#244 Vulvovaginitis for All Ages with Dr. Monica Christmas

November 30, 2020 | By Sarah Phoebe Roberts

Everything you need to know about candidiasis, bacterial vaginosis, and Genitourinary Syndrome of Menopause

Everything you need to know about vulvovaginitis: candidiasis, bacterial vaginosis, and Genitourinary Syndrome of Menopause. Join us on the journey of a lifetime as we learn all about diagnosing, treating and managing vulvovaginal conditions in patients of all ages. Plus, a bit on how to recognize and treat lichen sclerosus. Our brilliant guest for this episode is Dr. Monica Christmas (@drmonicaxmas on Twitter), who is a self-described yoga enthusiast, avid reader, wannabe artist and gynecologist. Dr. Christmas is currently an Assistant Professor at the University of Chicago in the section of Minimally Invasive Gynecologic Surgery where she is the director of the Menopause Program. Monica specializes in gynecologic surgery, abnormal uterine bleeding and menopause management with an interest in sexual dysfunction. Her focus is on helping women live healthy, vibrant, happy lives. 

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Credits

• Produced by: Kate Grant MD; Sarah Phoebe Roberts MPH
• Written by: Kate Grant MD
• Show Notes by: Sarah Phoebe Roberts MPH, Kate Grant MD
• Cover Art and Infographic: Kate Grant MD
• Hosts: Kate Grant MD; Matthew Watto MD, FACP; Paul Williams MD, FACP   
• Editor: Matthew Watto MD (written materials); Clair Morgan of nodderly.com
• Guest: Dr. Monica Christmas, MD

Sponsor

ACP’s I Raise the Rates

Join with other clinicians in working to raise influenza and other adult vaccination rates. Visit acponline.org/ai to access free tools and learn new strategies to support your efforts. 

VCU Health CE

The Curbsiders are partnering with VCU Health Continuing Education to offer FREE continuing education credits for physicians and other healthcare professionals. Visit curbsiders.vcuhealth.org and search for this episode to claim credit. See info sheet for further directions. Note: A free VCU Health CloudCME account is required in order to seek credit.

How to Claim VCU CME Credit

Time Stamps

• Sponsor – American College of Physicians ‘I Raise the Rates’ adult immunization initiative
• Sponsor – VCU Health CE curbsiders.vcuhealth.org
• 00:00 Intro, disclaimer
• 02:00 Guest bio and one-liner
• 04:50 Caste by Isabelle Wilkerson (author is also featured on the August 4th episode of NPR’s Fresh Air)
• 06:00 Sponsored message from ACP ‘I Raise the Rates’ initiative
• 07:00 Candidiasis case, diagnosis and management 
• 14:25 Recurrent candidiasis case 
• 24:00 Bacterial vaginosis (BV) case and treatment review
• 31:45 Management of recurrent BV
• 32:50 Management of vulvovaginitis in pregnancy
• 34:45 Vulvovaginal symptoms in menopausal patients
• 36:55 Genitourinary syndrome of menopause (GSM) 
• 39:20 Review of treatment options for GSM symptoms
• 42:15 Topical vs. systemic estrogen therapy
• 44:25 Signs/symptoms and examination findings for GSM
• 47:40 Management of painful sex and vulval skin changes in post-menopausal patient  
• 49:00 Discussion of lichen sclerosus diagnosis and treatment options
• 52:00 Role of pelvic floor therapy in treatment
• 54:30 Final pearls and Outro

Vulvovaginitis Pearls

1. Take a thorough history to assess lifestyle and hygiene habits (e.g. use of soaps, scented menstrual products, douches, not changing out of damp or wet exercise gear, etc.). Many things can disrupt the vaginal microbiome and cause or worsen vulvovaginal symptoms.
2. There are a variety of oral, intravaginal and topical (external) treatments that are effective for treating vulvovaginal conditions such as candidiasis and bacterial vaginosis (BV); patients with recurrent symptoms may require an extended treatment regimen.  
3. For older female patients, take annual exams as an opportunity to inquire about vulvovaginal symptoms that may be indicative of genitourinary syndrome of menopause (GSM) or a related condition. Visually reviewing the vulvovaginal area will spot any malignant change eg Squamous cell Carcinoma changes related to chronic Lichen Sclerosus.

Vulvovaginitis Across the Lifespan: Show  Notes 

Candidiasis: Assessment, diagnosis, treatment

Assessment:  

Make sure the patient is comfortable; avoid using a speculum if not necessary (especially if patient has never been sexually active). Patient can self-collect a vaginal swab if needed. Check outer labia for erythema, excoriations or fissures, look for thick “cottage-cheese” like discharge that is typically white in color but can sometimes be yellowish or greenish.

Take a history of lifestyle and hygiene practices e.g. what patient uses to wash vulval region, use of new detergents or bathing products, recent antibiotic treatment, new exercise routines, etc. 

Diagnosis: 

A wet prep can be done in the office and is easy, quick and inexpensive. Visualization of budding yeasts, pseudohyphae or hyphae is diagnostic. A culture can be done in cases that are resistant to treatment or recurrent. PCR testing is an option but cost may be a limitation. PCR has high sensitivity + specificity. If the patient is sexually active, do an STD workup as well.

Treatment: 

Oral and topical options, oral fluconazole (usually one-time dose) and/or an intravaginal azole. OTC azoles are available but may contain preservatives or other chemicals that can worsen symptoms. Advise lifestyle changes, e.g. using only water to wash the vulvovaginal area, don’t keep wet clothing or swimsuits on, avoid scented menstrual products. Treatment of patient’s sexual partner is usually not necessary but consider if partner has an uncircumcised penis as yeast can harbor under the foreskin. Current BASHH guidelines indicate there is no evidence for routinely treating asymptomatic male partners in either acute or recurrent vaginal candidiasis (Evidence Grade 1A).

Both candidiasis and BV infections should be treated in pregnancy. For pregnant patients with candidiasis, in the first trimester vaginal treatment is preferred over oral fluconazole. There have been some case reports for fetal malformation with high doses of fluconazole use for prolonged durations (400 to 1200 mg/day) in the first trimester. Note: Dr Christmas notes that a single oral fluconazole dose of 150 mg is acceptable for most pregnant women (expert opinion).

Recurrent candidiasis: How to manage?  

Re-assess for lifestyle and potential risk factors e.g. diabetes, STDs. If patient reports >3 infections per year they may require suppressive therapy or an extended regimen treatment. This could involve oral or topical/intravaginal therapy. Treat acute infection first, then give oral fluconazole weekly for up to 16 weeks; sometimes 6 weeks is enough depending on the patient. Note: The BASHH guidelines mention treating weekly for up to 6 months.

Alternative therapies: Dr. Christmas reports that anecdotally, boric acid capsules seem to be effective for patients with recurrent candidiasis of unknown cause who have not found relief from traditional treatments. She recommends patients insert one suppository every night for two weeks. May have to find a local pharmacy that can compound the capsules, or patients can order them online from Amazon. Other remedies such as intravaginal lactobacillus capsules, yogurt, tea tree oil, garlic etc. lack evidence of effectiveness and may worsen symptoms. 

Bacterial vaginosis: Assessment, diagnosis, treatment

Assessment: 

Take patient history and conduct a physical exam. The CDC recommends testing for STIs as well. Symptoms of bacterial vaginosis (BV) include thin, watery discharge that is white or greyish in color and may have a strong amine (‘fishy’) smell. Patients may report smell and a feeling of wetness, and sometimes vulvovaginal itching and irritation. BV is the most common cause of vaginal discharge and bad odor, but most women with BV are asymptomatic. 

Diagnosis: 

Do a wet mount: swab vaginal walls and put a drop of discharge with a drop of saline on a slide for microscopy. Presence of more than 20% clue cells can be diagnostic for BV. Can do 10% KOH ‘whiff’ test on the discharge, an amine/fishy smell suggests BV. Finally, BV often causes vaginal pH >4.5, so discharge can be checked with  nitrazine pH paper, which will usually turn bright blue. Other options: single swab multiplex PCR and DNA probe. 

Treatment: 

Lifestyle recommendations–similar to candida. Avoid douching, using body wash, scented panty liners, etc. There has also been some association between use of the copper IUD and an increase in BV (though the risk may be from irregular bleeding —Madden, 2012); combined oral contraceptive pills may also increase risk of candidiasis and possibly BV. There is no need to treat the patient’s partner unless it is a same-sex relationship and both are symptomatic. 

Oral or intravaginal metronidazole or intravaginal clindamycin is recommended. Alternatively, may use oral secnidazole, oral tinidazole or oral clindamycin. Patients should refrain from sexual activity during treatment (CDC 2015) or use barrier contraception —Bradshaw, 2013, which may protect from recurrence –. Due to a theoretical risk of a “disulfiram-like” reaction, patients have historically been counseled to abstain from alcohol use during treatment with oral nitroimidazoles, but The Curbsiders discussed how this is likely not a real thing –listen to #215 Medical Myths with Dr Doug Paauw.

After treatment, BV may recur in up to 30% of patients within 3 months and 58% within 12 months. Risk factors: douching, frequent sexual activity, h/o BV, persistence of pathogenic bacteria, or failure to reestablish a lactobacillus-predominant vaginal flora. Patients with at least 3 episodes in 1 year may require suppressive therapy (twice weekly suppressive metronidazole gel for 16 weeks after treatment of the acute episode). Changing the antibiotic or extending the course may be considered as well. Probiotics have not been shown to treat or prevent bacterial vaginosis.

Recurrent vulvovaginal complaint in perimenopausal patient 

Assessment: 

Genitourinary Syndrome of the Menopause (GSM), formerly called Atrophic Vaginitis, refers to a constellation of vaginal signs and symptoms due to menopause. It is experienced by ~40%-60% of older women (Angelou 2020). Symptoms include genital dryness, decreased lubrication w/sexual activity, discomfort or pain w/ sexual activity, post-coital bleeding, decreased arousal/orgasm/desire, irritation/burning/itching of the vulva or vagina, dysuria, and urinary frequency/urgency. 

Things to look for upon physical exam: skin pallor, hypopigmentation of the vulva, erythema, regression of the labia minora, thinning of the vaginal mucosa (tissues look more friable). Petechiae or fissures may be noted (see reference section below for image galleries). The Vaginal barrel can tighten/shrink, and shorten. Many physiologic changes and symptoms may be associated with decreased estrogen/absence of estrogen. 

Diagnosis: 

GSM is typically diagnosed clinically on exam/inspection; however, pH test and wet mount may be conducted if infection is also a risk. STI screening may be warranted. Candidiasis and BV are less common after menopause as estrogen levels fall.  If exam and testing are negative for infectious etiology or dermatitis and exam suggests vaginal atrophy due to hypoestrogenism, discuss prescription and non-prescription treatment options.

Treatment: 

Take history and make sure the patient is avoiding products with fragrance or preservatives that may be irritating to the vaginal tissues. Oils such as olive oil, coconut oil and mineral oil often are used but may increase risk of vaginal infections and have pungent odors.​

Topical moisturisers: moisturizers are applied to the vaginal tissue at least 2-3 times per week as maintenance therapy regardless of sexual activity. Hyaluronic acid based moisturizers have been found to relieve symptoms of dryness similar to vaginal estrogen.  

Lubricants: lubricants are to be used before sex. They can be applied directly to the vaginal tissue, penis or toys. Silicone based lubricants tend to be preferred. Water based lubricants tend to dry out more quickly.

Local estrogen therapy: comes in many forms e.g. cream, suppository, tablet, ring. The topical therapies are not systemically absorbed as much, so concerns that accompany systemic HRT (e.g. increased risk of DVT, stroke, breast cancer etc) are not as big of a concern. Vaginal cream, pill, suppository are similar dosing. Initially: every night for 2 weeks then can decrease to using it twice per week. Can be a little irritating to the vulvovaginal area, so twice per week may also be effective.

Systemic HRT will treat vaginal symptoms as well but should only be used if patients have bothersome vasomotor symptoms as well. Other options include a DHEA vaginal suppository and an oral SERM, ospemifene. Dr. Christmas notes that cost is a concern with DHEA and SERM agents.

Lichen sclerosus: Assessment, diagnosis, treatment

Lichen sclerosus is a condition affecting the vulvovaginal area. It can start at any age, but is most often diagnosed in women over the age of 50. It involves the skin of the perineum, labia minora/majora, clitoral hood, inguinal fold (often in a “hour glass” pattern), but never the vaginal mucosa. Patients often have a co-existing autoimmune condition e.g. thyroid disease, pernicious anaemia or alopecia areata. 

Assessment/Diagnosis:

Symptoms of lichen sclerosus include itching, bleeding, pain during sex, blisters, and friable skin. The patient may present with patchy, white skin that appears thinner than normal, or “parchment paper-like”. Hypopigmentation often takes on an hour glass distribution around the vaginal and anal area. Upon examination, may see an ulcerated area; a biopsy should be performed as lichen sclerosus can be associated with increased risk of  vulvar cancer (Squamous Cell Carcinoma, not HPV-related Vulva Intraepithelial Neoplasia aka VIN). A vaginal biopsy will give dx of lichen sclerosus or lichen chronicus.

Treatment: 

Lichen sclerosus tends to be chronic. Treatment can improve symptoms, but can’t eradicate them. It is treated with topical, high-potency steroids two times per day–small amount applied to the irritated area. Be careful (‘less is more’) since steroids can thin the tissue too. Once symptoms recede, the patient can either stop the steroid, use it intermittently (a few times weekly as needed) or switch to a less potent steroid. For some patients with chronic lichen sclerosus, seeing a pelvic floor physical therapist may be helpful as well. The purpose is to help patients learn to relax their pelvic floor muscles. Dr. Christmas recommends WomanLab.org as a resource for understanding pelvic floor physical therapy. 

Links*

1. Caste by Isabel Wilkerson 
2. WomanLab sexual health resource

*The Curbsiders participates in the Amazon Services LLC Associates Program, an affiliate advertising program designed to provide a means for sites to earn advertising commissions by linking to Amazon. Simply put, if you click on our Amazon.com links and buy something we earn a (very) small commission, yet you don’t pay any extra.

Goal

Listeners will learn to diagnose and manage common female genital conditions that can occur at any age, that impact sexual, physical and psychological function.

Learning objectives

After listening to this episode listeners will…  

1. Define common terms: Candidiasis, thrush,  vulvovaginitis, bacterial vaginosis (BV), gardnerella, atrophic vaginosis, vaginal atrophy, genitourinary syndrome of menopause (GSM), lichen sclerosus
2. Recognize the limitations of diagnostic testing and symptoms in the diagnosis of thrush, BV and atrophic vaginitis/GSM
3. Recognize the existence and purpose of the vaginal microbiome
4. Develop an approach to the sexually and non-sexually active patient when testing for vulvovaginal conditions, including for WSW patients (women who have sex with women)
5. Educate patients and have meaningful informed-consent discussions about prescription and OTC treatment options for thrush, BV and genitourinary syndrome of menopause
6. “Dos and Don’ts” when it comes to vaginal washes, douching, panty liners and underwear.
7. Define and identify genitourinary syndrome of menopause

Disclosures

Dr. Christmas reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures. 

Citation

Grant K, Christmas M, Robert SP , Williams PN, Watto MF. “#244 Vulvovaginitis for all ages with Dr Monica Christmas”. The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list Final publishing date November 30, 2020.

References

Guidelines

• British Association for Sexual Health and HIV. BASHH Guidelines on Bacterial Vaginosis (2012) and Vulvovaginal Candidiasis (2019).
• Centers for Disease Control and Prevention. Vulvovaginal Candidiasis. 2015 Sexually Transmitted Diseases Treatment Guidelines. Published online June 4, 2015. Available at: https://www.cdc.gov/std/tg2015/candidiasis.htm
• National Institute for Health and Care Excellence. Menopause: diagnosis and management. NICE guideline [NG23] Published date: 12 November 2015 Last updated: 05 December 2019. Available at: https://www.nice.org.uk/guidance/ng23

Candidiasis and BV

• Kairys N, Garg M. Bacterial Vaginosis. [Updated 2020 Jul 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459216/ 
• Iavazzo C, Gkegkes ID, Zarkada IM, Falagas ME. Boric acid for recurrent vulvovaginal candidiasis: the clinical evidence. J Womens Health (Larchmt). 2011;20(8):1245-1255. doi:10.1089/jwh.2010.2708
• Watson CJ, Pirotta M, Myers SP, Myers P. Use of complementary and alternative medicine in recurrent vulvovaginal candidiasis–results of a practitioner survey. Complement Ther Med. 2012;20(4):218-221. doi:10.1016/j.ctim.2012.01.004
• Parma M, Stella Vanni V, Bertini M, Candiani M. Probiotics in the prevention of recurrences of bacterial vaginosis. Altern Ther Health Med. 2014;20 Suppl 1:52-57.
• Recine N, Palma E, Domenici L, et al. Restoring vaginal microbiota: biological control of bacterial vaginosis. A prospective case-control study using Lactobacillus rhamnosus BMX 54 as adjuvant treatment against bacterial vaginosis. Arch Gynecol Obstet. 2016;293(1):101-107. doi:10.1007/s00404-015-3810-2
• Forcey DS, Vodstrcil LA, Hocking JS, et al. Factors Associated with Bacterial Vaginosis among Women Who Have Sex with Women: A Systematic Review. PLoS One. 2015;10(12):e0141905. doi:10.1371/journal.pone.0141905
• Plummer EL, Vodstrcil LA, Fairley CK, et al. Sexual practices have a significant impact on the vaginal microbiota of women who have sex with women. Sci Rep. 2019;9(1):19749. doi:10.1038/s41598-019-55929-7

Genitourinary syndrome of menopause (GSM)

• Portman DJ, Gass MLS, Vulvovaginal Atrophy Terminology Consensus Conference Panel. Genitourinary syndrome of menopause: new terminology for vulvovaginal atrophy from the International Society for the Study of Women’s Sexual Health and the North American Menopause Society. Menopause. 2014;21(10):1063-1068. doi:10.1097/GME.0000000000000329
• Smith AL, Wein AJ. Estrogen replacement therapy for the treatment of postmenopausal genitourinary tract dysfunction. Discov Med. 2010;10(55):500-510.
• Lethaby A, Ayeleke RO, Roberts H. Local oestrogen for vaginal atrophy in postmenopausal women. Cochrane Database Syst Rev. 2016;(8):CD001500. doi:10.1002/14651858.CD001500.pub3
• Cody JD, Jacobs ML, Richardson K, Moehrer B, Hextall A. Oestrogen therapy for urinary incontinence in post-menopausal women. Cochrane Incontinence Group, ed. Cochrane Database of Systematic Reviews. Published online October 17, 2012. doi:10.1002/14651858.CD001405.pub3
• Cano A, Estévez J, Usandizaga R, et al. The therapeutic effect of a new ultra low concentration estriol gel formulation (0.005% estriol vaginal gel) on symptoms and signs of postmenopausal vaginal atrophy:  results from a pivotal phase III study. Menopause. 2012;19(10):1130-1139. doi:10.1097/gme.0b013e3182518e9a 
• Bertoli, H.K., Rasmussen, C.L., Sand, F.L., Albieri, V., Norrild, B., Verdoodt, F. and Kjaer, S.K. (2019), Human papillomavirus and p16 in squamous cell carcinoma and intraepithelial neoplasia of the vagina. Int. J. Cancer, 145: 78-86. https://doi.org/10.1002/ijc.32078 

Image galleries*

• Images of vulval lichen sclerosus: https://www.dermnetnz.org/topics/vulval-lichen-sclerosus-images/
• Images of vulvovaginal candidiasis: https://dermnetnz.org/topics/vulvovaginal-candidiasis-images/?stage=Live
• Images of vulval intraepithelial neoplasia (VIN): https://dermnetnz.org/topics/vulval-intraepithelial-neoplasia-images/?stage=Live

*These image galleries primarily feature the presentation of vulvovaginal conditions in patients with light/white skin tones. There are, unfortunately, far fewer comparable image libraries that feature skin of color. The following are resources that may be helpful in identifying vulvovaginal and dermatological conditions in Black and Brown patients:

• http://www.atlasdermatologico.com.br/index.jsf 
• https://skinofcolorsociety.org/skin-of-color-dermatology-textbooks/
• https://www.brownskinmatters.com/all-conditions (check their Instagram for more pics)
• https://www.visualdx.com/diversity/