nitrate (1200 mg) (vaginal insert), miconazole nitrate (2%) (external cream)

Monistat 1 Simple Therapy Ointment

Tioconazole 300 mg (6.5%), with prefilled ointment applicator

Monistat 3 Complete Therapy Less Mess Ovule

Miconazole nitrate 200 mg (vaginal insert)

External cream

4 cooling wipes

Monistat 3 Cure & Itch Relief Less Mess Ovule

Miconazole nitrate (cream 2%; suppository 200 mg), treatment ovule suppositories plus cream)

Monistat 3 Cure & Itch Suppositories

Miconazole nitrate (200 mg vaginal insert) Miconazole nitrate 2% (external cream)

Monistat 3 Simple Cure Prefilled Cream

Miconazole nitrate (4% prefilled cream applicators)

Monistat 7 Cure & Itch Relief Cream

Miconazole nitrate 100 mg

Monistat 7 Complete Therapy Cream

Miconazole nitrate (2%) (100 mg per applicator), miconazole nitrate (2%) (external cream), disposable applicators, 6 cooling wipes

Mycelex-7 cream

Clotrimazole 1%

Vagistat-3 Combination Pack

Miconazole nitrate 200 mg (vaginal insert)

Miconazole nitrate 2% (external cream)

Atrophic Vaginitis

Although an estimated 45% of women experience AV, vaginal inflammation due to atrophy of the vaginal mucosa caused by decreased estrogen levels, only 25% seek treatment.¹ Women may experience AV and dyspareunia during menopause, the postpartum period, and when breastfeeding.¹ It may also occur after radiation or chemotherapy due to decreased production of ovarian estrogen or while taking anti-estrogen drugs, such as clomiphene, tamoxifen, danazol, raloxifene, leuprolide, or nafarelin.¹ Although rare, women taking low-estrogen oral contraceptives may develop this condition, too.¹

AV contributes to a host of symptoms including itching, burning, dryness, and irritation, all of which can lead to dyspareunia.^1,4 Selftreatment is recommended with mild to moderate symptoms with no bleeding, but is limited to easing the bothersome and primary symptom of dryness with lubricants.^1,4 Those with episodes of severe dryness, dyspareunia, and bleeding should be referred for medical evaluation.¹

Topical lubricants containing glycerin, propylene glycol, hydroxyl propyl methylcellulose, or mineral oil—as a single entity or a combination of 2 or more of these ingredients—are recommended.¹ As for most OTC medications, patients should see their primary care provider if there is no improvement or if symptoms appear to worsen.

Table 3: Examples of OTC Vaginal Lubricants

• K-Y Jelly
• Replens
• H-R Lubricating Jelly
• Vagisil ProHydrate Natural Feel Internal Vaginal Moisturizing Gel

Valued Resource

It is important for patients to understand the proper use of OTC products for vaginal issues. By providing pertinent information, pharmacists can be an important patient education resource for women in helping them make informed decisions about feminine care issues and their overall health. Be vigilant about reminding patients to contact their primary health care provider for severe issues or when in doubt about an issue.

During counseling, pharmacists can remind patients about feminine care cleansing products designed to maintain a healthy vaginal pH of around 4.5.^1,5 They can also remind women of the importance of being proactive about their gynecological health and scheduling annual checkups. Online Tables 2, 3, and 4 list vaginal anti-fungal agents, lubricants, and feminine hygiene products, respectively.

Table 4: Examples of Feminine Hygiene/Care Products

• Vagisil Odor Block Protection Wash
• Vagisil pH Balance Wash
• Vagisil Sensitive Plus Watch
• Vagisil Maximum Strength Anti-Itch Cream
• Vagisil Medicated Anti-Itch Wipes
• Cortizone-10 Feminine Relief Anti-Itch Cream

• Simply Summer’s Eve Gentle Foaming Wash
• Summer’s Eve Cleansing Cloths
• Summer’s Eve Freshening Spray
• Summer’s Eve Nighttime Cleansing Wash

• Femmesil Ultra Therapy

Pharmacists can also recommend these patient resources for feminine care:

• Vaginitis. The American Congress of Obstetricians and Gynecologists website: acog.org/Patients/FAQs/Vaginitis.

• Vaginal yeast infections. Office on Women’s Health website: womenshealth.gov/a-z-topics/vaginal-yeast-infections.

• Vaginal yeast infection. Medline Plus website: medlineplus.gov/ency/article/001511.htm

• Vaginal health. Monistat website: monistat.com/vaginal-health.

• Vaginal health videos. Vagisil website: vagisil.com/doctor.

• Education. Summer’s Eve website: summerseve.com/ education

Ms. Terrie is a clinical pharmacist and medical writer based in Haymarket, Virginia.

References

• Lodise N. Vaginal and vulvovaginal disorders. In: Krinsky D, Berardi R, Ferreri S, et al, eds. Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care. 18th ed. Washington, DC: American Pharmacists Association; 2015.
• Ferris DG, Nyirjesy P, Sobel JD, Soper D, Pavletic A, Litaker MS. Over-the-counter antifungal drug misuse with patient-diagnosed vulvovaginal candidiasis. Obstet Gynecol. 2002 Mar;99(3):419-425.
• Carr PL, Felsenstein D, Friedman RH. Evaluation and management of vaginitis. J Gen Intern Med. 1998;13(5):335-346. doi: 10.1046/j.1525-1497.1998.00101.x.
• Pearson T. Atrophic vaginitis. J Nurse Pract. 2011;7:502-505. doi : http://dx.doi.org/10.1016/j.nurpra.2010.08.016.
• Fashemi B, Delaney ML, Onderdonk AB, Fichorova RN. Effects of feminine hygiene products on the vaginal mucosal biome. Microb Ecol Health Dis. 2013;Feb 25;24. doi: 10.3402/mehd.v24i0.19703.