VAGINITIS UPDATE & TREATMENT PEARLS SANDY SULIK MD MEDICAL DIRECTOR PRIMARY CARE SERVICES – ST JOSEPH’S HEALTH ST JOSEPH’S FAMILY MEDICINE RESIDENCY PROFESSOR, UPSTATE MEDICAL CENTER I HAVE NO DISCLOSURES OBJECTIVES • Review the most common causes of vaginitis and treatments for each • Discuss emerging causes of vaginitis including mycoplasma genitalium and desquamative vaginitis • Discuss treatment strategies for recurrent vaginal infections VAGINITIS • One of the most frequent reasons to visit the OB/GYN office, Family Planning services, student health and primary care offices • ACCOUNTS FOR UP TO 10 MILLION OFFICE VISITS PER YEAR • Many women never get a clear diagnosis and often have recurrent symptoms • Causes discomfort and pain, days lost from work/school, discomfort with sexual functioning and issues with self image • Often associated with other STI’s, HIV, and other infections of the female genital tract VAGINITIS • Defined as a spectrum of conditions that cause vulvovaginal symptoms: • Itching • Burning • Irritation • Abnormal Discharge • Odor • Redness • Swelling • 3 Most Common etiologies of vaginitis: Trichomonas, Bacterial vaginosis, vulvovaginal candidiasis VAGINITIS – CLINICAL PRESENTATION • Inflammatory • presence of poly-morphonuclear neutrophils (PMNS) on microscopy • with physical findings of erythema and edema • Trichomonas, candidiasis, atrophic vaginitis, Mucosal erosive diseases, desquamative inflammatory vaginitis • Non-inflammatory • absence of PMNS • no erythema, no swelling with vaginal complaints of odor or abnormal discharge • Bacterial vaginosis most common, mixed VVC/BV BACTERIAL VAGINOSIS • Vulvovaginal infection caused by a pathogenic shift of the vaginal flora with a polymicrobial overgrowth of facultative and anaerobic organisms • Most common cause of vaginal complaints • Most common in women of reproductive age • More prevalent in African-American and/or American-Hispanic women than white women • Even adjusting for age, education, poverty – 3 x more common • Other risk factors: douching, recent course of antibiotic therapy, hypoestrogenism, smoking, IUD use • Decreased risk with estrogen-containing contraceptives and consistent condom use IMPLICATIONS OF BV INFECTION • Associated with obstetrical complications: • Preterm labor, PPROM, low birth weight, post partum endometritis, spontaneous abortion • Associated with surgical complications • Post-abortal endometritis, vaginal cuff cellulitis or abscess after hysterectomy, PID • Increased risk of acquiring other infections • HIV, HSV2, Neisseria gonorrhea, Chlamydia trachomatis, Trichomonas vaginalis, UTI’s SEXUAL TRANSMISSION? • Has been implicated in recurrent BV • Epidemiological studies are mixed • Multiple studies show up to 60% increased risk for BV in women with multiple sexual partners • Protective effect from both incident and recurrent BV with condom use SYMPTOMS AND FINDINGS • Typical presentation includes foul smelling or fishy vaginal discharge • Complaint of malodor is highly associated with BV (LR 3.2 [95% CI 2.1-4.7]) • Lack of perceived odor makes BV unlikely LR 0.07 (95% CI 0.01-0.51) • May be exacerbated by conditions that elevate the vaginal pH • Sexual intercourse with semen deposition • Presence of blood • Itching and burning unlikely (if present consider mixed infection with yeast or other inflammatory process), doesn’t usually cause dyspareunia • Examination findings: thin gray-white discharge, should not see erythema, fissuring or bleeding DIAGNOSTIC TESTING • Clinical diagnosis made by microscopic examination and measurement of vaginal pH • Classically 3 of 4 of Amsel’s criteria must be met • Thin homogenous gray-white discharge • An increased pH >4.5 • Release of an amine odor upon application of potassium hydroxide (+ Whiff test) • >20% clue cells on saline microscopy LAB TESTING • Saline wet mount • A wet smear that shows more than 20% of the epithelial cells are clue cells COMMERCIAL TESTS/NAAT AFFIRM VP III OSOM BVBLUE DNA probe testing that identifies Chromogenic test based on sialidase produced by Gardnerella vs Trichomonas and Candida Gardnerella, Bacteroides, etc on DNA concentrations Sensitivity 90% Specificity is 68% Sensitivity 88-98% and Specificity 95-97% compared to Gram stain TREATMENT OF BV • First line: 7 day course of oral metronidazole 500 mg BID • 7 day course of intravaginal clindamycin cream or 5 day course of intravaginal metronidazole gel • Clindamycin 300 mg orally for 7 days • Secnidazole (Secondax®/Solosec®) approved in 2018 for treatment of incident BV • Has a longer half life than metronidazole • Single dose regimen of 2 Gm • Intravaginal Clindamycin ovules x 3 days • Tinidazole 1 Gm daily for 5 days or 2 gm daily for 2 days • ALL regimens equally effective may respond to a second course of same therapy if first ineffective RECURRENT BV • Greater than 50% of women will have a repeat episode of BV within 1 year of treatment • Recurrent BV defined as 3 or more symptomatic episodes within 1 year • Failure of symptom resolution during appropriate antibiotic treatment should raise suspicion for mixed infection and need for further evaluation • Risk factors: prior history of BV, having a regular sex partner, having female sex partner, presence of both G vaginalis and A vaginae • Mechanisms: reinfection by sexual activity, failure to re-establish normal lactobacillus predominant flora, formation of biofilms TREATMENT OF RECURRENT BV • CDC recommendations 3 options after completion of a standard regimen: • Metronidazole vaginal gel 0.75% one full applicator twice weekly for 6 months • With the initiation of a standard treatment regimen start a 21 day course of vaginal boric acid capsules 600 mg once daily at bedtime. At completion of the boric acid treatment, start metronidazole vaginal gel 0.75% twice weekly for 6 months • After completion of standard regimen start oral metronidazole 2g and fluconazole 150 mg once every month RECURRENT BV TREATMENT • Other regimens that have been used: • Intravaginal metronidazole daily for 10 days followed by twice weekly for 4-6 months • Oral or intravaginal metronidazole for 3 days at the onset of menses for 3-6 months with antifungal therapy if history of candidiasis • In Canada a vaginal ovule with metronidazole 500 mg with nystatin 10,000 IU is available and can be used monthly to prevent recurrence TREATMENT OF PARTNERS • Not recommended • Studies to date are flawed and inconclusive • For women who have sex with women the rate of BV concordance among partners is high • If partner is symptomatic – reasonable to treat both • Small studies have shown male circumcision may reduce the risk of BV in female partners OTHER TREATMENTS • Vaginal administration of lactic acid to help restore the acidic pH of the vagina is thought to be helpful • Number of products available: Luvena, Gynofit gel • Oral Lactobacillus to improve the vaginal microbiome • Number of small studies have inconclusive evidence for or against Probiotics in treatment of BV USE OF POLICARBOPHIL-CARBOPOL ACIDIC VAGINAL GEL • A persistent high vaginal pH(>4.7) is a common alteration in women with recurrent BV • Use of a polycarbophil has been shown to be effective in reducing the vaginal pH • Polycarbophil is a weak polyacid large molecule that is neither absorbed nor immunogenic • It adheres to the vaginal epithelial cells until they turn over (3-5 days), buffers vaginal secretions near physiologic ph (4.3) POLICARBOPHIL-CARBOPOL ACIDIC GEL • Several small studies have shown use has effectively treated recurrent BV • No RCT’s have been done to date • One study used daily treatment of 2.5g of gel for one week followed by twice weekly for 6 weeks • 2nd study used 2.5 g biweekly for 6 weeks • Both showed improvement in BV and decreased recurrence compared to placbo or acidic douche USE OF VITAMIN C VAGINAL TABLETS • Several small studies have shown efficacy with Vitamin C Vaginal tablets • 250 mg silicon-coated vaginal tablets daily for 6 days • Studies showed statistically significant improvement in BV in the Vitamin C treated groups IUDS AND BV • The relationship between IUD use and BV is unclear – insufficient evidence to conclude one way or other • Thought to be related to the increase of unscheduled bleeding leading to a higher vaginal pH EFFECT OF DIET AND BV • One study looked at diet and occurrence of BV • Increased dietary fat (saturated fats) was associated with an increase in BV and severe BV • Significant inverse association of BV with diets high in folate, calcium and Vitamin E TRICHOMONAS • Trichomonas vaginalis: flagellated motile anaerobic protozoan organism which colonizes the vagina, urethra, par-urethral and Skene glands • Transmission is primarily sexual, can transmit via fomites, hot tubs, pools • Affects 3.7 million persons in the US annually • Prevalence in women 40 years and older is 11% overall and more common in women diagnosed with other STI’s including HIV • African-American women are disproportionally affected with a prevalence of 15% compared with 1.8% of white women IMPLICATIONS • Obstetric • Preterm birth, PROM, low birth weight • Gynecologic • Often coexists with other STI’s, HPV, and BV • PID and tubal infertility • Endometritis after delivery, abortion, or surgery • Facilitates acquisition and transmission of HIV RISK FACTORS • Change in sexual partners • Frequent sexual intercourse • Having 3 or more sexual partners in a month • Coexistent sexually transmitted infections (HIV) • Illicit drug use, smoking • Lack of barrier contraception • Low socio-economic