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Managing recurrent vaginitis: What works?
While vaginitis usually is considered a minor nuisance, many women experience chronic symptoms that persist or recur after treatment. What can clinicians do?
Recurrent vaginitis encompasses a broad array of problems, which include vaginal infections, vulvar skin disorders, and vulvovaginal atrophy, says Paul Nyirjesy, MD, professor of obstetrics and gynecology and director of the Drexel University Vaginitis Center in the Drexel University College of Medicine in Philadelphia.
What is vaginitis? The condition is defined as inflammation of the vagina marked by pain, itching, and/or a purulent discharge. The most common causes of infectious vaginitis are (depending on the population):
"In women with recurrent symptoms, obtaining an accurate diagnosis is crucial," says Nyirjesy. "For women where they have been told they have yeast infections, a yeast culture will confirm the diagnosis and allow proper selection of antifungal therapy."
The trend in the last 15 years has been for women to diagnose and treat themselves for VVC.2 Patients with recurrent symptoms should avoid self-treatment, as treating themselves might interfere with obtaining the correct diagnosis and might exacerbate symptoms, says Nyirjesy.
Women who have had prior yeast infections or bacterial vaginosis might think the source of their current discharge is similar to a previous condition and will self-medicate with an over-the-counter yeast medication, says Kimberly Workowski, MD, professor of medicine in the Division of Infectious Disease at Emory University and team leader of the Guidelines Unit in the Centers for Disease Control and Prevention's (CDC) Division of STD Prevention, both in Atlanta. The problem with self-medication is that other types of infectious vaginitis are not affected by the over-the-counter antifungal drug, Workowski notes.
All vaginal discharge doesn't mean vaginitis. It could indicate that some of the discharge is coming from the cervix or higher up in the female genital tract, says Workowski. Patients need to be counseled not to assume that all vaginal infection is due to what has been experienced before, especially if the patient has been sexually active and has been using non-barrier methods of protection, she advises.
Test before treating
While patients with recurrent vaginitis might represent a large portion of the daily calls into your facility, resist the urge to use a telephone diagnosis.2 Research findings indicate that diagnosis of vaginal symptoms by telephone often result in misdiagnosis.3
At a minimum, women with vaginitis should undergo office testing, which consists of a vaginal ph, amine or whiff test, wet mount, and 10% potassium hydroxide (KOH) test, says Nyirjesy.
For bacterial vaginosis, diagnosis can be obtained by using clinical criteria or Gram stain.4 Diagnosis by clinical criteria require three of the following symptoms or signs:
When using a Gram stain, determining the relative concentration of lactobacilli (long Gram-positive rods), Gram-negative and Gram-variable rods and cocci (i.e., G. vaginalis, Prevotella, Porphyromonas, and peptostreptococci), and curved Gram-negative rods (Mobiluncus) characteristic of BV is considered the gold standard laboratory method for diagnosing BV, according to the CDC. Clinicians also might look at the use of such rapid tests as the Affirm VP III test (BD Diagnostics, Sparks, MD), OSOM BV Blue (Genzyme Diagnostics, Framingham, MA), and the QuickVue Advance G. vaginalis (Quidel Corp., San Diego, CA).5
The right test matters when it comes to successfully treating vaginitis. Yeast cultures used to detect VVC increase sensitivity and allow for speciation of the organism. This detection is crucial to choosing the proper antifungal drug. Non-albicans species of Candida are less likely to respond to standard azole therapy.2
Many clinicians might resort to using the microscope to detect trichomoniasis, but such practice might not be successful, says Workowski. "The traditional approach has been to look at the secretions under the microscope, but we know that for some of these infections, using those traditional approaches can be insensitive, particularly with trichomoniasis, where you can only diagnose kind of up to 60% of patients who have trichomoniasis," she says.4
Culture can be used to test for infection, as well as two point-of-care tests: the OSOM Trichomonas Rapid Test (Genzyme Diagnostics) and the Affirm VP III (BD Diagnostics).
Continuing education is an important part of staying on top of current strategies to detect and treat vaginitis, says Workowski. The CDC offers free continuing medical education credits on vaginitis through its Self-Study STD Curriculum Modules for Clinicians, available on the CDC web site.
Earn free continuing medical/nursing education credit through the Centers for Disease Control and Prevention's (CDC's) Self-Study STD Curriculum Modules for Clinicians, available on the agency's web site. To access the modules, go to the STD portal of CDC, www.cdc.gov/std. Under "Key Resources," select "Training." Next, select "Continuing Education Online," then "STD Curriculum Self-Study Modules." Click on "Vaginitis" for the self-study module.