In-Depth Medical Notes

Bacterial Vaginosis (BV)

  • Nugent's Criteria for Diagnosing BV:

    • BV is diagnosed with a score of 7-10.
    • A score of 4-6 indicates intermediate flora.

  • Partner Treatment in Managing Recurrent BV:

    • Treatment of partners is essential to reduce recurrence, as untreated partners can cause reinfection.

  • IUD Usage and BV:

    • Higher incidence of BV is noted in women using copper IUDs.
    • The association with hormonal IUDs is unclear.

  • Management during Invasive Procedures:

    • Women with BV should be treated prior to invasive procedures to lower the risk of pelvic inflammatory disease (PID) and endometritis.

  • BV and STIs:

    • BV increases the risk of acquiring STIs (chlamydia, gonorrhea, herpes simplex type 2, HIV) by 2-4 times.

  • Risk of PID:

    • Women with BV are at increased risk of PID after surgical interventions such as IUD insertion or termination of pregnancy.

  • Common Symptoms of BV:

    • Symptoms include vaginal malodor and a thin, white or greyish vaginal discharge.

  • Complications of BV:

    • BV is associated with complications like increased risk of spontaneous abortion, premature labor, chorioamnionitis, postpartum endometritis, and PID.

  • Treatment for Male Partners of Women with BV:

    • Recommended treatment includes:
    • Metronidazole: 400mg PO twice daily for 7 days.
    • Clindamycin: 2% topical cream applied twice daily for 7 days.

  • Treatment for Asymptomatic Women Requesting BV Treatment:

    • Treat if requested, especially in ongoing relationships with male partners.

Candidiasis (Thrush)

  • Common Causes:

    • Caused by an overgrowth of vaginal yeasts, primarily Candida albicans.
    • Non-albicans species cause 10-20% of cases.

  • Contributing Factors to Candidiasis:

    • Factors include antibiotic use, pregnancy, diabetes, and immune suppression.

  • Conditions without Candidiasis:

    • Candidiasis does not occur in non-oestrogenised environments (e.g., prepubertal girls, postmenopausal women not on estrogen).

  • Symptoms of Candidiasis:

    • Symptoms include vaginal discharge, vulval dermatitis, itching, irritation, and soreness.

  • Characteristics of Vaginal Discharge:

    • Discharge is often thick, white, and curd-like, but can also appear yellow or green.

  • Diagnostic Tests:

    • Microscopy and pH evaluation assess for budding yeasts and determine pH (<4.5).
    • A higher pH (>4.5) may indicate BV.

  • Treatment for Acute Candidiasis:

    • Options include Clotrimazole vaginal cream/pessary for 3-6 nights or Miconazole vaginal cream.

  • Chronic/Recurrent Candidiasis:

    • Defined as 4 or more symptomatic episodes in a year, affecting 5-9% of women.
    • Treatment duration of at least 6 months for suppression is recommended.

  • Management of Chronic Candidiasis:

    • Induction therapy: Fluconazole PO 50mg daily or 150mg every 3-5 days for 10-14 days.
    • Suppression therapy: Fluconazole PO 100-200mg once or twice weekly for 6 months or longer.
    • If symptoms persist after treatment, increase antifungal dose or change antifungal class.

  • Cure Rates:

    • Cure rates for topical and oral azole therapies are between 80-90%.

  • Warnings for Patients:

    • Patients should be informed that treatments can weaken latex condoms.

Chlamydia

  • Overview:

    • Chlamydia is a common bacterial STI that is often asymptomatic in both men and women.

  • Symptoms:

    • In men: Urethritis with discharge, dysuria, proctitis.
    • In women: Cervicitis with discharge, post coital bleeding, proctitis.
    • Potential complications include PID and mother-to-child transmission.

  • Testing:

    • Best test for women: NAAT via endocervical swab.

  • Treatment:

    • Uncomplicated genital/pharyngeal infection: Doxycycline 100mg PO twice daily for 7 days or Azithromycin 1g PO stat.
    • Anorectal infection: Same as above, repeat Azithromycin as necessary.
    • Treatment for pregnant women: Azithromycin 1g PO stat or Amoxicillin 500mg PO three times daily for 7 days.

  • Follow-up Testing:

    • Retest at 3 months to exclude reinfection; not within 4 weeks of treatment unless symptomatic.

  • Patient Education:

    • Discuss partner notification, and patients should abstain from sexual activity for 7 days after treatment.

  • Patient Delivered Partner Therapy (PDPT):

    • Treatment for partners unable to attend, but not recommended for high-risk populations due to potential missed co-infections.

Gonorrhoea

  • Cause:

    • Caused by Neisseria gonorrhoeae.

  • Symptoms:

    • Urethral discharge in men, cervicitis in women, pharyngeal/rectal infections, which may be asymptomatic.

  • Testing:

    • NAAT options for testing in women include endocervical, self-collected vaginal swabs, and urine.

  • Culture:

    • Essential for antimicrobial susceptibility testing.

  • Management:

    • Uncomplicated gonorrhoea: Ceftriaxone 500 mg IM plus Azithromycin 1 g PO.
    • Pharyngeal gonorrhoea: Ceftriaxone plus higher Azithromycin dose.
    • Recommended screening: Annual for MSM (men who have sex with men).

  • Complications:

    • Can lead to PID in women and epididymo-orchitis in men.

Management of Cervical Cancer

  • Incidence:

    • Australia has low incidence rates but still reports several new cases of invasive cervical cancer annually.

  • Management:

    • Multidisciplinary approach essential, including assessment of disease stage using FIGO system.

  • Surgical Options:

    • Options vary by stage; fertility-sparing procedures available for early-stage cancer.

  • Treatment for Advanced Disease:

    • Chemotherapy and palliative care are crucial for managing advanced or recurrent cases.

  • Psychosexual Issues:

    • Address patient concerns about sexual health, fertility, and psychological impacts of the diagnosis and treatment.