Women Travel

As in any busy travel clinic at least half of our clients are women. It should first be emphasized that there are more similarities than differences between men and women. This should be the primary perspective used when giving advice on preventative medicine and when assessing post-travel problems, however, some unique problems do occur in women travelers. The purpose of the following article is to specifically emphasize this.

This is especially important since issues like contraception, pregnancy, safety and access to health care may not be addressed for women patients attending a travel clinic; and solutions for these problems may be especially difficult away from home

Contraception
Women traveling alone or with a partner need to consider their contraception issues. Even if they are not currently sexually active, contraception may be needed abroad. An oral birth control pill can help to prevent against pregnancy and against some diseases, (such as acne when using Diane 5). Enough pills should be brought for the whole trip. Some medical practitioners even recommend bringing 2-3 times the amount of all medications needed. Traveler's diarrhea is very common in travelers (it affects up to 50%) and may significantly decrease the absorption of the birth control pill. Many other medications may also do so, and woman taking any other medications should check for interactions with the birth control pill. Often over looked is the fact that even when taken correctly, the BCP gives less than 100% coverage, so women should always use an additional form of contraception. Barrier methods are essential in helping to prevent sexually transmitted diseases.

Emergency Contraception
Women traveling the world may become pregnant. Proper birth control methods, such as condoms and/or female condoms, should be arranged before you depart.

Morning After Pill

Many countries do offer emergency contraception i.e. the morning after pill. In Manitoba the "morning after pill" has been prescribed for women. The "morning after pill" includes several birth control pills, that when taken together, act to prevent the fertilization of an egg by sperm. Recently a formalized morning after pill has been developed- 'Plan B' which has greater effectiveness and less side effects than earlier versions of morning after pills.


Some Simple Facts about the Morning After Pill

The morning after pill has a greater chance of success if it is taken early, so a woman should not delay in asking for it and filling out a prescription from the pharmacy. It may be taken in the first 72hrs after unprotected intercourse.
The morning after pill is intended for women who might possibly become pregnant and will not affect prior pregnancies. Even if the morning after pill is used properly, it will not guarantee that a woman won't become pregnant. If a woman does become pregnant, their child will still be healthy, and having a pregnancy after using the morning after pill does not lead to birth defects. Taking the morning after pill may make a woman nauseous, similar to the early morning nausea of pregnancy.
This is because of the high amounts of estrogens. To counteract this, it is recommended to take some Gravol with the first morning after pill immediately and again in 12 hours, with the second pill.

Women Travelers seeking contraception:

The consortium for emergency contraception website will give travelers up to date information
about where they are going: http:/www.path.org/cec.htm
Emergency contraception website: http://not-2-late.com
Emergency contraception hotline: 1-888-NOT-2-LATE

Office of Population Research Emergency Contraception
http://ec.princeton.edu/worldwide/default.asp -this website provides information on emergency contraception
and is searchable by country.
Marie Stopes International
http://www.mariestopes.org.uk/abortion.html -provides information about emergency contraception, abortion, and sexual health by country.
The Centre for Reproductive Law and Policy
http://www.crlp.org/abortion1icpd.html -provides a list of countries where abortion is legal and explains what restrictions are in existence.
WHO Gender and Health Technical Paper
http://www.who.int/frh-whd/gaudH/Ghreport/gendertech.htm -article on gender and health.

Comparative Birth Control
There are many available types of contraception which are summarized below. Not every type is equally appropriate, so each woman should choose what is best for her.


Spermacides -easy to carry, bring from home
-long-term use may cause mucosal injury that may increase risk of HIV transmission.
Cap -needs to be fitted
-can use up to 48hrs, but need practice in correct use rubber may deteriorate in heat and humidity
Sponge -protects for 24hrs and may be left in place for 6hrs after intercourse
-one size, moisten with water, remove within 24-30 hrs to prevent Toxic Shock Syndrome
-easy to use and carry
Diaphragm -gives protection for 6hrs
-needs fitting and use of extra spermacide with repeated intercourse
-after use, leave in for 6hrs
Condoms -use good grade
-check for expiration date or poor quality
Female Condoms -spermacide not required -one use only -insert 8hrs prior -does not deteriorate in heat and humidity
Male Condoms Latex -possible allergy
-some oil lubricants destroy -"male controlled"
-may breakdown in heat and humidity
Lambskin/natural condoms -do not prevent virus
Hormonal Methods Progesterone Pill -may use if unable to take estrogen
-take everyday at same time
-decrease menstrual cramps, less bleeding -can use when breastfeeding
-useful for older women and smokers
-may have irregular bleeding
-does not prevent STD's
Combined Pill (estrogen and progesterone) -increase regularity of cycles
-less blood loss, cramping
-less pelvic inflammatory disease
-can be used for emergency contraception (need special preparation and instructions)
-should not take if blood clots
-need to take every 24hrs
-does not prevent STD's
-watch for drug interactions
Depo-Provera -intramuscular injection every 3months
Side Effects
-weight gain
-menstrual irregularities
-acne
-mood changes
-decreased libido
-good for women who can't take estrogen
-no memory for daily pill required
Norplant Implant -capsule under skin giving progesterone
-implants difficult to remove
-weight loss, acne -not recommended if; blood clots, liver tumors, breast cancer
-long-term protection 3-5yrs -irregular bleeding or no bleeding
IUD -increased risk of infection at time of insertion

Many other different methods of contraception exist.

Evra- the contraceptive patch
Evra is a new product for women that has been in the US for several months and recently has been introduced into Canada.
As a patch delivery system Evra is able to give women a continuous delivery of estrogen, as they would normally get from taking 21 daily contraceptive pills.
A new patch is put on every week for 3 weeks and then left off for one week. This has made it more convenient for women who, in the past, may have tended to forget to take their pills. There is even enough medication for 9 days. This means that there is enough forgiveness in the schedule even if a patch is left on for 2 days longer than scheduled, before being replaced.
These patches stay on well and cling even better than other patch systems like the nicotine, hormonal menopause patches or Duragesic (Pain patches) so young women can be active in swimming, hot tubs and all environments, without worries that the patch will loosen.

Who should not travel?
Healthy Pregnant women may travel, although the following groups are recommended not to travel:
Traveling is discouraged if:
-congenital or acquired heart disease
-history of blood clots
-severe anemia
-chronic lung disease
-obstetric risk factors

All pregnant women should be assessed early in their pregnancy, prior to their travel. PAP tests for all women are also recommended in order to screen for cervical cancer. Women going away for a year or more should get this done with their family doctor.

Vaccinations and Pregnancy
In general pregnant women should avoid vaccines that may have side effects that may affect them or the baby. The goal of immunizations and all preventative medical treatments are that the benefits of treatment should outweigh the risks of treatment and that no harm should be done. The following chart summarizes the characteristics of each immunization.

Immunizations During Pregnancy

Vaccine Live or Not Safe or Not
Measles, Mumps, Rubella Live Not Safe
Polio IPV (inactivated) Safe
Varicella Live Do Not Take
Tetanus-diphtheria Not Live Safe
Influenza Not Live Recommended 2/3 trimester
Meningitis Not Live Safe but only if needed
Typhoid Ty21a Live
Typhim VI Not Live
Not recommended
Use if needed
Hepatitis A Not Live Safe
Hepatitis B Not Live Safe
Japanese Encephalitis Not Live Side effects, not recommended unless high risk of infection
Tick Borne Encephalitis Inactivated Not recommended
Lyme Disease Vaccine no longer available
Rabies Not Live Not Live Not unless high risk
Immune Globulin Serums for:
Snake/spider bites Diphtheria, Rabies, Hep B Rabies, Tetanus, Varicella
Only if high-risk
Cholera Live Not recommended in Canada
Medications Safe for Pregnant and Lactating Women

Medication Pregnancy Breastfeeding
Tylenol (acetominophen) Safe-low dose Safe
Anti-inflammatory Drugs (Ibuprofen, Motrin) Safe in 1&2 trimester Safe
Antibiotics (Amoxicillin, Zithromax) Safe Safe
Cephalosporins Safe Safe
Clindamgin oral or vaginal Avoid 1st trimester Safe
Cloxacillin Safe Safe
Doxycycline Can stain fetal teeth Not Safe
Erythromycin Safe Safe
Nitrofurantain Safe-good for urinary infections Safe
Septra Safe Safe
Anti-diarrhea Medication
Comotil
Not Safe Not Safe
Immodium Safe Safe
Antacids Safe Safe
Bismuth(pepto-bismol) Not Safe Not Safe
H2 Blockers
Cimetidine (Tagamet)
Safe Safe
Ramitidine (Zantac) Safe Safe
Gravol Safe Safe
Anti-nausea
Accupressure Bands
Non-pharmaceutical
Safe Safe
Ginger Safe Safe
Meclizine Safe Safe
Vitamin B6 (Pyridoxine) Safe Safe
Milk of Magnesia Small amounts safe Safe
Psyllium Safe Safe
Hemmorhoids
- increase fibre and fluid in diet.
-Anusol HC suppository safe-minimal use
Upper Respiratory
Infections Antihistamines

Benadryl
Safe-use caution Not Safe
Claritin Safe-use caution Unknown
Sudafed Not safe in 1st trimester Unknown
Saline Nasal Spray Safe Safe
Topical nasal decongestants Safe Safe
Nasal Steroids Use if indicated Safe
Inhaled Steroids Safe Safe
Inhaled Ventolin Safe Safe
Anti-Malarials
Mefloquine
Not safe in 1st trimester Safe-does not protect infant
Chloroquine Not safe in 1st trimester Safe-does not protect infant
Malarone
(Avovaquone/Proguanil)
Unknown Unknown
Doxycycline Not Safe Not Safe
Primaquine Not Safe Not Safe
Halofantrine Not Safe Not Safe
Proquanil Safe-not effective as single Unknown
Fansidar Not Safe near term Safe short term
Quinine May cause severe Hypoglycemia Unknown
Azithromyacin Unknown Unknown

Insect Repellents
DEET

Safe - sparingly Safe
Anti-parasites
Albendazole
Avoid 1st trimester Unsafe
Metronidazole Avoid 1st trimester Use caution 1dose therapy and delay B/F 12-24hrs
Anti-virals
Acyclovir
Safe if indicated Safe
Altitude Medication
Acetazolamide (Diamox)
Not safe in 1st trimester unless indicated Not Safe
Dexamethasome (Decadron) Safe Not Safe
Calcuim Channel Blocker (Nifedipine XL) Only used to treat severe Pulmonary Anemia Safe
Water Purification
Iodine
Not Safe Not Safe


For further information on drugs in pregnancy, see: Organization of Tetrology Information Services: http://orpheus.ucsd.edu/CTIS/index.html

 



Suggestions For A Medical Kit For Women Travelers

Menstrual Supplies

-calendar
-supplies
- pad, moist towelettes, plastic bags
PMS medication (Ibuprofen, Mefanamic acid)
-medication for dysfunctional uterine bleeding
-premarin
-oral contraceptive pill
-Ibuprofen

Urinary Infections
-Ciprofloxicin 500mg PO BID x 3 days (also good for traveler's diarrhea)
-Macrobid 100mg PO BID x 7 days, if pregnant, urinary dipsticks

Vaginitis
Yeast infection (PH paper<4.5 likely to be a yeast infection)
-vaginal creams (Monostat)
-oral medication (Diflucan 150mg)
-mild soaps (Dove)
-change of breathable clothing

Bacterial Vaginosis (PH paper >4.7)
-metrogel cream, clindamycin cream, or metronidazole pills

Trichomonas (can be needed for women to diagnose themselves)
-metronidazole pill

Contraception

-chart to keep track of pills
-wrist watch timer to record when to take pills while crossing time zones
-male/female condoms
-spermacide
-pregnancy test
Emergency Contraception
-can discuss with doctor how to use the morning after pill
-available as Plan-B in Canada or use equivalent dose of birth control pills/gravol

Post HIV Prophylaxis
- if at high risk for unprotected sex.
This can be very expensive and people often get sick from the medication. Use updated recommendations

Pre-Menopause/Menopause
-vaginal dryness (estrogen cream)
-hot flashes
-estrogen replacement
-vitamin E
-Clonidine

Osteoporosis
-calcium
-vitamin D
-Fosamax

Pregnancy Supplies

-blood pressure cuff with stethoscope
-urine protein and glucose strips
-leukocyte esterase strips
-supplies for lactating mothers
-breast pumps/pads
-nipple cream

Personal Safety
-alarms
-pepper spray
-lessons in self-defense