Common Concerns in Women

From the Maryland Academy of Family Physicians’ 2009 Annual CME Assembly & Trade Show, held in Ocean City, MD

Educational Objectives

The goal of this program is to improve management of bacterial vaginosis (BV) and perimenopausal and menopausal symptoms. After hearing and assimilating this program, the clinician will be better able to:

1.   Use clinical findings to predict likelihood of BV.

2.   Distinguish BV from trichomoniasis and candidiasis.

3.   Screen appropriate patients for BV.

4.   Address symptoms and conditions associated with perimenopause and menopause, such as hot flushes.

5.   Describe uses and effects of hormone replacement therapy in menopausal and postmenopausal women.

Faculty Disclosure

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any per­sonal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the faculty and plan­ning committee reported nothing to disclose. In her lecture, Dr. Grossman discusses off-label or investigational use of a therapy, product, or device.

Acknowledgements

Drs. Grossman and Warrington spoke in Ocean City, MD, at the 2009 Annual CME Assembly & Trade Show, presented June 17-20, 2009, by the Maryland Academy of Family Physicians. The Audio-Digest Foundation thanks the speakers and the Maryland Academy of Family Physicians for their cooperation in the production of this program.

Bacterial Vaginosis

Nancy Beth Grossman, MD, Assistant Professor of Clinical Family Medicine, David Geffen School of Medi­cine, University of California, Los Angeles

Vaginal complaints: 40% to 50% due to bacterial vaginosis (BV); 4% to 35% of cases in primary care due to tricho­moniasis; 7% to 72% of cases in primary care undiagnosed

Evaluation: characteristics of discharge; symptoms (eg, itching, odor); self-diagnosis (not reliable); urinary tract in­fection (UTI); abnormal bleeding; dyspareunia

Significance of patient history: literature suggests higher likelihood ratio (LR) for particular finding signifies higher likelihood for particular diagnosis; discharge  —  not useful unless described by patient as “cheesy” (increases likeli­hood of candidiasis); itching  —  in absence of itching, candidiasis less likely (LR, 0.18); itching not useful for as­sessing likelihood of BV or trichomoniasis; in absence of perceived odor, BV less likely; candidiasis more likely with redness, swelling, and itching; complete history, physical examination, and laboratory testing required for most accurate diagnosis

Examination: discharge  —  amount (eg, more or less than usual); color (eg, clear, white, green, grey, yellow); consis­tency; inflammatory findings  —  excoriated vulva; tenderness; odor; significance of findings  —  presence of discharge alone does not distinguish between BV, trichomoniasis, and candidiasis; thick, curdlike, or white discharge more likely candidiasis; BV less likely with normal to mild amount of discharge and more likely with profuse amount; white discharge less likely BV; presence of inflammatory signs associated with candidiasis and trichomoniasis; trichomoniasis more likely in presence of inflammatory signs and in absence of thick or white vaginal discharge (consider prevalence in local population); BV more likely in presence of “high cheese” odor; candidiasis more likely with no odor

Microscopy: look for clue cells; bacilli with corkscrew motility indicative of BV; check whether lactobacilli scant (likely BV); perform potassium hydroxide and saline tests; look for trichomoniasis; check pH; perform “whiff” test; clue cells appear borderless and scratchy; if clue cells present, candidiasis unlikely; absence of trichomonads does not rule out trichomoniasis; sensitivity of microscopy for yeast varies; whiff test may be positive with candidi­asis, trichomoniasis, and BV (“part of the definition for BV”)

Other conditions: herpes simplex virus; physiologic discharge; chemical cause of symptoms (eg, lubricants); me­chanical cause (sexual history important; consider tampon use); allergic reactions (to, eg, latex); atrophic vaginitis; gonorrhea and/or chlamydia (not likely to cause vaginal discharge or specific complaint [eg, odor])

Bacterial vaginosis: overgrowth of bacterial species normally present in vagina with anaerobic bacteria; correlates with decrease or loss of protective lactobacilli; risk factors  —multiple sex partners; new sex partner; douching; to­bacco smoking; receptive anal intercourse before vaginal intercourse; uncircumcised male sex partner; unclear whether BV results from acquisition of sexually transmitted disease (STD); transmission  —  associated with sexual activity; rarely affects women who have never been sexually active; treatment of male partner not recommended; BV not sexually transmitted, except between homosexual females (female partner must be treated; transmission rates among homosexual women high; sexual history important); 50% asymptomatic; 50% report malodorous dis­charge

Diagnosis of BV: 3 of following criteria  —  vaginal pH >4.5; presence of 20% clue cells per high power field; positive amine or whiff test; homogenous, nonviscous, milky white (ie, thin and grey vs fluffy and white) discharge adher­ent to vaginal walls; cultures not recommended due to low specificity; DNA probe-based test for high concentra­tions of Gardnerella vaginalis, card tests for detection of elevated pH, and proline aminopeptidase might have clinical utility; cervical Papanicolaou test has no clinical utility

Treatment of BV: nonpregnant women  —  treat to relieve symptoms, or treat if woman to undergo surgical abortion or hysterectomy (treatment decreases postsurgical infection rates); pregnant women  —  treat to relieve symptoms; treating to reduce risk for infectious complications associated with BV during pregnancy controversial; BV associ­ated with premature rupture of membranes, preterm labor and birth, intra-amniotic infection, and postpartum endo­metritis; treatment may reduce risk for STDs; treatment of pregnant women with BV at high risk for preterm delivery might reduce risk for prematurity (consider screening high-risk pregnant women; high risk factors include history of preterm delivery or history of complication resulting in miscarriage); screen and treat during first prena­tal visit; treatment 60% to 80% effective (recurrence rates high); clindamycin cream  —  recommended for patients intolerant of metronidazole (eg, Flagyl); can disintegrate certain types of condoms; treatment during pregnancy  —  oral metronidazole, 250 mg tid for 7 days; oral clindamycin; use of vaginal Flagyl associated with preterm delivery and intra-amniotic infection

Alternative treatments: ask about use; oral lactobacillus  —most studies do not find benefit; difficult to dose; vaginal lactobacillus  —  poor evidence; no standardization of dosing; not recommended; pH-balanced tampons or gels do not affect BV rates; tea tree oil  —  poor evidence; risk for allergic rash

Screening for BV: screening of asymptomatic women not recommended; pregnant women at low-risk for complica­tions should not be screened; female partners of women with BV should be screened; screening before surgical abortion or hysterectomy recommended; benefits of screening unclear for patients at increased risk (eg, black eth­nicity, body mass index [BMI] <20, history of vaginal bleeding, short cervix, or pelvic infection); pregnancy  —screen if at high risk for preterm delivery; do not screen asymptomatic pregnant women at low risk for preterm de­livery; no direct evidence that screening for BV reduces adverse health outcomes

Patient counseling: after diagnosis, clarify that BV not heterosexually transmitted; educate about abnormal dis­charge and signs and symptoms of BV; risk reduction  —  avoid douching; limiting number of sex partners may help; web-based education (eg, www.cdc.gov)

Managing Perimenopausal and Menopausal
Symptoms

Verlyn O.F. Warrington, MD, MS, Assistant Professor, Department of Family and Community Medicine, Uni­versity of Maryland School of Medicine, Baltimore

Perimenopause: may start 5 to 10 yr before menopause; average age of onset, 45.5 to 47.5 yr; usually presents with vasomotor symptoms and irregular menses; follicle-stimulating hormone (FSH) level increases; inhibin level de­creases; estradiol and luteinizing hormone (LH) levels remain normal; length of menstrual cycle may vary due to anovulation or irregular maturation of follicles; rule out pathologic causes (eg, fibroids, endometrial cancer) of ir­regular bleeding; menstrual cycle shortens; follicular phase shortens; luteal phase remains »14 days; unintended pregnancies peak in women 40 to 44 yr of age; hot flushes present at »37 yr of age and persist to »63 yr of age

Menopause: absence of menses for 12 mo; onset typically at age 50 to 55 yr; tobacco smoking, fragile X gene, auto-immune disease, living at high altitudes, and history of surgically and/or medically induced menopause lower age of onset; age of menarche, ethnicity, parity, and use of oral contraceptives (OCs) do not affect age of onset; physiology  —  loss of ovarian sensitivity to gonadotropin stimulation; leads to follicular decline and dysfunction; quality and quantity of follicles decrease markedly 20 to 25 yr after menarche; FSH markedly increases, LH in­creases, and estrogen decreases; ovarian follicles disappear; menstrual bleeding ceases

Late postmenopause: ovarian stroma exhausted; no adrenal precursors to stimulate stroma; insufficient estrogen to sustain secondary sex tissues

Hot flushes: obese women have fewer than leaner women (may be due to greater peripheral conversion of sex hor­mones, leading to fewer symptoms of estrogen deprivation); risk factors include increased BMI (associated with in­creased “insulation”) and tobacco smoking; in most patients, hormone replacement therapy (HRT) controls symptoms; coincide with estrogen withdrawal; no significant difference in estrogen levels between symptomatic and asymptomatic women; premenarchal girls tend to have low estrogen levels and no hot flushes; thermoregulation  —  range between threshold for shivering and threshold for sweating narrows; clonidine can lower incidence and/or severity of hot flushes by narrowing thermoregulatory zone; usually limited to upper part of body (eg, chest, neck, and face); core body temperature and sweating increase, with increased conductivity of skin; treatment  —  control ambient temperature (with, eg, air conditioning); tobacco smoking cessation; relaxation; HRT effective in »90% of women (£30%-40% of women do not fill prescriptions or discontinue HRT within 1 yr); acu­puncture; acupressure

Considering HRT: consider age; if woman needs contraception, low-dose OC recommended; if woman does not need contraception, consider transdermal estrogen supplementation; consider comorbidities and contraindications; effects of estrogen on perimenopausal patient  —  maintains collagen content of epithelium; affects elasticity, thick­ness, and moistness of epithelium; estrogen receptors in vagina, vulva, and urinary system (patients with low estro­gen levels tend to have genitourinary symptoms eg, dryness, [especially with intercourse] burning, dyspareunia, leukorrhea, pruritus, malodorous discharge); physical examination  —epithelium tends to appear smooth, pale, and shiny; patchy petechiae; friability; diminished elasticity; sparse pubic hair; fusion of labia; introital stenosis; cervi­cal stenosis; decreased vaginal depth; urinary symptoms include urinary tract infections, frequency, dysuria, hema­turia, and stress incontinence; symptoms respond to intravaginal estrogen; treat until symptoms resolve

Sexual dysfunction: decreased arousal; decreased lubrication; decreased sensation to touch and vibration; decreased intensity of orgasm; combination of estrogen and testosterone indicated for low sexual desire; when giving testos­terone, transdermal patch preferred over oral testosterone; bupropion (eg, Wellbutrin) shown to decrease incidence of sexual difficulties; sildenafil (Viagra) and tadalafil (Cialis) used with some success; mechanical devices (eg, vi­brators, vacuum pumps)

Sleep disturbance: may be associated with vasomotor symptoms (eg, night sweats), mood disorder, or insomnia; es­trogen shown to improve sleep; sleep deprivation may manifest as cognitive disorders; 6.5% of women 30 to 39 yr of age have sleep apnea (16% of perimenopausal or menopausal women; may be due to weight gain and decreases in progesterone, melatonin, and growth hormone; consider sleep study)

Psychiatric symptoms: depression  —  »20% of women have depressive episodes; risk decreases postmenopausally; typically no significant recurrences after complete transition to menopause; thorough patient history essential; treatment with antidepressant appropriate; restoring estrogen may improve mood, but HRT not indicated as primary means of treating depression in perimenopausal or menopausal women; estrogen stimulates synthesis and expres­sion of neurotransmitters, increases monoamine oxidase (MAO) inhibitor activity, and increases serotonin synthe­sis; other psychiatric illnesses  —  schizophrenia usually diagnosed in late adolescence and early adulthood, but second peak in incidence occurs in women 45 to 50 yr of age; panic disorder; anxiety; new onset, relapse, or in­crease in obsessive compulsive disorder (OCD); women with bipolar disorder tend to have more depressive epi­sodes

Osteoporosis: bone mass density (BMD) ³2.5 SDs below peak bone mass or T score; patients with osteopenia have BMD 1.00 to 2.49 SDs below T score; hip fractures associated with significant mortality and morbidity; 20% of lifetime bone loss occurs within first 3 to 5 yr after menopause; trabecular bone more affected than cortical bone; amount of bone loss dependent on BMD at time of menopause (younger women with earlier onset of menopause tend to have more bone loss); white women tend to have greater bone loss than Asian women, who tend to have greater bone loss than darker-skinned women; other risk factors  —  decreased androgens; tobacco smoking; physi­cal inactivity; low body weight; low exposure to sunlight; checking BMD recommended for all menopausal women; no guidelines on initial age or frequency of screening; monitor treatment response by, eg, screening every 1 to 2 yr; HRT  —  shown to decrease risk for fracture by 25% to 50% in women <60 yr of age; preservation of bone health not indication for HRT; other therapies (eg, selective estrogen receptor modulators [SERMs], bisphospho­nates, calcitonin) recommended

HRT for cardiovascular disease (CVD): controversial; better outcomes suggested when HRT started early (ie, at onset of menopause, or within 3-5 yr); consider other conditions that limit ability to use HRT; transdermal estrogen associated with fewer thromboembolic events, but associated with improved cholesterol profile; duration of treat­ment debatable; Women's Health Initiative (WHI)  —findings included small but increased risk for coronary heart disease, stroke, and pulmonary embolism in women on combination progesterone and estrogen HRT, and small in­crease in risk for breast cancer; mean age of participants 63.3 yr; only 16% of participants <5 yr away from onset of menopause; only 10% of participants 50 to 54 yr of age; some participants had other risk factors for heart disease; Heart and Estrogen/progestin Replacement Study (HERS)  —  »2800 postmenopausal women followed for 4 yr; found no benefit of HRT for secondary prevention of CVD; subjects had established coronary artery disease; 25% of treatment arm dropped out of study; guidelines from North American Menopause Society  —  HRT should be used for menopausal vasomotor symptoms; CVD prevention not indication for long-term use of HRT; consider alterna­tives for prevention of osteoporosis; American College Gynecologists 2003 guidelines  —HRT should be used for shortest amount of time at smallest effective dose to relieve symptoms; therapy should be discontinued 5 yr after start of treatment; discuss risks and benefits of continuing therapy with patients; side effects of HRT  —  breast ten­derness; breakthrough bleeding (usually resolves in 6 mo; consider endometrial biopsy before starting; work up bleeding that persists after 6 mo); increase in thromboembolic rates; contraindications for HRT  —  current, past, or suspected breast cancer; estrogen-sensitive malignancies; undiagnosed bleeding; untreated endometrial hyperpla­sia; history of clotting; untreated hypertension; known hypersensitivities; active liver disease

Suggested Reading

Abad CL et al: The role of lactobacillus probiotics in the treatment or prevention of urogenital infections--a systematic review. J Chemother 21:243, 2009; Avis NE et al: Change in health-related quality of life over the menopausal transition in a multiethnic co­hort of middle-aged women: Study of Women's Health Across the Nation. Menopause May 8 [Epub ahead of print], 2009; Graziot­tin A et al: Depression and the menopause: why antidepressants are not enough? Menopause Int 15:76, 2009; Huppert JS: Trichomoniasis in teens: an update. Curr Opin Obstet Gynecol May 30 [Epub ahead of print], 2009; Lin KW et al: Screening for bacterial vaginosis in pregnancy to prevent preterm delivery. Am Fam Physician 79:697, 2009; McClelland RS et al: Prospective study of vaginal bacterial flora and other risk factors for vulvovaginal candidiasis. J Infect Dis Jun 199:1883, 2009; McKinlay SM et al: The normal menopause transition. Maturitas 61:4, 2008; Mitchell CM et al: Comparison of oral and vaginal metronidazole for treatment of bacterial vaginosis in pregnancy: impact on fastidious bacteria. BMC Infect Dis 9:89, 2009; Pace G et al: Body mass in­dex, urinary incontinence, and female sexual dysfunction: how they affect female postmenopausal health. Menopause May 19 [Epub ahead of print], 2009; Pirotta M et al: Bacterial vaginosis - More questions than answers. Aust Fam Physician 38:394, 2009.