ISSUES IN OFFICE GYNECOLOGY
| DIAGNOSIS AND TREATMENT OF VAGINITIS —Martin A. Quan, MD, Professor of Clinical Family Medicine,
David Geffen School of Medicine at the University of California, Los Angeles
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| Introduction: accounts for ≈10 million office visits annually and >7% of visits made to gynecologists; 1% of antibiotics
prescribed in ambulatory setting prescribed for women with vaginitis; presence of vaginal discharge not
synonymous with vaginal infection; Fleury showed that of 10,000 women complaining of vaginal discharge, only
two-thirds had final diagnosis of vaginal infection
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| Infectious vaginitis: most common cause of vaginal discharge (50%-60% of cases); bacterial vaginosis (BV), Candida
vaginitis and Trichomonas vaginitis most common causes
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 | BV: most common vaginal infection (50% of cases); variety of terms employed, eg, nonspecific, Haemophilus,
Corynebacterium, Gardnerella, and anaerobic vaginitis; polymicrobial disequilibrium in vagina manifested by
increased concentration of Gardnerella vaginalis and Mycoplasma hominis; characterized by increased concentration
of Mobiluncus, Prevotella, and Peptostreptococcus species, reduction of Lactobacillus (normal vaginal inhabitant),
and increased concentration of certain organic and aromatic amines, ie, trimethylamine, putrescine,
and cadaverine (overproduction responsible for fishy odor associated with disorder)
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| Candida vaginitis: second most common cause of infectious vaginitis; Candida albicans responsible for 80% to
90% of cases; 20% arise from non-albican species, eg, Candida glabrata and Candida tropicalis; C albicans
found on mucocutaneous surfaces; organism overgrows normal resident bacterial flora when host’s defenses
compromised, eg, from pregnancy, diabetes, broad-spectrum antibiotic use, excessive local heat and moisture
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| Trichomonas vaginalis: unicellular flagellated protozoan; third most common cause of infectious vaginitis (15%-
30% of cases); anaerobic parasite; nonvenereal transmission reported rarely (organism isolated from inanimate
objects, eg, swimming pools, hot tubs, toilet seats)
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| Infectious cervicitis: common but frequently overlooked cause (≤25% of patients presenting with vaginal discharge);
Chlamydia trachomatis, Neisseria gonorrhoeae, and herpesvirus etiologic agents
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| Normal discharge: composed of vaginal squamous cells suspended in fluid derived from transudation process occurring
across vaginal wall; clinical characteristics—clear to slightly cloudy; nonhomogeneous and highly viscous;
not associated with itching, burning, or malodor; normal increase in volume after ovulation, coitus, and
menses, and during pregnancy
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| History and physical: history—patient’s age; menstrual status; characteristics of discharge (eg, onset, color, consistency,
viscosity); associated symptoms (eg, itching, burning, malodor, dysuria, dyspareunia); past medical history
(eg, diabetes, recent infection, medications, method of contraception [high-dose oral contraceptives associated
with Candida vaginitis, intrauterine devices associated with BV]); sexual history; hygienic practices; gynecologic
examination—inspect discharge; close examination of vulvovaginal area and cervix
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| Vaginal pool wet mount: cornerstone of diagnosis; 2 slide preparations (one with normal saline and one with 10%
potassium hydroxide [KOH]); examine under low- and high-power objectives; microscopic appearance of normal
vaginal discharge—vaginal epithelial cells, few white cells, and abundance of large gram-positive rods; normal
vaginal epithelial cell identified by distinctive cellular outline; increased number of white blood cells
(WBCs)—defined as >10 WBCs per high-power field (alternatively, by qualitative measures, number of WBCs
exceeds number of epithelial cells); suspect cervicitis or Trichomonas vaginitis; variable number in Candida
vaginitis and reduced number in BV; motile trichomonads—diagnostic of Trichomonas vaginitis; 50% to 90%
of cases; pear-shaped organism slightly larger than WBC; identifiable by twisting jerking motion; examine
promptly using fresh normal saline (dead organism indistinguishable from WBC); clue cells—corroborate diagnosis
of BV; 90% of cases; stippled appearance of vaginal epithelial cell result of adherence of numerous coccobacilli
on surface; obscuration of cellular border (moth-eaten appearance) major diagnostic feature
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| KOH slide preparation and whiff test: examine after normal saline preparation; presence of pseudohyphae confirms
diagnosis of Candida vaginitis; consider C glabrata or Saccharomyces cerevisiae in presence of budding spores
and absence of pseudohyphae; whiff test—perform routinely, noting fishy odor when KOH added to discharge
sample; positive in three-quarters of patients with BV; lacks specificity; positive in anaerobic infections, particularly
Trichomonas; can be positive in 15% of patients with Candida vaginitis
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| Vaginal pH: valuable diagnostic adjunct to vaginal pool wet mount; helps differentiate normal from abnormal; provides
corroborating evidence for specific etiologic diagnosis; obtain discharge sample from lateral fornix (avoid
contamination with cervical secretions); interpret color change on narrow-range pH paper; normal pH in menstruating
woman 3.5 to 4.5; consider BV or Trichomonas vaginalis when pH >4.5; invalid if specimen contaminated
with blood, cervical secretions, semen, or certain douche preparations
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| Cotton swab test: confirms diagnosis of mucopurulent cervicitis; wipe ectocervix clean; with clean cotton swab,
obtain sample from endocervical canal; yellow mucopus pathognomic for mucopurulent cervicitis; positive with
>10 to 20 WBCs on oil immersion field on Gram stain
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| Cultures: limited role in evaluation; if Trichomonas suspected, but wet mount repeatedly negative, confirm by inoculating
discharge on modified Diamond’s medium; in patients with suspected Candida infection, confirm using
Sabouraud dextrose agar or Nickerson’s medium; culturing for G vaginalis rarely useful (isolated in 20%-50% of
women)
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| Mild-to-moderate Candida infection: traditional—polyene antifungal agent (nystatin [eg, Mycostatin] or early-
generation imidazole (miconazole [eg, Monistat] or clotrimazole [eg, Gyne-Lotrimin]); topical imidazole
agents—shorter regimens; butoconazole; clotrimazole; single-dose regimens—intravaginal tablet of clotrimazole
(Mycelex G); tioconazole (eg, Vagistat-1); topical triazole antifungal agent—terconazole (Terazol); shown
in vitro to have greater potency and broader spectrum; available in 3- or 7-day regimens; prescription required;
fluconazole—single 150-mg dose comparable to 3- to 7-day regimens using topical antifungal agents; for moderate
to severe infection, repeat dose in 72 hr
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| Recurrent Candida: identify predisposing factors (eg, diabetes, chronic antibiotic use, other medications, Candida
in partner [treat balanitis in partner], HIV infection); fungal cultures—identify non-albicans species (highly resistant
to agents used for Candida vaginitis); treat C glabrata with gentian violet or boric acid 600 mg in gelatin capsule
intravaginally daily for 7 to 14 days; treat C tropicalis with nystatin for 14 days or with topical imidazole
agent; last resort topical flucytosine (possible resistance if used frequently); repeated courses on ad lib or cyclic
basis—clotrimazole 100 mg vaginally for 3 days after menses; clotrimazole 500 mg vaginally once monthly cyclically
after menses; oral fluconazole 100 mg once monthly; most effective regimen (95% efficacy) against C albicans
oral ketoconazole 400 mg daily for 14 days, then 100 mg daily for 6 mo; drawbacks cost, hepatotoxicity, and
high recurrence when discontinued; Sobel showed high recurrence rate with oral fluconazole; options based on
2006 Centers for Disease Control and Prevention (CDC) guidelines—extended course of therapy recommended
for patient with recurrent C albicans; topical therapy for 7 to 14 days; fluconazole 100 to 200 mg orally on days 1,
4, and 7; maintenance regimens include oral fluconazole 100 to 150 mg once weekly, clotrimazole 500 mg vaginally
once weekly or topical agent twice weekly
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| Bacterial vaginosis: requires 3 of 4 diagnostic criteria, including thin homogeneous discharge, vaginal pH >4.5,
positive whiff test, and >20% clue cells on wet mount; metronidazole 500 mg bid for 7 days remains gold standard
of treatment; higher recurrence rate demonstrated with shorter regimens (single treatment of 2 g orally and 3- and
5-day regimens); single-dose regimens no longer recommended by CDC; other options—oral clindamycin 300 mg
bid for 7 days (data show 95% effective); vaginal metronidazole gel; clindamycin vaginal cream or ovules; relapse
rate higher than with 7-day course of metronidazole; alternative to metronidazole—tinidazole (Tindamax) approved
in May 2007; dosing regimens 1 g daily for 5 days or 2 g daily for 2 days; efficacy comparable to 7-day
course of metronidazole; studies show no benefit in treating male partner
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| T vaginalis: motile trichomonads on wet mount definitive diagnosis; culture on Diamond’s modified medium or
InPouch TV culture system; some laboratories offer polymerase chain reaction (PCR) test; treatment—
metronidazole treatment of choice; single 2-g dose or 500 mg bid for 7 days; single-dose regimen preferred because
of compliance issues and convenience; reserve 7-day regimen for those failing 2-g single-dose regimen; tinidazole
shown highly effective when given as single dose (2 g; with food); all nitroimidazole agents, eg,
metronidazole (eg, Flagyl), tinidazole associated with adverse effects (eg, nausea, vomiting, metallic taste; less
with tinidazole); metronidazole and tinidazole associated with disulfiram (Antabuse)-like reaction; instruct patient
to avoid alcohol for at least 24 hr when taking metronidazole, 72 hr when taking tinidazole; pregnancy—
metronidazole category B drug; tinidazole category C; metronidazole and tinidazole passed in breast milk; use single-dose
regimens; instruct patient to avoid breast-feeding for at least 24 hr with metronidazole and 72 hr with tinidazole;
trichomonas sexually transmitted disease (STD)—male partners require treatment; patient and partner
require evaluation for other STDs; counsel about HIV test and need for safer sexual practices
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| THE ADOLESCENT EXAMINATION— Delores (Dee) A. Anderson, RN, CFNP, Division of Obstetrics and Gynecology,
Mayo Clinic College of Medicine, Rochester, MN
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| Words of advice: most adolescents would prefer female provider—exception may be patient who has had same
male family health provider throughout childhood and adolescence; allow support person in room during physical
examination if requested—initial meeting and discussion with patient can be done alone; be respectful and
sincere—introduce yourself; if support person in room, first introduce yourself to patient and then to support person;
ask patient how she would like to be addressed—first name, nickname, Ms, or Miss; provide privacy—if examination
room has window, ask patient if she would like window covering closed; conduct initial interview while
patient still dressed; treat patient as adult; commend patient for positive aspects of her life; explain examination, familiarize
patient with instruments used in examination, and explain patient’s role in process—ensure she knows
purpose of visit; ask about her concerns; encourage patient to become involved in her health care; encourage
questions—listen attentively; explain at patient’s level without condescension; verify that patient understands information
provided; be prepared to answer tough questions, eg, “can I get a sexually transmitted disease (STD) if
we only have oral sex?”; provide honest answers and avoid lecturing (“I’m concerned about your alcohol consumption”
vs “you are drinking way too much alcohol”); ensure patient that what she tells you is confidential—unless
you are concerned patient will harm self or is in danger from others
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| Physical examination: take your time and be gentle—help her get into best position (frog leg) and explain reason
for position; tell her what you are going to do before you do it; warm speculum; stop examination if patient becomes
upset or anxious and finish another time; take time to teach—teach anatomy using diagrams and models; offer patient
mirror during examination, but do not force it; encourage her participation in breast examination (controversial,
some providers believe self-breast examination heightens anxiety if adolescent finds mass); discuss menstrual cycles
and how they work; teach normal vs abnormal, eg, mucus discharge changes as cycle continues; human papillomavirus
(HPV) immunization—recommended for young women 11 to 26 yr of age; series of 3 immunizations; discuss
effect HPV can have on gynecologic health; topics for discussion—date rape, alcohol intoxication (and other substance
abuse), abuse within relationship, contraceptive techniques, and STDs; adolescents do not always consider
consequences of behavior (eg, unprotected sexual intercourse); encourage patient to think about consequences (“if
you got pregnant, what would you do?” and “what is going to be happening in the next couple of years?”); review
examination with patient after she is dressed—ask her if she has any questions; explain how she will get results; explain
follow-up if Papanicolaou (Pap) test abnormal; provide age-appropriate written information; review how to
contact you if she has further questions; help patient set priorities and goals, do not set them for her
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Suggested Reading
Eschenback DA et al: A dose-duration study of metronidazole for the treatment of nonspecific vaginosis. Scand
J Infect Dis Suppl 40:73, 1983; Larsen M et al: Not so bad after all Women’s experiences of pelvic examination.
Fam Pract 14:148, 1997; Koumans EH et al: Indications for therapy and treatment recommendations for
bacterial vaginosis in nonpregnant and pregnant women: a synthesis of data. Clin Infect Dis 15:35, 2002; Ricciardi
R: First pelvic examination in the adolescent. Nurse Pract Forum 11:161 2000; Sobel JD et al: Maintenance
fluconazole therapy for recurrent vulvovaginal candidiasis. N Engl J Med 351:876, 2004.
Educational Objectives
| The goal of this program is to improve the diagnosis and treatment of infectious vaginitis and to provide techniques
that will provide a positive experience for the adolescent undergoing her first gynecologic examination. After hearing
and assimilating this program, the clinician will be better able to:
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| 1. Cite the 3 most common causes of infectious vaginitis.
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| 2. Utilize the most appropriate diagnostic modality for identifying the etiologic organism of infectious vaginitis.
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| 3. Manage the patient with infectious vaginitis.
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| 4. Consider the importance of conducting an adolescent’s first gynecologic examination in a way that fosters a
positive experience.
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| 5. Provide a positive experience for an adolescent’s first gynecologic examination and reduce patient anxiety.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty members 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 reported nothing to disclose.
Acknowledgements
Dr. Quan was recorded at Office Gynecology/Women’s Health for Primary Care, sponsored by the David Geffen
School of Medicine at the University of California, Los Angeles, held on August 9-12, 2007, in Anaheim, CA. Ms.
Anderson was recorded at OB/GYN Clinical Reviews, sponsored by Mayo Clinic College of Medicine, on November
2-3, 2006, in Rochester, MN.
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