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  • Nathan Riley, MD

Obgyno Wino Podcast Episode 22 - Vaginitis in Nonpregnant Patients

Updated: Dec 30, 2019

"Attending births is like growing roses. You have to marvel at the ones that just open up and bloom at the first kiss of the sun but you wouldn't dream of pulling open the petals of the tightly closed buds and forcing them to blossom to your timeline." - Gloria Lemay, Canadian midwife

2016 Pinot Noir from Carmel Road Winery

PB#215 - Published January 2020 (Replaced PB#72)

Five Pearls

  1. A careful history and physical exam are critical components of diagnosing vaginitis

  2. Estrogen plays a central role in maintaining the normal vaginal pH (< 4.5-4.7) and flora. When estrogen is deficient, many forms of vaginitis may result

  3. Trichomoniasis should always be treated, whether symptomatic or not; yeast infection or bacterial vaginosis treatment should be individualized outside of pregnancy, though treatment is generally warranted in pregnancy

  4. There are many conditions that mimic infectious causes of vaginitis, particularly in post-menopausal women (e.g. atrophic vaginitis, desquamative inflammatory vaginitis)

  5. Judicious use of antibiotics is always warranted


Background

- vaginitis: spectrum of conditions that cause itching, burning, irritation, and abnormal discharge (obviously an umbrella term!)

- three most common: bacterial vaginosis, vulvovaginal candidiasis (i.e. yeast infection), and trichomoniasis

- a large number of patients presenting with vaginitis go undiagnosed, and many of these are likely attributed to atrophic vaginitis, various vulvar dermatologic conditions, and vulvodynia


The role of estrogen


- in pre-pubescent women or peri- and post-menopausal women, estrogen is relatively deficient compared to reproductive-aged women

- the normal vaginal flora is comprised of millions of species of bacteria and yeast, and this harmonious balance is influenced not only by fluctuations in proportional levels of hormones but also sleep, stress, diet, etc.


Pearl: normal pH of vagina is <4.5-4.7


Components of your physical exam

- inspect external and internal anatomy (w/ speculum)

- check pH: swab the vaginal wall versus around the cervix due to tendency for cervical mucous, semen, and blood to have a higher pH (false positive)

- amine test: "whiff", accentuated by addition of 10% KOH

- prepare microscopy slides with saline and 10% KOH

- gram stain (** may not be necessary)

- culture (**may not be necessary)

- rapid tests for antigens or enzymatic activity (**may not be necessary)

- DNA detection methods (**may not be necessary nor useful)


Vulvovaginal candidiasis ("yeast")

- chief complaint: itching, burning, "cottage cheese" discharge

- diagnosis: pseudohyphae or blastospores on microscopy (more easily visualized with addition of 10% KOH)

- if inconclusive or treatment-resistance, get a culture

- microscopy is only 50% sensitive

A,C - spores; B - pseudohyphae

- complicated yeast infections are less likely to respond to primary therapy

- oral and topical regimens available

- oral are more expensive but also more effective in some situations; can cause GI side effects or liver toxicity

- topical regimens are less expensive and can cause local irritation


- for complicated yeast infection, oral fluconazole can be repeated in 3 days to increase cure rate from 67 to 80%

- after treatment of initial infection, suppression therapy can be initiated with oral fluconazole 150 mg weekly for 6 months

- weekly fluconazole can be hepatotoxic (but not as bad as former standard therapy ketoconazole)

- if significant liver enzyme elevations noted on suppression therapy, or if patient unable to tolerate GI side effects, clotrimazole 500 mg weekly or 200 mg twice weekly is acceptable alternative

- in pregnancy, no data to suggest that short-course, low-dose fluconazole is associated with birth defects; higher doses at 400-800 mg /d may have association, though trial of oral fluconazole at 150 mg dose is acceptable if poor response to topical -azoles

- if poor response to oral or topical -azoles or in non-albicans Candida infections, try boric acid 600 mg capsule per vagina once daily for 14 days

Pearl: for treatment-resistant yeast infection, make sure to get a culture!


Bacterial vaginosis (BV)

- generally classified as a relative paucity of lactobacillus + polymicrobial overgrowth (G. vaginalis and other facultative anaerobes)

- chief complaint: "fishy odor", pain, burning, white/gray discharge

- diagnosis requires 3 of 4 of Amsel's criteria or diagnosis can be made by Nugent score (gold standard in research setting)

- going by elevated pH and whiff test alone (2 of 4) has similar sensitivity/specificity


When and how to treat BV?

- treat if: symptoms unbearable, pregnancy, patient undergoing gyn surgery

- gyn surgery: higher risk of post-procedure infection if BV untreated prior

- pregnancy (if symptomatic): higher risk of preterm birth, PROM, and low birth weight if BV left untreated

Pearl: no evidence that forgoing treatment in asymptomatic BV in an uncomplicated pregnancy results in better outcomes - refer to Table 1 above for treatment regimens (metronidazole or clindamycin; topical or oral)

- oral regimens can cause GI distress

- wait until 24 hrs after last dose of metronidazole before consuming alcohol (can cause disulfuram-like reactions with both oral and topical preparations)

- recurrent BV: may be due to particularly pathogenic bacteria, reinfection, more failure of normal lactobacilli to reestablish (occurs in 30% of women)

- recurrent BV best treated with boric acid for 14 days then weekly metro gel 0.75% per vagina for 4-6 months


Trichomoniasis

- chief complaint: postcoital bleeding, irritation, greenish discharge

- physical exam might additionally reveal elevated pH, strawberry cervix, and motile organisms on microscopy


Strawberry cervix

Trichomonad

- microscopy only has 60% sensitivity for motile trichomonads

- if pH >4.5 and normal wet mount, collect a culture!

- rapid test for trichomonas antigens also acceptable

- patient and partner must be treated; this is a true STD unlike the others


Pearl: Trichomoniasis requires treatment for both patient and partner


- refer to Table 1 for treatment regimens

- Metronidazole and tinidazole equally effective

- Metronidazole safe in pregnancy; limited data on tinidazole

- avoid alcohol for 72 hrs after tinidazole to avoid disulfuram-like reaction

- for stubborn reactions: tinidazole 500 mg four times daily for 14 days


Conditions that can mirror infectious vaginitis

- atrophic vaginitis: pH > 4.5, parabasal cells on microsopy, amine test negative, treat with water-based lubricant and estrogen

- desquamative inflammatory vaginitis: pH > 4.5, greenish purulent discharge, parabasal cells on microscopy, amine test negative, treat with clindamycin


Random questions that always come up


Can I treat for yeast infection over the phone? Maybe. How certain are you that she has a yeast infection? Are you missing a UTI or cervicitis? Could this be secondary to atrophy?


What if I don't have access to a microscope? History, exam, culture. Gram stain can be helpful for BV. Rapid tests are available for T. vaginalis and G. vaginalis


What if pH is elevated but microscopy is normal? Culture + gram stain


What if clue cells or trichomonads are reported on PAP screening? For clue cells, only work it up if patient is symptomatic. For trichomonads, first get a wet mount. If that's inconclusive, send a culture. If culture not available, treat.


"Did I contract trichomoniasis from my boyfriend?" If not them, then somebody you've engaged with sexually over the past couple months. It's thought that trichomonads can hang around for a little while (unclear how long) without causing symptoms, so you may not have contracted it from your most recent partner, but definitely from one of your recent partners (all must be treated)


When should I recommend douching to my patients? More likely to do harm than good, but it can be helpful in an occasional patient with treatment-resistant or recurrent BV

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