UCSF Family Medicine Board Review 2013 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: CDC 2010: Trichomoniasis Differential Diagnosis Screening and Testing Category Condition • Screening indications – Infections Vaginal trichomoniasis (VT) HIV positive women: annually – Bacterial vaginosis (BV) Consider if “at risk”: new/multiple sex partners, history of STI, inconsistent condom use, sex work, IDU Vulvovaginal candidiasis (VVC) • Newer assays Skin Conditions Fungal vulvitis (candida, tinea) – Rapid antigen test: sensitivity, specificity vs. wet mount Contact dermatitis (irritant, allergic) – Aptima TMA T. vaginalis Analyte Specific Reagent (ASR) Vulvar dermatoses (LS, LP, LSC) • Other testing situations – Vulvar intraepithelial neoplasia (VIN) Suspect trich but NaCl slide neg culture or newer assays – Psychogenic Physiologic, psychogenic Pap with trich confirm if low risk • Consider retesting 3 months after treatment Trichomoniasis: Laboratory Tests CDC 2010: Vaginal Trichomoniasis Treatment Test Sensitivity Specificity Cost Comment Aptima TMA +4 (98%) +3 (98%) $$$ NAAT (like GC/Ct) • Recommended regimen Culture +3 (83%) +4 (100%) $$$ Not in most labs – Metronidazole 2 grams PO single dose Point of care – Tinidazole 2 grams PO single dose •Affirm VP III +3 +4 $$$ DNA probe • Alternative regimen (preferred for HIV infected women) • OSOM Rapid +3 (90%) +4 (100%) $$ CLIA waived – Metronidazole 500 mg PO BID x 7 days st NaCl suspension +2 (56%) +4 (100%) ¢¢ 1 line • Metronidazole safe at all gestational ages Pap smear +2 +3 n/a Confirm if low – Limited pregnancy data on Tinidazole prevalence • Treat sex partner(s) • Accuracy data: Huppert CID 2007 Targeted screening for other STIs: GC, Ct, syphilis, HIV BV: Pathophysiology CDC 2010 : VT Treatment Failure • • Non-inflammatory bacterial overgrowth Re-treat with either – – 100 x increase Gardnerella vaginalis Tinidazole 2 g PO single dose – – 1000 x increase in anaerobes Metronidazole 500 mg PO BID x 7 days – More pathogen types ( Mobiluncus, Mycoplasmas) • If repeat failure, treat with • Suppression of H 2O2-producing Lactobacillus crispatus and L. – Metronidazole 2 grams po x 3-5 days jensenii (L acidophilus is not present) • If repeat failure • >50% women carry G. vaginalis in their vaginal flora in the – Tinidazole 2-3 g po plus 1-1.5 g vaginally x14 days absence of BV – • Arrange for susceptibility testing: Call CDC!! Bacterial “C/S” of vaginal fluid doesn’t help in the – 770-488-4115 diagnosis of BV….or of any other vaginal infection BV: Sexually Associated or Transmitted? BV: Clinical Diagnosis • “Sexually associated” in heterosexuals • – Amsel Criteria : 3 or more of Rare in virginal women – – Homogenous white discharge Greater risk of BV with multiple male partners – – Condom use decreases risk, Amine odor (“whiff” test) But – pH > 4.5 (most sensitive) – No BV carrier state identified in men – Clue cells > 20% (most specific) – Treatment of partner does not affect recurrences • Spiegel criteria, Nugent score : Gram stain with • Women having sex with women (WSW) – – Few or no gram positive Lactobacillus spp. Infected vaginal fluid between women causes BV – – Studies of concurrence in lesbian couples suggest Excess of other gram negative morphotypes horizontal transmission BV: Laboratory Tests Who Should Be Tested for BV? Test Sensit Specif Cost Comment • Routine screening (asymptomatic): not indicated Nugent score +4 +4 ¢¢ Labor intensive • Standard diagnostic testing Point of care tests – Check discharge, amines, vaginal pH, clue cells Affirm VP III +4 +3 $$$ DNA probe • Microscopy not available or inconclusive OSOM BV Blue +3 +3 $$ CLIA moderate – Affirm VP III – G vag PIP +2 +3 $$$ CLIA moderate OSOM BV Blue – G vaginalis PIP, pH+amine test cards pH + amines +2 +2 $ CLIA waived • st “Shift in vaginal flora” on cervical cytology Amsel criteria +3 +2 ¢¢ 1 line – No consensus, but poor correlation with BV…most experts Pap smear +1 +2-3 n/a Coccobacilli recommend no further follow up CDC 2010: BV Treatment CDC 2010: Recurrent BV Recommended regimens – Metronidazole 500 mg PO BID x 7 days • Consider suppression with metronidazole vaginal gel twice – Metronidazole gel 0.75% 5g per vagina QD x 5 days weekly for 4-6 months (after full initial treatment) – Clindamycin 2% cream 5g per vagina QHS x 7 days • No evidence yet to support use of probiotics • Alternative regimens Don’t douche…with anything! – Tinidazole 2 g PO QD for 3 days • Use of condoms by male partners may reduce recurrences • – Tinidazole 1 g PO QD for 5 days Clean sex toys (or use condoms) between uses • – Clindamycin 300 mg PO BID x 7 days Avoid vaginal insertion after anal insertion of a finger or – Clindamycin ovules 100 mg per vagina QHS x 3 days penis CDC 2010: VVC Classification VVC: Laboratory • • Uncomplicated VVC (80-90%) KOH suspension − – Sporadic or infrequent VVC, and C. albicans: pseudohyphae and blastospores (buds) − – Mild-to-moderate VVC, and C. glabrata: blastospores only • – Likely to be Candida albicans, and NaCl suspension : many WBC, normal lactobacillus • – Immunecompetant pH : 4-6 • • Complicated VVC (10-20%) Amine test : negative • – Recurrent VVC, or Confirmatory tests - – Severe VVC, or Point of care test: Affirm VP III - – Non-albicans candidiasis, or Candida culture ( not: fungus culture) - – Uncontrolled DM, immunosuppression, pregnancy Candida PCR Treatments for VVC CDC 2010: Uncomplicated VVC Treatments • Non-pregnant women Drug OTC Prescription – 3 and 7 day topicals have equal efficacy and price Length of 7 d 3 d 1 d 7 d 3 d 1 d – Treatment Offer either : 1 or 3 day topical or oral fluconazole • Butoconazole X Topical: quickly soothing, but inconvenient • Clotrimazole X X X Oral: convenient, but effect is not immediate • Miconazole X X X If first treatment course fails – Terconazole X X Re-confirm diagnosis (r/o dual infection) – Treat with an alternate antifungal drug Tioconazole X X – Perform Candida culture to confirm and speciate Fluconazole (PO) X • No role for nystatin, candicidin CDC 2010: Complicated VVC Treatment CDC 2010: Complicated VVC Treatment Severe VVC Recurrent VVC (RVVC) • • Advanced findings: erythema, excoriation, fissures > 4 episodes of symptomatic VVC per year • • Topical azole therapy for 7-14 days, or Most women have no predisposing condition – Compromised host Partners are rarely source of infection • • Topical azole treatment for 7-14 days Confirm with Candidal culture before maintenance therapy; • Fluconazole 150 mg PO; repeat Q3 days 1-2 times also check for non-albicans species • Pregnancy Early treatment regimen: self-medication 3 days with onset of symptoms • Topical azoles for 7 days CDC 2010: Complicated VVC Treatment Vaginal Bleeding…What’s Normal? • • Recurrent VVC: Treatment Onset of menses – o – Treat for 7-14 days of topical therapy or fluconazole 150 By 16 years old with 2 sex characteristics mg PO q 72 o x3 doses , then – Start evaluation at 14 years of age if no sexual – Maintenance therapy x 6 months development • Fluconazole 100-200 mg PO 1-2 per week • Cycle length: 24-35 days • Itraconazole 100 mg/wk or 400 mg/month • Menstrual days: 2-7 days • Clotrimazole 500 mg suppos 1 per week • Menstrual flow: 20-80 cc. per menses • Boric acid 600 mg suppos QD x14, then BIW – Average flow: 35 cc. per menses • Gentian violet: Q week x2, Q month X 3-6 mo Abnormal Vaginal Bleeding (AVB) Abnormal Vaginal Bleeding (AVB) Symptom Definitions Symptom Definitions • Abnormal amount of bleeding • Abnormal amount of bleeding – Menorrhagia (hypermenorrhea) – Menorrhagia (hypermenorrhea) •Prolonged duration of menses •Prolonged duration of menses •Increased amount of bleeding per day •Increased amount of bleeding per day – Hypomenorrhea – Hypomenorrhea •Shorter menses •Shorter menses •Less flow per day •Less flow per day Abnormal Vaginal Bleeding Abnormal Vaginal Bleeding Symptom Definitions Symptom Definitions • Abnormal timing of bleeding: REGULAR Cycles • Abnormal timing of bleeding: IRREGULAR Cycles – Polymenorrhea: cycle length < 24 days – Metrorrhagia • 7 days 14 days 7 days14 days 7 days Light “irregularly irregular” bleeding – – Intermenstrual bleeding: (IMB) Menometrorrhagia 21 days • Heavy “irregularly irregular” bleeding 7 days 7 days 7 days – Post-coital bleeding (PCB) 7 days 3 2 10 days 2 4 7 days 7 days 7 days – Post-menopausal: bleeding >1 year after menopause intercourse intercourse Abnormal Vaginal Bleeding Abnormal Vaginal Bleeding (AVB) Symptom Definitions Is the patient pregnant? Is it uterine? • Decreased frequency of bleeding Is the bleeding pattern ovulatory or anovulatory? – Oligomenorrhea •No bleeding 36 days- 3 months Ovulatory = Regular Anovulatory = Irregular or no – Amenorrhea • Menorrhagia bleeding • • •No bleeding for… Hypomenorrhea Metrorrhagia/ MMR • • 3 cycle intervals or Polymenorrhea Oligomenorrhea • • Amenorrhea 6 months (in oligomenorrheic women) IMB • • PCB Post-menopausal Hx, PE, Abnormal Vaginal Preg test Bleeding (AVB) Non-Uterine Conditions: Cervix Preg test POS Preg test NEG • Cervix Neoplasms: IMB, PCB, PMB – Squamous cell carcinoma Pregnant Pelvic Exam – Adenocarcinoma • Location Abnl Uterine bleeding Non-uterine bleeding • Infections: IMB, PCB, menorrhagia • Viability – Mucopurulent cervicitis (chlamydia, gonorrhea, • GA Dating Cervix VaginaUrethra Anus mycoplasma hominis) • Benign