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Vaginitis and Cervicitis in the Clinic 2009.Pdf in the clinic Vaginitis and Cervicitis Prevention page ITC3-2 Screening page ITC3-3 Diagnosis page ITC3-5 Treatment page ITC3-10 Practice Improvement page ITC3-14 CME Questions page ITC3-16 Section Co-Editors: The content of In the Clinic is drawn from the clinical information and Christine Laine, MD, MPH education resources of the American College of Physicians (ACP), including Sankey Williams, MD PIER (Physicians’ Information and Education Resource) and MKSAP (Medical Knowledge and Self-Assessment Program). Annals of Internal Medicine Science Writer: editors develop In the Clinic from these primary sources in collaboration with Jennifer F. Wilson the ACP’s Medical Education and Publishing Division and with the assistance of science writers and physician writers. Editorial consultants from PIER and MKSAP provide expert review of the content. Readers who are interested in these primary resources for more detail can consult http://pier.acponline.org and other resources referenced in each issue of In the Clinic. CME Objective: To gain knowledge about the management of patients with vagini- tis and cervicitis. The information contained herein should never be used as a substitute for clinical judgment. © 2009 American College of Physicians in the clinic he vagina has a squamous epithelium and is susceptible to bacterial vaginosis, trichomoniasis, and candidiasis. Vaginitis may also result Tfrom irritants, allergic reactions, or postmenopausal atrophy. The endocervix has a columnar epithelium and is susceptible to infection with Neisseria gonorrhoeae, Chlamydia trachomatis, or less commonly, herpes sim- plex virus. Vaginitis causes discomfort, but rarely has serious consequences except during pregnancy and gynecologic surgery. Cervicitis may be asymptomatic and if untreated, can lead to pelvic inflammatory disease (PID), which can damage the reproductive organs and lead to infertility, ectopic pregnancy, or chronic pelvic pain. Because vaginitis and cervicitis are common, clinicians should be familiar with their prevention, diagnosis, and treatment. Prevention What factors increase the can thin the vaginal lining and risk for vaginitis and cervicitis? cause vaginal itching and burning. Unprotected sex and multiple A review of the available published data sexual partners increase the risk found that douching was practiced by for vaginitis due to bacterial vagi- 15.5% of adolescent girls and young 1. Garnett GP, Anderson nosis or trichomoniasis and of women in the United States and that the RM. Sexually trans- cervicitis due to gonorrhea, practice was strongly associated with mitted diseases and sexual behavior: in- chlamydia, or more rarely, herpes increased risk for PID, bacterial vagi- sights from mathe- simplex virus. Transmission rates nosis, and ectopic pregnancy (4). matical models. J In- fect Dis. 1996;174 increase with repeated exposure Suppl 2:S150-61. How can patients decrease their (1). Gonorrhea, chlamydia, and [PMID: 8843245] risk for vaginitis and cervicitis? 2. Centers for Disease trichomoniasis are transmitted Control and Preven- Consistently using condoms dur- tion. Sexually trans- exclusively through sexual contact mitted diseases treat- ing sexual intercourse and limit- (2). Bacterial vaginosis, a syn- ment guidelines, ing the number of sexual partners 2006. MMWR drome characterized by alter- Recomm Rep. reduces the risk for some infec- 2006;55:1-94. ations in the vaginal flora, has [PMID: 16888612] tions that can cause vaginitis and 3. Larsson PG, never been proven to be a sexual- cervicitis. Latex condoms are less Bergström M, Forsum ly transmitted infection (STI) U, et al. Bacterial vagi- prone to breakage than other nosis. Transmission, (3). Sexual transmission has not role in genital tract types and are recommended for infection and preg- been shown to cause vulvovaginal STI prevention. However, if latex nancy outcome: an candidiasis. enigma. APMIS. allergy prevents their use, poly- 2005;113:233-45. urethane condoms are an option. [PMID: 15865604] Antibiotics, uncontrolled 4. Merchant JS, Oh K, A woman should avoid sexual in- Klerman LV. Douch- diabetes, and other hormonal tercourse with a partner who has ing: a problem for changes may predispose patients adolescent girls and genital lesions or penile dis- young women. Arch to vaginal yeast infections. Pediatr Adolesc Med. charge. Treatment of patients 1999;153:834-7. Clothing that traps moisture may [PMID: 10437756] with STIs and their sexual part- 5. Laga M, Manoka A, also contribute to these infections ners can prevent recurrent vagini- Kivuvu M, et al. Non- or exacerbate symptoms. Vaginal ulcerative sexually tis and cervicitis. Good glycemic transmitted diseases contraceptives, damp or tight- control in women with diabetes as risk factors for HIV- 1 transmission in fitting clothing, scented deter- and avoidance of unnecessary an- women: results from gents and soaps, douches, a cohort study. AIDS. tibiotics may help to limit vagini- 1993;7:95-102. feminine sprays and deodorants, tis due to yeast. Avoidance of [PMID: 8442924] 6. Taha TE, Hoover DR, and poor hygiene can irritate potential causes of irritation, such Dallabetta GA, et al. the vulva and vagina and, possi- Bacterial vaginosis as vaginal contraceptives, scented and disturbances of bly, increase susceptibility to soaps, feminine hygiene products, vaginal flora: associa- tion with increased infection. A drop in hormone and damp or tight-fitting cloth- acquisition of HIV. levels after natural menopause ing, may also help to reduce the AIDS. 1998;12:1699- 706. [PMID: 9764791] or surgical removal of ovaries risk for some types of vaginitis. © 2009 American College of Physicians ITC3-2 In the Clinic Annals of Internal Medicine 1 September 2009 Prevention... Unsafe sex increases the risk for some types of vaginitis and cervici- tis. Irritants, allergens, and low estrogen levels can cause vaginitis and may in- crease susceptibility to infection. Antibiotics, uncontrolled diabetes, hormonal changes, and clothing that traps moisture may lead to vaginal yeast infections. Infectious vaginitis and cervicitis can often be prevented by using condoms and limiting the number of sexual partners. Patients should stop using products that can irritate the vulva and vagina. CLINICAL BOTTOM LINE Screening Should clinicians screen asymptomatic and not having nonpregnant women for causes of gynecologic surgery should not be vaginitis and cervicitis? screened for bacterial vaginosis. No Screening at-risk women for prospective studies have document- asymptomatic infections can reduce ed the prevention of PID or HIV long-term complications of un- with treatment of bacterial vaginosis. treated infections. Untreated gon- orrhea and chlamydia can lead to Screening can be performed in PID and subsequent infertility, conjunction with the annual 7. Martin HL, Richardson Papanicolaou smear or preopera- BA, Nyange PM, et al. tubal pregnancy, and chronic pain. Vaginal lactobacilli, Prospective studies have shown that tively in women with indications microbial flora, and risk of human im- bacterial vaginosis and STIs, in- for screening. Table 1 lists tests munodeficiency virus that may be useful in screening type 1 and sexually cluding trichomoniasis, are risk transmitted disease factors for HIV (5–8). and diagnosis. For detection of acquisition. J Infect Dis. 1999;180:1863-8. gonorrhea, culture permits sus- [PMID: 10558942] In the United States, routine screening for ceptibility testing, but cultures 8. Kamwendo F, Forslin chlamydia was shown to prevent PID in 1 L, Bodin L, et al. De- should be plated at the bedside creasing incidences trial in which women aged 18 to 34 years and immediately placed into 3% of gonorrhea- and were randomly assigned to chlamydia chlamydia-associated carbon dioxide and incubated. acute pelvic inflam- screening or usual care. At the end of fol- Unamplified probe assays for matory disease. A 25- low-up, women in the screening group year study from an gonorrhea and chlamydia are urban area of central had fewer verified cases of PID than Sweden. Sex Transm women in the usual care group (9 vs. 33; inexpensive and automated, but Dis. 1996;23:384-91. sensitivity is suboptimal (90% for [PMID: 8885069] relative risk, 0.44 [95% CI, 0.20 to 0.90]) (9). 9. Scholes D, Stergachis gonorrhea; 78% for chlamydia) A, Heidrich FE, et al. Prevention of pelvic Clinicians should screen women (11). Inexpensive enzyme immuno- inflammatory disease who are at risk for sexually trans- assays are available for chlamydia, by screening for cer- vical chlamydial in- mitted causes of vaginitis and cer- but sensitivity is only 55% to fection. N Engl J Med. vicitis for gonorrhea, chlamydia, 70%. Amplified DNA testing by 1996;334:1362-6. [PMID: 8614421] and T. vaginalis infections. Candi- polymerase chain reaction (PCR) 10. Joesoef MR, Schmid GP, Hillier SL. Bacteri- dates for screening include women or ligase chain reaction (LCR) is al vaginosis: review with new or multiple sexual part- the “gold standard” for gonorrhea of treatment options and potential clinical ners, history of unprotected inter- and chlamydia. Although it is ex- indications for thera- py. Clin Infect Dis. course, or history of STIs. In pensive, it can be performed on 1999;28 Suppl 1:S57- addition, all sexually active women vaginal, cervical, or urinary speci- 65. [PMID: 10028110] 11. Clarke LM, Sierra MF, younger than 24 years should re- mens (12, 13, 14). The gold stan- Daidone BJ, et al. Comparison of the ceive annual chlamydia screening. dard test for T.
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