(9) Vaginal and Vulvovaginal Disorders

Name all the vaginal & Vulvovaginal Disorders

1. Atrophic Vaginitis

2. Vulvovaginal Candidiasis (VVC)

3. VCC compared to:

   1. BACTERIAL VAGINOSIS — BV

   2. TRICHOMONIASIS

Atrophic Vaginitis

topics we cover?

1. Cause

2. Presentation/Risk Factor

3. Treatment - VAGINAL LUBRICANTS

4. Exclusions to Self-Care

Atrophic Vaginitis

Cause

↓ estrogen

→ atrophy of vaginal mucosa

→ ↓ vaginal lubrication

Occurs with:

• Menopause

• Postpartum/Breastfeeding

• Antiestrogenic drugs:

  • clomiphene

  • tamoxifen

  • raloxifene

Atrophic Vaginitis

Presentation

• Vaginal dryness

• Irritation

• Burning

• Itching

• Dyspareunia = painful intercourse

• May have spotting after sexual activity

Atrophic Vaginitis

Presentation - Important

First episode of postmenopausal spotting/bleeding
→ REFER for evaluation/cancer screening

Atrophic Vaginitis

Treatment:

1. Main Treatment: Vaginal lubricants

2. Avoid products that may worsen irritation:

   1. Powders

   2. Perfumes

   3. Spermicides

   4. Fragranced panty liners

Atrophic Vaginitis

Exclusions to Self-Care

REFER if:

• Severe presentations (vaginal dryness/dyspareunia/Significant bleeding)

• Symptoms extend outside vaginal area

  • e.g. groin/thighs

• Symptoms are not relieved by lubricant

• First episode of postmenopausal spotting/bleeding

Atrophic Vaginitis

VAGINAL LUBRICANTS - topics we cover

1. Products

   1. DO NOT USE PETROLEUM JELLY / VASELINE

2. Lubricant Counseling

   1. follow-up?

VAGINAL LUBRICANTS

Products-

• K-Y Jelly

• Astroglide/Replens

• Vagisil Intimate Moisturizer

VAGINAL LUBRICANTS

DO NOT USE PETROLEUM JELLY / VASELINE - Why?

• Not water soluble

• Difficult to remove

• Can damage latex condoms

• Can impair effectiveness of diaphragms

VAGINAL LUBRICANTS

Counseling

1. Frequency

Daily dryness / itching

→ use daily/as needed

Dyspareunia

→ use at time of intercourse

2. Location

Can apply:

• Internally

• Externally

• To vaginal opening

• To male partner/penis for dyspareunia

3. Efficiency

• Relief may occur within hours

• Duration usually <24 hours

4. Admin

• Use liberal amount initially

• Tailor amount/frequency to comfort

• No maximum amount/frequency

• Leakage can occur → panty liner may help

VAGINAL LUBRICANTS

Counseling: follow-up?

• Should improve within: 1 week

• If:

  • No improvement

  • Symptoms worsen

  • Vaginal bleeding develops

  • → REFER

• If effective → may continue long term.

VULVOVAGINAL CANDIDIASIS

topics we cover?

1. Cause

2. Risk-factor/ Presentation - VAGINAL pH TESTING

3. self-treat or refer? -

   1. RECURRENT / PERSISTENT VVC

   2. FIRST VVC EPISODE

4. Treatment - VAGINAL ANTIFUNGALS

   1. Products/Effectiveness

   2. COUNSELING

   3. ABSORPTION / SAFETY

   4. ADMINISTRATION

5. Other VVC products

6. follow-up?

VULVOVAGINAL CANDIDIASIS

Cause

• Caused by overgrowth of Candida

• Most common organism: Candida albicans

• Candida can normally be present in the vaginal flora

• Infection happens when it overgrows/overcolonizes

VULVOVAGINAL CANDIDIASIS

RISK FACTORS

• ↑ Estrogen

• Altered Flora / Immune Suppression

• ↑ Urinary Glucose

• Other

  • Sponge contraception

  • IUD contraception

VULVOVAGINAL CANDIDIASIS

RISK FACTORS: ↑ Estrogen

• Estrogen therapy

• Pregnancy

• High-dose combined oral contraceptives

• Cyclic menstrual-related infections

VULVOVAGINAL CANDIDIASIS

RISK FACTORS: Altered Flora / Immune Suppression

• Systemic corticosteroids

• Antibiotics

  • → ↓ normal/good bacteria
    → Candida can overgrow
    → VVC

• Antineoplastic drugs

• Immunosuppressants

VULVOVAGINAL CANDIDIASIS

RISK FACTORS: ↑ Urinary Glucose

↑ Urinary Glucose

• Uncontrolled diabetes

• SGLT2 inhibitors

• High sugar/refined carbohydrate intake

Mechanism

↑ urinary glucose
→ promotes Candida growth
→ ↑ VVC risk

VULVOVAGINAL CANDIDIASIS

PRESENTATION

Classic:

Thick + white + cottage-cheese/curd-like discharge

Also:

• Usually no foul odor/yeasty

• pH - NORMAL <4.5

• Itching

• Erythema/Vulvar edema

VULVOVAGINAL CANDIDIASIS

PRESENTATION: Important

VVC does NOT increase vaginal pH.

VULVOVAGINAL CANDIDIASIS

PRESENTATION: VAGINAL pH TESTING

• VVC: pH <4.5

• BV or Trichomoniasis: pH >4.5

VULVOVAGINAL CANDIDIASIS

PRESENTATION: VAGINAL pH TESTING:

Testing Restrictions?

• Do NOT test within:

  • 72 hours of:

    • Contraceptive spermicide

    • Antifungal product

  • 48 hours of:

    • Intercourse

    • Douching

  • 5 days of

    • Menstrual period

  • 
    

Memorize:

72 – 48 – 5

VULVOVAGINAL CANDIDIASIS

WHEN CAN VVC BE SELF-TREATED?

Infrequent + uncomplicated + mild-to-moderate infection

VULVOVAGINAL CANDIDIASIS

REFER / NO SELF-CARE?

• Severe symptoms

• Pregnancy

• Age <12

• Fever

• Pain

  • Pelvic pain

  • Abdominal pain

  • Back pain

  • Shoulder pain

• First VVC episode

• Recurrent/persistent infection

• Uncontrolled diabetes

• Long-term steroids

• Antineoplastic drug

VULVOVAGINAL CANDIDIASIS

RECURRENT / PERSISTENT VVC

Recurrent - Previous infection within last 2 months

→ REFER

Persistent - >3 infections/year

→ REFER

Memorize:

2 MONTHS + >3/YEAR

VULVOVAGINAL CANDIDIASIS

FIRST VVC EPISODE

• First VVC episode (gray area)→ exclusion from self-care

• Why? First-time patients may have difficulty distinguishing:

  • VVC

  • BV

  • Trichomoniasis

---

VULVOVAGINAL CANDIDIASIS

Treatment

• Treat the infection: Vaginal antifungal

• Relieve symptoms only (do NOT treat Candida infection) : Topical anti-itch product

VULVOVAGINAL CANDIDIASIS

ANTIFUNGALS - topics

• Products/Effectiveness

• ABSORPTION / SAFETY

• ADMINISTRATION

• COUNSELING

VULVOVAGINAL CANDIDIASIS

ANTIFUNGALS - products?

• Products

  • Butoconazole

  • Clotrimazole

  • Miconazole

  • Tioconazole

• Combination Products (Vaginal antifungal + topical component)

  • → especially helpful for:

    • Significant external vulvar itching

    • Irritation

VULVOVAGINAL CANDIDIASIS

ANTIFUNGALS - EFFECTIVENESS?

1. ALL ARE products EQUALLY EFFECTIVE

• Eradicate infection in: 80–90% of cases

• Available as:

  • Creams

  • Suppositories

  • Tablets

2. 1 day = 3 days = 7 days

   1. Faster relief ≠ more effective overall

VULVOVAGINAL CANDIDIASIS

ANTIFUNGALS - ABSORPTION / SAFETY

1. Systemic absorption: 3–10% = minimal

• Therefore: → Drug interactions unlikely

2. Adverse effects:

• Vulvovaginal burning

• Itching

• Irritation

(May be dose-related)

3. Contraindication - Imidazole allergy

VULVOVAGINAL CANDIDIASIS

ANTIFUNGALS - ADMINISTRATION

• Prefer: At night before bed

• Why? → ↓ leakage

• Counseling:

  • Wash vaginal area before use

  • Insert applicator as far as comfortably possible

  • Push medication into vagina

  • Wash reusable applicator with warm soap/water

  • Panty liner may help with leakage

  • Finish entire course

  • Do NOT skip days

---

• During Menstruation

  • ✅ Continue antifungal treatment

  • ✅ Use pads

  • ❌ Do NOT use tampons

• Why? Tampons absorb antifungal medication
  → ↓ medication delivery/absorption

VULVOVAGINAL CANDIDIASIS

ANTIFUNGALS - COUNSELING

EASY MEMORY

• Finish the course

  • ↑ recurrence + possible resistance

• 3 days → tampons/douching + condom/diaphragm concern

• No sex during treatment

• No partner treatment

  • VVC not an STI

Complete the full course

Do NOT stop early.

Stopping early:

→ recurrence
→ possible resistance

---

Tampons / Douching

Avoid until:

3 days after antifungal treatment

---

Intercourse

Avoid during treatment.

Why?

Vaginal antifungals may:

• Damage latex condoms

• Impair diaphragm contraceptives

Effect may persist for:

Up to 3 days after use

---

Partner Treatment

Partners are NOT treated

Why?

VVC is NOT an STI

VULVOVAGINAL CANDIDIASIS

FOLLOW-UP

Symptoms should improve in: 2–3 days

Infection should resolve in:~7 days

Refer if:

• No improvement within 3 days

• Symptoms persist >7 days

• Infection returns within 2 months

• Symptoms chang/worsen

Memorize:

3 DAYS → 7 DAYS → 2 MONTHS

Other VVC Products

1. SYMPTOMATIC RELIEF PRODUCTS

2. COMPLEMENTARY PRODUCTS - Lactobacillus

3. Other complementary products -  tea tree oil / gentian violet / boric acid

Other VVC Products

SYMPTOMATIC RELIEF PRODUCTS

1. These help:

• Burning

• Itching

• Irritation

2. BUT: They do NOT treat the fungal infection

3. Recognize active ingredients:(COME BACK)

• Benzocaine

• Hydrocortisone → external use; avoid prolonged use

• Povidone/iodine

• Cornstarch / aloe / mineral oil

• Sodium bicarbonate → sitz bath

Other VVC Products

COMPLEMENTARY PRODUCTS

• Lactobacillus = prevention

• NOT active treatment

• Why?

  → helps reestablish normal vaginal flora
  → may help prevent Candida overgrowth

Other VVC Products

OTHER COMPLEMENTARY PRODUCTS

Tea Tree Oil

• Vaginal suppository

• 6 nights

• Antibacterial + antifungal

---

Gentian Violet

• Vaginal application

• Used overnight or BID for up to 5 days

• Can stain:

  • Skin

  • Fabric

---

Boric Acid

• Vaginal suppository

• 600 mg QHS × 14 days

• May also be applied topically for symptom relief

• Important: DO NOT ingest orally - Toxic + teratogenic

BACTERIAL VAGINOSIS — BV (SKIP-REFER TO TABLE IN END)

• Presentation

  1. Discharge: Thin gray/off-white

  2. Odor: Fishy; Often worse after intercourse.

  3. pH >4.5

     Usually NOT much:

     • Itching

     • Irritation

     • Pain

• Treatment 1. NO SELF-CARE → REFER

  • Requires antibiotic treatment.

TRICHOMONIASIS (JUST LOOK AT YELLOW PART, REST IN TABLE IN END)

1. Presentation

• Copious + yellow-green frothy + malodorous discharge + pH >4.5

• Also: (COME BACK)

  • Pruritus

  • Vaginal irritation

  • Dysuria

  • Erythema

  • Vulvar edema

2. Important:

• About 50% of affected women may initially be asymptomatic

• Most men are asymptomatic

• STI

3. Treatment

• NO SELF-CARE → REFER

MASTER CHART