Making the Diagnosis
and Treating Appropriately!
Although the complaint of common vaginitis does not have the ring of the seriousness of endometriosis, lupus or diabetes, it still remains one of the most common complaints of women. For many years, physicians told women that the chronic itching was “in their heads." Women felt otherwise. They knew that ‘Doctors_Dont_Know’ all the answers. It was not until the 1980’s that doctors finally began to recognize that the flagellate Trichomonas was the source of many cases of vaginitis and would respond to antibiotic. Other culture techniques have since made diagnosis and treatment much easier.
There are four common types of vaginitis:
The growth of Candida is usually inhibited by the normal vaginal bacteria (lactobacillus) but is accelerated by oral contraceptives, broad-spectrum antibiotics, diabetes and pregnancy. This infection is second in number only to bacterial infections. It characteristically appears as a thick, white, “cottage cheese" discharge, reddened vulvar (outside) with swelling and excoriations from itching.
The physician can prepare a ‘wet smear’ with KOH to show the ‘yeast’ hyphae and budding. If he checks the pH of the vagina, he will find it to be quite acid: pH 4.0 to 4.7. Lastly, he can perform a culture that takes hours to two days to confirm the diagnosis.
There are nine treatments for yeast. These are to be used for the occasional infection and never on a daily basis.
Miconazole (Monistat): Over-the-Counter: 100mg vaginal suppository every night x 7 days, 200mg nightly x 3 days or 2% 5gm cream intravaginally nightly for 7 days.
Nystatin (Mycostatin): One vagnial tablet or 1 gm cream nightly for 7 to 14 days.
Clotrimazole (Gyne-Lotrimin, Mycelex-G): 100 mg vaginal tablet or 1% vaginal cream for 7 to 14 days, intravaginal.
Terconazole (Terazol): Prescription: 80 mg vaginal suppository or 0.4% cream intravaginally nightly for 3 days
Butoconazole (Femstat): 2% cream for 5 days
Ketoconazole (Nizoral): Prescription: 200mg tablet 1-2 daily for 7 to 14 days.
Diflucan: Prescription:100 to 150 mg tablet once weekly.
Boric Acid powder: Over-the-counter:600mg in gelatin capsules every day for 14 days.
GENTIAN VIOLET:Over-the-counter: 1% solution for topical use. Can be applied to tampon for use in vagina. Use gloves as this dye stains hands, clothes and porcelain.
Although this small one celled ‘animal’ was discovered in 1836, it was not recognized as the common cause of vaginitis until 1980. It is sexually transmitted and exists in both the male and female. The female is usually symptomatic while the male is unusually not symptomatic. Approximately 20% of all women will develop Trichomoniasis in their lifetime.
This organism infects the vagina, urethra, cervix, and bladder causing a multitude of symptoms and complaints. The primary complaint is a profuse ‘fishy’ discharge which may appear frothy, yellow to white to even green in color to the examiner. The cervix frequently bleeds with contact. The physician can offen see red puctate lesions and with colposcopy, tiny hook-like blood vessels. Under the microscope, these small animals are seen to move. Since cultures and pap smears identify 88% and 60% respectively, the wet smear is superior and a less expensive test. PH test show upwards of 5 to 7.0
Treatment is directed at eradication the Trichomoniasis vaginalis in both partners. Metronidazole cream may offer the woman temporary relief, but treatment of both the male and female with oral Metronidazole is preferred. Dosages of 500mg orally twice daily for 4 to 7 days are appropriate while avoiding sexual relations. Side-effects of Metronidazole include a metallic taste, diarrhea, overgrowth of yeast vaginal infecions and gastro-intestinal distress. If alcohol is ingested, vomiting may occur.
Bacterial Vaginosis including Chlaymdial Cervicitis and Gonorrhea: Bacterial vaginosis is usually a result of the bacteria, Gardenerella vaginitis. Often this infection appears with moniliasis, trichomoniasis or both.
The pH of the vagina is higher than monilia; 5- 6 with a gray malodorous profuse discharge. The organism G. vaginalis is seen on wet mount to coat the vaginal cells. Although 30-40% of women have no symptoms when cultured for this bacteria from their vaginal secretions. It accounts for fully one-third of all cases of vaginitis, though. Wet stains detect less than 50% and cultures no more than 67%. Therefore, treatment is directed whenever the physician is suspicious of this pathogen. One simple test is to place a drop of KOH on the wet smear. The release of a fishy odor is strongly suggestive of G. vaginalis.
Although oral and vaginal antibiotics of ampicillin and sulfa have been classically prescribed for Bacterial Vaginosis (G. vaginalis), the bacteria are often not susceptible. Present treatment relies on Metronidazole (Flagyl) 500mg twice daily for 7 days. Treatment of the partner and avoidance of intercourse is suggested as well. Topical Metronidazole may be added for local relief of symptoms.
Chlamydia is the most prevalent veneral disease in the United States today infecting 4.6 million new cases yearly. The Chlamydia trachomatis is an intracellular parasite that invades cervical endothelial cells and the urethral cells of women and men.
The diagnosis of C. trachomatis is only possible by culture or the use of monoclonal antibiody techniques invented in the last 15 years. Clinically, the physician finds a profuse, watery discharge from the cervix that under the microscope shows a multitude of white cells (leukocytes). Office slide tests are available making the diagnosis correct 90% of the time.
The oral antibiotics are most effective. Tetracycline 500mg twice daily for 7 days, doxycycline 100mg twice dialy for 7 days or erythromycin 500mg four times daily for 7 days for both partners are usually prescribed. Gastro-intestinal distress is a minor side-effect. Erythromycin, not tetracycline/doxycycline, is prescribed in pregnancy as the tetracyclines can damage the baby’s teeth and bone.
Pelvic Inflammatory Disease
BOTH Chlamydia and Gonorrhea can permanently damage the fallopian tubes as seen on the right. The term used is “Pelvic Inflammatory Disease" or “PID." The appearance of “knots" or the “string of pearls sign" shows that the tube has been damaged at multiple locations and is usually beyong repair. Note the end of the fallopian tube at the bottom is closed over or “clubbed." Most women with Chlamydia infections do not know that they have been infected until an infertility evaluation finds laparoscopic evidence as seen here.
The organism Neisseria gonorrhoeae is the most common reported communicable disease in the United States. It presents as cervicitis or vaginitis in women on reproductive age.
The discharge is profuse, odorless, nonirritating and creamy white to yellow in color. Infections can affect the Bartholin gland (on the side of the opening of the vagina), the fallopian tubes and may lead to pelvic inflammatory disease and ovarian abscess. The diagnosis is based on culture. Reports from cultures are available in approximately 48-72 hours.
The CDC current recommedations are Rocephin (ceftriaxone) or Spectinomycin 2 gm intramuscularly followed by doxycycline 100mg twice daily for 7 days. A small percentage of N. Gonorrhea is not sensitive to Rocephin or Spectinomycin so cultures must be secured. For oral N. Gonorrhea, one tablet of ciprofloxacin 500mg is given. Ampicillin and spectinomycin are neither effective for oral disease.
Genital herpes, a sexually transmitted diease, may be caused by herpes simplex virus type II or type II. Three-quarters of the infections are Type II. The prevalence is 20 million affected individuals with almost 1 million new cases each year. The majority of cases are seen in the 15 to 29 year old age group. More tha one-quarter of all outbreaks are asymptomatic.
There are three distinct patterns to herpes outbreaks: (1) first episode: severe outbreak with local symptoms and flu-like systemic complaints, (2) first episode, non-primary infections in those individuals with circulating antibodies-they have mild local symptoms lasting for a few days, and (3) recurrent herpes with less lesions and no systemic complaints. The diagnosis is made clinically at which time treatment is begun. Blood tests rely on the ELISA test for Herpes type I and II measuring the IGG (chronic infection) and IGM (acute infection) blood levels.
Treatment is directed at relieving symptoms. Local applications of acyclovir (Zovirax ointment) and oral tablets (Valtrex-500mg daily, Famvir 125, 250mg twice daily) are continued for 7- 14 days. The former treatment was Zovirax 200mg five times daily but this has been replaced by Zovirax 400mg twice daily or the newer agents.
Prevention depends on maintaining a normal bacteria flora of acidophillus. Avoid sugar and carbohydrates which raise the blood sugar. Avoid tub baths, lake swimming and hot tubs which can cause a local, chemical-induced vaginitis. Avoid antibiotics. Avoid caustic powder detergents and bleach on underwear. And avoid perfumed pads and tampons as they can cause local irritation as well.
For the most stubborn cases of recurrent yeast, we suggest the use of acidophillus (Llactobacillus) gel capsules in the vagina on a daily basis. Some women find that boric acid powder gel capsules is helpful. We advise our patients they may self administer Gentian Violet 1% on a tampon once weekly. Rarely do we hear further complaints.
Those individuals who fail to respond, especially when a predisposing factor is not recognized, may pose a difficult situation to the physician. Some of these individuals have an altered immune system and may show signs of oral thrush (coated tongue) or yeast on special gastrointestinal and digestive assays (see Great Smokey Diagnostic Laboratories). These indivduals may need extended treatments with oral agents including Diflucan, oral acidophillus, biotin and a drastic change in diet (off all glutens including wheat, bread, processed foods, etc.) Rarely do we need to treat the male partner in cases of chronic candidiasis (yeast) and when we do it is usually with topical antifungal creams.
Local applications of Gentian Violet and the prescription metronidazole (Flagyl) will treat more than 70% of all vaginal infections. The addition of tetracycline/ doxycycline or zithromycin will relieve culture proven bacterial infections. If cultures are negative, then the problems of chemicals (hot tubs), frequent douching (irritation), and diet must be systematically addressed. There is no such thing as a “simple" vaginal infection if the problem is not cured.