Vaginal Conditions Flashcards
At puberty, due to estrogen, the vaginal lining changes to ___________, which contains glycogen
stratified squamous epithelium
_______ uses the glycogen of the vagina to form lactic acid. This creates an acidic pH between 3.5 - 5.5
Lactobacillus bacteria
What is the purpose of the acidic environment in the vagina?
- the acidity helps maintain the normal vaginal flora and inhibitors the growth of pathogenic organisms
What changes to the environment of the vagina after menopause?
- thinning of the vaginal lining occurs, lactobacilli decline and the pH rises
What are the factors that influence the vaginal flora, pH and glycogen concentration include what?
- aging
- menstrual cycle hormonal fluctuations
- certain diseases- diabetes mellitus (increase of sugar peeing out)
- various medications (antibiotics)
- douching
- number of sexual parters (increases exposure to additional organisms)
What should be done to clean the vagina?
- vagina is self-cleaning through secretions and has protective substances (NO concern about vaginal cleanliness)
What are the adverse effects associated with douching?
- disruption of normal vaginal flora, increased risk of irritation or infection
- risk of genital tract infections, ectopic pregnancy, potential cervical cancer risk
- may prevent detection of infection
Douching is associated with what in pregnancy?
- preterm births, low birth weight infants and decreased fertility
What should douching be avoided in?
- avoid in pregnancy, use as a contraceptive or as a self treatment of vaginal infections, 24-48 prior to gynecologic exams and at least 3 days after last dose of a vaginal anti fungal medication
Genital towelettes may contain what?
- may contain perfumes, astringents, emollients and anti-invectives which may lead to irritation or allergic reactions
- occasionally can use, but daily cleansing with mild soap and water preferred
What are the risks of using a feminine deodorant spray?
- meant to decrease genital odour
- risk of masking an infection, causing irritation and allergic reactions
- do not apply to the inside of the vagina
What are some of the non-pharms to prevent vaginal irritation?
- wear cotton underwear only
- avoid tight fitting clothing and synthetic materials
- change pads and tampons regularly (at least every 4-8 hours), use only unscented products
- avoid vaginal sprays and deodorants
- change out of damp swimwear and sports clothing
- avoid long exposure to conditions that are hot and cause sweating
- wipe front to back after using the toilet
What is bacterial vaginosis?
- imbalance in the normal vaginal flora
- increased growth in organisms (aerobic bacteria) normal found in the genital tract and a decrease in lactobacilli
What are the complications associated with bacterial vaginosis and pregnancy?
- 2nd trimester miscarriage
- pre-term birth
- pelvic inflammatory disease
What are the risk factors associated with bacterial vaginosis?
- more common if sexually active
- new sexual partner
- IUD
- douching
(this is NOT sexually transmitted however)
What are the signs of bacterial vaginosis?
- thin, off-white/yellow or grey discoloured discharge
- vaginal pH of 5-6
What are the symptoms of bacterial vaginosis?
- fishy odour (can be stronger after sex)
- can be asymptomatic
- minimal itching
- LACK of inflammation- therefore there is no experience of dysuria or painful intercourse
Is bacterial vaginosis a referral?
YES
What is the treatment for asymptomatic BV?
- treatment is not required unless
- high risk pregnancy
- prior to IUD insertion or gynecological procedures
What is the treatment for symptomatic BV?
- requires rx treatment
- can use oral metronidazole, oral clindamycin, clindamycin 2% vaginal cream, or metronidazole 0.75% gel
What is the efficacy of yoghurt or L. acidophilus in treating bacterial vaginosis?
- lack of evidence for efficacy
Does the male partner require a treatment for BV?
- no
What is considered a recurrent vaginal infection?
- infection is considered recurrent if it occurs within 1-3 months of previous treatment, occurs in 15-30% of patients
- diagnosis must be reconfirmed by a physician (for BV)
What is the recommended treatment options for a recurrent BV infection?
- metronidazole 500 mg po bid for 10-14 days
- metronidazole gel 0.75%, one applicator once a day intra-vaginally for 10 days, followed by suppressive therapy of metronidazole gel bid for 4-6 months
What is the treatment of BV in pregnancy?
- oral treatment is preferred
- metronidazole 500 mg bid for 7 days
- clindamycin 300 mg po bid for 7 days
What is a trichomoniasis infection?
- STI caused by trichomonad vaginalis (a protozoa)
What are the risk factors of a trich infection?
multiple sexual partners, nonuse of barrier contraception, presence of other STI’s
What are the complications associated with a trich infection?
- low birth weight infants
- tubal infertility
What are the signs associated with a trich infection?
- large amounts of white or yawl frothy discharge (can also be green)
- redness of the vulva and the cervix
- vaginal pH > 6
What are the symptoms associated with a trich infection?
- no odour
- itching
- vaginal discharge (may or may not have green or yellow discharge)
- may be asymptomatic
What is the first line treatment for trich infections?
- oral metronidazole
- 2 Gm single dose
- 500 mg bid for 7 days
- cure rate is 90-95%
Should sexual partners be treated for trich infections as well?
yes (especially important because most men with rich infections are asymptomatic)
What is the treatment option available for trich infections in pregnancy?
- metronidazole oral: 2 g as a single dose is preferred, but can also use 500 mg bid for 7 days
What is vulvovaginal candidiasis (VC)?
- generally caused by candida albicans (80-90% of cases)
- the normal flora of the vagina can become pathogenic when there is a change in the sexual environment
Is vulvovaginal candidiasis sexually transmitted?
no
What are the signs associated with VC?
- white, clumpy curd-like discharge
- inflammation and redness in the vaginal area
- vaginal pH <4.5
What are the symptoms associated with VC?
- itching (severe)
- pain during sex
- no odor
- stinging/burning
- may be asymptomatic
What are the risk factors associated with VC?
- medications (antibiotics, hormone ingestion and chemotherapy)
- menses (rare prior to menses and post menopausal)
- pregnancy
- stress
- immunocompromised
- diabetes (poorly controlled)
- clothing (tight fitted and synthetic fabrics)
- irritants (scented products, douches)
What are the goals of treatment in treating vaginal infections?
- relieving signs and symptoms of the infection
- eradicate the infection
- prevent recurrence
- prevent misdiagnosis and therefore a delay in treatment
What are the guidelines for a patient to self-treat VVC?
- uncomplicated (not recurrent)
- previously diagnosed with VVC
- mild to moderate symptoms
- NOT pregnant
- over 12 years old
- has had less than 3 episodes in the past year, with no signs and symptoms within the last 2 months
What are the red flags for referral in a VVC infection?
- first episode
- less than 12 years of age
- pregnancy
- symptoms of fever, pain in lower abdomen, back or shoulder
- many corticosteroid or immunosuppressive drug use
- diabetes or an HIV infection
- recurrent infection (less than 2 months, 4 infections within a 12 month period)
What are some of the non-pharms that should be recommended to treat a VVC infection?
- keep tissue healthy and free for irritation by using good genital hygiene
- avoid vaginal deodorants, douching, harsh soaps and perfumed products
- avoid tight clothing and synthetic underwear. Recommend cotton underwear and loose fitting undergarments and pants
- NO evidence that eating yogurt will treat the infection
Imidazoles are all ________ in treating VVC? Which ones can you use?
- equally effective (80-90% effectiveness)
- clotrimazole (canesten)
- miconazole (monistat)
- butoconazole (rx)
- terconazole (rx)
What are the different OTC options for clotrimazole?
- intravaginal and topical OTC options
What is clotrimazole used for?
- used for mild to moderate fungal infections
What are the side effects of clotrimazole?
- itching, burning, bloating and irritation
What is the difference in efficacy between the 1 day, 3 day or 6 day treatments for anti-fungals?
- regardless if you use a 1 day, 3 day or 6 day treatment, then your symptoms will all resolve in 7 days
- THERE IS NO DIFFERENCE
- with the one day, you have a greater risk of side effects and no faster resolution, so typically do not recommend this
What are the side effects mostly seen with miconazole?
- itching, burning, headaches, allergic contact dermatitis, skin rashes
OTC antifungals should be used once daily at ______
bedtime
In what timeframe should patients experience some relief?
- 24-48 hours (may take a week for complete relief)
Should tampons or douching be used while on these OTC treatments?
- no! not to be used for 3 days after treatment
Should condoms of diaphragms be used while on OTC treatments for vaginal infections?
- not to be used during or for 3 days after treatment
- oil based and may cause either to fail
What is the dose of fluconazole?
- single dose oral medication available OTC
- clinical cure 97% within 5-16 days
Can fluconazole be used in pregnancy?
no, its contraindicated in pregnancy
Fluconazole is not recommended for females under the age of ____, unless under the advice of a physician
12 y/o
What are the side effects of fluconazole?
- headache, nausea, abdominal pain, dyspepsia, dizziness
Can butoconazole 2% be used in pregnancy?
only to be used in 2nd or 3rd trimester - category C (studies are lacking)
What are the side effects associated with butoconazole 2%?
- vaginal irritation, burning, itching
- contains mineral oil
Can terconazole be used in pregnancy?
- avoid during 1st trimester (possibility of absorption)
What are the side effects of terconazole?
- headache, abdominal pain, vaginal burning or itching, fever, chills
Is terconazole a prescription product or an OTC product?
rx
What is the expected timeframe of improvement of symptoms?
within 48-72 hours
What is the expected timeframe of symptom resolution?
resolution of symptoms is in 7 days
After how may days should a person be referred?
if symptoms do not resolve in 7 days
Should be a referral if there is a recurrence of symptoms within _____
2 months
Should we be recommending products with benzocaine in it?
- NO! They are said to relieve itching but can cause local reactions, therefore they are generally not recommended
Recurrent candidiasis is wen there is more than ___ episodes in one year
4
Recurrent candidiasis is more likely in women with what conditions?
- uncontrolled diabetes
- immunosuppression
- pregnancy
What is typically the initial treatment of a recurrent candidiasis infection?
- fluconazole 150 mg every 72 hours (3 doses)
- topical azoles for 10-14 days
- boric acid intravaginally for 14 days
What is typically used as maintenance for recurrent candidiasis infections?
- minimum of 6 month treatment- relapse rate is high
- fluconazole 150 weekly
- ketoconazole 100mg OD
- clotrimazole 500mg once a month
- boric acid 300mg intravaginally for 5 days each month beginning on first day of menstrual cycle
You can self medicate for uncomplicated VVC only when the patient has _______
been diagnosed by a physician
What is toxic shock syndrome?
- an acute illness caused by a toxin producing Staphylococcus aureus (commonly found pathogen in the vulvar tissue)
Who is at risk for TSS?
- menstruating women using tampons, women using contraceptive spouse, diaphragm, cervical cap
- anyone with a surgical wound infection
What are the symptoms associated with TSS?
- sudden high fever, diarrhea, vomiting, disease, weakness, muscle aches, fainting or near fainting, sunburn-like rash in the palms of the hand and the soles of the feet
Does someone that exhibits signs of TSS need to be referred to the doctor?
- yes, they do
