Vaginal Discharge

Common Causes
• Physiological
• Candida
• Bacterial Vaginosis
• STI
• Non infective causes ( ectopy, Foreign Body,
Malignancy)

Normal Vaginal flora
• Lactobacilli
• Anaerobes
• Diptheroids
• Coagulase negative staphylococci
• Alpha haemolytic streptococcus

Overgrowth of normal vaginal flora
• Candida Albicans
• Staphylococcus Aureus
• Group B Strep ( Strep. Agalactiae)

Commonest causes of altered
vaginal discharge
In women of reproductive age

Vaginal discharge – infective causes
Non STI
BV
Candida
STI
• Chlamydia trachomatis
• N gonorrhoeae
• Trichomonas vaginalis
• Herpes Simplex

Non Infective Causes of Vaginal
Discharge
• Foreign Body
• Cervical polyp/ectopy
• Fistulae
• Allergic reactions
• Personal Hygiene

Bacterial Vaginosis
• Commonest cause of abnormal discharge in
women of reproductive age
• Can occur & remit spontaneously
• Not an STI but link with sexual behaviour

Bacterial Vaginosis
• Overgrowth of mixed anaerobic organisms
replacing Lactobacilli
• Increase in vaginal PH > 4.5

• Gardenerella (Commensal in 30-40% of
asymptomatic women) commonly found
• Prevotella
• Mycoplasma hominis
• Mobiluncus
Bacterial Vaginosis

Vulvo-vaginal Candidiasis
• Overgrowth of yeasts
• Candida Albicans – 70-90%
• Candida Glabrata – 10-30%

Vulvo-Vaginal Candidiasis
• Only treat if symptomatic
• Often precipitated by use of antibiotics
• Diabetes
• Immunocompromise
• NOT associated with tampons/sanitary towels

Chlamydia trachomatis
• Most common bacterial STI in the UK
• Asymptomatic in 70 % of women

Chlamydia Trachomatis
• Vaginal discharge – cervicitis
• Post coital bleeding
• Intermenstrual bleeding
• Lower abdominal pain
• Dyspareunia
• Dysuria

Trichomonas Vaginalis
• Vaginal Discharge + Dysuria
• STI
• Rarer than BV or VVC

Management of a lady with vaginal
discharge
• Clinical & Sexual History ( Vaginal Discharge is
a poor predictor of STI)

Management of a lady with vaginal
discharge
• Assessment of Symptoms • Characteristics of the
discharge
• What has changed
• Onset
• Duration
• Odour
• Cyclical changes
• Colour
• Consistency
• Exacerbating factors

Vaginal Discharge
• Associated Symptoms
• Upper Genital Tract
disease
• Itching
• Dyspareunia
• Vulval/Vaginal Pain
• Dysuria
• Abnormal bleeding
• Pelvic/Abdominal Pain
• Fever

Vaginal Discharge
• Dermatological conditions ( Lichen Planus) –
superficial dyspareunia & itch (RCOG
Guidance on Vulval Disease)
• Enquire re OTC Rx of VVC ( Women are not
good at self diagnosis)
• Examination & Swabs

Bacterial Vaginosis
Initial cure rates 70-80%
Clindamycin & Metronidazole – comparable
efficacy

Bacterial Vaginosis
• 1st Line Rx – oral Metronidazole ( less
expensive than vaginal preparations)
• Metronidazole safer than oral Clindamycin
(pseudo-membranous colitis)
• Acidifying gels may prevent recurrence
• Rx of male partners ineffective in recurrence
prevention
• Consider Rx female partners

Vulvo-Vaginal Candidiasis
• Rx with oral or vaginal antifungals (cure rate –
80%)
• No data to support Rx or screening of partners
• Vaginal & oral Rx – equally effective
• Vulval symptoms – topical antifungals

Trichomonas Vaginalis
• 1st Line Rx – oral Metronidazole
• Rx partners

Recurrent Vaginal Discharge
• REFER TO THE GUM CLINIC

Recurrent Bacterial Vaginosis
• Median recurrence rate – 58 % after
treatment
• Risk Factors : New/multiple partners, oral
sex, Cu – IUCD
• COCs & condoms reduce the risk of BV

Recurrent Bacterial Vaginosis
• Optimal Rx of recurrence has not been
established
• Twice weekly Metrondiazole gel ( only 33%
remained recurrence-free 12 months after
stopping)
• Acidifying gels – 2 lactic acid vaginal products
available in the UK

Recurrent Vulvo-Vaginal Candidiasis
• 4 or more episodes of symptomatic,
mycologically proven VVC in 1 year
• Suppression & Maintenance treatment

POLYCYSTIC OVARIES
Prevalence 5-10%

Polycystic Ovary Syndrome (PCOS)
• Hyperinsulinaemia
• Glucose intolerance
• Metabolic syndrome

Macroscopically – ovaries enlarged & lobular
Seen in 30 % of women presenting with infertility

Atretic follicles, theca cell hyperplasia & generalised
increase in stroma
Disruption of regular ovulatory processes
Hyperandrogenaemia
Raised LH levels & altered LH:FSH ratio

Peripheral distribution of multiple subcapsular cysts
USS appearance NOT specific for PCOS

PCOS
• 20 % of self selected normal women had PCOS
on scan
• 5 % of the general population is hirsute
• 75% of women with secondary amenorrhoea
fulfil diagnostic criteria for PCOS

PCOS – Clinical Features
• Onset between 15-25 years of age
• Infrequent cycles
• Hirsutism
• Acne
• Acanthosis Nigricans
• Obesity
• Frank virilisation does NOT appear in PCOS

Described in medical literature in the 1800s
John Sampson(1927) introduced the term endometriosis – retrograde
flow of endometrial tissue through the fallopian tubes & into the
abdominal cavity as the primary cause of the disease

Treatment of PCOS
• Laparoscopic cauterisation of ovaries
• Ovulation Induction ( for Infertility)
• Oestrogen + Cyproterone acetate (for
acne/hirsuitism)
• Metformin ( helps weight loss & ovulation)
• Spironolactone (50-100mg/day) – anti androgen
• Diet & lifestyle
• Cosmetic measures

Endometriosis
• Prevalence – widely varying figures
• 10 % of women in the reproductive age group
• 25-35% of infertile women
• 4 per 1000 women aged 15-64 hospitalised
each year
• Does not occur before menarche
• Not confined to nulliparous women

Endometriosis – Symptoms & Signs
• Dysmenorrhoea
• Dyspareunia
• Diffuse pelvic pain
• Symptoms from rectal/urethral/bladder
involvement
• Low back pain
• Infertility associated with above symptoms
• Menstrual dysfunction not increased

Endometriosis – Symptoms & Signs
DD
Chronic pelvic pain
Fibromyalgia
Depression
IBS
Interstitial cystitis
PID
Fibroids
Ovarian Cysts

Pelvic Pain – different presentations
• 15-16 year old with severe dysmenorrhoea
• 35 year old post laparoscopic sterilisation –
pain since she stopped the COC
• Pain associated with menstruation or may be
non cyclic
• Endometriosis may co exist with other
conditions
• In women < 25 years think of STIs

Diagnosis of Endometriosis
Laparoscopy – both diagnosis & treatment
USS

Chocolate cyst of left ovary (Dr Malpani’s blog)
Chocolate cysts tend to be complex & have a ground glass appearance

Relationship between pain & endometriosis unclear
Classic blue or black powder burn appearance
Lesions can be red, black, blue or white & non pigmented
Tan, creamy, fresh appearing endometrium can also be observed

Ovary – most common site for implants & adhesions
Distribution of endometriosis may be widespread – anteriorly &
posteriorly over the broad ligament & cul-de-sac

Treatment of endometriosis
• Pain relief
• Concern re cancer
• Recurrence of cyst/endometriosis
• Fertility

Medical treatment of Endometriosis
• NSAIDs
• COC
• DMPA
• Provera
• GnRH agonists ( add back HRT)
• Transvaginal Danazole ( low dose 50-100mg)
• Watchful expectancy
• AVOID POLYLAPAROSCOPY