Diseases/conditions that can mimic vaginitis: Cervicitis (due to infection with N. gonorrhoeae, C. trachomatis, or herpes) can produce discharge; if concomitant endometritis (pelvic inflammatory disease), purulent discharge from the cervical os may mimic vaginal discharge.
Several treatment options are available for women with vulvovaginal candidiasis (Table II).
Table II.
Over-the-counter products (all administered intravaginally by applicator or suppository) By applicator daily Butoconazole 2% cream (5 g) for 3 days OR Clotrimazole 1% cream (5 g) for 7-14 days OR Clotrimazole 2% cream (5 g) for 3 days OR Miconazole 2% cream (5 g) for 7 days OR Miconazole 4% cream (5 g) for 3 days OR Ticonazole 6.5% ointment once OR By vaginal suppository daily Miconazole 100 mg for 7 days OR Miconazole 200 mg for 3 days OR Miconazole 1200 mg once OR Prescription medications Intravaginal products Butoconazole 2% cream (5 g) for 1 day OR Nystatin 100,000-unit vaginal tablet daily for 14 days OR Terconazole 0.4% cream (5 g) intravaginally daily for 7 days OR Terconazole 0.8% cream (5 g) intravaginally daily for 3 days OR Terconazole 80 mg vaginal suppository daily for 3 days OR Oral medication Fluconazole Single dose of 150 mg tablet
What are the adverse effects associated with each treatment option?
Metronidazole or tinidazole (oral): avoid use of alcohol during and for 24 hours after treatment with metronidazole and for 72 hours after tinidazole
Clindamycin cream: oil base may weaken latex condoms and diaphragms for up to 5 days
Topical therapy for candidiasis causes local burning in 5%-10% of patients
What are the possible outcomes of vaginitis?
Bacterial vaginosis: treatment is effective (80%-85%), but recurrence is common (30% by 3 months; up to 80% by one year).
Because re-infection following treatment of trichomoniasis is common (in one study 17% were re-infected within 3 months, and in another study 30% at one year), rescreening at 3 months can be considered.
A small percentage of women (<5%) will have four or more episodes of VVC in one year (recurrent vulvovaginal candidiasis or RVVC).
What causes this disease and how frequent is it?
Approximately 75% of women experience at least one episode of VVC; 40%-45% will have two or more. Adolescence is a typical time for a first episode. By age 25, half of all college students will have had one or more episodes of candidiasis. Risk factors include pregnancy, luteal phase of the menstrual cycle, nulliparity, recent use of broad spectrum antibiotics, use of spermicides, and age 15-19.
Prevalence of trichomonas infection is approximately 10%-20% (especially prevalent in women aged 16-35) but the prevalence varies widely depending on the population sampled. Risk factors include change in sex partners, intercourse twice weekly or more, 3 or more partners in the past month, and the presence of other sexually transmitted infections.
The prevalence of bacterial vaginosis also varies widely (10%-50%). The etiology of bacterial vaginosis is unknown, but a change in vaginal ecology (predominance of lactobacillus) results in an overgrowth of Gardnerella vaginalis and anaerobes (Prevotella spp, Peptostreptococci, Mobiluncus spp). Risk factors for bacterial vaginosis include more than one sex partner, change of partner in the last 30 days, having a female sexual partner, and douching.
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How do these pathogens/genes/exposures cause the disease?
What complications might you expect from the disease or treatment of the disease?
Bacterial vaginosis is associated with adverse pregnancy outcomes such as preterm birth and low birthweight infants. It is also associated with increased risk for pelvic inflammatory disease, post-abortion infection and HIV infection.
Trichomoniasis is associated with upper genital tract infection (including pelvic inflammatory disease), post-abortion and post-delivery infections, and preterm birth. T. vaginalis increases the risk for persistent HPV infection and for acquiring herpes and HIV.
Are additional laboratory studies available; even some that are not widely available?
Nucleic acid amplification tests for detection of T. vaginalis infections
How can vaginitis be prevented?
Condoms can decrease the risk for trichomoniasis and bacterial vaginosis.
Avoid douching, use of scented products (soaps, sanitary pads) or other feminine “hygiene” products. Limit use of broad spectrum antibiotics or steroids whenever possible. Avoid wearing nylon or tight undergarments or wearing exercise clothing for long periods of time (anything that traps moisture against the perineum).
A Cochrane review concluded that there is insufficient evidence to recommend for or against the use of probiotics in the treatment of bacterial vaginosis or prevention of recurrence.
What is the evidence?
“Sexually transmitted diseases guidelines, 2010”. . vol. 59. 2010. pp. 56-62. (The definitive source and standard of care for evaluation and treatment of sexually transmitted diseases. Contains guidelines applicable to both child and adult populations.)
Eckert, LO. “Acute vulvovaginitis”. New Engl J Med. vol. 355. 2006. pp. 1244-52. (A concise review of the evaluation and managment of vulvovaginitis. Information is applicable to adults and to adolescents. Excellent tables summarize key diagnostic features, diagnostic tests available, and current treatment regimens.)
Wilson, JF. “In the clinic. Vaginitis and cervicitis”. Ann Intern Med.. vol. 151. 2009. pp. ITC 3-1-ITC3-16. (A concise review of the evaluation and management of vaginitis and cervicitis in adult women; information is applicable to adolescents.)
Huppert, JS. “Trichomoniasis in teens: an update”. Curr Opin Obstet Gynecol. vol. 21. 2009. pp. 371-8. (A comprehensive review of the epidemiology, clinical presentation, diagnosis, and treatment of trichomonas infections among adolescents.)
Nyirjesy, P. “Vulvovaginal candidiasis and bacterial vaginosis”. Infect Dis Clin N Am. vol. 22. 2008. pp. 637-52. (A thorough review of these two common infections. Data are drawn from adult studies, but information generally applicable to adolescents as well.)
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Marrazzo, JM, Martin, DH. “Management of women with cercvicitis”. Clin Infect Dis. vol. 44. 2007. pp. S102-10. (Although now 5 years old, a good review of what we know and don't know about cervicitis.)
Hwang, LY, Shafer, M-A, Neinstein, LS, Gordon, CM, Katzman, DK, Rosen, DS, Woods, ER. “Vaginitis and vaginosis”. pp. 723-32. (An adolescent-focused chapter on vaginitis and vaginosis.)
Woods, ER, Emans, SJ, Emans, SJ, Laufer, MR, Goldstein, DP. “Vulvovaginal complaints in the adolescent”. pp. 525-51. (A comprehensive review of vulvovaginal complaints focused on adolescents.)
Senok, AC, Verstraelen, H, Temmerman, M, Botta, GA. “Probiotics for the treatment of bacterial vaginosis”. Cochrane Database Syst Rev. 2009.
The etiology of BV is uncertain; it is not a true vaginitis because there is no evidence of inflammation when present. BV is associated with sexual activity but is not considered a sexually transmitted infection. It is not clear whether asymptomatic women with BV who are not pregnant or about to undergo genital tract instrumentation should be treated.
Previous research suggested that recurrences of trichomoniasis were due to reinfection; however, more recent studies (using more sensitive detection methods) suggest that in some women, treatment temporarily suppresses levels of organisms to a level that cannot be detected, but over time symptoms recur. (See reference #3 by Huppert above for more detail).
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