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    Recurrent vulvovaginitis: Tips for treating a common condition

     

    Bacterial vaginosis

    BV is one of the most common causes of vaginal discharge. Its prevalence among college students is 5% to 25% and up to 61% in women with other sexually transmitted infections (STIs). It presents as profuse discharge with a fishy odor. Women who douche, are African American,6 smoke, or have more frequent intercourse or new partners are at higher risk of infection.7 Patients often consider the odor to be an indication of uncleanliness and so can exacerbate the situation with douching or other hygiene techniques that can allow the pathogen to further gain ground. 

    Vulvar irritation often accompanies these symptoms and can be a result of epithelial cell damage, irritation from the discharge, or irritating products that further damage the sensitive vulvar skin. Untreated BV not only causes irritating vulvovaginal symptoms, but has also been linked to other health consequences such as increased risk of preterm delivery, postpartum fever, post-hysterectomy vaginal cuff cellulitis, postabortal infection, endometritis, and an increased risk of acquiring a STI (HIV, herpes simplex virus, gonorrhea, chlamydia, and trichomonas).8 Effective treatment is essential to promote a woman’s overall health.

    Diagnosis

    BV is the result of overgrowth of anaerobic organisms (eg, Gardnerella vaginalis, Prevotella, Mycoplasma, and Mobiluncus) in the vagina. The overgrowth of these organisms replaces lactobacilli and increases the vaginal pH.9 Lactobacilli can produce H2O2, which is a potent natural microbicide. The fishy odor is caused by the release of amines from vaginal peptides after breakdown by these organisms. Epithelial cell sloughing and vaginal transudate create the other symptoms experienced by women. The clinical diagnosis of BV is done by Amsel’s criteria, requiring 3 of the 4 criteria listed in Table 2. A Gram stain is the gold standard for the diagnosis of BV but its use clinically is limited by time and resources. Commercial tests are not widely used but can be if microscopy is not available. This can be expensive and time-consuming, so Amsel’s criteria is the preferred method of diagnosis. Amsel’s criteria has a sensitivity of over 90% as compared to Gram stain and is the most cost-effective method of diagnosis.

    Culture has no role in the diagnosis of BV because G. vaginalis is detected over half of the time in healthy, asymptomatic women. BV should not be empirically treated if found on a Pap smear unless the patient is symptomatic.10

    Treatment

    The mainstay of treatment for BV is metronidazole, orally or topically. Table 3 lists initial treatment regimens. Clindamycin regimens may be less effective than metronidazole but alternative regimens are offered for convenience, intolerance, or other issues that may preclude prescribing metronidazole. Tinidazole is also an option for those unable to tolerate the gastrointestinal side effects of metronidazole.11

    Oral regimens are associated with more side effects than vaginal therapy with similar efficacy.12 These regimens offer high rates of cure, 70.5% to 80% at 1 month. However, more than 30% of patients will present with recurrence of symptoms at 3 months, and more than 50% will have recurrence by 12 months.

    Performing a test of cure at the end of a treatment for a recurrent infection is one way to determine if subsequent infections are due to persistence of the initial infection or a reinfection. Cure is defined as all Amsel’s criteria-negative.9


    Theories abound as to why recurrence rates are so high. One theory is that a normal vaginal ecosystem was not fully reestablished after initial therapy. Other possibilities include undertreatment of the initial infection, underlying predispositions, or behavioral risk factors. Reinfection is also another possibility. Whatever the cause, other therapies are often necessary to keep a woman free of symptoms. Retreatment with the initial regimen is a reasonable first step, keeping in mind that the longer therapy regimens may have more therapeutic success.10


     

    Merida Miller, MD
    Dr. Miller is Associate Professor of Obstetrics and Gynecology, University of Iowa, Iowa City.

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    • Dr. Neil S. Gladstone
      I appreciated Dr. Miller's discussion of a common and vexing problems for both patients and clinicians. For 45 years, I have seen more unhappy patients with BV than any other condition including malignancies. At least with cancer, there is hope of a cure. With BV it never goes away. The two most important tools for the clinician in diagnosis BV are pH paper and a microscope. After the history, which is predictable, and after my vaginal exam. I do a pH on the discharge taken from the upper aspects of the vagina. The pH helps to direct what comes next. If the pH is in the acidic range the differential diagnosis is either Candida (yeast) or leucorrhea. If the patient presents with a history suggestive of yeast and she has a "Typical" cottage cheese discharge, and we are not dealing with multiple recurrences, I elect to treat with either topical or oral agents. For problem cases I will use a NAAT testing procedure. If the pH is in the alkaline range, I do a wet smear. If there is no evidence of Trichomands and with presence of Clue Cells, I make the diagnosis of BV. My treatment is two fold: I take the time needed to explain to the patient what are the triggers for BV, that the bacteria that cause the BV symptoms are residents of the vagina and can not be totally eliminated, and the change in pH temporarily eliminates the beneficial action of Lactobacillus. In this environment it is the anaerobes that were listed in the article that predominate. I encourage all patients to use condoms at all times and to use tampons to get rid of menstrual blood as quickly as possible. Instead of continually prescribing Metronidazole or Clindamycin orally, I use Boric acid vaginal suppositories 600 mg for at least one week. Patients do not like the topical antibiotics as the perception these measures do not work. They are unhappy because the oral antibiotics do not work because the "infection" keeps reoccurring, I never reference BV as a STI,but I also talk about keeping the environment of the vagina healthy by keeping out the offending substances and restoring the pH. The suppositories help with Candida as well. One part of therapy most clinicians especially non OBGYNS fail to do is to use a steroid and antifungal topical combination for the skin of the vulva. This maneuver provides relief for the irritated itchy skin. Each patient gets a written information about BV and I always offer to discuss the diagnosis with reluctant partners. This approach is not the panacea for BV , but I think it is more successful than the manner most people treat BV.This is anecdotal information, but I think it would merit someone with the time and patients to do a RCT. Also, I am very liberal in ordering STI panels including the use of NAAT panels. Neil S Gladstone, MD, FACOG,CCD

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