As travel health nurses, we know that not all travelers are alike. One important goal of the pre-travel encounter is to customize our prevention messages. Women who travel internationally can benefit when we include some gender-specific health and safety content. While not an exhaustive list, here are some counseling tips you may find helpful the next time you see a woman in your practice. The name brands are suggestions only – ATHNA does not participate in any product endorsement and does not benefit financially from mentioning any product.
Hygiene Practices
- Sanitary pads and tampons may not be available or may not be up to the same standard you are used to, consider bringing your own.
- Toilet facilities are different in some locations and toilet paper isn’t used in many countries. Pack rolls of toilet paper in your bag or bring some moistened cleansing wipes such as Kleenex Cottonelle® These are available in resealable travel packs or tubs.
- Remember, too, that in many countries all paper and personal hygiene products go in bins, never in the toilet.
Constipation
- Bowel habits may change with travel. Consider bringing fiber supplements (like Metamucil® or Citrucel® – they both come in individual packets), or a mild laxative (MiraLAX® – Polyethylene glycol 3350). Hemorrhoid medications like Preparation H® or Tucks® may be helpful.
Urinary Tract Infections
- If you are prone to bladder infections, speak with your provider about taking some medication with you. Often Ciprofloxacin, used for traveler’s diarrhea, can be used for treatment of a bladder infection. However, you must complete an appropriate course (usually 3 days).
- You may also want to bring some Pyridium®, which can help the symptoms but you will still need antibiotics to treat the infection. Bladder infections should be treated as soon as possible to avoid a more serious infection of the kidneys.
- Most urinary tract infections are caused by E. coli bacteria from the anal area moving up into the urethra. Traveler’s diarrhea can increase the risk of this happening, so following food and water precautions to avoid TD can also help prevent UTIs.
Vaginitis
- If you are prone to yeast infections it might be advisable to bring some treatment (like Monistat® or Diflucan®) with you. Antibiotics for traveler’s diarrhea and doxycycline, an antibiotic sometimes given for prevention of malaria, may also cause yeast infections.
- You can help prevent vaginitis by avoiding wet clothing, tight clothing, underwear at night, douching and unwashed sex toys.
Women and High Altitude
- Estrogen containing contraceptives such as combined oral contraceptives, the Ortho Evra Patch®, and Nuvaring® all have a somewhat higher risk for blood clots, although the risk is low relative to pregnancy. Certain conditions at altitude (e.g. dehydration or immobility if stranded in tents due to bad weather may increase the risk). In addition, these methods are less effective than IUDs and implants, and can be quite inconvenient while traveling. You may want to consider the Mirena® IUD which does not contain estrogen and usually diminishes or eliminates periods. If you have a history of high blood pressure, blood clots, or migraines, discuss the possible implications of high altitude with your clinician.
Safety, Sexual Harassment, and Sexual Assault
- Traveling in unfamiliar areas can increase your risk of sexual harassment and sexual assault, so take precautions; travel with companions, make sure someone knows your whereabouts, and use only reputable public or private transportation.
- Travel at night can add to your risk.
- Be mindful that Western dress and customs may clash with local cultural attitudes about women. Research your destination before traveling. Dress in a manner that helps you “blend in with the crowd” and leave valuable jewelry at home.
- Avoid excessive alcohol and never drink from a glass that has been unattended. Do not use illegal drugs.
- Avoid tattoos as they increase the risk of HIV as well as Hepatitis B and C.
Contraception
- If you are a frequent traveler or if you are planning to stay abroad for a long period, consider a more convenient method such as an IUD (Skyla® or Liletta®, both good for 3 years; Mirena®, good for 5 years; or ParaGard®, good for 10 years) or Nexplanon® (good for 3 years). IUDs are inserted into the uterus and Nexplanon® is placed in the upper arm. IUDs and Nexplanon, known as Long Acting Reversible Contraception (LARC,) are the most effective methods of birth control, working for years all by themselves. The American College of Obstetricians and Gynecologists, the American Academy of Pediatrics, and the Centers for Disease Control all recommend these as first-line contraceptive options.
- Talk to your provider about using your method in a continuous fashion (oral contraceptives or Nuvaring®) to avoid having menses while traveling. Mirena® is also a good option to help avoid menses.
- If you are on birth control pills and you are traveling across time zones make sure you are taking 1 pill every 24 hours. You may want to use condoms as a back-up in case of any errors.
- Vomiting and diarrhea may decrease the effectiveness of oral contraceptives; make sure you check with your provider for specifics on what to do if this happens and use condoms as a back-up.
- Consider bringing a course of Plan B® (or other form of emergency contraception) in case you need one while away, these may not be readily available.
- Always use condoms (male or female) with any new partner regardless of other methods used, to help prevent sexually transmitted infections. It’s best to bring these with you as quality can vary at destination.
- Unless additional rings are available at destination, Nuvaring® users may want to consider another method if they will be abroad longer than 4 months. They expire after that time.
- Since pills, patches, and rings maintain their effectiveness best when stored between 68-77 F, consider an IUD or Nexplanon® if you anticipate any temperature extremes during travel (i.e. travel to the tropics or high altitudes).
- Contraception is currently covered under The Affordable Care Act.
Deep Vein Thrombosis
- Blood clots in the legs can occur during or after long flights or bus/car/train rides. In some instances, the clots move to the lungs to cause a life-threatening condition called pulmonary embolism.
- While this is unlikely in young people with no risk factors, women who are pregnant or who use a method of contraception that contains estrogen (oral contraceptives or Nuva Ring®) are at increased risk.
- Other risk factors include but are not limited to obesity, a family history of DVT, pulmonary embolism or other blood clots, patients with SLE (systemic lupus erythematosus), or inflammatory bowel disease (ulcerative colitis or Crohn’s disease).
- To help prevent clots, keep moving: get up and move around every hour when possible, flex and extend your ankles and knees, and avoid sleeping agents such as Ambien®. Drink plenty of water to keep hydrated – this is especially important if you contract traveler’s diarrhea, avoid alcohol and coffee which are dehydrating. For certain travelers, support stockings that meet the criteria of 15-30 mmHg exerted at the ankle (e.g. over the counter Sockwell™ Compression Socks) may be indicated. Sometimes there are no symptoms with DVT but symptoms may occur during the flight or immediately afterwards. If you notice persistent leg pain, swelling, or increased warmth in your leg, see a health care provider.
Pre-pregnancy
- If there is a possibility you could be pregnant or you are planning to become pregnant and contemplating a trip, it is best to contact your provider to discuss any potential risks a trip might pose to you or your developing fetus. We strongly advise women:
- To avoid malaria areas during pregnancy and to avoid becoming pregnant for 3 months after returning from a malarial area
- To avoid travel to areas with Zika virus if you are pregnant or planning to become pregnant. Your sexual partner should also avoid these areas. Sign up to receive Zika updates for your destination with CDC’s new text messaging service. Text PLAN to 855-255-5606 to subscribe. If you are sexually active and traveling in a Zika area, it is imperative to use a reliable form of contraception (e.g. LARC) to avoid an unplanned pregnancy. Travelers should engage in safe sex (use condoms) every time. Men (whether they are trying to conceive or not) living in areas with no active transmission of Zika virus, but returning from active transmission areas, should abstain from sex or practice safe sex for a period of at least 6 months upon return. Women in the same circumstances should use condoms for 8 weeks. These recommendations apply to both symptomatic and asymptomatic persons. The CDC recommends that travelers to Zika areas continue to use insect precautions for 3 weeks after returning home so they do not spread Zika to uninfected mosquitoes here.
- Immunizations:
- Ideally, all women should be up to date on all routine vaccines before becoming pregnant. Inactivated flu vaccine is recommended in non-immunized pregnant women. Tdap is recommended in every pregnancy, ideally at 27-36 weeks gestation. Meningococcal vaccine (A,C,W,Y) is provided depending on risk. Meningococcal (B), Hepatitis A, and Hepatitis B vaccines are recommended in some situations. Inactivated typhoid (injectable), rabies (tissue culture derived), Japanese encephalitis, pneumococcal, polio (IPV), and cholera vaccines are given in some circumstances. The risks and benefits of vaccinating in pregnancy are considered on an individual basis.
- Live vaccines like measles, mumps, rubella, nasal influenza, and varicella vaccines are usually contraindicated pregnancy. Yellow fever and oral polio vaccines are generally not given in pregnancy but may be in certain circumstances. Oral typhoid is usually not given due to theoretical risks. It is recommended that a woman wait >28 days to become pregnant after getting a live vaccine.
- Malaria Prevention: Chloroquine and mefloquine are considered safe in pregnancy. Doxycycline and primaquine are contraindicated in pregnancy. Atovaquone-proguanil (e.g. Malarone®) is not recommended due to lack of data.
- Traveler’s Diarrhea: Ciprofloxacin is not given in pregnancy. Azithromycin is currently the recommended drug in these cases.
- Altitude: it is best for pregnant women to avoid activities at altitude unless they are already accustomed to it. Providers must consider individual risks for spontaneous abortion, ectopic pregnancy, and pre-term labor, as well as any existing medical problems. Trips above 12,000 feet are not recommended for the pregnant travelers especially in the 3rd trimester.
- Flying: most commercial airlines restrict international travel after 32-36 weeks. They may require a letter from your clinician, which lists your expected date of delivery.
- Activities: scuba diving and water skiing or other sports, which may result in serious trauma, are contraindicated in pregnancy.
- Hepatitis E: not vaccine preventable and very dangerous for pregnant women, food and water precautions are advised.
Additional Resources:
Hormonal Contraceptives and Travel to Altitude, Keyes Linda E. High Altitude Medicine & Biology. March 2015, 16(1): 7-10. doi:10.1089/ham.2014.1111.
Julie Richards, President
American Travel Health Nurses Association
ATHNA 