Chronic Recurrent Vaginitis: What Really Works? Everything You’re Itching to Know R. Mimi Secor, MS, M.Ed, FNP-BC, FAANP Newton Wellesley ObGyn, Newton, Massachusetts Newton, Massachusetts Secor 2013 copyright

Mimi Secor, MS, M.Ed, FNP, FAANP  NP

35 years  Newton Wellesley ObGyn, Newton, Mass  Visiting Scholar at Boston College  National Speaker, Media Consultant  NEW, Coauthor, Gyn Exam text, 2012, Springer  Coauthor, Advanced Health Assessment of Women: Skills and Procedures, 2010  2011 Inspiration in Women’s Health Award, NPWH Honorable mention  Fellow in the AANP  President Emerita, Senior Advisor, NPACE  Worked in Alaska for 7 years  Owned private practice for 12 years Secor 2013 copyright

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R. Mimi Secor, MS, FNP, FAANP Disclosure  GenPath-

Speaker

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Vaginitis Objectives  Discuss

optimal diagnostic testing for vulvovaginitis 30 minutes

 Describe

strategies to prevent and treat acute and chronic Bacterial Vaginosis (BV), Yeast (VVC) and Trichomoniasis, Atrophy, Mixed 30 minutes

 Discuss

common vulvar dermatologic conditions including causes, diagnosis & treatment of selected conditions 30 minutes Secor 2013 copyright

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TTT Test

- often and early

Treat

Test

- effectively

- of cure, follow-up Secor 2013 copyright

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Normal Flora of Healthy Vagina

Lactobacilli pH 4.0 Estrogen STI protection

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Gardnerella Mycoplasmas anaerobes Mobiluncus Others

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Vulvitis: Need to Clarify Vaginal, Cutaneous Yeast, Contact, Allergic, Other

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Vulvar Symptoms  





Irritants, over cleansing Allergens  Condom allergy is rare Infections  Genital Herpes Type 2 Skin conditions  Lichen Simplex Chronicus/ LSC  Lichen Sclerosis / LS  Lichen Planus / LP  Other  Eczema, atrophy, etc. Secor 2013 copyright

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Vulvar Irritants, Allergens  Soaps

 Bubble

 Pads  Shaving  Oral

sex  Spermicides  Lubricants  Underwear  Dyes, fragrances  Soap in undies

baths  Shampoo  Hot tubs  OTCs, Scripts  Preservatives in these  Over cleansing  You

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name it... 13

Personal or Family History of Skin Sensitivities?

 Fair

skin  Light hair  Sensitive skin  Skin conditions  Family history  Sensitive

vulva Secor 2013 copyright

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Vulvar Care Guidelines, “Less is More”  Wash

with warm water only: NO soap  Soak and Seal  Use mineral oil, Vaseline, Crisco: to prevent & treat itching  Avoid shaving, thong underwear and douching!  Wear all cotton, white underwear (wide design)  Wash underwear in very hot water  Use ½ laundry soap, double rinse, do NOT hand wash  Sleep without underwear, wear loose clothing  Avoid sex if symptoms, pain, infection: for 1 week+  Use non-irritating lubricants: Standard KY, Femglide, Poise, and Sliquid  Do NOT use: Astroglide or warming/scented lubricants 15 Secor 2013 copyright

Diagnosis of Vulvovaginitis  Vaginal

discharge: inaccurate  pH testing; “Nitrazine” paper or NEW swab “VS-Sense”  KOH, amine, whiff test:  Vaginal microscopy: 60-80% accurate  Affirm test: Gardnerella, yeast, trich: Clinically correlate!  Vaginal cultures: NOT recommended  Vaginal “fungal” culture useful (with speciation), up to 2 weeks  NEW: PCR Testing: 1 collection, multiple detections  GenPath, MDL, Quest, Lab Corp, etc.  STI testing: as indicated  Genital Herpes Type 1, 2 by IGG serology Lowe NK et al. Accuracy of the clinical diagnosis of vaginitis compared with a DNA probe laboratory standard. Obstet Gynecol 2009 Jan; 113:89. Findings: 64.5% clinical correlation with DNA testing,16 Secor 2013 copyright Trich highest, BV lowest

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negative

positive

Clinical Presentation of VVC: Vulvovaginal Candidiasis

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Identifying Yeast Forms

Secor 2013 copyright Secor RMC. Clinical Excellence for Nurse Practitioners. 1997;1:29-34.

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Diagnostic Tests for Chronic VVC  Wet

mount negative:

 Fungal • •

culture and speciate! Non PCR: 1 week+ for results PCR: 3-5 days (NEW)

 Unilateral • •

symptoms: Rule out genital herpes HSV Serology IGG for Type 2 Secor 2013 copyright

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First Episode of Recurrent Herpes  Atypical

symptoms common  1/6 Americans, ¼ women  Prevalence incr. w age 1/3 > 30 yr  Always rule out  Especially if premenstrual  Unilateral sx  Even if relieved with yeast meds  Suppression

is effective Valacyclovir 500-1gm po daily Acyclovir 400 mg po BID Secor 2013 copyright

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VVC, Yeast: Per CDC 2010 Uncomplicated or Complicated  Sporadic,

infrequent  Not chronic/recurrent  Mild/moderate symptoms  Non-immune compromised  Likely

C. albicans  1 to 7 day therapy equal  Oral or vaginal meds  Prescription = OTC efficacy Secor 2013 copyright

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 RVVC

- 5%  4 or more infections/ year  Severe symptoms  Non-albicans  Uncontrolled diabetes, debilitation, immunosuppression  Fungal

culture KEY  Longer Therapy needed

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Chronic C. albicans: Fungal Culture and Speciate  ORAL:  Fluconazole

150 mg oral Day 1, 3, 6, total 3 doses Culture negative, then 100/150/200 mg weekly x 6 mo OR  VAGINAL: 1-2x week x 6 months  Butaconazole (Gynazole)  Clotrimazole, tioconazole ointment (Monistat 1)  “Test

of cure” 2 weeks post-treatment, then monthly (culture)

CDC 2010, Sobel J. NEJM 2004:351:876-83

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Chronic Non-C. albicans: Fungal Culture & Speciate Longer duration Rx: 7-14 days  Butaconazole/ Gynazole: single dose, x weekly x 2; x2 monthly  Boric acid suppositories pv qd x 14 days (600 mg), x2 weekly •

Max 6 months, safety/toxicity issues, AVOID oral & in Pregnancy

 Nystatin

suppositories pv qd x 14 days (100,000 u), x2 weekly • Unclear efficacy, but very safe  F/u: 1-2 weeks post-rx repeat culture : if negative  Maintenance: 2 x weekly x 6 months+, monthly culture, PRN  REFER

to specialist if symptoms recur www.CDC.gov/stds 2010 Secor 2013 copyright

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Patient with 10 year history of Chronic Vaginitis

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NEW: High Correlation with Yeast and Mycoplasma Genitalium n - 516  High correlation with yeast and M. genitalium  P < 0.05 

 Lesser

association between C. trachomatis, and U. urealyticum, no assoc. w N. gonorrhea

Kye Hyun Kim, Mi-Kyung Lee, Vaginal Candida and Microorganisms Related to Sexual Transmitted Diseases in Women with Symptoms of Vaginitis, Korean J Clin Microbiol Vol. 15, No. 2, June, 2012, http://dx.doi.org/10.5145/KJCM.2012.15.2.49 Secor 2013 copyright

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Mycoplasma Genitalium •

“Sexual transmitted” Tosh,A, Van Der Pol, Barbara et. al., Journal of Adolescent Health, 2007. C Anagrius, B Lore´, J S Jensen, Sex. Trans. Infection 2005

• •

More prevalent than gonorrhea Less prevalent than Chlamydia Manhart, Lisa, Holmes, King, et. al. American Journal of Public Health, June 2007.

• •

Urethritis: In men & women Cervicitis in women: Role poorly understood Still debated & more research needed Secor 2013 copyright

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Mycoplasma Genitalium: •

Spontaneous preterm delivery: Independent risk factor Edwards, et.al. Journal of Maternal-Fetal and Neonatal Medicine, June 2006.

•

PID: Frequently detected from cervix, endometrium

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Endometritis and PID treatment failure persistent endometritis and continued pelvic pain.

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Cefoxitin, Doxycycline - may NOT be effective:



C.L. Haggerty, et. al. Sexually Transmitted Infections, 2008.

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Mycoplasma Genitalium: To Treat or Not to Treat? “No

convincing evidence to treat solely these organisms when treating; urethritis, cervicitis, BV or trichomoniasis” Dr. Nyirjesy 2010

Role of Mycoplasma and Ureaplasma Species in Female Lower Genital Tract Infections  Patel MA, Nyirjesy P.  Current Infectious Disease Report (2010) 12:417–422  DOI 10.1007/s11908-010-0136-x Secor 2013 copyright 

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Mycoplasma Genitalium: Treatment • • • • • •

NO cell wall, so B-lactam antibiotics NOT effective Only use: Tetracyclines, macrolides, fluoroquinolones Azithromycin 1 gm orally stat, partner too Azithromycin x 5 days: 500 mg po day 1, then 250 mg day 2-5 Moxifloxacin 400 mg orally x 7 days (NOT ofloxacin) Consider testing, treating partner: per Dr. Gilbert, NYC If patient symptomatic!

Role of Mycoplasma and Ureaplasma Species in Female Lower Genital Tract Infections Patel MA, Nyirjesy P. Curr Infect Dis Rep (2010) 12:417–422 DOI 10.1007/s11908-010-0136-x Secor 2013 copyright

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TTT  Test

- often and early

 Treat

 Test

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- effectively

- of cure, 1 -2 months

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BV Linked to Increased Risk of ObGyn Complications  STIs

Herpes HSV-2 • HPV • GC and Chlamydia • HIV  PID and Infertility  Cervicitis  Cystitis  Post-Gyn surgery and Postpartum infections  Increases risk of Preterm delivery •

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BV

Lactobacilli

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Gardnerella vaginalis Genital mycoplasmas Anaerobes Mobiluncus spp 35 bacterial species

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Diagnose BV per CDC 3 of 4 Amsel’s Criteria  Coaty,

white discharge: must correlate w/other criteria  Elevated pH > 4.7: sensitive but not specific  KOH

amine “whiff” test: predictive  Clue cells: predictive  Pap

& vaginal cultures: NOT reliable  Affirm test: correlate with other criteria, pH, amine Secor 2013 copyright

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Clinical Presentation of BV

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2010 CDC Guidelines, BV Not-Pregnant Recommended: Similar efficacy  Metronidazole 500 mg orally bid x 7 days  Metronidazole gel, 1 applic vaginally @hs x 5 days  Clindamycin cream 1 applic vaginally @hs x 7 days Alternatives: Similar efficacy  Clindamycin 300 mg orally bid x 7 days  Clindamycin Vaginal Ovules, 1 vaginally @ hs x 3 days  Clindamycin 100 mg vaginal single dose  Tinidazole 2 g orally daily x 3 days (Cat C)  Tinidazole 1 g orally daily x 5 days (Cat C) Secor 2013 copyright

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2010 CDC Guidelines for BV in Pregnancy Recommended:  Oral preferred because of possible subclinical upper-genital-tract infection!  Metronidazole 500 mg orally twice a day for 7 days  Metronidazole 250 mg orally TID for 7 days*  Clindamycin 300 mg orally twice a day for 7 days Other Regimens:  Clindamycin vaginal; may be associated with adverse pregnancy outcomes if used in second half of pregnancy after 20 weeks Low and High risk for preterm delivery:  Evidence insufficient to assess impact of screening for BV  Evidence inconsistent if Rx of asymptomatic pt w BV reduces adverse pregnancy outcomes Secor 2013 copyright

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Chronic BV: Common & Complex  30%

recur in 1-3 months, 80% at 9 Months

 Follow-up

1 month for Test of Cure: Amsel’s

 Condoms!

 Avoid

IUS: esp. Copper/ Paragard Secor 2013 copyright

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Chronic Bacterial Vaginosis: Rule out HSV  Longer

therapy: double initial therapy duration Clindamycin, Tinidazole, Boric acid, MTZ pv higher dose  Test of Cure, 1 month  4 -6 months “intermittent” vaginal therapy; twice wkly Sobel et al, AJOG 2006;194:1283-1289. Metronidazole vaginal x 10 days, then x 4 months

 Condoms,

avoid douching, avoid Paragard/Copper IUS

Schwebke & Desmond. Clinical Infect Dis. 2007 Jan 15;44(2):220-221

 Possibly

effective: no thongs, reduce stress,  NEW: Vitamin D & BV: Bodnar, L. J Nutr. 2009;139:1157-1161 Vit D and DIV/LP, Vit D >50 ng/ml, Cutis 2010 July; 89  NOT effective: LB supplements, yogurt, pH acidifying agents, H2O2 douches, treating male partner

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CDC Trichomoniasis Treatmen:t High in Teens and Older Women Over 40!  Common,

often ignored, latent, no screening

guidelines  Risks: Preterm Labor, HIV, other STIs  Increased

in women > 40 years and older  Ages 18-39 yrs = 8-9%, 40-44 yrs=10%  45-49+ yrs =13% !  Most unscreened and untreated!

Gaydos, 2011, Abstract at Annual Mtg Int Soc of Sti Research, N 7598 women. Secor 2013 copyright

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Diagnosing Trichomoniasis in Women  “Variable

symptoms”, discharge, itching • Profuse yellow, green, gray/watery  Vaginal pH: elevated > 4.7  Amine/Whiff/KOH: negative  Wet Mount: • 60-70% accurate, MUST read immediately • Avoid hypersonic saline, or drying!  Pap: NOT reliable, correlate w/ pH/wet mount Secor 2013 copyright

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Diagnosing Trich in Women: IF Negative Wet Mount, Must Confirm Lab Culture is Gold STANDARD: Diamond’s, In-Pouch TV, etc. BUT 3 day process, Sensitivity 95%, Specificity 99.8% In-office:  Affirm VP lll: 45 minutes or overnight  “Osom” Rapid Antigen Test by Genzyme: “In-office” option (CLIA waived): 10 mins  BOTH: Sensitivity 83%, Specificity 97% Lab based:  Amplicor: PCR by Roche, S/S 88-97%/98-99%  PCR NEW: GenPath, MDL,Quest, Lab Corp: 3-5 days 51 Secor 2013 copyright

Trichomoniasis Treatment 2010 CDC STI Guidelines:  Always

treat male partner (MTZ x 1 week best for men)

 First •

•

Line: Equal efficacy: Metronidazole 2 gms orally, (Category B) OR Tinidazole (Tindamax) 2 gm orally (Cat C) • Contraindicated in pregnancy/ lactation

 Alternatives • •

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Atrophic Vaginitis    

 

 

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Vulva- ‘Sticky sign’ Erythema, mottling Pallor Flattening of rugae Leukorrhea variable Esp. amount May mimic BV, Trich, HSV Or other etiologies

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Diagnostic Work up of Atrophic Vaginitis

       

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Vaginal pH abnormally high > 5  Proxy test for estrogen levels = maturation index Negative Amine KOH ”Whiff “test Few Lactobacilli Mixed bacteria, grainy epithelial cells WBCs variable Immature epithelial cells, maturation index Avoid non-specific vaginal cultures, Pap inaccurate Test for STIs as appropriate! Secor 2013 copyright

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Atrophic = Abnormal Vaginal pH, CPT code 83986 

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pH Range 4.0-7.5 Normal = 4.0-4.5 (proxy for normal estrogen levels) BV, Trich, Atrophic = > 4.5 CLIA Waived

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Nitrazine Vaginal pH test “NitraTest”: order by roll • Requires multiple steps, • Match color with numerical pH reading (yellow=4.0 normal)



NEW: Vaginal pH Swab Test “VS-Sense”: 90% accurate • Rapid results: 10 second test for BV, Trich, Atrophy • Yellow swab = Normal pH • Blue swab = Abnormal, elevated pH Secor 2013 copyright

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Differential Diagnosis  BV  STIs;

Trich, Herpes, etc  Precancers  Vulvar

dermatoses Lichen sclerosis Lichen simplex chronicus Lichen planus Irritant, allergen, eczema, etc. Secor 2013 copyright

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Local Vaginal Estrogen Options: Minimal Systemic Absorption Sig: Daily for 2-4 weeks, every other day, then twice weekly prn  Vaginal estrogen creams: 0.5-2 gms pv at bedtime  Conjugated Equine Estrogen /CEE “Premarin”  Estradiol “Estrace”, etc.  Estradiol vaginal tablet “Vagifem” 10 mcg dose ONLY  If dry atrophy, or introital dyspareunia= may be less effective Bachman et al, Ob Gyn. 2008 jan;111(1):67-76 (RCT)  Vaginal estradiol ring “Estring”: every 3 months  Effective, convenient, may help OAB as pessary Secor 2013 copyright

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Atrophic Vaginitis: Local Vaginal Estrogen Prevent Secondary VVC/Yeast – 50% Risk!  Daily

for 2 to 4+ weeks; longer if comorbidities  Twice Weekly maintenance OR  Vaginal estrogen ring (Estring) every 3 months  Daily Introital application:  Minimal systemic absorption  Breast tenderness initially secondary to thin epithelium  Probably OK if breast cancer history  Sexual rehab: COMPLEX!  Dilator exercises, regular sex, lubricants, romance, sleep  Orgasm before intercourse, Manage OAB, Hot flashes, Vv, etc. Secor 2013 copyright

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Vulvitis: Complex Vaginal, Cutaneous Yeast, Contact, Allergic, Atrophy

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Non-neoplastic Epithelial Disorders Selected Conditions  Vulvitis:  Vaginitis:

mixed, atrophic effects  Contact, irritant, allergic, infectious, cutaneous yeast  Sensitive skin, various skin conditions  Lichen Simplex Chronicus /LSC  Squamous Cell Hyperplasia /SCH, Eczema  Lichen Sclerosis/ LS  Lichen Planus/ LP  Desquamative Inflammatory Vaginitis/ DIV Secor 2013 copyright

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Lichen Simplex Chronicus (LSC) Skin Thickening from Scratch, Itch  Unclear

etiology  Pruritus, burning, pain  Irritants, allergens, infections  Appearance variable  Vulvar KOH  Vaginal yeast culture  Biopsy, when in doubt! Secor 2013 copyright

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LSC Management: Scratch, Itch Cycle from Skin Thickening Diagnosis of Exclusion  Eliminate

irritants, allergens, etc. no soap, etc.  Vulvar care: vaseline, open to air, tea compresses, ice  Treat yeast: vaginal and cutaneous  External anti-fungal 3+ wks: nystatin ung 100,000u/gm  Intravaginal anti-fungal if needed x 2 weeks  Topical steroids (avoid Lotrisone, Mycolog combo)  Clobetasol 0.05% ung BID x 2-4 weeks, then taper  Hydrocortisone ointment 1% OTC, bid prn  Oral options  Diphenhydramine/ Benadryl 25-50 mg po hs  Hydroxyzine /Atarax10-50 mg po hs 69 Secor 2013 copyright

High Grade VIN Vulvar Intraepithelial Neoplasia  KOH:

negative  Skin problem hx: negative  Unresponsive to topicals  Refer  Will

require multiple biopsies

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Lichen Sclerosis (Late) White patches, loss of landmarks, etc.  Biopsy

to confirm  Clobetasol 0.05% ung  Daily/bid x 2-4 weeks  QOD x 2-4 weeks  Then twice wkly  Dynamic self care  Emollients !  Vaseline, Crisco  5% malignancy risk  F/u every 3 months

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Lichen Planus  Lacey,

reticulated lesions  Focal erythema  Associated gum disease  Mimics LSC, LS early  Loss of lower labia minora  Vulvar biopsy  Manage same as LS  Subset DIV, Desquamative Inflammatory Vaginitis  Intravaginal steroids 

Hydrocortisone acetate 25 mg BID/TID x2 wks

 10%

hydrocortisone pv

 REFER

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Vaginitis Objectives: Summary  Discuss

optimal diagnostic testing for vulvovaginitis

 Describe

strategies to prevent and treat acute and chronic Bacterial Vaginosis (BV), Yeast (VVC) and Trichomoniasis, Atrophy, Mixed

 Discuss

common vulvar dermatologic conditions including causes, diagnosis & treatment of selected conditions Secor 2013 copyright

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TTT  Test •

often and early

 Treat •

effectively

 Test •

- of cure follow-up 1 month 74

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Thank You and Good Luck! Questions Welcome R. Mimi Secor, MS, M.Ed, FNP-BC, FAANP www.MimiSecor.com Twitter @MimiSecorNP Facebook, LinkedIn, YouTube, my Blog Secor 2013 copyright

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References •

Beigi RH. Sexually transmitted diseases. 2012. Chichester, UK: Wiley Blackwell. (Vulvovaginal candidiasis, desquamative inflammatory vaginitis, and atrophic vaginitis, chapter 17).

•

Sobel, JD. Vaginitis, Cervicitis . In Infectious Diseases by Tan et al. 2008 (2nd ed), chapter 17, 326350. Philadelphia: ACP.

Bacterial Vaginosis/BV •

•

•

Schwebke & Desmond. A randomized trial of duration of therapy with metronidazole plus or minus azithromycin for treatment of symptomatic BV. Clinical Infectious Diseases. 2007 Jan 15;44(2):220221. Bodnar, L. Vitamin D deficiency is associated with bacterial vaginosis in the first trimester of pregnancy. Journal of Nutrition. 2009;139:1157-1161. Gilbert, Donders et al. Vaginal flora changes on Pap smears after insertion of levonorgestrelreleasing intrainterine device. Contraception. 2011 April; 83 (4): 352-356. (increased vaginitis risk) Secor 2013 copyright

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References Yeast  Kye Hyun Kim, Mi-Kyung Lee, Vaginal Candida and Microorganisms Related to Sexual Transmitted Diseases in Women with Symptoms of Vaginitis, Korean J Clin Microbiol Vol. 15, No. 2, June, 2012, http://dx.doi.org/10.5145/KJCM.2012.15.2.49 (n - 516, high correlation with yeast and M. genitalium P < 0.05)  Sobel JD. Vulvovaginal candidiasis. In: Sexually Transmitted Diseases, Holmes KK, Mardy PP et al. (Editors), 2008, Chapter 45, McGrawhill, NY, NY p 823-838. Atrophic Vaginitis  Kingsberg S, et al. Atrophic vaginitis. Int J Womens Health. 2010;1:105-111.  North American Menopause Society. Atrophic vaginitis. Menopause. 2007;14:357-369.  Mayo Clinic. Vaginal atrophy. http://www.mayoclinic.com/health/vaginal-atrophy/DS00770. Accessed January 23, 2012.  Goldstein I. Atrophic vaginitis. J Womens Health (Larchmt). 2010;19:425-432.  Nappi RE, et al. Atrophic vaginitis. Maturitas. 2010;67:233-238.  Bachmann GA, et al. Atrophic vaginitis. Am Fam Physician. 2000;61:3090-3096. Secor 2013 copyright

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References Yeast/BV Probiotics and prevention (conflicting results) Ya W, Reifer C, Miller LE. Efficacy of vaginal probiotic capsules for recurrent bacterial vaginosis: a double-blind, randomized, placebo-controlled study. Am J Obstet Gynecol. 2010;203:120.e1-120.e6. (DB-RCT w N =120, Yes) Ehrstrom S, Daroczy K, Rylander E, et al. Lactic acid bacteria colonization and clinical outcome after probiotic supplementation in conventionally treated bacterial vaginosis and vulvovaginal candidiasis. Microbes Infect. 2010;12:691-699. (RCT w N= 95, No ) Shalev E, Battino S, Weiner E, et al. Ingestion of yogurt containing Lactobacillus acidophilus compared with pasteurized yogurt as prophylaxis for recurrent candidal vaginitis and bacterial vaginosis. Arch Fam Med. 1996;5:593-596. (RCT w N=46, Yes BV, No yeast)

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References Vitamin D and Vaginitis • Peacocke M. et al. Desquamative Inflammatory Vaginitis as a Manifestation of Vitamin D Deficiency Associated With Crohn Disease: Case Reports and Review of the Literature Cutis 2010 July; 89. (N=4, sx improved when Vit D levels high normal) •

Bodnar, L. Vitamin D deficiency is associated with bacterial vaginosis in the first trimester of pregnancy. Journal of Nutrition. 2009;139:1157-1161. (BV rates higher if Vit D lower)

Vulvar Dermatology Edwards L, Lynch P. Genital dermatology atlas. 2011. Philadelphia: LWW.

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Resources www.asccp.org (new PAP, HPV guidelines) www.cdc.gov/stds (new 2010 guidelines) www.nams.org (menopause info for clinicians, pts) www.asha.org (great patient education materials) www.issvd.org (vaginitis info for clinicians, pts) http://obgyn.med.umich.edu/patient-care/womenshealth-library/vulvar-diseases (clinician and pt resources) www.nva.org (National Vulvodynia Association) www.acog.org Secor 2013 copyright

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