It’s not just a yeast infection

It’s not just a yeast infection

A detailed look into underdiagnosed pelvic, vaginal and vulvar issues

Susan Mitchell-Derenski RN, MSN, WHNP-BC

BJC Medical Group

Disclosures

I am a Merck trained

Nexplanon

instructor.

WHO am I?

Worked in Women’s Health for 11 years

RN at Mercy Labor and Delivery for 7 years

Went to UMSL for MSN, trained in clinics, private practice, health departments

WHNP for 4 years with BJC Medical Group- 4 years in OB/GYN practices, almost 2 years with Perinatology practice

Member of NPWH, AWOHN, MONA, Sigma Theta Tau, SNAPAvid Pilates goer, yogi, runner cycler and triathlon enthusiastsWomen’s Rights AdvocateInterested in Pediatric Gynecology, Vulvar Hygiene, Mental Health throughout women’s LifespanNew Mom and Wife

Common Patient Complaints

“My vagina itches and I tried Monistat with no relief”

“I have tried three doses of

Diflucan

and I am still itching and uncomfortable”

“I itch at night really bad only”“My bottom feels like it is on fire”“I have pain with bowel movements and intercourse, same area”“I always have vaginal discharge no matter what scented products I use it still smells.”

Review of Vulvar, Pelvic, Vaginal Anatomy

VulvoVaginal

Candidias

Most common type of vaginal infection

white, clumpy discharge that adheres to the vaginal walls, cottage cheese like discharge noted by patient

Occasional Dysuria/misdiagnosed for UTI occasionally

Usually no odor, unless co-diagnosis of BVNegative Amine test, 3.8-4.0 ph, (some see yeast hyphae on wet KOH mount)-rareErythematous, irritated vulvar and surrounding tissuesUsually following antibiotic use, change in medications, change in vulvar/vaginal environment due to news behaviors such as new partner, new personal lubricants, new soaps, new detergents, recent douching

Positive Vaginal swab- Candida

Albicans

, Candida

Tropicalis

, Candia

Stellatoidea

Uncomplicated-treat with 1-3 days of

diflucan

and topical steroid and antifungal cream-

Lotrisone

is my favorite

Complicated-treat with

difucan

every 72 hours for 14 days, then possible monthly treatment, check for undiagnosed DM

Bacterial Vaginosis

Disturbance in the

ph

and overgrowth of bacteria in the normal vagina flora, NOT a STI

Biggest complaint is foul/fish smelling odor (increased following intercourse) sometimes followed by increase in vaginal discharge and feeling extremely damp in their underwear

Upon speculum exam: gray-white, sometimes green discharge in vaginal vault, odor, sometimes very obvious once speculum is inserted Wet mount: no WBC’s seen, clue cells present, positive amine test, 4.5 and above ph (normal vaginal ph 3.8-4.5)Can occur 5 prior or 5 days following menses, with change behaviors such as partner, personal lubricants, detergents, lotions, douching, new medications, life changes like stress and change in exercise routine or diet have shown changes to

ph

Misdiagnosed A LOT for yeast or missed

trichomoniasis

(see next slide)

Treatment vaginal or oral with

miconazole

or clindamycin with 5-7 day treatments, occasionally need 14 day treatment or prophylaxis surrounding triggers (menses, intercourse)

If recurrent- need to discuss changing behaviors- use olive oil for lubricant, no underwear, coconut oil or Crisco as moisturizer, NO DOUCHING, probiotic use to establish healthy flora

Tricky, trichomoniasis

Sexually transmitted Infection, highly contagious, most prevalent

nonviral

STI

Can be asymptomatic and last for months to years in men or womenMalodorous discharge, yellow to green discharge, Can be the cause of Bartholian Gland cysts, cervitis Common reoccurrence if exposure occurs too soon after treatment Wet mount- trichomonaids

seen within 10 minutes of collection of discharge

Antigen Testing is highly sensitive in women, cannot easily test on men, not in the “standard”

sti

screening, often goes undetected

Treatment is metronidazole orally ONLY, cure rate is 88%

REALLY Educate abstinence until symptoms resolve if symptomatic and/or both partners have been treated

Vulvar Itching that is NOT yeast: Who

ya

gonna

Call? Vulvar Disorder Busters

Lichen Sclerorus- only involves vulva, not vaginal, pruiritis that is NOT yeast, painful vulva, c/o usually at night/disturbs their sleep, usually occurs in perimenopausal/postmenopausal womenLS- skin appears in plaque, white porcelain in appearance, leathery, can cause

pupura

, can appear like cigarette paper, can cause fusing of labia,

phimosis

of clitoral head, and fissures, Diagnosis- with symptoms however, can mimic other vulvar disorders, usually biopsy is standard

LS-

topical steroid (

clobetasol

proprionate

) Treatment for 2-4 weeks, then as needed up to 6 months, if

phimosis

occurs- topical estrogen

reccommened

controversial on how often to treat or how aggressive, follow-up at 3 and 6 month intervals necessary

Vulvar Itching/Pain

that is NOT yeast: Who

ya

gonna

Call? Vulvar Disorder Busters Lichen Planus- often confused with LS, can occur in oral cavity and genital mucosa, related to cell-mediated immunity, most common is erosive- causing pain and scarring, looks more like shiny papules, however can look white with striae like LS LP- makes vaginal tissues almost friable, increase vaginal discharge and dyspareunia

LP-

Treatment with topical

seroid

, however reoccurrence is common, some use auto-immune medications such as methotrexate,

hydrochloroquine

, this is chronic and requires constant treatment, like any other autoimmune disease consider consulting

Dermatolgy

as well

DRYNESS: How to best tackle this?

VulvoVaginal

Atrophy

- can occur postpartum with breastfeeding mom’s, advise topical estrogen for short intervals and natural personal lubricant such as olive oil

VVA

-in peri-menopausal/postmenopausal, 50% of them experience, c/o dyspareunia, may be the cause of decreased libido (be careful), dryness with wiping, states feel like sandpaper, can have an outline of light/ incontinence pad in vulvar regionsVVA- ph is usually more alkaline around 7 and above, vaginal flora is altered, many vulvar irritants can REALLY irritate vulva, fissures of vestibule can occur VVA-

decreasing exposure to irritants, coconut oil/other natural vaginal moisturizers, more effective than vaginal lubricants, low dose estrogen therapy has been shown in some to show great improvement, oral

osphimifene

is second line, has shown some improvement, high risk of side effects, also advise increase in intercourse, can increase blood flow to area and increase healing

Pelvic Pain: Where is it really coming from, not always an ovarian cyst!

Not going to discuss endometriosis or ovarian cysts- that are whole other topics

Levator

Ani

Syndrome/Pelvic Floor Dysfunction- occurs back part of pelvis, vs genital pain, anterior pelvic pain, pain with sitting, pain with bowel movement, some with relief after, no visible pathology on speculum exam, can be cause of dyspareuniaLAS- upon digital exam of posterior wall of vagina tender on right and left side, usually REALLY tight and patient will jumpRisk Factors- traumatic birth, operative vaginal birth, surgery of anus, has history of IBS Treatment-

Kegel

muscle exercises, digital massage by therapist,

sitz

baths,

electrostimulation

by therapist- women’s health physical therapist, control constipation/diarrhea, symptoms can resolve with lifestyle changes

Genital/Pelvic Pain: Where is it really coming from, not always an ovarian

cyst/YEAST/UTI!

Vulvodynia

- (used to be called

vestibulitis

)feels like tearing, burning, rawness of vulva/vaginal area, most common with normal appearing vulva, no cause like infection, inflammatory process, neoplasia, neurologic, really diagnosis of exclusion, diagnosis with cotton swab testTreatment of vulvodynia- lifestyle modifications, vulvar hygiene modifications, sometimes hypnotherapy, behavioral therapy, vaginal moisturizers Vaginismus-

involuntary spasm of the muscle in the vagina, can be due to trauma, abuse, history of dyspareunia, have seen in young girls with fear of tampon use, can be co-diagnosed with

vulvodynia

, must show symptoms for a course of 6 months or more, diagnosis made with a full health history including psychological evaluation and rule out other sources of painful vaginal penetration/pelvic pain

Treatment of

vaginismus

-

may take awhile, behavioral therapy, sex therapy, personal lubricants sometimes, may need partner therapy, hypnotherapy, possible vaginal

dialators

Pelvic Floor Weakness: Do

Kegel’s

really do it?

Painful intercourse

Difficulty to orgasm

Incontinence-stress/urge, may need to involve uroKEGEL muscle exercises- start them young… teach young girls what they areDiscuss good pelvic floor etiquette (not holding bladder, avoid bladder irritants, sit properly on toilet, DO NOT squat over toilet, no using phone on toilet, empty bladder prior to working out, know where your bathroom is, some weight lifting can be hard on pelvic floor)Weight kegel muscles exercises/seek women’s health PT- much more available then we think

(almost ALL PT companies, rehab systems have women’s health PT trained therapist(almost always women) Do explain much more intensive vaginal exam

Patient Education: Best resources, Myths revealed

Vulvar Hygiene is so critical

NO DOUCHING

Baths are okay however without bubble bath, baking soda

DIVA CUP- using reusable menstrual cups

Vaginal/Vulvar area is not supposed to have flowers or smell like flowersDiscourage Shaving/poor waxing hygieneEncourage intercourse except with early onset of infectionTry to empower women regarding their vaginal, vulvar hygiene A well women exam usually DOES NOT Address all of these issues! GOOD Patient education websites:http://

www.acog.org/Patients

http://

divacup.com

http://www.womenshealthapta.org/patients

/

https://

www.cdc.gov/women/initiatives/index.htm

https://npwomenshealthcare.com

/

https://

www.plannedparenthood.org/learn/womens-health

Thank you!

Please email me at

Susan.Mitchell@bjc.org

with any women’s health questions

References

Boardman, L. &Kennedy, M. (2016) Practice Bulletin Diagnosis and Management of Vulvar Skin Disorders.

ACOG

, 93.

Faught, B. (2016) The Elusive Vulva,

NPWH, 4(6), 10-14.Funaro, D., Lovett, A., Levroux, N., & Powell, J.(2014) A Double Blind randomized Prospective Study Evaluating Clobetasol Proprionate 0.05% Versus Topical Tacrolimus 0.1% in Patients with Vulvar Lichen Scelrosus

.

Journal of the American Academy of Dermatology,

71(1), 84-91.

doi

: 1.1016/j.jaad.2014.02.019

Geisler, W.,

Lensign

, S., Press, C. & Hook, E. (2013) Spontaneous Resolution of Genital Chlamydia

T

rachmonatis

infection in Women and Protection from Reinfection,

Journal of Infectious Diseases 207(12), 1850-1856. doi:10.1093/infdis.2013

Guidelines for Women’s

Healthcare:A

Resource Manual. (2014).

ACOG. (4

th edition) Retrieved from http://www.acog.org/Resources-And-Publications/Guidelines-for-Womens-Health-CareLee, A., Bradford, J., & Fischer, G.(2015) Long Term Management of Adult Lichen Sclerosus. JAMA Dermatology, 151(10), 1061-1067. doi: 10.1001/jamadermatol.2015.0643

References

Portman, D., Bachmann, G. & Simon, J. (2013)

Ospemifene

, A Novel

S

elective Estrogen Receptor Modulator for Treating Dyspareunia Associated with Postmenopausal Vulvar and Vaginal Atrophy. The Journal of North American Menopause Society, 20(6), 623-630. doi

: 10.1097/gme.2014.013

Reichman

, O.,

Moyal-Barracco

, M., &

Nyirjesy

, P.(2015)

Vulvovaginal

Candidias

as a Chronic Disease: Diagnostic Criteria and Definition.

Journal of Lower Genital Tract Disease

, 19(1), e23-24.

doi

:

10.1097/LGT.2015.038Schalkwyk, J. & Yudin, M. (2015)

Vulvovaginitis: Screening of Trichomniasis, Vulvovaginal Candidias, and Bacterial Vaginosis. Journal of Obstetirics and Gynaecology Canada, 31(3), 266-274Seehusen

, D., Baird, D., &Bode, D. (2014) Dyspareunia in Women. American Family Physican, 90(7), 465-470.Shaaban, O., Abbas, A., Moharram, A., Farhan

, M. &

Hasanen

, I. (2015) Does Vaginal Douching Affecting the Type of

C

andida

Vulvovaginal

infection?

Medical Mycology, 53(8), 817-827.

doi

: 10.1093/mmy.2015.10.1093

Santoro, N.,

Worsley

, R., Miller, K., Parish, S. & Davis, S. (2016) Role of Estrogens and Estrogen-Like Compounds for

Femal

Sexual Function and Dysfunction, The Journal of Sexual Medicine, 13(3), 305-316. doi:10.1016/jsxm.2015.11.015.