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Need to know - vaginal discharge

Genitourinary physician Dr Olwen Williams OBE answers questions from GP Dr Tonia Myers on empirical prescribing, Streptococcus B, treating recurrent thrush and managing pre-pubertal girls

Genitourinary physician Dr Olwen Williams OBE answers questions from GP Dr Tonia Myers on empirical prescribing, Streptococcus B, treating recurrent thrush and managing pre-pubertal girls

1. Is it reasonable to suggest an empirical trial of treatment for thrush or bacterial vaginosis (BV) based on a history at first presentation of vaginal discharge, rather than automatically taking swabs?

41187072I prefer a microbiological diagnosis through tests – for candida, BV and Trichomonas vaginalis by taking a high vaginal swab for Gram stain ‘wet preparation' and culture and also for chlamydia and gonorrhoea.

Don't forget to take a sexual history. Physiological discharge can be confirmed by the absence of pathogens and the only treatment necessary is reassurance. At a subsequent presentation with identical symptoms and a previous diagnosis it is acceptable to treat empirically.

2. Our pathology lab often reports ‘commensals only', from high vaginal swabs in symptomatic women and does not report organisms such as Gardneralla vaginalis. Is this consistent with BV or should women just be reassured that the report was ‘normal'?

Ask your microbiologist –are they doing microscopy on high vaginal swab specimens? BV is confirmed by grading the flora seen on Gram staining-identification of ‘clue cells', measuring the pH of the vagina – greater than 4.7 (I don't routinely do this), and a history and examination that suggests a thin homogenous discharge with a fishy smell in the absence of any vaginitis .

Culture of G. vaginalis does not give a diagnosis of BV – as about 50% will grow G. vaginalis on culture.

3. Now that first smears are not taken until age 25, I feel far less inclined to pass a speculum in teenagers, even if they are sexually active. Now that chlamydia assays can be done with vaginal swabs rather than endocervical swabs, would swabs without a speculum be reasonable in young girls with persistent discharge?

Genital examination is an intimate examination requiring a chaperone, even if a speculum is not passed. We must ensure that an invasive process is not made into a traumatic experience, but at the same time give ‘gold standard ‘ investigations rather than ‘half standard' ones.

Passing a speculum allows for the correct samples to be taken from the lateral /posterior vaginal fornix. It allows for visual inspection of the cervix and vaginal walls, it also facilitates the identification and removal of any foreign bodies that may be responsible for the discharge.

Self-taken vulval nucleic acid amplification test (NAAT) chlamydia swabs are ideal as non-invasive methods that negate the need for an examination, but in practice they do not replace investigation via speculum of all the causes of vaginal discharge.

As an aside, all women aged 20 upwards are invited to participate in the Welsh cervical screening programme.

4. How should we do speculum examinations in pregnancy?

If the woman refuses to have a speculum passed, empirical treatment based on symptomatology is acceptable, but if there is any suspicion of risk of an STI she should have a full set of swabs. There is no evidence that passing a speculum has an impact on the pregnancy, but it can be technically challenging in the third trimester.

5. What is current best practice for managing positive swabs for Streptococcus B in non-pregnant and pregnant women?

There is no indication for treating a non-pregnant or a pregnant woman if she is reported to have a group B streptococcus on her high vaginal swab, unless labour has started.

It is estimated that 25% of all women carry group B streptococcus in their vagina or rectum. There is no screening programme in pregnancy in the UK, unlike in the USA. In the UK, if a pregnant women is found to carry group B streptococcus at 35-37 weeks of gestation, then high-dose IV penicillin should be given once labour starts. Intervention before this is not recommended. There are no randomised controlled trials on intervention.

Mortality in the neonate from early onset disease is 8% for term babies and 18% for pre-term.

Guidelines written in 2003 are available from the Royal College of Obstetricians and Gynaecologists.

6. What should one do with a pre-pubertal girl with a vaginal discharge?

The incidence of vaginal discharge in this group is unknown but it is the commonest gynaecological problem in the age group.

A variety of pathogens including staphylococcus, streptococcus, Haemophilus influenza, anaerobes, but rarely candida, have been identified as the cause. However, investigation and management has to consider the possibility of child sexual abuse. Urethral and low vaginal swabs for chlamydia and gonorrhoea are essential

in suspicious cases. Ideally, these young girls should be referred to community paediatricians. New guidelines on the physical examination of sexually abused children were published this March by the Royal College of Paediatrics and Child Health.

If there are foreign bodies in the vagina, examination and removal may have to be done under anaesthetic.

Personally, I feel it is imperative to establish a diagnosis and perform the investigations at a joint examination with my community paediatrician.

I tend to avoid topical azoles and oestrogens as first-line management. Improving genital hygiene and avoiding perfumed products in the bath may help.

7. In higher risk women who are at risk of an STD, or have co-existent pelvic pain, is the standard GP practice of taking an endocervical swab for chlamydia and gonorrhoea and a high vaginal swab adequate or should we be encouraging them to attend a department of sexual health for full screening?

The British Association for Sexual Health and HIV (BASHH) has some excellent guidelines on screening for STIs in asymptomatic and symptomatic women.

The essential difference is the recommendation to Gram stain the high vaginal swab and endocervical swab and do on-site microscopy to aid early identification of gonorrhoea and polymorphs, which may aid management in the symptomatic woman.

You have to assess whether the woman will attend the sexual health service. If she has pelvic infection, the delay in starting therapy by referring her untreated may affect her fertility. On the other hand, can you do partner notification to prevent her getting reinfected?

Pelvic infection should be treated without delay. The diagnosis is clinical.

The current standard therapy to cover all pathogens is ceftriaxone 250mg IM, followed by 14 days of both doxycycline 100mg bd and metronidazole 400mg bd.

An alternative to doxycycline is ofloxacin 400mg bd or 14 days.

Remember to consider pregnancy.

8. What is your advice for women with recurrent thrush? Is there any evidence that one preventive regime is better than another? Is there a good online resource with the regime options?

It's important to consider a variety of issues when managing candidal vulvovaginitis in women of reproductive age. Recurrent vulvovaginal candidiasis is defined as four or more symptomatic episodes per year with two microbiological proven episodes when the patient has symptoms.

First line of investigation is a full sexual and medical history, confirming Candida albicans is the offending organism, excluding predisposing conditions such as diabetes mellitus, antimicrobial use, excessive use of feminine products, immunosuppression and pregnancy.

Also consider allergy and causes of hyperoestrogenaemia.

General advice includes:

• use of soap substitute such as Dove

• use of vulval emollients such as Diprobase – this soothes the itch if it is refrigerated before being applied

• avoiding tight clothing around the genital area

• avoiding local irritants and douching.

Sometimes contraception needs to be reviewed and a long-acting method such as Depo-Provera could be considered.

All Candida albicans species are sensitive to the azoles, while the non-Candida species have developed a degree of resistance. Candida krusei is resistant to fluconazole.

Various regimes have been suggested and the latest BASHH guideline (www.bashh.org) – currently out for consultation – suggests the following in women who are not pregnant or breast-feeding:

• fluconazole 150mg, every 72 hours in three doses

• a maintenance dose of fluconazole 150mg once a week for six months.

Other drugs can be used for maintenance, such as clotrimazole pessary 500mg once a week for six months.

Six months of maintenance is necessary, and 90% of women remain disease free during treatment. This regime is unlicensed.

Patients with a history of atopy may benefit from zafirlukast 20mg twice daily or cetirizine 10mg daily, both for six months.

A guideline on the management of vulvovaginal candidiasis is available from BASHH.

9. What about BV that recurs or persists after treatment? Women get desperate about this because of the smell, especially after sex. Is there anything that helps to prevent recurrence?

This is a perennial question with a perennial answer, I'm afraid. We have no solutions. A vast amount of research has come up with hypotheses, some innovative treatments but no long-term ‘cures'.

We know the pathology behind the condition: an overgrowth of a mixture of anaerobes in the vagina, which replace the hydrogen peroxide-producing lactobacilli.

Attempts to reintroduce the lactobacilli through a variety of non-human sources have defeated researchers. Live yoghurt doesn't work.

We know that the condition can spontaneously remit. Women who smoke or have an IUD seem to have a higher prevalence. BV does not appear to be sexually transmitted. Treatment of sexual partners has no impact on recurrence, but it may be associated with sexual activity.

BASHH guidelines suggest the following for recurrent BV:

• suppressive therapy: metronidazole gel 0.75% twice weekly for four to six months to decrease symptoms, after an initial treatment daily for 10 days

• metronidazole orally 400mg bd for three days at the start and end of menstruation, combined with fluconazole 150mg as a single dose if there is a history of candidiasis.

Other treatments being studied at present include combinations of antibiotics with probiotic therapy and hydrogen peroxide.

10. What is the relationship between BV, miscarriage and pre-term birth? Who needs treatment?

The Cochrane Collaboration did an excellent review of antimicrobial therapy for BV in pregnancy. It is now well recognised that BV during pregnancy is associated with poor perinatal outcome and predisposes to pre-term birth, with the possibility of neonatal sequelae secondary to prematurity. The mechanism by which this occurs is not yet fully understood.

It's estimated that between 12 and 20% of pregnant women have BV during pregnancy. The majority are asymptomatic, some will spontaneously resolve without treatment, but the majority will persist. Identification and treatment may therefore reduce the pre-term birth (PTB) rate, however the Cochrane review concluded that screening and treating all women for asymptomatic BV in pregnancy to prevent PTB is not currently recommended in the UK. Until a randomised controlled trial answers the question, it suggested that guidelines should recommend treatment of symptomatic pregnant women prior to 20 weeks' gestation with metronidazole 400mg twice daily for five to seven days, which may reduce the risk of PTB.

BASHH has published a national guideline for the management of bacterial vaginosis.


11. I have several patients who are not in a current sexual relationship or a long-term stable relationship with positive swabs for Trichomonas vaginalis. How long can it be carried and is it invariably an STD?

Trichomonas vaginalis is an interesting STD, considered to be the commonest worldwide, but not in the UK. The organism can affect the vagina, Bartholin's and Skene's glands as well as the urethra.

It may be asymptomatic, but it is generally characterised by a green frothy vaginal discharge, vulvovaginal soreness, itching and dysuria.

Men don't tend to get symptoms, or it may cause urethritis. As men harbour the organism in the urethra, if they are not treated concurrently with their female partner they will reinfect her. There does not seem to be any data on the length of time the organism remains in the genital tract.

12. Do cervical erosions or ectopy cause discharge? If a woman with cervical ectopy has persistent troublesome discharge but no obvious organism, is referral for cautery reasonable?

Let's consider the physiology and anatomy of the cervix. The cervical canal is lined with columnar epithelium, while the external area is covered with squamous epithelium. The area between these differing types is the transformation zone and where they meet is the squamo-columnar junction. The position of the transformation is under the influence of oestrogen. The presence of oestrogen sends the junction more externally – into the vagina. So, young women as they go through puberty, women on the oral contraceptive and those with infections such as Chlamydia cervicitis have transformation zones that lie outside the cervical canal, commonly referred to as cervical ectopy.

I attempt to explain to the woman that having a cervical ectopy is a variation on normal. It may predispose to some degree of increased vaginal secretions, and is under the influence of hormones.

I avoid the use of the term ‘erosion' as it sounds pathological. I always ask the woman if she is using tampons all the time, and if she is explain that this can predispose her to toxic shock syndrome – and in itself be the cause of the problem. I advise against douching and using feminine vaginal products.

I may suggest, if she is on the combined pill, a change to a progesterone-only product. Sometimes on repeat microbiological tests (high vaginal swab for candida, BV, transvaginal and endocervical swabs for Chlamydia and gonorrhoea) a cause may be found.

If all else fails, I may refer for cautery, explaining that surgery is a last resort.

Dr Olwen Williams is clinical director of the integrated sexual health service in Conwy and Denbighshire NHS Trust. She has a special interest in STDs in adolescents and children. She was awarded an OBE in 2006 for services to medicine in Wales

Competing interests: none declared

What I will do now What I will do now

Dr Myers reflects on the answers to her questions

• Putting emollients in the fridge is a great tip to help soothe acute vulval itch
• I will firmly reassure women that passing a speculum in pregnancy has no association with miscarriage
• For women with troublesome recurrent thrush worsened by the combined pill, I will suggest a long-acting contraceptive such as Depo-Provera as an alternative
• I will tell patients neither live yoghurt as a treatment for BV nor probiotics for thrush are of proven benefit
• I will highlight smoking as a risk factor
• I will reassure women there is no indication for treating strep B on an HVS unless labour has commenced

Dr Tonia Myers is a GP in Chingford, Essex

thp vag Trichomonas vaginalis

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