Self Care: Vaginal & Vulvovaginal Disorders (copy)

True/False: vaginal symptoms can be present with anyone with vaginas REGARDLESS OF

• sexual orientation (straight, homosexual)

• sexual activity (active or not)

• menopause status

true

Approximately 65% of people experiencing vaginal symptoms have either

1. bacterial vaginosis (BV)

2. vulvovaginal cadidiasis (VVC)

3. trichomonaisis

can infections be polymictobial?

yes

What are some NORMAL bacteria/ fungus that live in the vagina, what makes them beneficial?

• lactobacillus —> beneficial bc/ maintains pH at 4 to 4.5 protecting vagina from infection from other bacteria

• gardnerella vaginalis

• prevotella

• bacteroids

• moviluncus (imbalance in this flora can lead to disease states)

• candida albicans (fungi)

how do decreased estrogen (can be caused by menopause) levels effect the normal bacteria in the vagina?

decreased estrogen —> changes vag flora —> inc pH —> vaginal atrophy

Normal Vaginal Discharge (leukorrhea): protects against bacteria

• odorless

• clear/ white

• viscous or sticky

• NORMAL increases can occur during ovulation, pregnancy, after menstruation

• normally discharge does NOT lead to irritation, itching, or burning?

• vary w vag irritants, barrier contraceptive products, tampons

bacterial vaginosis

polymicrobial infection due to vaginal flora imbalance

• inc

  • gardnella vaginalis

  • anaerobes

  • mycoplasma hominis

• dec

  • lactobacillus

responsible for 30% of vaginal symptoms

risk factors for bacterial vaginosis

• multiple/new sexual partners (can happen even w/o sex)

• sex

• IUD

• prev pregnancy

• douching (washing w water)

• tobacco

does your partner ALSO need to be treated if YOU have bacterial vaginosis?

NO

Bacterial Vaginosis: signs/symptoms

• ph over 4.5 (normally 4-4.5)

• discharge thin, white/grey, foamy w fishy odor —> gets worse after sex or menstruation

  • (IF NO ODOR THEN NOT BACTERIAL)

  • fishy odor is a must

• unlikely: vaginal irritation / dysuria (painful pee)

  • more in VVC & trichomoniasis

bacterial vaginosis complications

• pelvic inflammatory dx (PID)

  • pathogens go up repro tract into uterus

  • different treatment from uncomplicated bacterial vaginosis

• preterm birth

• transmission of HIV

can bacterial vaginosis be treated OTC or do you have to have a prescription?

MUST be prescription CANNOT treat OTC

• clindamycin

• metronidazole

• topical or oral (5g q night for 5 days)

• not mandated for partners

Trichomonas- STI caused by vaginosis parasite

• responsible for 15-20% of vaginal infections

• most commonly in

  • black and hispanic communities

  • low socioeconomic

  • hx of incarcerations

trichomoniasis risk factors

• multiple/new sex partners

• not using barrier contraceptives

• other STIs

Trichomonias Signs/ Symptoms:

• pH over 4.5

• FROTHY, yellow-green (discolored), smelly discharge

• dysuria/vaginal irritation

• symptoms usually not right away- most people feel symptoms after 6 months if they feel any at all

  • most men DO NOT feel symptoms but are reservoirs for infections

Hallmark = strawberry cervix- little polyps in cervix

trichomoniasis complications

• PID

• easier transmission of HIV

• low-birth-weight infants

• tubal infertility (relating to fallopian tube dysf)

Can trichomoniasis be treated OTC or does it HAVE to be prescription?

NO OTC products, MUST be treated with prescription

What are the prescription treatments that are available for treating trichomoniasis?

• metronidale

• tinidazole

Should partners of patients with trichomonias also be treated with either metronidazole or tinidazole?

YES (individuals should avoid sexual intercourse until they and all partners have completed treatmenrt and are asymptomatic)

How are metronidazole and tinazole taken for trichomoniasis?

metronidazole = 1st line = 500mg oral 2x a day for 7 days

tinazole = one time dose

Vulvovaginal Candidaisis (20-25% of vag infections (nearly 75% have at least one VVC inf)

• yeast or monilasis infection- fungal, specifically candida

  • albicans- uncomplicated

  • glabrata- comp

  • topicalis- comp

  • parapsilosis- comp

  • krusei)- comp

tx depends on type of candida

What are some risk factors for vulvovaginal candidiasis (VVC)?

• pregnancy

• drugs (antibiotics, immunosupressants, estrogen)

• diabetes

• tight fitting, nonabsorbent clothing or pantyhose

Vulvovaginal Candidiasis (VVC) s/s

• normal pH

• dysuria common

hallmark= thick, white ‘cottage cheese’ discharge w (bready) or without odor

is vulvovaginal candidiasis (VCC) treatment available by prescription, or can it also be given OTC?

CAN TREAT OTC if

• mild-moderate classic symptoms

• infrequent vaginal symptoms

• antibiotic associated VVC

after tx OTC, medical eval should be done within 1 week or if recurrence within 2 mo

refer if any of these self-care exclusions

• pregnancy

• less than 12y

• diabetes

• HIV inf

• taking corticosteroids or antineoplastics (predisposing)

• warfarin

• recurrent (over 3 infections/yr or prev inf 2 months ago)

• first VVC episode

• concurrent:

  • fever

  • pain in pelvic area/lower abdomen/back/shoulder

what are the goals of treating Vulvovaginal candidasis?

• relieve symtpoms

• eradicate infection

• re-estbalish normal flora

non-pharmacologic tx of Vulvovaginal candidiasis?

dietary modification

• decrease sugar + refined carbohydrates —> stop feeding fungi and pathogens

• eat yoghurt containing live cultures (provides good bacteria + restores normal flora)

pharmacologic tx VVC

imidazole antifungals- ORAL only

• alter fungal MEMBRANE (dec ergosterol synthesis)

• inhibit CYP450 enzymes in the fungal membrane

• oral- fluconazole 150 mg one time

  • q72h if complicated

• creams/ointments/suppositories

  • 
    

NOT likely to have drug interactions, but be careful w/ warfarin, corticosteroids, and antineoplastics)

What are examples of creams/ointments that are available for Vulvovaginal Candidasis?

1. Clotrimazole 1% cream

2. Clotrimazole 2% cream

3. Miconazole nitrate 2% (Monistat 7)

4. Miconazole nitrate 4% (Monistat 3)

5. Tioconazole 6.5% (Vagistat 1 + Monistat -1 Day)

How often do you take the following Vulvovaginal candidasis creams?

3. Clotrimazole 1% cream

• into vagina for 7 days + vulva twice daily PRN for itching

1. Clotrimazole 2% cream

• for 3 days

3. Miconazole nitrate 2% (Monistat 7)

• into vagina for 7 days + vulva twice daily PRN for itching

3. Miconazole nitrate 4% (Monistat 3)

• qd for 3 days

• apply to vulva BID prn for itching

5. Tioconazole 6.5% (Vagistat 1 + Monistat -1)

• insert ointment into vag qd for 1 day

What are the combo packs available for Vuvlovaginal Candidiasis?

1. Monistat 1 combo (day or night)

• miconazole 2% cream + miconazole 1200mg suppository

• suppository for 1 day + cream twixe daily prn for up to 7 days

1. Monistat 3 or Vagistat 3:

• miconazole 2% cream + miconozole 200mg suppositories

• suppository for 3 days + cream twixe daily prn for up to 7 days

suppositories application

Vaginal Application

1. Wash hands

2. Open pouch containing suppository

3. Insert the suppository in wider end of the applicator

4. Insert applicator into vagina as far as it will comfortably go (standing or lying down)

5. Push the plunger all the way in as far back into the vagina as possible

6. Remove applicator from the vagina

7. can applicators be reusable- yes, after washing w warm soap & water

8. lie down as soon as possible after inserting the suppository

Vulva Application (External) ٫ for creams that come in combination packs

1. Wash hands

2. Squeeze a small amount from the tube

3. Apply to itchy/irritated areas up to 2x daily

do miconazole single dose and 7 day treatments have similar cure rates? yes

which one has faster symptoms relief?- single dose

are there similar results between miconazole, clotrimazole, and ticonazole?- yes

WHICH treatment is recommended by CDC for pregnancy and diabetes?- 7 day

YES

single day

yes

7 DAY IS RECOMMENDED FOR DIABETES AND PREGNANCY

General Counseling for vulvovaginal candidiasis treatment":

• Start treatment at any time of day or before bed (preferred)

• lying down will reduce leakage of product from the vagina

• burning may occur

• Should you continue to use product for the full extent even if your symptoms have improved?- yes, to 3 or 7 day

• Should you continue to use product even during menstruation?- yes

• Consider avoiding tampons to avoid impaired absorption

• Avoid sex

• Can antifungals irritate partners- Yes

• Antifungal vaginal formulations may damage latex condoms

• spermicides/diaphragms may irritate the local area

What are some complementary/ alternative therapies alongside miconazole/ tioconazole / clotrimaziole for vulvovaginal candidiasis?

Nonspecific

• adjunctive for specific symptoms

• not typically recommended

• contains benzocaine, hydrocortisone, povidone-iodine (not recommended)

alternative therapies

• lactobacillicus preparations (probiotics)

• tea tree oil supp

• sodium bicarbonate sitz bath

• gentian voilet soaked tampons

• boric acid - 600mg vaginal capsule x 14 days (used in those who do not respond with antifungals BUT avoid in pregnancies)

Vulvovaginal Candidasis Monitoring:

• symptoms could lessen within 2~3 days and resolve in 1wk

• length of treatment DOES NOT correspond w resolution time

• patient should call health care provider if different symptoms occur

Atrophic Vaginitis:

• vaginal atrophy due to decreased estrogen

• 45% of postmenopausal individuals experience symptomatic atrophic vaginitis

• occur during menopause, postpartum period, and breastfeeding (vaginal epithelium thins and lubrication declines)

• may occur in individuals w decreased ovarian estrogen production (radiation + chemotherapy)

what are some medications that can cause atrophic vaginitis?

• antiestrogenic drugs

• aromatase inhibitors

• gonadotropic-releasing hormones

What are signs and symptom of atrophic vaginitis?

• dyspareunia - painful sex bc/ of lack of lubrication

• vaginal irritation - dryness, burning, itching

• thin watery bloody, yellow discharge- smelly

• spotting/blood (go to doctor to make sure its not cancer)

what are the goals of therapy for atrophic vaginitis?

• reduce or eliminate symptoms

• provide lubrication to vaginal tissue if dryness is the cause of pain

What are some non-pharmacological treatments for atrophic vaginitis?

AVOID IRRITANTS

• powders/perfumes

• spermicides

• panty liners

VAGINAL LUBRICANTS:

• temporarily moisten vaginal tissues

• only water-soluble lubricants can be used with latex condoms/diaphrams

• applied intravaginally, vulva, or partners penis

What are two kinds of lubricants that are out there? Which kind should you use and which should you avoid?

1. water/silicone based lubricants - RECOMMENDED

   • Improves symptoms of vaginal dryness

   • relieves burning + itching

   • facilitates intercourse + reduce pain

2. oil/ petrolatum- based - NOT RECOMMENDED

• may damage latex condoms and impair contraceptive methods

What is an example of a home test kit that can be used to test if you are going through a vaginal infection?

pH test (if candidiasis/yeast then NO change in pH —> if change then bacterial vaginosis or trichomoniasis)

AZO test = vaginal pH test

Vaginal Douching:

• maintain hygiene of the vagina

• ADEs

  • disruption of vaginal flora

  • allergic reactions

  • pelvic inflammatory disease (PID) + ectopic pregnancy

You should avoid douching at least __ hrs after sexual intercourse when vaginal spermicide is used

6-8 h

Which infections CANNOT be treated over the counter?

Which CAN be treated OTC?

Who is excluded from OTC treatment for this type of infection?

• bacterial vaginosis + trichomoniasis CANNOT BE TREATED OTC

• vulvovaginal candidasis CAN be treated topically (oral must be prescribed)

• exclusions

  • pregnancy

  • less than 12

  • predisposing drugs (neoplastics + warfarin + corticosteroids)

  • recurrent diseases

  • FIRST episode of VVC