Vaginal Discharge

Common Causes Physiological Candida Bacterial Vaginosis STI Non infective causes ( ectopy, Foreign Body, Malignancy)

Normal Vaginal flora Lactobacilli Anaerobes Diptheroids Coagulase negative staphylococci Alpha haemolytic streptococcus

Overgrowth of normal vaginal flora Candida Albicans Staphylococcus Aureus Group B Strep ( Strep. Agalactiae)

Commonest causes of altered vaginal discharge In women of reproductive age

Vaginal discharge – infective causes Non STI BV Candida STI Chlamydia trachomatis N gonorrhoeae Trichomonas vaginalis Herpes Simplex

Non Infective Causes of Vaginal Discharge Foreign Body Cervical polyp/ectopy Fistulae Allergic reactions Personal Hygiene

Bacterial Vaginosis Commonest cause of abnormal discharge in women of reproductive age Can occur & remit spontaneously Not an STI but link with sexual behaviour

Bacterial Vaginosis Overgrowth of mixed anaerobic organisms replacing Lactobacilli Increase in vaginal PH > 4.5

Bacterial Vaginosis Gardenerella (Commensal in 30-40% of asymptomatic women) commonly found Prevotella Mycoplasma hominis Mobiluncus

Vulvo-vaginal Candidiasis Overgrowth of yeasts Candida Albicans – 70-90% Candida Glabrata – 10-30%

Vulvo-Vaginal Candidiasis Only treat if symptomatic Often precipitated by use of antibiotics Diabetes Immunocompromise NOT associated with tampons/sanitary towels

Chlamydia trachomatis Most common bacterial STI in the UK Asymptomatic in 70 % of women

Chlamydia Trachomatis Vaginal discharge – cervicitis Post coital bleeding Intermenstrual bleeding Lower abdominal pain Dyspareunia Dysuria

Trichomonas Vaginalis Vaginal Discharge + Dysuria STI Rarer than BV or VVC

Management of a lady with vaginal discharge Clinical & Sexual History ( Vaginal Discharge is a poor predictor of STI)

Management of a lady with vaginal discharge Assessment of Symptoms Characteristics of the discharge What has changed Onset Duration Odour Cyclical changes Colour Consistency Exacerbating factors

Vaginal Discharge Associated Symptoms Upper Genital Tract disease Itching Dyspareunia Vulval/Vaginal Pain Dysuria Abnormal bleeding Pelvic/Abdominal Pain Fever

Vaginal Discharge Dermatological conditions ( Lichen Planus) – superficial dyspareunia & itch (RCOG Guidance on Vulval Disease) Enquire re OTC Rx of VVC ( Women are not good at self diagnosis) Examination & Swabs

Bacterial Vaginosis Initial cure rates 70-80% Clindamycin & Metronidazole – comparable efficacy

Bacterial Vaginosis 1st Line Rx – oral Metronidazole ( less expensive than vaginal preparations) Metronidazole safer than oral Clindamycin (pseudo-membranous colitis) Acidifying gels may prevent recurrence Rx of male partners ineffective in recurrence prevention Consider Rx female partners

Vulvo-Vaginal Candidiasis Rx with oral or vaginal antifungals (cure rate – 80%) No data to support Rx or screening of partners Vaginal & oral Rx – equally effective Vulval symptoms – topical antifungals

Trichomonas Vaginalis 1st Line Rx – oral Metronidazole Rx partners

Recurrent Vaginal Discharge REFER TO THE GUM CLINIC

Recurrent Bacterial Vaginosis Median recurrence rate – 58 % after treatment Risk Factors : New/multiple partners, oral sex, Cu – IUCD COCs & condoms reduce the risk of BV

Recurrent Bacterial Vaginosis Optimal Rx of recurrence has not been established Twice weekly Metrondiazole gel ( only 33% remained recurrence-free 12 months after stopping) Acidifying gels – 2 lactic acid vaginal products available in the UK

Recurrent Vulvo-Vaginal Candidiasis 4 or more episodes of symptomatic, mycologically proven VVC in 1 year Suppression & Maintenance treatment

POLYCYSTIC OVARIES Prevalence 5-10%

Polycystic Ovary Syndrome (PCOS) Hyperinsulinaemia Glucose intolerance Metabolic syndrome

Macroscopically – ovaries enlarged & lobular Seen in 30 % of women presenting with infertility

Atretic follicles, theca cell hyperplasia & generalised increase in stroma Disruption of regular ovulatory processes Hyperandrogenaemia Raised LH levels & altered LH:FSH ratio

Peripheral distribution of multiple subcapsular cysts USS appearance NOT specific for PCOS

PCOS 20 % of self selected normal women had PCOS on scan 5 % of the general population is hirsute 75% of women with secondary amenorrhoea fulfil diagnostic criteria for PCOS

PCOS – Clinical Features Onset between 15-25 years of age Infrequent cycles Hirsutism Acne Acanthosis Nigricans Obesity Frank virilisation does NOT appear in PCOS

Described in medical literature in the 1800s John Sampson(1927) introduced the term endometriosis – retrograde flow of endometrial tissue through the fallopian tubes & into the abdominal cavity as the primary cause of the disease

Treatment of PCOS Laparoscopic cauterisation of ovaries Ovulation Induction ( for Infertility) Oestrogen + Cyproterone acetate (for acne/hirsuitism) Metformin ( helps weight loss & ovulation) Spironolactone (50-100mg/day) – anti androgen Diet & lifestyle Cosmetic measures

Endometriosis Prevalence – widely varying figures 10 % of women in the reproductive age group 25-35% of infertile women 4 per 1000 women aged 15-64 hospitalised each year Does not occur before menarche Not confined to nulliparous women

Endometriosis – Symptoms & Signs Dysmenorrhoea Dyspareunia Diffuse pelvic pain Symptoms from rectal/urethral/bladder involvement Low back pain Infertility associated with above symptoms Menstrual dysfunction not increased

Endometriosis – Symptoms & Signs DD Chronic pelvic pain Fibromyalgia Depression IBS Interstitial cystitis PID Fibroids Ovarian Cysts

Pelvic Pain – different presentations 15-16 year old with severe dysmenorrhoea 35 year old post laparoscopic sterilisation – pain since she stopped the COC Pain associated with menstruation or may be non cyclic Endometriosis may co exist with other conditions In women < 25 years think of STIs

Diagnosis of Endometriosis Laparoscopy – both diagnosis & treatment USS

Chocolate cyst of left ovary (Dr Malpani’s blog) Chocolate cysts tend to be complex & have a ground glass appearance

Relationship between pain & endometriosis unclear Classic blue or black powder burn appearance Lesions can be red, black, blue or white & non pigmented Tan, creamy, fresh appearing endometrium can also be observed

Ovary – most common site for implants & adhesions Distribution of endometriosis may be widespread – anteriorly & posteriorly over the broad ligament & cul-de-sac

Treatment of endometriosis Pain relief Concern re cancer Recurrence of cyst/endometriosis Fertility

Medical treatment of Endometriosis NSAIDs COC DMPA Provera GnRH agonists ( add back HRT) Transvaginal Danazole ( low dose 50-100mg) Watchful expectancy AVOID POLYLAPAROSCOPY