Treatment of Vaginitis

Treatment of VaginitisDr Wong Ying Grace黃 凝 醫 生OG specialistMBBS MRCOG DCH(Ireland)FHKAM (O&G) FHKCOGJune 23, 2013

Diseases characterized by vaginal dischargeCareful historySexual behaviorsGender of sex partnersMensesVaginal hygiene practices (douching)Other medications

3 diseases most frequently associatedwith vaginal discharge1. Bacterial Vaginosis 細 菌 性 陰 道 炎2. Trichomoniasis 陰 道 滴 蟲3. Candidiasis Albicans 念 珠 菌

Bacterial vaginosis 細 菌 性 陰 道 炎陰 道 内 正 常 菌 群 失 調 所 致 , 陰 道 内 有 大 量 的細 菌 、 伴 有 陰 道 分 泌 物 性 質 改 變 的 一 組 症 候群Lactobacillus ( pH)Mixed growth of anaerobic bacteria(bacterial floral imbalance)

Bacterial Vaginosis 細 菌 性 陰 道 炎• BV is a polymicrobial clinical syndromerepresents a complex change in the vaginal floracharacterized by a reduction in concentration of thenormally dominant hydrogen‐peroxide producinglactobacilli, and an increase in the concentration ofanaerobic Gram negative bacteriaeg Prevotella sp, Mobiluncus sp, Gardnerellavaginalis, Ureaplasma, Mycoplasma.

Bacterial vaginosis 細 菌 性 陰 道 炎• Loss of lactobacilli• pH rises• Massive overgrowth of vaginal anaerobes• These anaerobes produce large amounts ofproteolytic carboxylase enzymes, which breakdown vaginal peptides into a variety of aminesthat are volatile, malodorous with vaginalsquamous cells exfoliation.

Bacterial Vaginosis (BV) 細 菌 性 陰 道 炎BV is the most prevalent cause of vaginal discharge ormalodor (CDC guideline 2010)• About 50 to 75 % of women with BV are symptomatic• When symptomatic, the symptoms are off –white, thin,homogenous “fishy smelling” discharge which is morenoticeable after coitus and during menses• In US, National survey (self collected vaginal swabs of over3700 women) ‐ the prevalence of BV was 29 percent in thegeneral population of women aged 14 to 49 yo

Bacterial Vaginosis 細 菌 性 陰 道 炎• BV is associated with:1 having multiple sex partner2 a new sex partner3 Douching4 lack of condom5 lack of vaginal lactobacilli(most experts believe that BV does not occur inwomen who have never had vaginal intercourse)

Bacterial Vaginosis 細 菌 性 陰 道 炎• Women with BV are at increased risk:• 1 acquiring STD’s(HIV, gonorrhea, Chlamydia, HSV2)• 2 complications of pregnancy (pretermlabour)/gynaecological surgery

Bacterial VaginosisDiagnostic criteria:BV can be diagnosed• 1 by Gram stain: relative concentrations oflactobacilli vs Gram negative/Gramvariablerods and cocci and curved Gram‐negative rods• 2 by clinical criteria

Bacterial VaginosisClinical criteria (amsel criteria) –at least 3 criteriamust be present:1. homogenous thin grayish white discharge thatsmoothly coats the vaginal walls2. presence of clue cells(ie epithelial cells with borders obscured bysmall bacteria) on microscopic exam3. pH of vaginal fluid >4.54. A fishy odor of vaginal discharge before or afteraddition of 10% KOH (the whiff test)

Bacterial Vaginosis• DNA probe based test for high concentrations ofGardnerella vaginalis has been acceptable test.(CDC guideline ‐2010)• Pap smear is not reliable for diagnosis of BV• Vaginal culture has no role in diagnosis becauseBV reprsents complex changes in the vaginal flora.

Bacterial Vaginosis• Treatment• BV can resolve spontaneously in up to 1/3 ofwomen.• Therefore, treatment is not necessary forasymtomatic women (CDC recommendation)• Aim is to relieve vaginal symptoms and reduce inthe risk for acquiring Chlamydia or Neisseria, HIVand other viral STD’s.

Bacterial VaginosisRecommended regimen:Metronidazole 500mg BD oral for 7 days(Consuming alcohol should be avoided during treatment and for 24 hours thereafter)Metronidazole gel 0.75%one full applicator 5 gram intravaginally once a dayfor 5 daysClindamycin cream 2% one full applicator 5 gram intravaginal at bedtime for 7daysAlternative regimen:Tinidazole 2 gram orally once daily for 2 daysOr Tinidazole 1 gram orally once daily for 5 daysOr Clindamycin 300mg oral twice daily for 7 days• (CDC guideline 2010)

Bacterial Vaginosis• Douching may increase the risk of relapse• Women should refrain from intercourse or usecondoms consistently during treatment period

Bacterial Vaginosis• Follow up visits are unnecessary if symptoms resolve• Recurrence of BV is common, so women should beadvised to return if symptoms recur• Monthly oral metronidazole administered withfluconazole has been evaluated as suppressive therapy.• Routine treatment of sex partner is not recommended

Bacterial Vaginosis• Special considerations• Allergy:• Intravaginal clindamycin cream is preferred incase of allergy or intolerance to metronidazoleor tinidazole.

Bacterial Vaginosis in pregnancy• ACOG and CDC recommends not to routinely screenand test all pregnant women with asymptomatic BV toprevent preterm birth.• There may be benefits to early screening andtreatment of asymptomatic pregnant women who haveprevious history of preterm delivery.• Recommended dose for pregnant women• Metronidazole 500mg BD oral for 7 days• Or 250mg oral three times daily for 7 days• Or Clindamycin 300mg oral BD for 7 days

Bacterial Vaginosis• Women undergoing pregnancy terminationwho have asymptomatic BV• ‐ should be given flagyl to prevent post‐opinfectious complications• (up to date 2013)

Bacterial Vaginosis• Use of probiotics (intravaginal lactobacillusformulations) to treat BV –no sufficientevidence for or against efficacy.

Trichomoniasis 陰 道 滴 蟲Men may not have symptoms, some may haveurethritisWomen have diffuse malodrous, yellow‐greendischarge with vulva irritation.Many women do not have symptomsDiagnosis‐ microscopy –wet preparation slides

Trichomoniasis• Culture test is sensitive and highly specificRecommended treatment• Metronidazole 2 gram orally in a single dose• Tinidazole 2 gram orally in single doseAlternative treatmentMetronidazole 500mg orally twice a day for 7 daysUse of metronidazole gel is not recommended becauseless efficacious

Trichomoniasis• High rate of reinfection.• Therefore rescreening for trichomoniasis at 3months following initial infection can beconsidered for sexually active women withtrichomoniasis (CDC guideline 2010)• Sexual partner should be treated

Trichomoniasis• Vaginal trichomoniasis has been associated withadverse pregnancy outcomespremature rupture of membranespreterm labour, low birth weight.• Women can be treated with 2 gram metronidazole in asingle dose at any stage of pregnancy.• Multiple studies and meta‐analyses have notdemonstrated an association between metronidazoleuse during pregnancy and teratogenic effects.

Trichomoniasis• Lactating women –if administermetronidazole, withhold breastfeed duringtreatment and for 12‐24 hours after the lastdose will reduce exposure of metronidazole toinfants.

Vulvocandidiasis 念 珠 菌• Candida Albicans• Pruritus vaginal soreness, beancurd likedischarge• Diagnosis –gram stain, wet preparation,culture

VulvocandidiasisClotrimazole cream, Butoconazole cream,miconazole cream, Ticonazole creamNystatin vaginal tablet 100,000unit one tablet 14daysTerconazole 80mg vaginal suppository onesuppository for 3 daysFluconazole 150mg oral tablet single doseItraconazole 200mg BD for a single day

Recurrent Vulvovaginal Candidiasis• Longer duration of initial therapy• E.g. 7‐14 days of topical therapy• or 100mg, 150mg, 200mg oral dose offluconazole (Diflucan) every third day for atotal of 3 doses to attempt mycologicremission (CDC guideline 2000)

Recurrent Vulvovaginal Candidiasis• Oral fluconazole 100mg, 150mg or 200mgdose weekly for 6 months is the first line oftreatment. (CDC guideline 2000)

Pregnant womenwith Vulval Candidiasis• Only topical therapies can be used

Vulval CandidiasisSporonox (itraconazole) 200mg BD poVsoral Fluconazole (Diflucan) 150mg QD po for onceSimilar efficacy• Itraconazole vs fluconazole for the treatment of uncomplicatedacute vaginal and vulvovaginal candidiasis in nonpregnant women:a metaanalysis of randomized controlled trials.• Pitsouni E, Iavazzo C, Falagas ME.• Am J Obstet Gynecol. 2008 Feb;198(2):153‐60.

Zalain ‐ sertraconazole• Safe to use. Effective• Drugs. 2009;69(3):339‐59. Sertaconazole: a review of its use in themanagement of superficial mycoses in dermatology and gynaecology.Croxtall JD, Plosker GL.

Conclusion• 1 Bacterial vaginosis, trichomoniasis and vulvovaginal candidiasis are themost common infectious causes of vaginitis.• 2. Bacterial vaginosis is a polymicrobial clinical syndrome resulting fromreplacement of lactobacillus in the vagina with high concentrations ofanerobic bacteria.•• 3. Bacterial vaginosis is associated with having multiple sexual partners, anew sexual partner, vaginal douching and lack of condom use.•• 4. Women with bacterial vaginosis are at increased risk of acquiringsexually transmitted diseases, complications of pregnancy andcomplications after gynaecological surgery.•• 5. Women with trichomoniasis have symptoms characterized by a diffuse,malodorous, yellow‐green vaginal discharge.

Thank you

Management of PIDRCOG guideline 2008• Oral Ofloxacin 400mg BD daily +oralmetronidazole 400mg BD for 14 days• IM Ceftriaxone (Rocephin) 250mg single dose+oral doxycycline 100mg BD daily+metronidazole 400mg BD for 14 days

Management of acute PID• RCOG guideline 2008• Ceftrizxone 2g (Rocephin) by iv infusion plusIV doxycycline 100mg BD daily, followed byoral doxycyline 100mg BD and oralmetronidazole 400mg BD for a total of 14 days