Vaginal and Vulvovaginal Disorders

Atrophic Vaginitis: Definition

Atrophy(reduction in size) of vaginal mucosa secondary to decreased estrogen levels

What can cause atrophic vaginitis

• menopause

• postpartum

• breastfeeding

• antiestrogenic drugs: clomiphene, tamoxifen, raloxifene

atrophic vaginitis: presentation

Decreased vaginal lubrication→ irritation, dryness, burning, itching, dyspareunia(persistent or recurrent pain before, during, or after sexual intercourse)

atrophic vaginitis: Treatment Goals

Reduce or eliminate symptoms of dryness, burning, itching, dyspareunia

atrophic vaginitis: Treatment Approach

• Avoid exacerbating products such as powders, perfumes, spermicides and panty liners

• vaginal lubricants

atrophic vaginitis: Exclusions for Self-Care

• severe for vaginal dryness, dyspareunia, or bleeding

• Symptoms not confined to the vaginal area

• symptoms not relieved by use of vaginal lubricants

• first episode of post-menopausal spotting/bleeding

Vaginal lubricants

• Water Soluble: Astroglide, K-Y Jelly, Vagasil intimate moisturizer lotion

• Petroleum jelly should NOT be used→ difficult to remove, may damage latex condoms or impair efficacy of diaphragms

Vaginal lubricant: counseling

• apply daily for dryness, irritation or itching. Apply at time of intercourse for dyspareunia.

• Can be applied both externally and internally. For dyspareunia, apply to both vaginal opening and penis.

• Use liberal quantity initially, tailor amount and frequency to comfort level. Can be applied as frequently as necessary.

• Relief of symptoms may be apparent within hours of application. Duration of action is generally less than 24 hours.

• If no improvement is noticeable within a week, symptoms worsen or vaginal bleeding is experienced, see MD.

• Leakage may occur. A panty liner can avoid stains.

Vulvovaginal Candidiasis

overcolonization by candida fungi

What can cause Vulvovaginal Candidiasis

• pregnancy

• contraceptives

• estrogen therapy

• menstruation

• diabetes mellitus

• antibiotics

• immunosuppressant

• systemic corticosterioids

• antineoplastic agents

• sponge or IUD contraceptive use

• increased excretion of urinary glucose

Vulvovaginal Candidiasis: Presentation(classic symptoms)

thick, white(cottage cheese) discharge

Vulvovaginal Candidiasis: Differentiating signs and symptoms

• no odor

• normal pH

• erythema, itching, and/or vulvar edema

Vulvovaginal Candidiasis: Testing

• yeast infections do NOT alter the vaginal pH

• Can be tested using Vagisil screening kit

Vulvovaginal Candidiasis: Goals Treatment

Relief of symptoms, eradication of infection and reestablishment of normal vaginal flora

Vulvovaginal Candidiasis: Treatment approach

• Self-treatment for infrequent, uncomplicated, mild-moderate infections

• To treat infection: Vaginal antifungals, complementary therapy

• To relieve symptoms: topical anti-itch product

Vulvovaginal Candidiasis: Exclusions to self-care

• severe symptoms

• pregnancy or age <12

• concurrent fever or pain in the pelvic area, abdomen, back, or shoulder

• predisposing illness(DM,HIV) or meds(steroids, antineoplastics)

• recurrent or persistent infections (>3 infections/year or previous infection within last 2 months)

• first vulvovaginal episode

Vaginal antifungals overview

• FDA Approved: imidazoles: blutoconazole, clotrimazole, miconazole, ticonazole

• Available as vaginal creams, suppositories, and tablets

• systemic absorption is minimal

• AE: vulvovaginal burning, itching, and irritation

• only contraindication: allergy to imidazoles

Vaginal Antifungal: Administration

• Administer cream/ointment/tablet at night before bed to reduce leakage

• Wash vaginal area prior to use

• Vaginal creams come pre-filled or require patient to fill tube with cream before application.

• Vaginal administration can be done while standing or laying down. Assume position and insert applicator into the vagina as far as it will go comfortably.

• Push cream through applicator as far back in the vagina as possible. Tablet and suppositories are deposited by pressing the plunger until it stops.

• Remove applicator and wash pieces in warm soap and water.

• Panty liner can be worn to reduce leakage, do not use tampons because they can reduce abosorption

• Continue use for length of time specified on product, do not skip days, even during menstrual flow

Symptomatic Relief Prod; Active/Brand/ App notes-Benzocaine

• Active: Benzocaine

• Brand Name(s): Vagisil Anti-itch, Vagisil max, vagi gard Cream

• App Notes: apply externally

Symptomatic Relief Prod; Active/Brand/ App notes-Hydrocortisone

• Active: Hydrocortisone

• Brand Name(s): Vagisil satin anti-itch cream

• App Notes: apply externally, avoid prolonged use, ok with vaginal antifungal

Symptomatic Relief Prod; Active/Brand/ App notes-povodine/iodine

• Active: povodine/iodine

• Brand Name(s): betadine medicated supp/douche

• App Notes: n/a

Symptomatic Relief Prod; Active/Brand/ App notes-cornstarch/aloe/mineral oil

• Active: cornstarch/aloe/mineral oil

• Brand Name(s): summer’s eve, vagisil feminine powder

• App Notes: apply externally to absorb moisture

Symptomatic Relief Prod; Active/Brand/ App notes-sodium bicarbonate

• Active: sodium bicarbonate

• Brand Name(s): Sitz bath

• App Notes: 1tsp sodium bicarbonate + 1 pint

  water. Add 2-4Tbsp to bath and sit

  in it for 15 minutes

Lactobaccilus: complementary product

• used to re-establish normal vaginal flora

• not likely effective in treatment, can be used to prevent infection

Tea tree oil:complementary product

• dual antibacterial/antifungal properties

• 200mg supp x 6 nights

Gentain Violet: complementary product

• tampon soaked in gentian violet inserted into vagina for several hours/overnight or twice daily for up to 5 days

• will stain fabric and skin

Boric Acid: complementary product

• 600mg vag supp QHS x 14 days

• boric acid 5% in lanolin can be applied topically for symptomatic relief

• can be toxic and teratogenic-DO NOT INGEST ORALLy

Vaginal Candidasis : Counseling

• Do not stop therapy early, doing so is a common reason for recurrence and possible resistance.

• Do not use tampons or douche until 3 days after antifungal treatment

• Refrain from intercourse during treatment. Antifungal can damage latex condoms and make diaphragm contraceptives ineffective for up to 3 days post use. Partners are not treated

• Symptoms should improve in 2-3 days and resolve within a week.

• Seek medical attention if symptoms do not improve in 3 days, persist for longer than 7 days, or recur within 2 months

• Seek medical attention if symptoms change or worsen

Bacterial Vaginosis(BV): classic symptoms

◦ Thin, watery, off-white, tan, grey, sometimes foamy discharge

◦ Unpleasant fishy odor that increases after intercourse

◦ Elevated pH

BV: Differentiating signs and symptoms

◦ Purulent discharge

◦ Not usually associated with itching, irritation and pain

◦ Increased vaginal discharge

BV: Treatment Approach

• self care nor appropriate

• refer to MD

Trichomoniasis: Classis Symptoms

• Copious, malodorous, yellow-green, frothy discharge

◦ Pruritus, vaginal irritation and dysuria

◦ No symptoms initially in 50% of affected women

◦ Most men are asymptomatic

Trichomoniasis: Differentiating signs and symptoms

◦ Erythema(redness) and vulvar edema

◦ Yellow discharge

Trichomoniasis: Treatment Approach

self-care not appropriate