Vaginitis Flashcards
Describe the presentation of normal vaginal secretions.
-Generally odorless
-Clear / slight white color with egg white consistency
-1-4mL secreted daily
-Acidic pH (3.8 to 4.2)
-Lactobacillus bacteria predominant
Pronounced white vaginal discharge may be indicative of what?
Yeast Infection
Yellow’ey-Green vaginal discharge may be indicative of what?
STI
Gray vaginal discharge may be indicative of what?
Bacterial Vaginosis (BV)
Pink vaginal discharge may be indicative of what?
Vaginal Irritation, Implantation Bleeding, Cervical Bleeding
Red vaginal discharge may be indicative of what?
Cervical Polyp, Endometrial / Cervical Cancer, Menstruation, Cervical Infection
Fungal infection of the exterior pubic region of a female might be referred to as what condition?
Vulvovaginal Candidiasis (VVC)
-Vulva = Outside, Vaginal = Inside… Important distinction.
Do Genital Warts & Herpes present as Vaginitis?
-Nope… Generally, presents as open sores & bleeding / pain.
Non-Infectious Vaginitis causes?
-Postmenopausal / Menopausal Atrophy
-Changes to bacterial flora of the vagina
-Foreign body retention (ie. Tampon)
-Allergies
Order the following Infectious Vaginitis-causing conditions by increasing pH:
Vulvovaginal Candidiasis
Atrophy
Trichomoniasis
Bacterial Vaginosis
1) Vulvovaginal Candidiasis: pH is < 4.5
2) Bacterial Vaginosis: pH is 5-6
3) Trichomoniasis: pH is > or = 6
4) Atrophy: pH is 7
A fishy odor & creamy, gray discharge may be indicative of what infectious Vaginitis-causing condition?
Bacterial Vaginosis
Frothy & wet discharge with a fowl scent & potential pruritis may be indicative of what infectious Vaginitis-causing condition?
Trichomoniasis
“Cottage Cheese-like discharge”, odorless, & localized stinging / burning in & around the vagina may be indicative of what infectious Vaginitis-causing condition?
Vulvovaginal Candidiasis
What distinguishing factor does VVC present that other Vaginitis conditions usually don’t?
Severe Pruritis
What sorts of things may alter normal vaginal flora?
-Puberty
-Menstruation
-Estrogen / OCP Therapy
-Pregnancy
-Post-Menopause
-Antibiotics
-Vaginal Surgery (ie. Hysterectomy / Abortion)
What might be some risk factors that leave a woman susceptible to vaginal infection?
-Uncontrolled Diabetes
-Broad Spectrum Antibiotics
-Immunosuppression
-Medications (Chemo, Corticosteroids, Contraception)
-Diet
-Stress
-Pregnancy
-Menses
-Chemical Irritants
-Synthetic / Non-Breathable Undergarments & Clothing
When is a woman most susceptive to VVC infection (at what age range)?
30-40yrs… Rare before puberty.
What other patient symptoms are indicative of VVC infection (Hint: Two “dys” symptoms)?
Dysuria - Painful urination
Dyspareunia - Painful intercourse
When do we need to refer for VVC?
-1st time experiencing symptoms
-If discharge presents an odor (potentially indicative of another type of infection… bacterial?)
-Pregnant
-Pre-Puberty
-Underlying chronic illness or immunocompromised
-Recurrence within 2 months
-Presence of other symptoms (Fever / Pelvic or Abdominal Pain / Rashes / Sores)
-Heightened risk of STI (Unprotected Sex & multiple sexual partners)
Jane (35yrs old) comes into your Pharmacy presenting VVC-like symptoms. You do a screen & identify that her vaginal discharge is odorless, this is not her first time experiencing VVC-like symptoms, & she isn’t pregnant. She’s had intercourse with one partner over the past year & has come in for the same thing about 6 weeks ago. There’s no indication she’s immunocompromised & she’s otherwise healthy. What’s the most appropriate course of action?
Referral… There’s recurrence of potential VVC within two months (6 weeks falls within the 8 week cut off).
Are there any long-term consequences of VVC in terms of a woman’s fertility?
Nope… None in terms of vaginal scarring either.
Why are we much quicker to jump the gun on referring Bacterial Vaginosis in comparison to Vulvovaginal Candidiasis?
-Increased risk of obtaining / passing on STI’s… STI’s can lead to severe complications such as infertility & permanent organ damage, as well as increase the risk of HIV infection.
Antifungal agents we use to treat Uncomplicated VVC?
Clotrimazole
Miconazole
Terconazole
Nystatin
Clotrimazole dosing regimens (for vaginal tablets)?
500mg vaginal tab x 1 dose
200mg vaginal tab x 3 night-time doses
Clotrimazole dosing regimens (for vaginal cream application)?
1%: 1 applicator of cream PV HS x 7 days
2%: 1 applicator of cream PV HS x 3 days
10%: 1 applicator of cream PV HS x 1 day
-For Vulva irritation & itchiness, external application BID or prn until subsides.
Miconazole dosing regimens (for vaginal ovules)?
100mg HS x 7 days
400mg HS x 3 days
1200mg HS x 1 dose
Miconazole dosing regimens (for vaginal cream application)?
2%: 1 applicator of cream PV HS x 7 days
4%: 1 applicator of cream PV HS x 3 days
-For Vulva irritation & itchiness, external application BID or prn until subsides.
What benefit does 1-3 day treatment have over 7 day treatment? Does the shorter treatment duration mean vaginal infections will clear up quicker?
-Increased compliance on shorter treatment plan…
-Resolution still takes ~3 to 7 days.
Oral Fluconazole dosing regimen?
1 dose of a 150mg oral capsule… Enough to maintain concentrations within vaginal secretions for 72hrs or potentially longer.
Who is it unsuitable to give Oral Fluconazole to?
Girls < 12yrs (pre-Puberty)
What capsular Antifungal product is potentially fatal if taken po?
-Boric Acid… Poisonous agent (only use PV).
When is Boric Acid a suitable AF agent?
-If patient has an allergy or is resistant to azoles.
When do we expect some improvement in a VVC patient taking OTC products? Full resolution?
Improvements: ~3 days
Resolved: ~7 days
-Seek Physician if it persists beyond a week (could be indicative of a different infection)!
Are Oral / Topical Azole products relatively well-tolerated?
-Absolutely… Some may have allergies or intolerances to them, but they are very safe to use (potential for some local irritation, but that’s about it).
Continue treatment of a vaginal yeast infection even if symptoms disappear? Do I use it during menstrual cycle? Can I have sex during usage of oral / topical products?
i) Yes… Stick course of treatment out even if symptoms go away.
ii) Yes… And avoid tampon usage during this time.
iii) Not recommended… During treatment + 3 days (~10 days no sex), as sex can be uncomfortable, reduce contraceptive effectiveness & increases possibility of transmission to partner.
Meena comes into your Pharmacy asking if yogurt can be used to clear up her friend’s vaginal yeast infection… What advice would you give her?
-Probably minimal effectiveness but worth a try if they want an alternative to drug treatments… However, use unsweetened yogurt & avoid adding honey to the fray (as sugars could fuel bacteria if it isn’t Candidiasis).
Prescribed agents for resistant yeast infections?
Terconazole 0.4% cream
Topical Nystatin 100 000 Units
Dosing regimen of Terconazole 0.4% cream?
Applicator PV HS x 7 days
Dosing regimen of Topical Nystatin?
Applicator PV HS x 2 weeks
Is Terconazole safe in pregnancy? Topical Nystatin?
Terconazole: Avoid 1st Trimester… Can be used 2nd / 3rd if benefits outweigh risks.
Topical Nystatin: Very safe agent for pregnant women to use.
Two other products to avoid giving to pregnant women with yeast infections?
-Oral Fluconazole & PV Boric Acid Tabs… Increased miscarriage & birth defect risk.
-Consider giving Topical Azoles or Topical Nystatin instead.
Is vaginal douching necessary to prevent infection?
-Absolutely not (and can actually be harmful)… Disrupts normal bacterial flora, potentially acts as an irritant & can increase risk of ascending infection.
Gwenyth comes into your Pharmacy complaining of vaginal irritation. She’s post-menopausal & complains of vaginal dryness. What OTC product might you give her?
Vagisil or other vaginal lubricants
Jane comes into your Pharmacy complaining of hot flashes & vaginal irritation / itchiness. She is also post-menopausal. What potential prescriptive option is available to treat her co-morbid symptoms?
Hormone Replacement Therapy (used when hot flashes & itchiness are demonstrated together)
What Azole product is often used in the treatment of Bacterial Vaginosis?
Metronidazole
Dosing regimen for Metronidazole in BV treatment?
Oral: 500mg tab x 7 days; 2g tab x 1 dose
0.75% Gel: Applicator (5g) PV OD x 5 days
What other common prescription grade treatment is used to treat BV?
2% Clindamycin Cream… Applicator (5g) PV OD x 7 days.
CanesBalance Gel is another prescription grade product used to treat BV. What unusual allergy demonstrated by a patient would make this product unsuitable to use?
Shellfish
A Dr. has faxed in a prescription to your Pharmacy. Identify the problem with this drug choice…
Drug: 0.75% Metronidazole Gel (for treatment of Trichomoniasis infection).
SIG: Insert 1 applicator (5g) PV OD x 5 days
-Intravaginal Metro Gel is NOT effective!!! Treatment must be oral & systemic (swap for either 2g one time treatment or 500mg BID x 7d).
