Check your approach to vaginal symptoms

Check the chart of your next patient. She says she has vaginal itching and irritation, odor, and vaginal discharge. What is your next step?

Vaginal complaints are the most common reason for gynecological consultation, accounting for about 10 million office visits each year.1 When it comes to managing vaginal symptoms, women's health providers are taught to use the classic approach in evaluating vaginal symptoms, examining discharge characteristics as well as performing pH tests, whiff test, and microscopy with both normal saline and potassium hydroxide (KOH).2 But how often do providers follow all of the steps, and how effective are they in diagnosis of vaginal symptoms?

According to an Internet survey of 556 nurse practitioners and 608 physicians, while most providers conduct a physical examination before treatment, performance of a wet mount, whiff test, and pH are done less commonly.2 While about 60% of providers said they always or often test for gonorrhea and chlamydia, only about one-third did a culture for Candida albicans, which accounts for about 20%-25% of all cases of vaginitis.1

Basing diagnoses simply on vaginal symptoms can pose problems in effective treatment.3 Telephone consultations for vaginitis often result in misdiagnosis.4 Evidence suggests that telephone diagnosis and management of vaginitis/vaginosis symptoms is often not accurate. In a study of 253 patients, investigators found that providers' diagnostic accuracy was poor; telephone diagnosis for trichomonas, bacterial vaginosis, and yeast was inaccurate most of the time when compared with microscopic findings.5

The time is ripe for new approaches to diagnosing and treating vaginal symptoms, says Matthew Anderson, MD, assistant professor in the department of family and social medicine at the Albert Einstein College of Medicine of Yeshiva University in New York City.

"Most doctors do not follow the [diagnostic] algorithm, so the real question is, is the diagnostic algorithm relevant?" he says.

Anderson is preparing to do a randomized pilot study, where one arm of the study will have women who receive the entire algorithm: wet mount, pH test, and whiff test. In the other arm, women will be treated empirically, says Anderson. Women will be rechecked for symptoms after two weeks.

Anderson and fellow researchers performed a structured literature review for information on sensitivity and specificity for symptoms, signs, and office laboratory procedures using the terms diagnosis with vaginitis, vaginal discharge, candidiasis, bacterial vaginosis, and trichomoniasis.6 They found that while the cause of vaginal complaints may be easily diagnosed when typical findings appear in microscopy, the poor performance of individual symptoms, signs, and office laboratory tests often makes it problematic to identify the cause of vaginal symptoms.

"Vaginal symptoms may be the most common gynecological complaint in primary care, but much remains to be learned about their clinical diagnosis," the researchers state.6

Self-care eyed

In 2002, women in the United States spent more than a half-billion dollars on medications to treat vulvovaginal candidiasis; about half of this amount was spent on over-the-counter preparations.7

Can women determine for themselves the appropriate care for vaginal symptoms? Researchers surveyed 552 women ages 16 and older on the classical signs of pelvic inflammatory disease, bacterial vaginosis, acute cystitis, vaginal trichomoniasis, and vulvovaginal candidiasis (VVC). Of the 552 surveyed, 365 of the women reported a prior VVC diagnosis. However, only 34.5% of them could correctly identify VVC symptoms in the survey.8

Synova Healthcare of Media, PA, is launching a new at-home test called Fem-V, a noninvasive diagnostic test developed to assist women in diagnosing vaginal infections at home. The test uses a detection strip attached to a panty liner to test the pH and dilution of vaginal discharge. Test results will help women determine if an over-the-counter treatment may be considered or if they should seek treatment from a health care professional, according to the company.

The product, to be sold in retail pharmacies, was scheduled for a May 2006 launch as of CTU press time. The over-the-counter test carries a retail price of $7.99, according to Patty Bowman, Synova's vice president of marketing.

References

  1. Kent HL. Epidemiology of vaginitis. Obstet Gynecol 1996; 165:1,168-1,176.
  2. Anderson MR, Karasz A. How do clinicians manage vaginal complaints? An Internet survey. MedGenMed 2005; 7:61.
  3. Allen-Davis, JT. Why we can't diagnose based on symptoms alone. In: Optimal Diagnosis of Vaginitis. OBG Management 1998; November:1S-5S.
  4. MacNeil JS. Diagnose vaginitis by exam, not by phone. OBG Management 2005; 40:26.
  5. Allen-Davis JT, Beck A, Parker R, et al. Assessment of vulvovaginal complaints: Accuracy of telephone triage and in-office diagnosis. Obstet Gynecol 2002; 99:18-22.
  6. Anderson MR, Klink K, Cohrssen A. Evaluation of vaginal complaints. JAMA 2004; 291:1,368-1,379.
  7. Ferris DG, Dedle C, Litaker MS. Women's use of over-the-counter anti-fungal pharmaceutical products for gynecologic symptoms. J Fam Pract 1996; 42:595-600.
  8. Marrazzo J. Vulvovaginal candidiasis. Br Med J 2003; 326:993-994.