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Clinical 1 (Part B) > 7 - Vaginal Conditions > Flashcards

7 - Vaginal Conditions Flashcards

1
Q

Describe the vaginal physiology

A
  • At puberty, due to estrogen, vaginal lining changes to stratified squamous epithelium, which contains glycogen
  • Lactobacillus bacteria uses the glycogen to form lactic acid. This creates an acidic pH of 3.5-5.5
  • This acidity helps maintain the normal vaginal flora and inhibits growth of pathogenic organisms
  • After menopause, thinning of the vaginal lining occurs, lactobacilli decline and pH rises
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2
Q

List some factors that influence the vaginal flora, pH and glycogen concentration

A
  • aging
  • menstrual cycle hormonal fluctuations
  • certain diseases (ex. diabetes mellitus)
  • various medications (ex. medications)
  • douching (flushing the area will disrupt normal flora)
  • number of sexual partners (increases exposure to additional organisms)
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3
Q

How can diabetes mellitus change vaginal pH?

A

If its not being managed or it’s a new condition, your body has to excrete the glucose in some way (often through urine) if it is left in vagina, other bacteria can eat the glucose as food and change pH.

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4
Q

Describe vaginal discharge

A
  • It will change in amount, consistency, and appearance throughout menstrual cycle.
  • It is odourless, clear, or white, viscous or sticky.
  • An increase in vaginal secretions is normal during ovulation, pregnancy, following menses, sexual excitement or emotional flares. **It should not cause irritation, burning or itching.
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5
Q

What is a normal amount of discharge?

A
  1. 5 gram/day

* generally clear, odourless or colorless

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6
Q

Describe vaginal hygiene

A

Basically, the vagina is self-cleaning through secretions and has protective substances.
There are products out there but they are useless and can actually disrupt normal flora.

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7
Q

Describe Douching

A
  • Use of liquids to flush vaginal cavity
  • Found to have no sustained benefit (and can potentially cause harm - disruption of normal flora)
  • Upsets natural acidic balance
  • Lots of potential adverse effects:
    • Disruption of normal flora
    • Risk of genital tract infections, ectopic pregnancy, potential cervical cancer risk
    • May prevent detection of infections
  • Can be associated with preterm births, low birth weight infants and decreased fertility
  • Avoid douching in pregnancy, as a form of contraceptive or self-treatment of vaginal infections, 24-48 hours prior to gynecologic exam and at least 3 days after the last dose of a vaginal anti fungal medication.
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8
Q

Describe genital towelettes

A
  • May contain perfumes, astringents, emollients and anti-invectives which may lead to irritation or allergic rxns
  • Ocasional use, but daily cleansing with mild soap and water preferred
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9
Q

Describe vaginal cleansers

A

-Meant for external genitalia, no proven benefit versus mild soap and water

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10
Q

Describe feminine deodorant sprays

A
  • Meant to decrease genital odour, contain perfumes, and propellants
  • Risk of masking an infection, causing irritation and allergic reactions
  • Do not apply to inside of vagina
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11
Q

List some non-pharms to prevent vaginal irritation

A
  • Wear cotton underwear
  • Avoid tight fitting clothing and synthetic materials
  • Change pads and tampons every 4-8 hours, use only unscented products
  • Avoid vaginal sprays and deodorants
  • Change ou of damp swim wear and sports clothing
  • Avoid long exposure to conditions that are hot and cause sweating
  • Wipe front to back
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12
Q

What is Bacterial vaginosis?

A

Imbalance in normal vaginal flora

-Increased growth in organisms (anaerobic bacteria) normally found in the genital tract & a decrease in lactobacilli

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13
Q

Bacterial vaginosis:

Complications?

A
  • 2nd trimester miscarriage
  • pre-term birth
  • pelvic inflammatory disease
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14
Q

Bacterial vaginosis:

Risk factors?

A
  • more common if sexually active
  • new sexual partner
  • IUD
  • douching
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15
Q

Bacterial vaginosis:

Sexually transmitted ??

A

not usually

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16
Q

Bacterial vaginosis:

Signs

A
  • thin, off-white/yellow or grey discoloured discharge

- vaginal pH 5-6

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17
Q

Bacterial vaginosis:

Symptoms

A
  • unpleasant “fishy” odor
  • can be asymptomatic
  • minimal itching

*Painful intercourse and painful urination are NOT symptoms because there is no inflammation

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18
Q

Bacterial vaginosis:

Treatment if they are asymptomatic

A

Treatment not required except:

  • High risk pregnancy
  • Prior to IUD insertion, gynecological procedures
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19
Q

Bacterial vaginosis:

Treatment if they are symptomatic

A

Requires Rx Tx:

  • Oral or topical metronidazole
  • Oral or topical clindamycin
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20
Q

Bacterial vaginosis:

Does male partner need treatment?

A

No - it is not sexually transmitted

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21
Q

Bacterial vaginosis:

When is it considered to be recurrent?

A

If it occurs within 1-3 months of previous treatment
(occurs in 15-30% of patients)

*Diagnosis must be reconfirmed by physician

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22
Q

Bacterial vaginosis:

Recommended Rx Tx for recurrent conditions?

A

Oral or topical Metronidazole

*Metronidazole gel 0.75%, one applicator (5g) once a day intra-vaginally for 10 days, followed by suppressive therapy or metronidazole gel twice a week for 4-6 months

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23
Q

Bacterial vaginosis:

Treatment in pregnancy

A
  • Oral treatment preferred
  • Metronidazole (500mg orally twice daily for 7 days)
  • Clindamycin (300mg orally twice daily for 7 days)
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24
Q

Describe Trichomoniasis

A

Sexually transmitted infection caused by Trichomonas vaginalis (a protozoa)

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25
Q

Trichomoniasis:

Complications?

A
  • Low birth weight infants

- Tubal infertility

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26
Q

Trichomoniasis:

Risk Factors?

A
  • Multiple or new sexual partners
  • Nonuse of barrier contraception
  • Presence of other STIs
27
Q

Trichomoniasis:

Is it a reportable STI?

A

No - not in Mb

Ghonorrea, syphillis

28
Q

Trichomoniasis:

Signs?

A
  • Large amounts of white or yellow frothy discharge (may be green-yellow)
  • Redness of vulva and cervix
  • Vaginal pH > 6
29
Q

Trichomoniasis:

Symptoms?

A
  • No odor
  • Vaginal discharge
  • Itching
  • May be asymptomatic
30
Q

Trichomoniasis:

Treatment ?

A

Oral metronidazole
-2gm single dose
OR
-500 mg BID for 7 days

31
Q

Trichomoniasis:

Do you treat sexual partners?

A

heck yes you do

32
Q

Trichomoniasis:

Treatment in pregnancy?

A

Oral metronidazole
-2gm single dose preferred
OR
-500 mg BID for 7 days is alternate treatment

33
Q

Describe Vulvovaginal Candidiasis (VVC)

A
  • Generally caused by Candida albicans

- Normal vaginal flora can become pathogens when there is a change in the vaginal environment

34
Q 
Vulvovaginal Candidiasis (VVC):
Is it sexually transmitted?
A

No

35
Q 
Vulvovaginal Candidiasis (VVC):
Signs?
A

White, clumpy, curd-like discharge

  • Inflammation/redness of vaginal area
  • vaginal pH < 4.5
36
Q 
Vulvovaginal Candidiasis (VVC):
Symptoms?
A
  • Itching (severe)
  • Pain during sexual intercourse
  • No odor
  • Stinging/burning
  • May be asymptomatic
37
Q 
Vulvovaginal Candidiasis (VVC):
Risk factors?
A
  • Medications: Antibiotics (alter normal flora), Hormone ingestion (OC’s, HRT), chemotherapy
  • Menses (rare prior to menses and post menopausal)
  • Pregnancy
  • Stress
  • Immunocompromised
  • Diabetes (poorly controlled)
  • Clothing (tight fitting/synthetic fabrics)
  • Irritants (scented products, douches)
38
Q 
Vulvovaginal Candidiasis (VVC):
Goals of treatment
A
  • Relieve signs and symptoms of the infection
  • Eradicate the infection
  • Prevent recurrence
  • Prevent misdiagnosis and therefore a delay in treatment
39
Q 
Vulvovaginal Candidiasis (VVC):
Guidelines for self-treatment?
A
  • Uncomplicated (not recurrent)
  • Previously diagnosed as VVC
  • Mild to moderate symptoms
  • NOT pregnant
  • > 12 years old
  • Frequency (has had less than 3 episodes in the past year, and no signs within the last 2 months)
40
Q 
Vulvovaginal Candidiasis (VVC):
Red flags/referral
A
  • First episode
  • < 12 years of age
  • Pregnancy
  • Symptoms of fever, pain in the lower abdomen, back or shoulder
  • Medication use (corticosteroids, immunosuppressive drugs)
  • Medical conditions (Diabetes, HIV infection)
  • Recurrent infection (<2 months, 4 infections within a 12 month period)
41
Q 
Vulvovaginal Candidiasis (VVC):
Non-pharm Therapy
A
  • Keep tissue healthy and free from irritation by using a good genital hygiene measures.
  • Avoid vaginal deodorants, douching, harsh soaps and perfumed products
  • Avoid tight clothing and synthetic underwear. Recommend cotton underwear and loose fitting undergarments and pants
  • Dietary modifications?
42
Q

Describe imidazoles (azoles)

A

-Equally effective
-80-90% effective in relieving symptoms
-Little systemic absorption
-Clotrimazole - OTC
-Miconazole - OTC
-Butoconazole - Rx
Terconazole - Rx

43
Q

Describe Clotrimazole

A
  • Intravaginal or topical OTC options
  • Used for mild to moderate fungal infections
  • Side effects: Itching, burning, bloating, irritation
44
Q

Describe Clotrimazole Products

A 
Canesten 1 (Ovule or Cream plus external cream)
Canesten 2 (Tablet or Cream plus external cream)
Canesten 6 (6 day cream)
45
Q

Describe Miconazole Nitrate

A
  • Intravaginal or topical OTC options
  • Used for mild to moderate fungal infections
  • Side effects: Itching, burning headaches, allergic contact dermatitis, skin rashes
46
Q

Describe Miconazole Nitrate Products

A 
Monistat 1 (Ovule plus external cream)
Monistat 3 (Ovules or Cream plus external cream)
Monistat 7 (Ovules or Cream plus external cream)
47
Q

Crucial Patient Information for Vaginal Infections

A
  • Use once daily at bedtime
  • Use according to product instructions
  • Some relief within 24-48 hours
  • May take a week for complete relief
  • Tampons/Douching
    • Not to be used for 3 days after treatment
  • Condoms or diaphragms
    • Not to be used during or for 3 days after treatment
    • Oil based and may cause either to fail
48
Q

Describe Fluconazole

A
  • Single dose oral medication available OTC
  • Clinical cure 97% within 5-16 days
  • CI in Pregnancy (OTC)
  • As a self-treatment
  • It is okay if the Dr. diagnoses it as VVC
  • Not recommended in females < 12 unless under the advice of a physician
  • Side effects - headache, nausea, abdominal pain, dyspepsia, dizziness
49
Q

Describe Fluconazole Products

A

CanesOral (1 oral capsule - 150 mg)

Canesten Oral Combipak (1 capsule + External Cream)

50
Q

Describe Butoconazole 2% - Rx

A
  • Intravaginal or topical prescription options
  • Used for mild to moderate fungal infections
  • Pregnancy: Only to be used in 2nd or 3rd trimester (Category C - studies are lacking)
  • Side effects: Some vaginal irritation, burning, itching
  • Contains mineral oil
51
Q

Describe Butoconazole 2% - Rx Products

A
  • Gynazole 1 Cream (Prescription only)

- Single dose profiled applicator (5gm)

52
Q

Describe Terconazole - Rx

A
  • Intravaginal or topical Rx options
  • Used for mild to moderate fungal infections
  • Pregnancy: Avoid during 1st trimester (possibility of absorption)
  • Side effects: Headache, abdominal pain, vaginal burning and itching, fever, chills
53
Q

Describe Terconazole - Rx Products

A

Terazol 7 Vaginal Cream
-Terconazole 0.4% (20mg/applicatorful)

Terazol 3 Vaginal Ovules
-Terconazole (80mg/ovule)

54
Q

Monitoring Parameters for vaginal infections

A
  • Improvement of symptoms within 48-72 hours
  • Resolution of symptoms in 7 days
  • Referral if symptoms do not resolve in 7 days or symptoms worsen
  • Recurrence of symptoms within 2 months
55
Q

See slides 38-40 for treatment options

A

okay

56
Q

Describe Adjunctive therapy

A
  • Several OTC products marketed for vulvovaginal infections
  • Number of products contain local anesthetics such as benzocaine (eg. Vagisil) and are said to relieve irrational and itching
  • But they do not treat the cause of the itching and can cause local reactions, therefore not recommended
  • Probiotic Lactobacilus - possibly ineffective
57
Q

Describe Recurrent Candidiasis

A
  • > 4 episodes in one year
  • Must be confirmed by obtaining a vaginal culture
  • Severe symptoms
  • Possible diagnosis in women with:
    • Uncontrolled diabetes
    • Immunosuppression
    • Pregnancy
58
Q

Describe the Initial treatment of recurrent candidiasis

A
  • Fluconazole 150 mg every 72 hours (3 doses)
  • Topial azoles for 10-14 days
  • Boric acid intravaginally for 14 days
59
Q

Describe the Maintenance treatment of recurrent candidiasis

A
  • Minimum of 6 months treatment - relapse rate is high
  • Fluconazole 150mg 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
60
Q

What is toxic shock syndrome (TSS) ??

A

-An acute illness caused by a toxin producing Staph aureus (commonly found pathogen in the vulvar tissue)

61
Q

Who is at risk of toxic shock syndrome (TSS) ??

A
  • Menstruating women using tampons, women using contraceptive sponge, diaphragm, or cervical cap
  • Anyone with a surgical wound infection
62
Q

Symptoms of toxic shock syndrome (TSS) ??

A

Sudden high fever, diarrhea, vomiting, dizziness, weakness, muscle aches, fainting or near fainting, sunburn-like rash in the palms of the hand & the soles of the feet

63
Q

Treatment for toxic shock syndrome (TSS) ??

A

IMMEDIATE REFERRAL MAN

*if untreated, may be fatal

Clinical 1 (Part B) (11 decks)

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