Women's Health- Vaginal Infections

1. Gardasil 9 (protects against 9 strains that cause warts and/or cancer)

2. Use of condoms (reduces risk of condyloma)

What are 2 ways to prevent HPV and/or genital warts?

Syndrome characterized by vaginal discharge and/or irritation

What is vaginitis?

1. Bacterial Vaginosis (BV)

2. Candida Vulvovaginitis (CVV) or "yeast"

3. Trichomonas Vaginitis (TV) or "Trich"

4. Atrophic Vaginitis

What are the 4 most common types of vaginitis?

Change in balance of bacteria that's normally found intravaginally, typically overgrowth of bacteria called Gardnerella Vaginalis

What is bacterial vaginosis?

Nucleic Acid Amplification Test (NAAT)

What is a specific lab test that can be used to test for BV?

Get specimen on a swab and put in medium and send to lab to evaluate for BV

What happens in a Nucleic Acid Amplification Test?

If already met 3/4 of Amsel's criteria

When might you not do a NAAT?

1. Thin white or yellowish discharge

2. pH greater than 4.5

3. Positive Whiff test

4. Clue cells when doing a wet mount

What are the 4 clinical criteria for BV diagnosis?

Amsel's Criteria

What are the clinical criteria for BV also known as?

3/4

How many of the criteria are needed for the diagnosis of BV?

Vaginal itching and burning (may or may not be there)

What is another possible symptom of BV that may or may not be there?

1. Metronidazole

2. Clindamycin

What are two medications used to treat BV?

500 mg, one tablet po twice daily x 7 days

Metronidazole BV treatment

Intravaginal tube 2% cream, 1 applicator (5 grams) intravaginally at night x 7 days

Clindamycin BV treatment

40 g tube and 7 applicators

What should you give the patient if they choose to use Clindamycin?

1. Allergies

2. Ability to swallow pills or use applicators (patient compliance)

3. Drug interactions

4. Cost and insurance

5. If they are pregnant

What are factors that help to choose what is used to treat BV?

Controversial and currently not recommended

What is the treatment of the partner like for someone with BV?

If partner is circumsized; if not, the fold of skin can harbor bacteria

What should you ask if someone has BV?

Yeast/fungal infection

What is Vaginal Candidiasis also known as?

common type of vaginitis you will see

Vaginal Candidiasis is the most _______________________________

75%

What percentage of women will experience at least 1 episode of a yeast infection?

Candida Albicans

What causes most yeast infections?

- People with diabetes mellitus (yeast likes sweet, dark, damp, area)

- Recent antibiotic use (kills all bacteria, yeast can overgrow)

Who are yeast infections commonly seen in?

- Might complain of itching (pruritus)

- White, curd-like vaginal discharge (cottage cheese)

- Erythema

- Burning after urination

What are 4 common presentations of Vaginal Candidiasis (yeast/fungal infections)?

1. Wet Mount- look under microscope to see if we can see yeast cells

2. May require cultures as only 50% of cases will have a positive KOH

3. Experienced clinicians may treat based on typical "cottage cheese" type discharge, then culture if no resolution of symptoms

4. Findings may be reported on cytology smear

5. Women may self diagnose based on symptoms and the availability of OTC treatments

What are 5 ways to diagnose Vaginal Candidiasis (yeast/fungal infections)?

Probably don't treat

What if someone is asymptomatic but thinks they may have a yeast infection?

1. OTC treatments include topical antifungals

2. Prescription antifungals (both topical and oral)

3. Culture positive yogurt intake has not been consistently found to decrease recurrences or to prevent post antibiotic CVV (some will benefit because it adjusts pH of vagina)

4. Strict DM (diabetes) control may decrease recurrences (control high blood pressure)

5. Use of cotton underwear

6. Screen patient for diabetes if infections are recurrent or persistent

6 treatment options for Vaginal Candidiasis?

Monistat/Miconazole 7 2% 9 gram prefilled applicators x 7 days, one applicator a night x 7 days

What is the most common OTC topical antifungal to treat yeast infections?

Diflucan 150 mg tab, one tablet daily x1

What is the most common prescription antifungal to treat yeast infections?

Fluconazole

What is the generic name of Diflucan?

Trichomonas vaginalis

What bacteria causes trichomoniasis?

flagellated (has tail) protozoan

What type of bacteria is trichomonas vaginalis?

STI (sexually transmitted infection)

What type of infection is trichomoniasis?

1. Frothy yellow/greenish/whitish discharge

2. Plus or minus foul smelling discharge

3. May have vulvar erythema

4. Burning or itching

5. When you look at cervix during speculum exam, you may see strawberry spots on cervix

What is the clinical presentation of Trichomoniasis?

1. Microscopic identification of actively swimming Trichomonads (wet-mount)

2. Culture (NAAT) if patient has persistent symptoms and Trichomonads not identified on prior exam

What are the 2 ways you can diagnose Trichomoniasis?

Nucleic Acid Amplification Test

What does NAAT stand for?

1. Metronidazole 2 g po as single dose or 500 mg 1 tab po BID x 7 days

2. Prolonged treatment may be needed for persistent symptoms

3. Treatment of all sexual partners of women with Trichomonas is indicated

What is the treatment of Trichomoniasis like?

Shrinkage of the vaginal endometrium

What is atrophic vaginitis?

Decreased estrogen production (after menopause in 50s), so mostly seen in people who have gone through menopause

What causes atrophic vaginitis?

Asymptomatic

Patient with atrophic vaginitis may be what?

Very thin and susceptible to trauma (it shrinks)

Atrophic vaginitis causes the vaginal endometrium to be what?

Friable- bleeds easily

What is the vagina like after menopause (in atrophic vaginitis)?

1. Vaginal dryness

2. May complain of spotting, esp after intercourse

3. Pain with intercourse (dyspareunia)

4. Vaginal tissue may be friable (bleed easily)

What are the 4 clinical presentations of atrophic vaginitis?

Topical estrogen (Premarin vaginal cream 0.625 mg strength with applicator, 30 g tube, 0.5 grams intravaginally twice weekly, give applicators)

What is the treatment option for atrophic vaginitis?

Chlamydia Trachomatis

What bacteria causes Chlamydia, a sexually transmitted infection?

Common STI in women

How common is chlamydia?

Bacteria

What is chlamydia classified as?

Infertility and ectopic pregnancies

What two things is chlamydia associated with?

Pelvic Inflammatory Disease (PID)

What may Chlamydia progress to?

- May be asymptomatic

- Purulent discharge (pus-like)

- Burning

- Urinary frequency

- Dysuria (pain with urination)

- Inflammation of urethra and vulva

- May identify erythema intravaginally

What is the clinical presentation of Chlamydia like?

1. Lab testing using NAAT is the current standard (vaginal swab)

2. If testing for Chlamydia, should also test for gonorrhea because of high number of co-infections (50% of women had both in recent study)

What are 2 ways to diagnose chlamydia?

Doxycycline 100 mg 1 tab po BID x 7 days

What is the treatment for Chlamydia?

neisseria gonorrhea

What bacteria causes Gonorrhea?

Most affected women are asymptomatic

What symptoms do most women with gonorrhea have?

PID

What may Gonorrhea progress to?

Infertility and increased risk of ectopic pregnancy

What can Gonorrhea cause?

- Vaginal discharge (pus-type)

- Urinary frequency

- Dysuria

- Burning

- Inflammation of urethra, vulva, vagina

What are the 5 clinical presentation of Gonorrhea like?

NAAT

What is used to diagnose Gonorrhea?

- Ceftriaxone 500 mg IM x 1

- If chlamydia positive, add the Doxycycline

What are the 2 treatment options for uncomplicated gonorrhea?

General term for acute, chronic, or recurrent infection of internal pelvic structures (ovaries, fallopian tubes, uterus, cervix)

What is the definition of Pelvic Inflammatory Disease?

1. Bacteria (chlamydia or gonorrhea)

2. Use of intrauterine devices (IUDS)

3. Post-abortion

4. Rarely other pelvic surgeries

What are the 4 most common causes of PID?

Women with multiple sexual partners

Who is PID most common in?

1. May be a fever but not necessary for diagnosis

2. Insidious or acute lower abdominal/pelvic pain

3. Usually bilateral (can be unilateral)

4. Might complain of pelvic pressure or back pain

What are the 4 clinical presentations of PID?

- Purulent vaginal discharge

- Abdominal tenderness (press on, say it hurts)

- Tenderness on cervical motion (bimanual exam)

What are the 3 PE findings with PID?

Clinical findings (in exam room)

What is the diagnosis of PID usually based on?

1. Abdominal pain and tenderness

2. Vaginal and cervical discharge

3. See white blood cells on wet-mount (infection)

4. Temp greater than 101

What are 4 things that can help make the diagnosis of PID?

Ectopic pregnancy, appendicitis (right side pain), ovarian cyst or torsion

What are differential diagnoses associated with PID?

Ceftriaxone 500 mg IM as single dose + Doxycycline 100 mg 1 tab po BID x 14 days + Metronidazole 500 mg 1 tab po BID x 14 days

What are the outpatient treatments for Pelvic Inflammatory Disease?

- Temp greater than 102

- Presence of TOA (tube ovarian abscess), not just infection one one or both sides

- If they are pregnant

- Doesn't respond to outpatient treatment

- If they can't tolerate the meds you gave them

What are reasons to admit someone with PID?

Human Papilloma Virus

What does HPV stand for?

Very common STI in the US

How common is HPV?

Over 100 different strains

How many different strains are there of HPV?

Genital warts and benign low-grade cell change

What are the low-risk HPV strains associated with?

Cancers

What are the high-risk HPV strains associated with?

Strains 16 and 18 (most common high risk strains)

What strains are 70% of all cervical cancers caused by?

Strains 6 and 11 (most common low risk strains)

What strains are 90% of genital warts caused by?

Condyloma

What are genital warts also called?

The time from when they are exposed to an infection to when they first present with symptoms

What is the incubation period?

2-18 months

What is the incubation period for genital warts?

HPV

What are genital warts caused by?

frequent

Genital wart reoccurrence is...

- Visual inspection is main diagnosis, but can biopsy if unsure

- Can be identified on PAP smear

What is the way to diagnosis Condyloma?

1. Presence of condyloma (can bring patient in)

2. Itching, burning, painful (irritated more on urethra, location is factor in pain)

What are 2 symptoms of genital warts?

Present it right

What should you do with the Gardasil 9 vaccine with patients?

Location and number

What does the treatment for genital warts depend on?

1. Liquid nitrogen to freeze warts AKA Cryotherapy

2. Snip biopsy- use scalpel, snip off at base, send to lab

3. Laser therapy (vaporize abnormal cells)

4. May go away on their own

5. Topical creams that can be used to shrink warts

What are the 5 possible treatment options for Genital Warts?

More isolated condyloma

What is Cryotherapy typically used for?

Imiquimod

What is a common topical cream for genital warts?

Herpes Simplex Virus

What does HSV stand for?

Oral herpes

What is type 1 HSV?

Genital herpes

What is type 2 HSV?

Cold sores

What does Type 1 HSV present as?

2-7 days (relatively short)

What is the incubation period of Type 1 oral herpes?

By sexual contact

How is type 2 HSV acquired?

Someone with HSV can transmit it to sexual partners without knowing they have it/without having visible symptoms

What is asymptomatic shedding?

Up to 70%

What percentage of Type 2 HSV is transmitted via asymptomatic shedding?

1. Prodrome

2. Vesicles appear on a red base

3. Vesicles erode over a period of time, leaving painful ulcers

4. May be associated inguinal lymphadenopathy

5. Lesions may persist for days and days or go away quickly (depends on patient)

What are the signs and symptoms of Type 2 HSV?

period of time when patient has numbing or tingling prior to outbreak of visual lesions right at the site of eruption

What is the Prodrome in Type 2 HSV?

Before vesicles appear on a red base; prior to outbreak of actual physical symptoms

When does the Prodrome occur?

Vesicles erode over a period of time, leave painful ulcers

What happens after the active vesicles appear on a red base?