Advice for Women Travelers

Women's Travel Medicine Kit

Women travelers, especially those embarking on adventure travel itineraries or planning extensive travel abroad, may find it beneficial to augment the basic travel medical kit (see Chapter 1 ) with supplies and medications specific to a given woman's life stage and reproductive health. Table 14.2 lists items that might be included in a travel medical kit for women, and Table 14.3 provides some Internet resources for further information on health issues of women travelers.

Menstruation

Women between 12 and 55 years old menstruate, on average, once a month, with a high degree of variability among women. During travel, a woman should be prepared for either the worst menstrual period of her life with more cramping and more bleeding than usual or for her periods to actually cease. Menses may cease or become irregular during travel for a number of reasons other than pregnancy. For example, the mere stress of traveling, including changes in sleep patterns, diet, activity, illness, and time zones, can easily disrupt a woman's menstrual cycle. Recommendations can be made regarding measures to take depending on whether she uses oral contraceptives, her previous history, and the result of a self-pregnancy test. A woman should be warned that just because she is not menstruating while traveling does not mean she is not ovulating. She still needs a method of contraception to prevent unplanned pregnancy. Self-pregnancy tests are also important in the evaluation of a sexually active woman of reproductive age to help determine whether her abdominal pain and/or abnormal vaginal bleeding could be related to a pregnancy.

It is important to carry sufficient disposable sanitary napkins or tampons, since they are not available in many countries. Menstrual cups are another option. There are also reusable tampons made out of sea sponges and a variety of washable pads. Reusable products are ideal for the environmentally concerned backpacker and the long-term traveler. Pre-moistened towelettes for personal hygiene and plastic bags to dispose of sanitary supplies are also useful.

Some women prefer not to have a menstrual cycle while traveling. One option to control the menstrual cycle is through the use of a hormonal contraceptive method, such as the combined oral contraceptive pill, patch, or vaginal ring. By skipping the “hormone free” week and continuing the active hormone component (pill, patch, or ring) as directed, no withdrawal bleeding occurs, until the woman is ready to stop the active hormone and get withdrawal bleeding.

Medication for menstrual cramping and other symptoms of premenstrual syndrome should also be carried in the medical kit ( Table 14.2 ).

Urinary Tract Infections

Women are prone to UTIs during travel as a result of multiple factors, including dehydration, less frequent urination because of a lack of convenient toilets, fewer available facilities for hygiene, an increase in sexual activity, and other changes in exercise, diet, and clothing. Preventive measures include instructions for female travelers to stay well hydrated and to urinate wherever there is convenient access to a public toilet whether or not the bladder is full.

A number of plastic and paper funnel devices have been designed so that a woman may urinate in the standing position. Another option to try for a cold night in a tent or when there is no bathroom facility is a “portable john.” This is a unisex funnel that empties into a biodegradable plastic bag with biodegradable filler that turns the urine into a solid so it will not spill. The personal urinal bags can be used until full (800 cc or 28 oz), then disposed of.

To maintain hygiene, it is important to carry a supply of paper tissues or toilet paper and some packets of pre-moistened towelettes in a fanny pack or backpack. If an older woman is experiencing vaginal dryness and urinary frequency or urgency without dysuria, recent data suggest that estrogen vaginal creams, a vaginal ring, or even an oral contraceptive pill intravaginally once a week may decrease urogenital dryness and frequency symptoms. Vaginal moisturizers (e.g., Replens) can also be used. If a woman experiences increased frequency, urgency, and dysuria, she should be advised how to diagnose and treat herself for a UTI with an antibiotic and an analgesic.

If an older woman has a problem with stress incontinence or bladder control, she should consult with a physician specializing in female urinary tract problems in advance of the anticipated trip. For minor problems, a woman can be taught to do Kegel exercises and should bring a supply of panty liners.

Vaginitis

Women are at risk for vaginitis during travel, secondary to many of the same reasons as for UTI. One of the most common causes of vaginitis is Candida albicans. This organism usually causes a thick cottage cheese-like white discharge with vulvar and vaginal itching. The risk of yeast vaginitis may be greater if doxycycline is used for malaria chemoprophylaxis or if other broad-spectrum antibiotics are used for the treatment of traveler's diarrhea or other medical problems.

Several topical preparations against yeast are available over the counter, including nystatin, miconazole, and clotrimazole vaginal creams or troches. Prescriptions for resistant cases can be recommended, such as tetrazole vaginal cream (3 days) or fluconazole (150 mg as a single oral dose). Many women prefer to use the oral medication, as the vaginal creams can be messy during travel. Other women feel the vaginal creams help with the symptoms of itching. A hydrocortisone cream may also be used if needed for vulvar itching. Any persistent symptoms should be evaluated by a gynecologist when returning home. Even if a woman has never had vaginitis, it is important to prepare her for the possibility, especially for extended travel.

Another common cause of vaginal discharge is bacterial vaginosis. This is caused by overgrowth of the bacteria in the vagina, which can be due to many of the same causes listed previously. The discharge is usually more of a grayish color with a fishy odor. Bacterial vaginosis is treated with metronidazole tablets taken orally or clindamycin vaginal cream applied topically. If a female traveler develops a discharge and pelvic pain after a new sexual encounter, she may have a sexually transmitted disease and should follow the recommendations discussed in Chapter 41, Chapter 42, Chapter 43, Chapter 44 .

Contraception

Contraceptive advice should be included in the pre-travel counseling for all women of reproductive age at risk for pregnancy. It should also be included in the pre-travel counseling for men who might put women at risk for pregnancy. This is especially important if the man's partner might be in a country where she might not have easy access to contraception.

Women may become pregnant as a result of a lack or misuse of contraception, and women travelers are no exception. In the United States, over 50% of pregnancies are unplanned. If a woman is already using contraception, the method should be evaluated for its ease of use and reliability during travel along with any special recommendations concerning its use during travel. If a woman wishes to try a new contraceptive method, ideally she should begin months before travel, especially if she is planning to be overseas long-term or will be living in a remote area. Back-up plans for what the woman should do if she loses her present method should be discussed. The International Planned Parenthood Federation (IPPF) keeps a worldwide guide to contraceptives and an address list of family planning agencies available on the Web ( Table 14.3 ).

Sexually Transmitted Infections

Sexually transmitted infections (STIs) are of special importance to women due to gender-related pathophysiology that leads to an increased rate of transmission from an infected male to an uninfected female. In addition, women suffer more serious sequelae from a sexually transmitted disease, such as pelvic inflammatory disease or infertility, than do men.

To prevent STIs, one should avoid casual sex or practice safe sex by using condoms, regardless of concomitant use of another method of birth control. High-quality latex condoms are an essential part of the personal medical kit of adult travelers, regardless of gender and whether or not sexual activity during travel is planned or unplanned. A female condom made out of polyurethane is an effective alternative for persons allergic to latex. Travelers may be provided with an information card or sheet summarizing STI signs and symptoms for use in self-diagnosis and possible treatment if remote from professional medical care. One resource is the sexual health website at the Centers for Disease Control and Prevention (CDC; www.cdc.gov/sexualhealth/ ). Women travelers should be informed about the availability of antiretroviral drugs and their use in post-exposure human immunodeficienty virus (HIV) prophylaxis (termed non-occupational post-exposure prophylaxis [NPEP]) following a high-risk sexual exposure or sexual assault. The rate of HIV transmission from an infected male to an uninfected female is estimated to be equivalent to a high-risk needle stick. Thus, NPEP should be started preferably within 1 hour and no later than 72 hours after a high-risk exposure.

In certain cases, a woman traveler may be given an NPEP “starter kit” of a 3- to 5-day supply of antiviral drugs. This can be used in an emergency until the situation can be further evaluated and/or more medication can be obtained. As the drugs can be associated with significant adverse effects, ongoing NPEP treatment should be administered under medical supervision. These medications are not available in most developing countries.

Gynecologic Concerns at Altitude

Women taking oral contraceptives may continue them at moderate altitudes (<3600 m, or 12,000 ft), since the risk of pregnancy may be greater than the risk of thrombosis. Women on oral contraceptives have a higher risk of deep vein thrombosis (DVT)/pulmonary embolism (PE) at any altitude, estimated to be about 5/100,000. Pregnancy increases the risk of DVT/PE 12-fold to about 60/100,000. Women on oral contraceptives should be advised to consider other contraceptives for extended stays at very high altitudes (>5500 m), because of a theoretical increased risk of thrombosis and PE.

Basic Questions to Answer When Counseling Pregnant Women

Pregnant women anticipating travel to remote places need to have the following questions answered before confirming their itinerary:

• 1.

  What medical, obstetric, social, and demographic risks are associated with travel?

• 2.

  Are the required and recommended immunizations for the itinerary safe in pregnancy?

• 3.

  What drugs against malaria and other parasitic illnesses are safe in pregnancy?

• 4.

  What prophylactic or therapeutic measures against traveler's diarrhea are safe in pregnancy?

• 5.

  What medical services are available in the area(s) of destination?

• 6.

  What does her health insurance cover if she is out of area for delivery or pregnancy-related complications?

• 7.

  What are signs of serious pregnancy-related illness for which emergency medical help should be sought?

• 8.

  What are some general guidelines to follow for the medical management of illness that will safeguard the pregnant woman and her fetus?

Cultural aspects of traveling while pregnant or nursing should also be researched prior to travel. Customs vary in different cultures. Breast feeding an infant in public areas may not be allowed in some cultures.