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Download It`s not just a yeast infection - St. Louis Nurses in Advanced Practice
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IT’S NOT JUST A YEAST INFECTION C 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, SNAP • Avid Pilates goer, yogi, runner cycler and triathlon enthusiasts • Women’s Rights Advocate • Interested in Pediatric Gynecology, Vulvar Hygiene, Mental Health throughout women’s Lifespan • New 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 BV • Negative Amine test, 3.8-4.0 ph, (some see yeast hyphae on wet KOH mount)-rare • Erythematous, irritated vulvar and surrounding tissues • Usually 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 creamLotrisone 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 women • Malodorous 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 women LS- 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, followup 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 erosivecausing 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 regions • VVA- 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 dyspareunia • LAS- upon digital exam of posterior wall of vagina tender on right and left side, usually REALLY tight and patient will jump • Risk 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 test • Treatment 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 codiagnosed 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 uro • KEGEL muscle exercises- start them young… teach young girls what they are • Discuss 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 flowers Discourage Shaving/poor waxing hygiene Encourage intercourse except with early onset of infection Try 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! C Please email me at [email protected] 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 Trachmonatis 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. (4th edition) Retrieved from http://www.acog.org/Resources-And-Publications/Guidelines-forWomens-Health-Care • Lee, 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 Selective 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), e2324. doi: 10.1097/LGT.2015.038 • Schalkwyk, J. & Yudin, M. (2015) Vulvovaginitis: Screening of Trichomniasis, Vulvovaginal Candidias, and Bacterial Vaginosis. Journal of Obstetirics and Gynaecology Canada, 31(3), 266-274 • Seehusen, 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 Candida 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 EstrogenLike Compounds for Femal Sexual Function and Dysfunction, The Journal of Sexual Medicine, 13(3), 305-316. doi:10.1016/jsxm.2015.11.015.
