1MEN’S AND WOMEN’S HEALTH – OCTOBER 4TH, 2007

VAGINITIS

LECTURE 10
NORMAL VAGINAL ENVIRONMENT:
• Vagina: areas that are aerobic or anaerobic
• Dominant microflora is lactobacillis. Also see candida (normal!)
• Metabolic products of bacteria are H2O2, lactic acid. Creates anti-microbial and acidic environment.
• Estrogen maintains the cells of the vagina
• Normal pH of vagina is 3.5-4.5

• Larger cells due to estrogen

• Lactobacilli nourished by cells of vagina. Lactobacilli create the vaginal discharge. Discharge changes as a result of
changes in the cells that they feed on.
• Thinner discharge around ovulation. More profuse around ovulation and in second half of cycle.
• Will see discharge on os of cervix during vaginal exam.
• Delicate balance in vaginal environment: changed by stress, intercourse, medication, infection, hormonal factors,
hygiene and douching
• In discharge: RBC, WBC, epithelial cells and bacteria

Discharge due to vaginitis

• Discharge created by vaginitis looks different. If discharge varies from picture above, have to investigate.
• Important to make diagnosis, know specific organism that is causes problem.
• “Yeast infection” often diagnosed, sometimes over phone. Only 37% of cases are actually yeast infection. Yeast is
not even the most common cause of vaginitis. Can’t make

Sequelae of vaginitis
• PID: infection of ovaries, uterus, fallopian tubes, often STD.
• Have to address it: can have serious consequences.

Types of vaginitis (3)

Tools for exam:

• Note: a gynaecological exam is NOT always a PAP test. Can assess health of vagina, cervix through speculum
exam.
• PH testing: might help ID pathogen
• Wet mount: looking at slide with microscope. See type of cells present.
• KOH test: looking for hyphae spores
• The Whiff test: for gardenerella, other types of bacteria. “You’re in your garden looking for clue cells, come across a
flower and do a whiff test”
• Culture: not an in-house test
• Many of these tests can be done in-house to dx organism

MUCOCUTANEOUS CANDIDIASIS
• Has to do with balance between lactobacillis and candida (c. albicans)
• Basic vaginal pH is RELATIVE to normal vaginal environment (eg. 6 is “basic” as normal vaginal pH is 3.5-4.5)
• Risk factors (increase chance of getting infection: sugar intake, diabetes, corticosteroid use, oral contraceptive use,
antibiotic use, HIV infection, pregnancy, wearing pantyhose
• Increase over the past 20 years: increase in asthma (use of corticosteriods), diabetes, increased use of antibiotics,
birth control pills)

• Symptoms are not consistent across the board, therefore have to investigate thoroughly
• Slide is picture of typical discharge of candidiasis.
• Cervix: smoother tissue than the rugated vaginal tissue.
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• Discharge is clumpy, although colour is normal

Diagnosis of candidiasis:
• KOH for candidiasis is on a slide. Look for hyphae and spores
• Higher than normal pH (due to less lactobacilli)
• “cottage cheese” discharge
• Often get erythema due to pruritis, swelling of vulva

• Can spread to inguinal area and upper thigh, especially if immunocompromised, diabetic.
• If you see recurrent yeast infections, consider these in your ddx.

Slide: “spaghetti and meatballs” of candida.

BACTERIAL VAGINOSIS
• Anaerobic bacteria dominates. Caused by Gardnerella vaginalis, but others are responsible too. Remember it is not
just G. vaginalis.
• Risk factors: those that reduce amount of lactobacilli: antibiotic use, increased sexual partners (although not a
sexually transmitted infection), douching

Symptoms:
• Distinct from candidiasis: not as much pruritis
• “adherent”: stuck to the walls of vagina, face of cervix.
• Fishy odour is increased after intercourse and menses. What you smell are the amines of the bacteria, when the
bacteria break up. Sperm and blood are more basic, breaks up the cells, causes fishy odour.

Diagnosis:
• Not done with KOH preparation (when testing, do 2 samples, 1 with KOH and 1 without.)
• With KOH: fishy odour right away, but transient.
• PH typically elevated to 5-5.5.
• Culture won’t tell you too much, as gardnerella is normally found in the vagina. Swab may not be necessary.

Sequelae
• Can complicate pregnancy
• Reduces the amount of mucous in the vagina which is naturally protective against STIs.

Slide:
• Discharge is thinner, greyer than in candidiasis
• Next slide is of clue cell. Clumping of normal cells, stippling of bacteria around the outside. Sticks cells together.

TRICHOMONIASIS
• Directly related to sexual contact (STD)

Symptoms:
• Bubbling in discharge. Very different from other discharges.
• Will have pruritis and burning.

Diagnosis:
• If you see it on a wet mount, you know it is responsible. Not a normal organism found in vagina.
• However, test is only 60-80% effective. Negative test doesn’t rule out trichomoniasis
• “strawberry cervix”: Not in all patients (most don’t have it). But if you see it, you know it is trichomoniasis. Has
vascular bundles on cervix that look like petechiae
• Refer immediately if you diagnose this. Both partners must be treated
• Single celled flagellated organism.

CYTOLOGIC VAGINOSIS
• “too much of a good thing”: due to lactobacilis
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• COPIOUS discharge. More than normal.
• Symtoms are cyclical: follow increase in estradiol and luteal phase.
• Normal pH
• If you do wet mount, would see increase in lactobacilli.
• On speculum exam, could be confused most easily with candidiasis (discharge is same colour, less odour). Look at
character of discharge: if it is clumpy, think of candidiasis
• Why does it happen? Increase in estrogen causes increase in lactobacilli. Often occurs due to change in birth control
pills, overdose on probiotics
• Doesn’t cause further pathology, just inconvenient (lots of discharge, some pain)

HORMONAL (ATROPHIC) VAGINITIS

• Due to decrease in estrogen levels. Post-menopausal women
• Decrease in LB is due to decrease in estrogen. Decrease in acidic metabolic products from LB, therefore more
alkaline environment
• Colour of vaginal tissue will be more white (less pink)

Symptoms:
• Can have itching, burning.
• Friable tissue, therefore blood may be present in discharge.

ALLERGIC VAGINITIS
• History: change in laundry soap? Body soap? Vulva will also be irritated if soap is cause

FOREIGN BODY
• Any foreign body causes foul-smelling, watery discharge.
• Important to do good clinical history.
• This can happen in the vagina too (eg. tampons that are forgotten in vagina)
• Will see foreign body with speculum exam.

Vaginosis vs. vaginitis

• Less irritation in vaginosis
• Caused by bacteria already in vagina

CASES:
1. 29-year old woman: probably bacterial vaginosis. Douching will predispose her to this infection
2. 44-year old woman: What is going on? Meds for candidiasis, trichomonis haven’t worked. Do a swab, possibly
resistant candidiasis.
3. Last case: not enough info to diagnose. Skip it.

TREATMENT:
• Lots you can do with diet. Candida diet: specific to candidiasis, but reducing sugars will help with immunity
• Probiotics like yogurt: to increase lactobacillis: maybe 1-2 cups per day?
• Vitamin A: immune function, health and growth of epithelial tissue
• Vitamin C and bioflavonoids: immunity. Vit. C: integrity of connetive tissue
• Zinc: immune and epithelial growth
• Use of yogurt internally: be sure to introduce correct bacteria (eg. Lactobacillis)

Topical applications
• Chlorophyll: soothing to tissue
• Insertion of garlic on a thread (like a tampon). Don’t leave in too long!
• Tea tree oil as douche or on tampon
• Gentian violet: specific to candida

CERVICAL DYSPLASIA
Notes on this lecture will be sent to us or posted on e-college

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• Other conditions that affect cervix.
• So many names for cervical dysplasia. Occurs in the os.
• Other names: see notes
• CIN: cervical intraepithelial neoplasm (? I think?)

• Cervical os: presents into vaginal canal. At lower third of uterus.

• Type of cells on face of cervix? External: stratified squamous epithelium. Inside os: simple columnar.
• Transition area is called the squamo-columnar junction (SCJ). Important area in cervical dysplasia

• Dysplastic changes: HPV is agent.

• Caught on routine screening tests: women don’t usually come in complaining of dysplasia, although they may have
irregular bleeding after menses.

HPV
• 40 are “high risk”: these are the genotype that cause genital warts and cervical dysplasia.
• Many other factors that govern transition from HPV to cervical cancer.
• This is where we have role
o Smoking
o Multiple sexual partners (high risk partners)
o Female with male partner whose previous female partner had cervical dysplasia
o Oral contraceptive pill
o Immune suppression (HIV)

PAP smear:
• Brush inserted into os, want to get cells from SCJ
• Liquid base is convenient: if the test comes back positive, can use the same sample to test for HPV DNA.
• 80-90% sensitive: but since cervical cancer is so slow-growing, will probably be caught on next exam.

Results:
• LSIL: there are some changes in the cells of the cervix, but they are progressing slowly. Cancer is not imminent,
watchful waiting, but should have colposcopy.
• HSIL: greater concern. Refer: need conventional medical intervention, including colposcopy.
• Both can be reversed, more commonly with LSIL.
• Carcinoma in situ: contained within the uterus
• ASCUS: atypical cells of undermined significance. Don’t know what they mean…
o Woman over 30? Do HPV DNA screening
o Watchful wait with another PAP in 3 months
o Post-menopause: colposcopy.
• Algorhythm of what to do with ASCUS result: will be included in notes.

Colposcopy:
• Inspection. Looking at cervix with microscope
• Can see cells more clearly.

Treatment options:
• Focus on maintaining cells of cervix.

HPV vaccine
• Gardasil: put out by Merck.
• 4 high-risk strains: 6,11 (genital warts); 16, 18 (cervical dysplasia)
• Only approved in women 9-26 (maybe for men in Europe?)

Pros of vaccination Cons of vaccination

Reduces risk Adverse effects have been reported (VAERS). People may have had other vaccines at same
time… but there have been deaths.
Most people don’t Macleans: gives false sense of security: “anti-cancer” vaccine, people don’t do screening, parents
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have reaction don’t talk to kids about protection, creates resistance?
Concerns about safety: why implement a nation-wide protocol based on little research?
There is no epidemic! Highly manageable cancer, easy to detect. Women who die of it are
generally in underserviced areas/populations.
Population is too young to speak for themselves (Toronto school board is giving it to 12-13 year
old girls)

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