Transcript Cigarette Smoking and Frequency of Menopausal Hot Flashes

Vaginitis and
Sexually Transmitted Infections
VETERANS HEALTH ADMINISTRATION
Learning Objectives
Identify common causes of vaginitis
Describe risks, symptoms, treatment, and prevention
strategies for common vaginal infections and how to
educate patients
Understand the components of a good sexual history
Discuss how to evaluate risk for sexually transmitted
infections and how they present differently in women
Vaginitis
Most frequent reason American women visit the
provider
More than 10 million office visits per year
Many related to infections that are
transmitted by sexual contact
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Most Common Causes of Vaginitis
Overgrowth of vaginal flora/organisms
Sexually transmitted infections
Non-infectious causes (leukorrhea, atrophic
vaginitis, progestin-only contraceptives, foreign
bodies, reactions to deodorants, latex, vaginal
sprays, spermicides, semen)
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Initial Questions
Timing
Description
Sexual history
Medications
Comorbidities
Personal habits
How long?
First time or recurrence?
Odor?
Itching?
Bleeding?
New partners?
Recent antibiotics?
HIV?
Diabetes?
Douching? Lubricants?
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The Sexual History - CDC’s 5 P’s
1. Partners
• Men, women, both?
• How many partners in past
2 months? Past 12 months?
3. Protection from STIs
• What is she doing?
• What is her understanding of
what she should be doing?
2. Practices
• Vaginal/anal/oral sex?
• Intravenous drug use?
• Ever exchange sex for
money or drugs?
4. Past history of STIs
• Previous STIs in her or her
partner(s)?
5. Pregnancy prevention
• What is she using?
Condom use?
• When and with whom?
• If not used all the time, in
what situations?
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Final probe…
“Is there anything else that I
need to know about?”
Assess discharge (color,
viscosity, odor, adherence to
vaginal walls)
Visualize cervix to rule
out cervicitis
Approach
to
Vaginitis
Lab tests (pregnancy,
pH, wet mount,
cultures, BD Affirm)
Opportunity for birth control
and Plan B discussions
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Common Causes of Vaginitis
Bacterial Vaginitis
+
Candidiasis
+
Trichomonas
= 90% of vaginitis cases
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Bacterial Vaginosis (BV)
• Lack of protective lactobacilli that keep
anaerobes in check
• Most common cause of discharge, but
50% of women are asymptomatic
• Risk factors: douching, deodorant
sprays, contact irritants
Diagnosis: need 3 of the following
-
Thin, milky-white discharge smoothly coating vaginal walls
pH >4.5
“Fishy” amine odor with 10% KOH (whiff test)
Clue cells (>20%) on wet mount
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Bacterial Vaginosis (BV)
• Women with BV may be at higher risk for:
- Acquiring STIs including HIV, gonorrhea, chlamydia, herpes
- Post-op infections after gynecologic procedures
- Pregnancy complications (premature rupture of
membranes, premature delivery, low‐birth weight)
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30% of women have a recurrence in 3 mos, 50% in 12
Often identified in female-female partnerships
NOT an STI - there is no role for treating partners
Recurrent BV: Consider maintenance tx with metronidazole gel
Treatment: metronidazole 500mg BID x 7 days; topical therapy
also available
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Vulvovaginal Candidiasis (Yeast infection)
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Overgrowth of normal vaginal flora
75% of women experience it; half have recurrences
Itching, redness, burning, ‘cottage cheese discharge’, no odor
Risk factors:
- DM, antibiotics, douching, spermicides, corticosteroids,
pregnancy, HIV, exogenous estrogens, immunosuppression
Diagnosis
- Pseudohyphae on KOH
- pH ≤4.5
Treatment
- Fluconazole 150mg x 1 or
intravaginal antifungal x 7 dy
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Complicated Vulvovaginal Candidiasis (VVC)
Recurrent VVC
• 7-14 days topical therapy
• Fluconazole 150mg Q 72 hours x 3 doses, then 150mg weekly
x 6 months
• Alternatively, clotrimazole 200 mg vaginal cream twice weekly
or 500 mg vaginal suppository once weekly
Severe VVC/Compromised host
• 7-14 days of topical therapy
• 150 mg dose fluconazole – repeat in 72 hours
Non-albicans VVC
• Culture if >4 episodes per year
• 600mg boric acid vaginally daily x 14 days
• 7-14 days non-fluconazole therapy (intravaginal nystatin)
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Patient Education for Candidiasis
• Lack of vaginal lactobacillus bacteria allows overgrowth of yeast
fungus
• Can be spread through oral-genital contact
• Take medicine as directed
• Avoid douches or feminine sprays
• Mineral oil in topical antifungal preparations may erode latex
condoms and diaphragms. Use plastic or polyethylene condoms.
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Trichomoniasis
• Itching, burning, redness, pain during
urination/intercourse, strawberry cervix
• Frothy, thin, malodorous, yellow-green
discharge; 70-85% of women asymptomatic
• Risk factors: multiple partners, low SES, STI hx
• Caution treatment in pregnancy
Diagnosis
- pH > 4.5; trichomonads on wet mount (read
slide within 10 min)
Treatment
- Metronidazole 2 grams x 1
- Sexual partners must be treated
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Patient Education for Trichomoniasis
• Can last for years without treatment
• Metronidazole may trigger cramps, nausea, vomiting,
headaches and flushing if combined with alcohol
– Avoid alcohol use during treatment and 24-72 hrs after
• No metronidazole during first trimester of pregnancy
• No sex until patient/partner(s) complete treatment
• Can recur; re-evaluate if symptoms persist
• Trichomonas may facilitate HIV transmission
• Reduce risks: abstinence, mutual monogamy, latex condoms,
limit number of sex partners
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Remember Other Causes of Vaginitis
• 25-40% of symptomatic patients will not have a
specific cause after diagnostic testing
• DDx Vaginitis:
Atrophic vaginitis
Retained foreign body
Mucous membrane
Surgical site infection
Post-childbirth granulation tissue
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Erosive lichen planus
Lichen sclerosis
Pemphigoid
Malignancy
Sexually Transmitted
Infections (STIs)
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Risk Among Military Women
• Women in the military are at increased risk of STIs
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Less regular condom use
Higher rates of binge drinking
Higher positive screening rates for active duty
Higher rates of unintended pregnancy
• 33% of women Veterans reported unintended sex
while under the influence of alcohol or drugs during
military service
• Sexual assault during service may increase risk
Goyal et al. Am J Obstet Gynecol, 2012; Goyal e al. J Womens Health, 2012.
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Chlamydia
• 1.6 million new infections per year
• Found in cervix, urethra, throat, rectum
• Frequent/urgent urination with burning,
vaginal discharge, post-intercourse light
bleeding, lower abdominal pain; but
75% of women are asymptomatic
• Associated with PID (can lead to scarring, infertility, tubal
pregnancy)
• Perinatal transmission results in neonatal conjunctivitis in 30-50%
of exposed babies
Diagnosis: NAAT can be used with female urine, direct florescent
antibody is not as sensitive, EIA even less sensitive
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Chlamydia Screening and Treatment
USPSTF recommends screening asymptomatic women…
 Yearly for all sexually active women ≤ 24 years
 Yearly for sexually active women > 24 years with risk factors
• African American, new male sex partner, 2+ partners in
preceding year, inconsistent condom use, hx of prior STI
 All pregnant women at first prenatal visit
Treatment
- Antibiotics (azithromycin 1 g orally in single dose or doxycycline
100 mg orally twice daily x 7 days)
- Retest at 3 mos or when patient seeks care in next 12 mos
- Evaluate and treat partners
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Gonorrhea
• Grows in vagina, cervix, urethra, mouth,
throat, eyes, anus
• Penetrance to women in 50% of sexual
encounters
• Painful urination, vaginal discharge, bleeding
between periods; but 50% of women are
asymptomatic
• Associated with Bartholin’s cyst , PID
• Evaluate and treat partners; retest at 3-6 mos or within 12 mos
Diagnosis: NAATs, DNA probe, endocervical culture
Treatment: dual tx with Ceftriaxone as single IM dose, plus either
azithromycin orally single dose or doxycycline twice daily x 7 days
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Patient Education for Gonorrhea
• If untreated, can lead to PID, scarring of fallopian tubes, and
ultimately infertility
• Increases susceptibility to HIV infection
• Some strains of gonorrhea are resistant to treatment, report
unresolved symptoms or those that return within 1-2 weeks
• Retest in 3-6 months to rule out re-infection
• No sex until patient/partner(s) complete
treatment
• Reduce risks: abstinence, mutual monogamy,
latex condoms, limit number of sex partners
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Pelvic Inflammatory Disease
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Upper genital tract infection
Diagnosis is made on clinical findings
Can be subtle
Potential complications: infertility, ectopic pregnancy
Consider with pelvic/lower abdominal pain without
other cause and CMT, uterine or adnexal tenderness
• Other: inflammatory markers, vaginitis
• Empiric Treatment should cover gonorrhea/chlamydia
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+/- metronidazole for anaerobic coverage
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Genital Herpes Simplex Virus (HSV-2)
• 25% of population has serological evidence; 1 in 4 women and
1 in 5 men ages 15-45
• Transmitted by kissing, skin-to-skin contact, vaginal/oral/anal sex
- Can be transmitted when symptoms are not present
• Primary outbreak occurs 1 week after contact
- Fever, chills, headache, painful lymph nodes in groin
- Pain or itch usually precedes blisters/skin ulcers
- 75% with primary genital HSV infection are asymptomatic
• Outbreaks can occur 4-5 times/year; most frequent in first year
• After resolution, asymptomatic intermittent viral shedding occurs
even in absence of genital lesions
• Complications: viral encephalitis, sexually transmitted proctitis
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Herpes Cervicitis
Genital Herpes
Diagnosis
- Often inaccurate if based only on H&P
- Viral culture for active lesions
- PCR to detect asymptomatic virus shedding
- Direct fluorescent antibody for clinical specimens
(can determine herpes subtype )
Treatment
- Antiviral meds treat primary herpes and
suppress recurrent outbreaks (daily
antivirals can decrease recurrences by
70-80% for those with 6+ episodes/yr)
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Patient Education for Genital Herpes
• No cure. Symptoms may recur; frequency varies by person.
• First attack is usually worst; 40% never have second outbreak
• Outbreaks can be related to menses, intercourse, sunbathing,
stress
• Inform all partners; abstain from sex when symptomatic
• Can be transmitted without symptoms; use latex condoms
• Herpes increases likelihood of spreading HIV
• Topical treatments don’t work; analgesics help painful lesions
• Inform provider if you become pregnant
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Condyloma lata lesions (secondary
syphilis)
Syphilis
40,000 new cases each year
• Primary: chancre or ulcer
• Secondary: rash, lymphadenopathy
• Tertiary: years later, neurologic
infection throughout body
Diagnosis
- VDRL and RPR; FTA-ABS can confirm diagnosis
Treatment
- Early infections: single-dose benzathine penicillin
- Late latent infections of unknown duration: benzathine penicillin
in 3 doses each at 1 wk intervals
- Clinical and serological FU tests at 6 mos and 12 mos post-tx
- Treat partners presumptively
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Patient Education for Syphilis
• Return for 6- and 12-month follow-up appts
• No sex until patient/partner(s) complete treatment
• Pregnant women should have a blood test for syphilis to prevent
passing infection to the baby
• People with syphilis are more likely to become infected if
exposed to HIV through sex; people with HIV + syphilis are more
likely to spread HIV to others
• Reduce risks: abstinence, mutual monogamy, latex condoms,
limit number of sex partners
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HPV-Related Genital Warts
• Caused by HPV subtypes 6 and 11
• Benign but very contagious
• Pink or flesh-colored, raised/flat spots
resemble cauliflower
• Found inside/outside vagina or anus, on
nearby skin, on cervix, lips, mouth, tongue,
throat
• Women can be infected with no symptoms
• Can take 6 mos to develop
Treatment
- Creams (Polophyllin TCA, Aldara or imiquimod 5%)
- Cryosurgery, laser therapy, electro-cauterization, excision
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Patient Education for Genital Warts
• Even though warts may be removed, viral infection can't be cured
• Warts often return; they are benign but very infectious
• No sex until patient/partner(s) complete treatment
• Get regular Pap smears
• Best prevention is abstinence or sex with only one uninfected
partner; condoms help prevent infection, but don’t cover all
affected skin
• Topical treatments can cause changes in pigmentation
• Gardasil immunization for uninfected partners <27 years of age
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Human Immunodeficiency Virus (HIV)
• Growing problem for women: Black/Hispanic women represent
<29% of US women, but account for 79% of female AIDS cases
• Nonoxynol-9 spermicide may increase transmission risk
• Transmitted by vaginal/anal/oral sex, needle sharing, occupational
exposure, transplant, artificial insemination, contaminated
transfusion
• Testing:
– CDC: screen everyone for HIV, any time at any site at least once,
and yearly for anyone at risk
– VA: no age limit; verbal consent suffices; no pre-post test
counseling required but must provide written materials
– POC testing now available (OraQuick)
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VHA Guidance on Clinical Preventive Services
• VHA develops Guidance Statements on Clinical
Preventive Services (screenings, immunizations,
brief health behavior counseling, preventive
medications)
• Approved statements are posted here:
http://vaww.prevention.va.gov/Guidance_on_Clinical_Preve
ntive_Services.asp
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Helpful References and Resources
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CDC. A Guide to Taking a Sexual History.
http://www.cdc.gov/std/treatment/SexualHistory.pdf
CDC. Self-Study STD Modules for Clinicians. Vaginitis. 06/15/12.
http://www2a.cdc.gov/stdtraining/selfstudy/vaginitis/default.htm
CDC. 2010 STD Treatment Guidelines..
http://www.cdc.gov/std/treatment/2010/default.htm
CDC. HPV Vaccination. 02/07/13.
http://www.cdc.gov/vaccines/vpd-vac/hpv/default.htm#ed
Seattle STD/HIV Prevention Training Center. The Practitioner’s
Handbook for the Management of Sexually Transmitted
Disease. Seattle: University of Washington, 2013.
http://www.stdhandbook.org/
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Additional References
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Goyal V, Borrero S, Schwarz EB. Am J Ob GYN. 2012 Jun; 206 (6):
463-469.
Goyal V, Mattocks KM, Sadler AG. J Womens Heath. 2012 Nov;
21(11): 1155-1169.
Workowski KA, Berman SM. Centers for Disease Control and
Prevention sexually transmitted diseases treatment guidelines.
Clin Infect Dis. 2007;44(s3):S73-6
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Authors
Catherine Staropoli, MD
VA Maryland Healthcare System
Linda Rawers, MSN, FNP
VISN 19 Lead Women Veterans’ Program Manager
Kathleen McIntyre-Seltman, MD
VA Pittsburgh Healthcare System
Linda Baier Manwell, MS
University of Wisconsin-Madison, Division of General Internal Medicine
Molly Carnes, MD, MS
University of Wisconsin-Madison Center for Women’s Health Research
Karen Goldstein, MD, MSPH
Durham VA Medical Center
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