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beavoi ded.
Managementopti onsfor com plicatedor r ecurrent
yeastv aginitis
Extendany 7-day regi mento10to14day s
Eliminateuseofny lonorti ght-fittingcl othing
Considerdi scontinuingoral contracepti ves
Considereating8oz yogurt(w ithLactobacillus
acidophiluscul ture)perday
Improvegl ycemiccontrol i ndi abeticpati ents
Forl ong-termsuppressi onofrecurrentvagi nitis,use
ketoconazole,100m g(½of200-m gtabl et)qdfor6
months
D. Recurrent i nfection i s defi ned as m ore than four
episodes pery ear.S uppressivetherapy for6 months
is recommendedaftercom pletionof10to 14 days of
astandard regimen. Oralk etoconazole,100m gdai ly
for 6 m onths, has been show n to reduce th e recur
rence rate to 5%. I f the sex ual partner has bal anitis,
topicaltherapy shoul dbeprescri bed.
IV. Trichomoniasis
A. Trichomoniasis i s responsi ble for l ess than 25% o f
vaginal infections. T he i nfection i s caused by
Trichomonas vaginalis,w hichi sasex ually transmitted
disease.M ostm enareasy mptomatic.
B. Diagnosis
1. Acopi ous,w aterydi schargei s common, and some
patients m aynoti ce an odor. Often few sy mptoms
arepresent.U sually,thevul vaand vaginalm ucosa
arefreeofsi gnsofi nflammation.T hedi schargei s
thin and characteri zed by an el evated p H, usual ly
6to7.Occasi onally,sm all punctatecervi calhem or
rhages w ith ul cerations (stra wberry cervi x) are
found.
2. Microscopicex aminationofvagi nalfl uid mixed with
saline sol ution ( w et prep ) show s an i ncreased
number of l eukocytes and m otile tri chomonads.
Microscopy has a sensi tivity of onl y 50% to 70%.
Trichomonads are som etimes reported on P ap
smears,butfal se-positiveresul tsarecom mon.
3. Culturefori dentificationofT vaginalis has a sensi
tivity of 95% and shoul d be perform ed when t he
clinicalfi ndings are consistentw ithtri chomoniasis
but m otile organi sms are absent. A rapi d DNA
probe test, w hich has a sensi tivity of 90% and a
specificityof99.8% ,canal sobeused.
C. Treatment. Oral m etronidazole (Fl agyl, P rotostat) i s
recommended. T reatment of m ale sex ual partners i s
recommended. Metronidazolegel (M etroGel-Vaginal)
is lesseffi caciousthanoral anti infectivetherapy . The
single 2-g dose of oral m etronidazole can be used
safelyi nany tri mesterofpregnancy .
Treatmentoptionsfor tr ichomoniasis
Initialm easures
Metronidazole(Fl agyl,P rotostat),2gP Oi nasi ngle
dose,orm etronidazole,500m gP Obi dX 7day s,or
metronidazole,375m gP Obi dX 7day s
Treatm alesex ualpartners
Measuresfor tr eatmentfailur e
Treatmentsex ualcontacts
Re-treatw ithm etronidazole,500m gP Obi dX 7day s
Ifi nfectionpersi sts,confi rmw ithcul tureandre-treat
withm etronidazole,
2-4gP OqdX 3-10day s
V. BacterialV aginosis
A. Bacterial vaginosis isapol ymicrobiali nfectioncaused
by an over growth of anaerobi c organi sms. I t i s the
mostcom moncause of vaginitis, accountingfor50%
ofcases.Gardnerel la vaginalis hasbeeni dentifiedas
oneofthek eyorgani smsi nbacteri alvagi nosis.
B. Diagnosis
1. Most have vagi nal di scharge (90% ) and f oul odor
(70%). T ypically there i s a hom ogeneous vagi nal
discharge,pH hi gherthan4.5, cl ue cells (epithe
lial cells studded with coccobacilli on m icroscopic
examination,andaposi tive w hiff test.
2. A s pecimen of vagi nal di scharge i s obtai ned by
speculum, and the pH i s determ ined before the
specimen i s di luted. N ext, the w hiff test i s per
formed by addingseveral dropsof10% K OHtothe
specimen.T hetesti sposi tivew hena fishy odor is
detected. Fi nally, the speci men is vi ewed by
wet-mountm icroscopy.
C. Treatment consi sts of ora l metronidazole, 500 m g
twice a day for 7 day s. C ommon si de effects of
metronidazole i nclude nausea, a norexia, abdom inal
cramps, and a m etallic taste. A lcohol m ay cause a
disulfiram-like reaction. U se of si ngle-dose
metronidazolem ayresul ti nahi gherrecurrencerate
and an i ncrease i n gastrointestinal si de effects.
Topicalcl indamycini sanopti on,but the cream may
weakenl atexcondom sanddi aphragms.
VI. Otherdiagnosescausingv aginalsy mptoms
A. One-third o f p atients with va ginal sy mptoms w ill n ot
have l aboratory evi dence of ba cterial vagi nosis,
Candida, or T richomonas. Other cause s of the
vaginal sy mptoms i nclude cervi citis, al lergic reac
tions,andvul vodynia.
B. Atrophic v aginitis shoul d be considered i n
postmenopausalpati entsi fthem ucosaappearspal e
andthi nandw et-mountfi ndingsarenegati ve.
1. Oral estr ogen (P remarin) 0.3 m g qd sho uld
providerel ief.
2. Vaginal r ing estr adiol (Estring), a sila stic r ing
impregnatedw ithestradi ol,i s thepreferredm eans
of del ivering estrogen to the vagi na. T he si lastic
ring del ivers 6 to 9 µ g of estradi ol to the vagi na
daily. T he ri ngs are changed once every three
months. C oncomitant progesti n therapy i s not
necessary.
3. Conjugated estr ogens (P remarin), 0.5 gm of
cream, or one-ei ghth of an appl icatorful dai ly into
the vagi na for three weeks, fol lowed by tw ice
weeklythereafter. C oncomitant progesti n therapy
isnotnecessary .
4. Estrace cr eam (es tradiol) can al so by gi ven by
vaginal appl icator at a dose of one-ei ghth of an
applicator or 0.5 g (w hich contains 50 µ g of
estradiol) dai ly i nto the vagi na for three w eeks,
followed by tw ice w eeklythereafter. C oncomitant
progestintherapy i snotnecessary .
C. Allergyandchem icalir ritation
1. Patients shoul d be questi oned abou t use of sub
stances that cause al lergic or chem ical i rritation,
such as deodorant soaps, l aundry d etergent,
vaginalcontracepti ves,bathoi ls,perfu medordy ed
toilet paper, hot tub or sw imming pool che micals,
andsy ntheticcl othing.
2. Topical steroi ds and sy stemic anti histamines can
helpal leviatethesy mptoms.
References:S eepage166.
Gynecologic Oncology
CervicalC ancer
Invasivecervi calcarci nomai sthethi rdm ostcom moncancer
intheU nitedS tates.T heI nternationalFederati onofGy necol
ogy and Obstetri cs (FI GO) r ecently revi sed i ts stagi ng
criteria. S urvival rates for w omen w ith ce rvical cancer
improve whenradi otherapyi scom bined with cisplatin-based
chemotherapy.
I. Clinicalev aluation
A. Human p apillomavirus is th e m ost im portant fa ctor
contributing to the d evelopment of cervi cal
intraepithelial neopl asia and cervi cal cancer. Other
epidemiologic risk factors associ ated w ith cervi cal
intraepithelial neopl asia and cervi cal cancer i nclude
historyof sex ual i ntercourse at an earl yage, m ultiple
sexualpartners,sex ually transmitteddi seases(i nclud
ing chl amydia), and sm oking. A dditional ri sk factors
include a m ale partner or partners w ho have had
multiplesex ualpartners;previ ous historyofsquam ous
dysplasias of the cervi x, vagi na, or vul va; and
immunosuppression.
B. The si gns and sy mptoms of earl ycervi cal ca rcinoma
include wateryvagi naldi scharge,i ntermittentspotti ng,
andpostcoi talbl eeding. Diagnosis often canbem ade
with cy tologic screeni ng, col poscopically di rected
biopsy,orbi opsyofagross or palpable lesion.I ncases
of suspec ted m icroinvasion and earl y-stage cervi cal
carcinoma, cone bi opsy of the cervi x i s i ndicated to
evaluate th e p ossibility o f in vasion o r to d efine th e
depth an d extent of m icroinvasion. C old k nife cone
biopsy provi des the m ost accurate eva luation of the
margins.
C. Histology. Thetw om ajorhi stologicty pes of invasive
cervical carci nomas are squam ous cel l carci nomas
and adenocarci nomas. S quamous ce ll ca rcinomas
comprise 80% of cases, and adenocarci noma or
adenosquamous carci noma com prise approx imately
15%.
II. Management
A. Earlycarci nomasofthe cervix usuallycanbem anaged
bysurgi caltechni quesorradi ationtherapy .T hem ore
advanced carci nomas requi re pri mary treatm ent w ith
radiationtherapy .
B. Stagingofcer vicalcar cinoma
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