UCSF Family Medicine Board Review March 16, 2014 Vaginitis and Abnormal • There are no relevant financial relationships with any commercial Vaginal Bleeding interests to disclose Michael Policar, MD, MPH Professor of Ob, Gyn, and Repro Sciences UCSF School of Medicine [email protected] Vulvovaginal Symptoms: Differential Diagnosis Category Condition Infections Vaginal trichomoniasis (VT) Bacterial vaginosis (BV) Vulvovaginal candidiasis (VVC) MMWR 2010; 59 (RR-12): 1 Skin Conditions Fungal vulvitis (candida, tinea) Contact dermatitis (irritant, allergic) Vulvar dermatoses (LS, LP, LSC) Vulvar intraepithelial neoplasia (VIN) Psychogenic Physiologic, psychogenic Updated Guidelines to Be Published in 2015 CDC 2010: Trichomoniasis Screening and Testing Trichomoniasis: Laboratory Tests Test Sensitivity Specificity Cost Comment • Screening indications – HIV positive women: annually Aptima TMA +4 (98%) +3 (98%) $$$ NAAT (like GC/Ct) – Consider if “at risk”: new/multiple sex partners, history of STI, Culture +3 (83%) +4 (100%) $$$ Not in most labs inconsistent condom use, sex work, IDU Point of care • Newer assays •Affirm VP III +3 +4 $$$ DNA probe – Rapid antigen test: sensitivity, specificity vs. wet mount •OSOM Rapid +3 (90%) +4 (100%) $$ CLIA waived – Aptima TMA T. vaginalis Analyte Specific Reagent (ASR) NaCl suspension +2 (56%) +4 (100%) ¢¢ 1st line • Other testing situations Pap smear +2 +3 n/a Confirm if low – Suspect trich but NaCl slide neg culture or newer assays prevalence – Pap with trich confirm if low risk • Consider retesting 3 months after treatment Accuracy data: Huppert CID 2007 CDC 2010: VT Treatment CDC 2010 : VT Treatment Failure • • Recommended regimen Re-treat with either – – Metronidazole 2 grams PO single dose Tinidazole 2 g PO single dose – – Tinidazole 2 grams PO single dose Metronidazole 500 mg PO BID x 7 days • • Alternative regimen (preferred for HIV infected women) If repeat failure, treat with – – Metronidazole 500 mg PO BID x 7 days Metronidazole 2 grams PO x 3-5 days • Metronidazole safe at all gestational ages • If repeat failure – Limited pregnancy data on Tinidazole – Tinidazole 2-3 g PO plus 1-1.5 g vaginally x14 days • Treat sex partner(s) • Arrange for susceptibility testing: Call CDC!! • Targeted screening for other STIs: GC, Ct, syphilis, HIV – 770-488-4115 BV: Pathophysiology BV: Sexually Associated or Transmitted ? • • Non-inflammatory bacterial overgrowth “Sexually associated” in heterosexuals – – 100 x increase Gardnerella vaginalis Rare in virginal women – – 1000 x increase in anaerobes Greater risk of BV with multiple male partners – – More pathogen types ( Mobiluncus, Mycoplasma) Condom use decreases risk • But Suppression of H 2O2-producing Lactobacillus crispatus and L. – jensenii No BV carrier state identified in men – • >50% women carry G. vaginalis in their vaginal flora Treatment of male partner does not affect recurrences – • Women having sex with women (WSW) Bacterial “C/S” of vaginal fluid doesn’t help in the – diagnosis of BV….or of any other vaginal infection Infected vaginal fluid between women causes BV – BV concurrence in WSW couples suggests horizontal transmission BV: Clinical Diagnosis Characteristic Discharge With BV • Amsel Criteria : 3 or more of – Homogenous white discharge – Amine odor (“whiff” test) – pH > 4.5 (most sensitive) – Clue cells > 20% (most specific) • Spiegel criteria Nugent score – Gram stain with •Few or no gram positive Lactobacillus spp. •Excess of gram negative morphotypes BV: Clue Cells on Saline Suspension NOT a clue cell NaCl Slide: BV >20% of Saline: 40X epithelial objective cells are Clue cells clues Reduced Source : Seattle STD/HIV Lactobacilli Prevention Training Center at the University of Washington Ragged cell border NOT a clue cell BV: Laboratory Tests Test Sensit Specif Cost Comment Nugent score +4 +4 ¢¢ Labor intensive Point of care tests Affirm VP III +4 +3 $$$ DNA probe OSOM BV Blue +3 +3 $$ CLIA moderate G vag PIP +2 +3 $$$ CLIA moderate pH + amines +2 +2 $ CLIA waived Amsel criteria +3 +2 ¢¢ 1st line Pap smear +1 +2-3 n/a Coccobacilli Who Should Be Tested for BV? CDC 2010: BV Treatment • Routine screening not indicated Recommended regimens • Diagnostic testing – Metronidazole 500 mg PO BID x 7 days – Check discharge, amines, vaginal pH, clue cells – Metronidazole gel 0.75% 5g per vagina QD x 5 days • Microscopy not available or inconclusive – Clindamycin 2% cream 5g per vagina QHS x 7 days – Affirm VP III Alternative regimens – OSOM BV Blue – Tinidazole 2 g PO QD for 3 days – G vaginalis PIP, pH + amine test cards – Tinidazole 1 g PO QD for 5 days • “Shift in vaginal flora” on cervical cytology – Clindamycin 300 mg PO BID x 7 days – No consensus, but poor correlation with BV…most experts – Clindamycin ovules 100 mg per vagina QHS x 3 days recommend no further follow up CDC 2010: VVC Classification CDC 2010: Recurrent BV • Uncomplicated VVC (80-90%) • Consider suppression with metronidazole vaginal gel twice – Sporadic or infrequent VVC, and weekly for 4-6 months (after full initial treatment) – Mild-to-moderate VVC, and • No evidence yet to support use of probiotics – Likely to be Candida albicans, and • Don’t douche…with anything! – Immunecompetent • • Use of condoms by male partners may reduce recurrences Complicated VVC (10-20%) – • Clean sex toys (or use condoms) between uses Recurrent VVC, or – • Avoid vaginal insertion after anal insertion of a finger or Severe VVC, or – penis Non-albicans candidiasis, or – Uncontrolled DM, immunosuppression, pregnancy VVC: Laboratory • KOH suspension Candidal − C. albicans: pseudohyphae and blastospores (buds) Pseudo- − C. glabrata: blastospores only hyphae • NaCl suspension : many WBC, normal lactobacillus • pH : 4-6 10% KOH: 10X objective • Amine test : negative • Confirmatory tests Source - : Seattle STD/HIV Point of care test: Affirm VP III Prevention Training Center - Candida culture ( not: fungus culture) at the University of - Candida PCR Washington Yeast CDC: Treatments for VVC PMNs and pseudohyphae Yeast Drug OTC Prescription Pseudohyphae Length of 7 d 3 d 1 d 7 d 3 d 1 d Treatment Saline: 40X PMNs Yeast Butoconazole X objective buds Clotrimazole X X X Miconazole X X X Source : Seattle STD/HIV Prevention Terconazole X X Training Center at the Tioconazole X X University of Washington Squamous epithelial cells Fluconazole (PO) X CDC 2010: Uncomplicated VVC Treatments CDC 2010: Complicated VVC Treatment • Non-pregnant women Severe VVC – 3 and 7 day topicals have equal efficacy and price • Advanced findings: erythema, excoriation, fissures – Offer either : 1 or 3 day topical or oral fluconazole • Topical azole therapy for 7-14 days, or • Topical: quickly soothing, but inconvenient Compromised host • Oral: convenient, but effect is not immediate • Topical azole treatment for 7-14 days • If first treatment course fails • Fluconazole 150 mg PO; repeat Q3 days 1-2 times – Re-confirm diagnosis (r/o dual infection) Pregnancy – Treat with an alternate antifungal drug • Topical azoles for 7 days – Perform Candida culture to confirm and speciate • No role for nystatin, candicidin CDC 2010: Complicated VVC Treatment CDC 2010: Complicated VVC Treatment Recurrent VVC (RVVC) • Recurrent VVC: Treatment • > 4 episodes of symptomatic VVC per year – Treat for 7-14 days of topical therapy or fluconazole 150 o • Most women have no predisposing condition mg PO q 72 x3 doses , then – – Screen for HIV and Type 2 DM if risk factors Maintenance therapy x 6 months • – Partners are rarely source of infection Fluconazole 100-200 mg PO 1-2 per week • Itraconazole 100 mg/wk or 400 mg/month • Confirm with Candidal culture before maintenance therapy; • also checks for non-albicans species Clotrimazole 500 mg suppos 1 per week • • Early treatment regimen: self-medication 3 days with onset Boric acid 600 mg suppos QD x14, then BIW • of symptoms Gentian violet: Q week x2, Q month X 3-6 mo Vaginal Bleeding…What’s Normal? Abnormal Vaginal Bleeding (AVB) Symptom Definitions • Onset of menses • – By 16 years old with 2o sex characteristics Abnormal amount of bleeding – – Start evaluation at 14 years of age if no sexual Menorrhagia (hypermenorrhea) • development Prolonged duration of menses • • Cycle length: 24-35 days Increased amount of bleeding per day – • Menstrual days: 2-7 days Hypomenorrhea • • Menstrual flow: 20-80 cc. per menses Shorter menses • – Average flow: 35 cc. per menses Less flow per day Abnormal Vaginal Bleeding Abnormal Vaginal Bleeding (AVB) Symptom Definitions Symptom Definitions • Abnormal timing of bleeding: REGULAR Cycles • Abnormal amount of bleeding – – Menorrhagia (hypermenorrhea) Polymenorrhea: cycle length < 24 days •Prolonged duration of menses 7 days 14 days 7 days14 days 7 days •Increased amount of bleeding per day – Intermenstrual bleeding: (IMB) – 21 days Hypomenorrhea 7 days 7 days 7 days • Shorter menses – Post-coital bleeding (PCB) •Less flow per day 7 days 7 days 7 days intercourse intercourse Abnormal Vaginal Bleeding Abnormal Vaginal Bleeding Symptom Definitions Symptom Definitions • Abnormal timing of bleeding: IRREGULAR Cycles • Decreased frequency of bleeding – Metrorrhagia – Oligomenorrhea • Light “irregularly irregular” bleeding •No bleeding 36 days- 3 months – Menometrorrhagia – Amenorrhea • Heavy “irregularly irregular” bleeding •No bleeding for… 7 days 3 2 10 days 2 4 3 cycle intervals or 6 months (in oligomenorrheic women) – Post-menopausal: bleeding >1 year after menopause Abnormal Vaginal Bleeding (AVB) Hx, PE, Abnormal Vaginal Preg test Bleeding