1. Vaginal Discharge

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

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

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

5. Commonest causes of altered vaginal discharge
In women of reproductive age

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

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

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

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

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

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

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

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

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

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

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

21. 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

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

23. 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

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

25. 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

26. 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

27. Trichomonas Vaginalis
1st Line Rx – oral Metronidazole
Rx partners

28. Recurrent Vaginal Discharge
REFER TO THE GUM CLINIC

29. 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

30. 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

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

32. POLYCYSTIC OVARIES
Prevalence 5-10%

33. Polycystic Ovary Syndrome (PCOS)
Hyperinsulinaemia
Glucose intolerance
Metabolic syndrome

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

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

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

37. 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

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

39. 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

44. 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

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

48. 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

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

50. 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

51. Diagnosis of Endometriosis
Laparoscopy – both diagnosis & treatment USS

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

53. 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

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

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

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