Gynaecology Flashcards
Define atrophic vaginitis
Atrophic vaginitis refers to dryness and atrophy of the vaginal mucosa related to a lack of oestrogen.
Atrophic vaginitis can also be referred to as genitourinary syndrome of menopause.
It occurs in women entering the menopause.
Describe the presentation of atrophic vaginitis
Atrophic vaginitis presents in postmenopausal women with symptoms of:
- Itching
- Dryness
- Dyspareunia (discomfort or pain during sex)
- Bleeding due to localised inflammation
Consider atrophic vaginitis in older women presenting with recurrent UTI, stress incontinence or pelvic organ prolapse.
Describe what can be seen in the examination of atrophic vaginitis
Examination of the labia and vagina will demonstrate:
Pale mucosa Thin skin Reduced skin folds Erythema and inflammation Dryness Sparse pubic hair
Describe the management of atrophic vaginitis
Vaginal lubricants can help symptoms of dryness. Examples include Sylk, Replens and YES.
Topical oestrogen can make a big difference in symptoms. Options include:
- Estriol cream, applied using an applicator (syringe) at bedtime
- Estriol pessaries, inserted at bedtime
- Estradiol tablets (Vagifem), once daily
- Estradiol ring (Estring), replaced every three months
Topical oestrogen shares many contraindications with systemic HRT, such as breast cancer, angina and venous thromboembolism. Women should be reviewed annnually.
Define bacterial vaginosis
BV refers to overgrowth of anaerobic bacteria in the vagina. It is caused by a loss of the lactobacilli bacteria in the vagina. BV can increase the risk of women developing STIs.
Describe the aetiology of bacterial vaginosis
Lactobacilli are part of healthy vaginal bacterial flora. These produce lactic acid which keeps the vaginal pH under 4.5.
The acidic environment keeps other bacteria from overgrowing but in BV, since there is less lactobacilli, the pH rises. Te more alkaline environment enables anaerobic bacteria to multiple.
Give examples of anaerobic bacteria associated with bacterial vaginosis
- Gardnerella vaginalis (most common)
- Mycoplasma hominis
- Prevotella species
Describe the risk factors of bacterial vaginosis
- Multiple sexual partners (although it is not sexually transmitted)
- Excessive vaginal cleaning (douching, use of cleaning products and vaginal washes)
- Recent antibiotics
- Smoking
- Copper coil
Describe the presentation of bacterial vaginosis
- FISHY-SMELLING
- watery grey or white vaginal discharge
half of the women with BV are asymptomatic
itching, irritation and pain are not typically associated with BV so think other causes
Describe the investigations of bacterial vaginosis
- speculum examination to confirm typical discharge and swab
- vaginal pH testing using swab and pH paper (normal = 3.5-4.5)
- charcoal swab for microscopy which shows CLUE CELLS!
What are clue cells?
epithelial cells from the cervix that have bacteria stuck inside them, usually gardnerella vaginalis.
Describe the management of bacterial vaginosis
Metronidazole orally or by vaginal gel. Clindamycin is an alternative but less optimal.
Assess the risk of additional pelvic infections with swabs for chlamydia and gonorrhoea
What should you advice to someone when prescribing metronidazole?
Avoid alcohol as it can have disulfiram-like-reaction with nausea and vomitting, flushing and sometimes severe symptoms of shock and angioedema
What are the complications of bacterial vaginosis?
Can increase the risk of catching STIs
In pregnant women:
- miscarriage
- preterm delivery
- premature rupture of membranes
- chorioamnionitis
- low birth weight
- postpartum endometritis
Define vaginal candidiasis
commonly referred to as “thrush” is a vaginal infection with a yeast from the candida family, most commonly candida albicans.
What are the risk factors for vaginal candidiasis?
Diabetes Mellitus
Drugs: antibiotics, steroids
High oestrogen: Pregnancy
Immunosuppression: HIV
Describe the presentation of vaginal candidiasis
- COTTAGE CHEESE , non offensive discharge
- thick white discharge
- vulval and vaginal itching, irritation and discomfort
- dyspareunia
- dysuria
Describe the investigations of vaginal candidasis
often treatment is started based on presentation.
Vaginal pH using swab and pH paper to differnetiate between BV and trichomonas (pH >4.5) and candidiasis (pH <4.5)
Charcoal swab with microscopy can confirm diagnosis
Describe the management based on NICE guidelines of vaginal candidiasis
Initial uncomplicated cases, any of the following:
- single dose of intravaginal clotrimazole cream (5g of 10% cream) at night
- A single dose f clotrimazole pessary (500mg) at night
- 3 doses of clotrimazole pessaries (200mg) over 3 nights
- single dose of fluconazole (150mg)
What is the OTC medication for vaginal candidiasis?
Canesten Duo: it contains a single fluconazole tablet and clotrimazole cream to use externally.
What do you need to warn women about in regards to antifungal creams and pessaries?
They can damage latex condoms and prevent spermicides from working so alternative contraception is required for at least 5 days after use.
What is the management for recurrent vaginal candidiasis?
Recurrent = 4 or more in 1 year.
Induction: oral fluconazole every 3 days for 3 doses
Maintenance: oral fluconazole weekly for 6 months.
What is tested first in the cervical smear?
hrHPV first and if that is positive then cytology is performed
Management of negative hrHPV test
return to normal recall, unless:
- the test of cure (TOC) pathway: individuals who have been treated for CIN1, CIN2, or CIN3 should be invited 6 months after treatment for a test of cure repeat cervical sample in the community