Vaginitis

1. Vaginitis What’s Really Going on Down There?

2. Objectives • To understand the most common forms of vaginitis • To be able to distinguish between and to diagnosis the causes of vaginitis • To select the most appropriate treatment for various forms of vaginitis.

3. Vaginitis • Vaginal discharge is the most common symptom complaint in gynecology • Prompts about 10million visits a year • Variety of causes, but most common are infection and atrophy • three main types of infection are bacterial vaginosis accounts for 50% of cases. Trichomonas and Candidal are 25% each. • Atrophy universally associated with menopause

4. Causes of Vaginitis • Type of Vaginitis • Allergic • Atrophy • Chemical irritation • Foreign Body with or w/o infection or trauma • Lichen planus • Bacterial Vaginosis • Trichomoniasis • Vulvovaginalcandidiasis • Etiology/comments • Latex, sperm, douching, hygiene products • Estrogen deficiency • Soaps, Hygiene products • Tampons, pessary or other contraceptive device • Associated with skin or oral lesions • Gardnerella, bacteroides, mycoplasmahominis • TricamonasVaginalis • C. albicans, glabrate, tropicalis

5. Bacterial Vaginosis • Replacement of normal Lactobacillus sp. in the vagina with high concentrations of anaerobic bacteria • Cause of microbial alteration is not fully understood. • Associated with multiple sex partners, douching, and lack of lactobacilli. • Up to 50% of women with BV may not report any symptoms.

6. Bacterial Vaginosis • Thin, homogeneous, white discharge that coats the vaginal walls • Presence of clue cells on micro examination • pH of vaginal fluid >4.5 • A fishy odor of vaginal discharge before or after treatment with KOH solution (whiff test)

7. BV Treatment regimens • Recommended regimens • Metronidazole 500mg po twice a day for 7 days. • Metronidazole gel 0.75% one full applicator intravaginally for 5 days • Clindamycin cream 2% one full applicator intravaginally for 7 days • Alternative regimens • Metronidazole 2g orally single dose. • Clindamycin 300mg orally twice a day for 7 days • Clindamycin ovules 100mg intravaginally for 3 days • Routine treatment of sexual partners not recommended

8. BV in Pregnancy • Associated with adverse pregnancy outcomes to include PROM, preterm birth, preterm labor and postpartum endometritis. • All symptomatic pregnant women should be evaluated and treated. • Recommended regimens • Metronidazole 250mg orally three times a day for 7 days • Clindamycin 300mg orally twice a day for 7 days.

9. Candida Vaginitis • Produced by a ubiquitous airborne gram-positive fungus • >75% of cases are caused by Candida Albicans • 5-20% are produced by C. glabrata and C. tropicalis. The percentage of infections from these two organisms have increased in the past few years. • Candida species are part of the normal flora of 25% of women. Prevalence greater in the rectal and oral mucosa. When the ecosystem of the vagina is disturbed, candida becomes an opportunistic pathogen. • Lactobacilli inhibit the growth of fungi in the vagina; however, when the relative concentration of lactobacilli declines, the rapid overgrowth of Candida occurs.

10. Candida Vaginitis • Primarily a disease of child bearing years. • Approximately 3 out of four women will have a least one infection during their lifetime • Rarely found mixed with Trichomonas or bacterial vaginosis. • Not associated with other sexually transmitted diseases. • 10% of male partners may have concomitant penile infection. However, treatment of partners does not reduce the recurrence rate • No direct relationship to the number of organisms and patient signs/symptoms

11. Causes of Candida Vaginitis • C. albicans is not usually a pathogenic organism. Overgrowth in vagina is caused by host factors that establish growth • Hormonal factors: changes associated with both pregnancy and menses. ? High estrogen levels • Depressed cell immunity: exogenous corticosteriods, AIDS etc • Antibiotic use: broad spectrum that destroy lactobacilli

12. Candidal Vaginitis • Normal odorous thick white discharge that adheres to vaginal walls. • Hyphal forms or budding yeast cells on microscopic evaluation • Pruritus • pH level <4.5

13. Treatment • Topical application of imidazoles- miconazole, clotrimazole, butoconazole or tioconazole. • Equal effectiveness between the traditional 7 day therapy and 3 day. • Exert action by changing the permeability of the surface membrane of the fungus. • Cure rates exceed 90% • Most women prefer oral therapy with single dose Diflucan 150mg which produces therapeutic concentrations in vaginal secretions for a minimum of 72hr

14. Recurrent Infections • Defined as 4 or more episodes of symptomatic vaginal infections during 12month time period • Women are 3X more likely to be asymptomatic carriers of C.albicans • ? Drug sensitivity • Culture of vaginal discharge to identify fungus species • Potential therapy includes gentian violet, boric acid, povidone-iodine douching or dietary changes.

15. Treatment of Recurrent Infections • Acute Episodes • Clotrimazole 100mg intravaginally X 7 days • Diflucan 150mg po X1 • Ketoconazole 200mg po daily X14days • Boric Acid 600mg vaginal suppository bid X14 days • Prophylaxis • Clotrimazole 100mg 2 tabs intravaginally twice weekly for 6 months • Ketoconazole 100mg po daily for 6 months • Diflucan 150mg po qmonth • Boric Acid 600mg vaginal suppository daily during menstruation

16. Trichomonas Vaginalis • Unicellular flagellated protozoan that inhabits the vagina and lower urinary tract. • Estimated 2.5 to 3 million cases in the U.S. each year. • Most common non-viral and non-chlamydial sexually transmitted disease. • Incubation period 4-28 days and can survive up to 24hrs on wet surface.

17. Trichomonas Vaginitis • Copious amounts of yellow-gray to green frothy mal odorous discharge • pH level >4.5 • Mobile, flagellated organisms and leukocytes on wet-mount. • Vulvovaginal irritation and dysuria

18. Trichomonas Treatment options • Initial measures: (including asymptomatic patients) • Flagyl 2gm po x1 or • Flagyl 500mg po bid x 7days • Treat male sexual partners • Treatment failures: • Re-culture patient • Retreat with Flagyl 2gm po followed by trial of Flagyl 2gm po daily X 5 days if patient still infected after second treatment.

19. Atrophic Vaginitis • Estimated 10 to 40% of postmenopausal women have symptoms of atrophic vaginitis. • In pre-menopausal women, the vaginal epithelium is rugated and rich in glycogen stores. Lactobacilli depend on glycogen for from sloughed vaginal cells. Lactic acid produced by these cells lowers vaginal pH to 3.5- 4.5. This is essential for the body’s natural defense against infection • Menopause is the leading cause of decreased circulating levels of estrogen • After menopause, the endometrium is thinned and the increased vaginal pH predisposes the vagina and urinary tract to infection and mechanical weakness.

20. Symptoms • Decrease in vaginal lubrication • Dryness • Dyspareunia • Vulvar pruritus • Yellow malodorous discharge • Urethral discomfort • Sexual dysfunction

21. Diagnosis • History: exogenous agents that may cause or aggravate symptoms. • Perfumes, powders, soaps, panty liners. Tight-fitting clothing and use of synthetic materials can worsen symptoms. • Exam: atrophic epithelium appears pale smooth and shiny. • Inflammation and easy friability. External genitalia may also have diminished elasticity, sparsity of pubic hair, vulvar lesions • Lab findings: • serum hormone levels, cytologic examination of smears and ultrasound of endometrial thickness. Elevated pH level (>5).

22. Treatment Options • Estrogen replacement: • Most effective in the restoration of anatomy and resolution of symptoms. • Replacement therapy restores the normal pH levels and thickens and revascularizes the normal epithelium • Systemic therapy: • may not eliminate the symptoms in 10-25% of patients. • Usually needed for 24months to eradicate dryness but some may not respond to this length of treatment • Transvaginal therapy: • effective in relieving symptoms without causing significant proliferation of the vaginal epithelium. • Multiple delivery systems to include creams, pessaries or hormone releasing ring. • Moisturizers and lubricants: • Help maintain natural secretions and coital comfort. • May be used in conjunction with estrogen replacement therapy or as alternative therapy. Effectiveness is generally less then 24hr.

23. Question #1 • A 31year old married white female complains of vaginal discharge, odor and itching. Speculum exam reveals a homogenous yellow discharge, vulvar and vaginal erythema and a “strawberry” cervix. • The most likely diagnosis is • A. Candidal Vaginitis • B. Bacterial Vaginosis • C. Trichomonal Vaginitis • D. Chlamydial infection • E. HSV type 2

24. Answer #1 • C. Trichomonal Vaginitis

25. Question #2 • 22yo female presents for recurrent vaginal discharge. She states that discharge is white in color and has slight odor. Occurs several times a year and she tries OTC antifungal meds to help resolve the issue. No itching or irritation. Denies douching or using perfumes or powders over area. Symptoms usually occur around menses. Has not had formal evaluation; her PCM prescribed oral Diflucan based on her symptoms after she left a T-con. • On PE: no vulvar lesions. +white discharge that pools in the posterior fornix. Normal appearing cervix. pH<4.5. No hyphae noted. Gram stain noted several gram positive rods. Based on these findings, you decide • A. Treat her for extended period with oral antifungals while awaiting culture results • B. Reassure patient that discharge is physiologic and review hygiene with her. • C. Treat with Flagyl 500mg po bid for 7 days • D. Recommend that patient return for evaluation after extended period off medications and re-evaluate

26. Answer #3 • B. Reassure patient that discharge is physiologic and review hygiene with her.

27. Question #3 • Which of the following statements are true? • A. The USPSTF concludes that the evidence is insufficient to recommend for or against routinely screening high-risk pregnant women for bacterial vaginosis • B. The USPSTF recommends against routinely screening average-risk asymptomatic pregnant women for bacterial vaginosis • C. All of the above. • D. None of the above

28. Answer #3 • C. All of the above. • The USPSTF found good-quality studies with conflicting results that screening and treatment of asymptomatic bacterial vaginosis in high-risk pregnant women reduce the incidence of preterm delivery. The magnitude of benefit exceeded risk in several studies, but the single largest study reported no benefit among high-risk pregnant women. • There is good evidence that screening and treatment of bacterial vaginosis in asymptomatic women who are not at high risk do not improve outcomes such as preterm labor or preterm birth.

29. Vaginitis • Objectives • Epidemiology • Classifications • Bacterial Vaginosis • Presenting signs/symptoms • Diagnostic evaluation • Treatment • Trichomonas • Presenting signs/symptoms • Diagnostic Evaluation • Treatment • Candidal • Presenting signs and symptoms • Diagnostic evaluation • Treatment • Atrophic • Presentation • Diagnostic Eval • Treatment

30. Question #4 • Pruritis Vulvae • A. Is effectively treated with local estrogen • B. Is associated with thin vaginal epithelium • C. Occurs as a part of normal menopause • D. Can occur secondary to candidiasis or trichomoniasis

31. Answer #4 • D. Can occur secondary to candidiasis or trichomoniasis