5 - Vaginal Conditions Flashcards
What is the vagina?
Fibromuscular structure that connects vulva w/ cervix and uterus
What happens to the vagina during puberty?
Estrogen causes vaginal lining to change to stratified squamous epithelium, which contains glycogen
What is important about the glycogen in the vagina?
- Lactobacillus use glycogen to form lactic acid, which makes the pH 3.5-5.5
- Acidic environment maintains normal vaginal flora and inhibits growth of pathogenic organisms
What occurs after menopause?
Vaginal lining thins, lactobacilli decline, and pH rises
What are some factors that influence vaginal flora, pH, and glycogen concentration?
- Aging
- Menstrual cycle hormonal fluctuations
- Certain diseases (ex: diabetes)
- Various medications (oral or parenteral)
- Douching
- Number of sexual partners
How does diabetes mellitus affect the vagina?
When the body is experiencing hyperglycemia, the body will try to get rid of extra sugar through the urine, which introduces more glucose to the area, providing a food source for microorganisms
Increase in vaginal secretions is normal during _______
- Ovulation
- Pregnancy
- Following menses
- Sexual excitement
- Emotional flares
What is douching?
Using liquid to flush the vaginal cavity
What are disadvantages to douching?
- No sustained benefit
- Upsets natural acidic balance
- Disrupts normal vaginal flora, increasing risk of irritation or infection
- Increases risk of genital tract infections, ectopic pregnancy, potential cervical cancer risk
- Prevent detection of infection
When should douching not be done?
- Pregnancy
- As a contraceptive or self-tx of vaginal infection
- 24-48 hours prior to gynecologic exam
- At least 3 days after last dose of vaginal antifungal medication
What is preferred over the use of genital towelettes?
Daily cleansing w/ mild soap and water
Are cleansers recommended?
As long as only using on external genitalia, no significant risk, but also no proven benefit over mild soap and water
What are disadvantages to feminine deodorant sprays?
- May mask an infection
- May cause irritation and allergic reactions
What is a disadvantage to genital towelettes?
May lead to irritation or allergic reactions
What are some non-pharms to prevent vaginal irritation?
- Wear cotton underwear to allow moisture to escape
- Avoid tight fitting clothing and synthetic materials
- Change pads and tampons regularly; use only unscented products
- Avoid vaginal sprays and deodorants
- Avoid long exposure to conditions that are hot and cause sweating
- Wipe front to back after using the toilet
What is bacterial vaginosis?
- Increased growth in organisms normally found in genital tract
- Decrease in lactobacilli
What is the difference between vaginitis and vaginosis?
- Vaginitis = inflammation and swelling
- Vaginosis doesn’t cause inflammation, so painful urination/intercourse should not be a sx
What are some complications associated w/ bacterial vaginosis?
- 2nd trimester miscarriage
- Pre-term birth
- Pelvic inflammatory disease
What are risk factors for bacterial vaginosis?
- More common if sexually active
- New sexual partner
- IUD
- Douching
Is bacterial vaginosis sexually transmitted?
Not usually
Can bacterial vaginosis be asymptomatic?
Yes
What are signs and sx of bacterial vaginosis?
- Thin, off-white/yellow or grey discoloured discharge
- Vaginal pH 5-6
- Unpleasant “fishy” odour
- Minimal itching
What should be done if a px is suspected to have bacterial vaginosis or trichomoniasis?
Referred
What is involved in diagnosing bacterial vaginosis or trichomoniasis?
- Physical exam
- Lab testing of sample of vaginal fluid
Are there any OTC products to treat bacterial vaginosis?
No
Do asymptomatic px w/ bacterial vaginosis require tx?
No, unless the woman has a high risk pregnancy or it is prior to IUD insertion or gynecological procedures
What is the preferred tx for a px w/ symptomatic bacterial vaginosis?
- Metronidazole 500 mg PO BID for 7 days
- Metronidazole 0.75% gel, 5g intravaginally hs for 5 days
- Clindamycin 2%, 5g intravaginally hs for 7 days
Do sexual partners of a px w/ bacterial vaginosis need tx if they are asymptomatic?
No
Can lactic acid be used to treat bacterial vaginosis?
No, considered significantly less effective than Rx therapies
What is the theory behind using lactic acid for tx of bacterial vaginosis?
Lactic acid thought to return vaginal pH to an acidic environment, allowing healthy vaginal flora to be restored
When is bacterial vaginosis considered recurrent?
If occurs w/in 1-3 months of previous tx
What must be done if bacterial vaginosis if recurrent? What is the tx
- Diagnosis must be reconfirmed by physician
- Tx = metronidazole 500 mg PO BID for 10-14 days
- If 1st tx not effective, 0.75% metronidazole gel, 5g intravaginally hs for 10 days followed by suppressive therapy of metronidazole gel twice a week for 3-6 months
What is the tx for bacterial vaginosis during pregnancy?
- Oral tx preferred
- Metronidazole 500 mg or clindamycin 300 mg PO BID for 7 days
What is trichomoniasis?
Sexually transmitted infection caused by Trichomonas vaginalis
What may happen if trichomoniasis is left untreated?
- Progress to urethritis or cystitis
- Associated w/ reproductive issues
- During pregnancy - preterm delivery, low birth weight
What are risk factors for trichomoniasis?
- Multiple or now sexual partners
- Nonuse of barrier contraception
- Presence of other STI’s
What are the signs and sx of trichomoniasis?
- Large amounts of white or yellow frothy discharge
- Redness of vulva and cervix
- Vaginal pH 6 or higher
- Itching, dysuria (painful urination), no odour
Can trichomoniasis be asymptomatic?
Yes
What is the tx for trichomoniasis?
Oral metronidazole, 2g single dose or 500 mg BID for 7 days
Do sexual partners of a px w/ trichomoniasis need to be treated?
Yes
What is the tx for trichomoniasis in pregnancy?
Same as other tx (2g single dose preferred)
What is another name for vulvovaginal candidiasis?
Yeast infection
What commonly causes vulvovaginal candidiasis?
Candida albicans
Is vulvovaginal candidiasis sexually transmitted?
No
When is vulvovaginal candidiasis considered self-treatable?
If the woman has had a previous diagnosis of candidiasis
What are the signs and symptoms of vulvovaginal candidiasis?
- White, clumpy, curd-like discharge
- Inflammation/redness of vaginal area
- Severe itching
- Pain during sexual intercourse (dyspareunia)
- Stinging/burning
- External dysuria
Can vulvovaginal candidiasis be asymptomatic?
Yes
What are risk factors for vulvovaginal candidiasis?
- Medications (antibiotics, hormones, chemo)
- Menses
- Pregnancy
- Stress
- Immunocompromised
- Poorly controlled diabetes
- Tight fitting clothing
- Irritants (scented products, douches)
- Diet
What are the goals of treatment for vulvovaginal candidiasis?
- Relieve signs and symptoms of infection
- Eradicate infection
- Prevent recurrence
- Prevent misdiagnosis, which causes a delay in treatment
What are the guidelines for self-treatment of vulvovaginal candidiasis?
- Uncomplicated (not recurrent)
- Previously diagnosed
- Mild to moderate sx
- *Not pregnant
- Older than 12 y/o (post puberty)
- Had less than 3 episodes in past year and no signs w/in past 2 months
What are red flags for vulvovaginal candidiasis?
- First episode
- Less than 12 y/o
- Pregnant
- Sx of fever, pain in lower abdomen, back, or shoulder
- Medication - corticosteroids, immunosuppressive drugs
- Medical conditions - diabetes, HIV
- Recurrent infection (less than 2 months since previous episode)
What are some non-pharms for vulvovaginal candidiasis?
- Genital hygiene (avoid vaginal deodorants, douching, harsh soaps, perfumed products)
- Avoid tight clothing and synthetic underwear (use cotton underwear and loose fitting undergarments and pants)
Which type of antibiotic is used for vulvovaginal candidiasis?
Imidazoles/azoles
What are side effects of clotrimazole?
- Itching
- Burning
- Bloating
- Irritation
Do one day treatments for vulvovaginal candidiasis provide any further benefits?
- No b/c symptom relief takes 2-3 days
- Does have a greater chance of adverse effects
What are side effects of miconazole nitrate?
- Itching
- Burning
- Headache
- Allergic contact dermatitis
- Skin rash
What are some counselling tips for tx of vulvovaginal candidiasis?
- Use once daily at bedtime
- Use according to product instructions
- Some relief w/in 24-48 h
- May take 1 week for complete relief
- Do not use tampons/douche for 3 days after tx
- Don’t use condoms or diaphragms during or for 3 days after tx b/c products are oil based and may cause either to fail
What are contraindications for fluconazole?
- Pregnancy
- Not recommended in px under 12 y/o unless physician advice
What are side effects of fluconazole?
- Headache
- Nausea
- Abdominal pain
- Dyspepsia
- Dizziness
What are side effects of terconazole?
- Headache
- Abdominal pain
- Vaginal burning and itching
- Fever, chills
What is a contraindication for terconazole?
1st trimester of pregnancy
What is the monitoring for vulvovaginal candidiasis?
- Improvement of sx w/in 48-72 h
- Resolution of sx in 7 days
- Refer if sx don’t resolve in 7 days or sx worsen
- Recurrence of sx w/in 2 months
What is considered recurrent candidiasis?
4 or more episodes in 1 year
What is the initial tx for recurrent vulvovaginal candidiasis?
- Fluconazole 150 mg every 72 h (3 doses)
- Topical azoles for 10-14 days
- Boric acid intravaginally for 14 days
What is the maintenance tx for recurrent vulvovaginal candidiasis?
- Minimum of 6 months tx
- Fluconazole 150 mg weekly
- Ketoconazole 100 mg once daily
- Clotrimazole 500 mg once per month
- Boric acid 300 mg intravaginally for 5 days each month, beginning on first day of menstrual cycle
What is the recommended therapy for vulvovaginal candidiasis of a pregnant woman?
Topical azole, 7 day tx
What is toxic shock syndrome?
Acute illness caused by a toxin produced by Staph aureus
Who is at risk of getting toxic shock syndrome?
- Menstruating women using tampons
- Women using contraceptive sponges, diaphragm, or cervical cap
- Anyone w/ surgical wound infection
What are the sx of toxic shock syndrome?
- Sudden high fever
- Diarrhea
- Vomiting
- Dizziness
- Muscle aches
- Fainting
- Sunburn-like rash on palms of hands and soles of feet
