Vaginal infections; Abnormal vaginal bleeding; Menopause

Educational Objectives

The goal of this program is to improve management of vaginal infections and abnormal vaginal bleeding. After hearing and assimilating this program, the clinician will be better able to:

1. Counsel patients about treatment and risk for bacterial vaginosis.

2. Select appropriate tests and therapy regimens for vaginal trichomoniasis and vulvovaginal candidiasis.

3. Identify and treat structural and nonstructural causes of abnormal uterine bleeding.

4. Discuss treatment options for dysfunctional bleeding and recurrent menorrhagia.

5. Review safety and efficacy data about treatment of menopausal symptoms with hormone therapy.

Summary

Introduction: vaginal discharge not always sign of infection; symptoms include irritation, itching, burning, and vaginal discharge; vulvar dermatoses — lichen sclerosis in older women; lichen simplex chronicus (hypertrophy of vulvar skin from scratching); contact dermatitis; vaginal discharge can be related to anatomic problems (eg, fistula, mucorrhea, mucopurulent cervicitis); physiologic or psychogenic

Bacterial vaginosis (BV): noninflammatory; decrease in normal vaginal flora (Lactobacillus crispatus or Lactobacillus jensenii); ­100-fold increase in Gardnerella (anaerobe normally found in vagina); ­1000-fold increase in anaerobes and more pathologic organisms that cause symptoms; since vaginal Gardnerella normally present in >50% of women of reproductive age, vaginal culture and sensitivity testing not performed in nonpregnant women; sexually associated, but not horizontally transmitted from men to women; rare in virginal women; multiple male sex partners increases risk; condom use decreases risk; no BV carrier state in men; treatment of male partners to reduce recurrences in women ineffective; exposure to seminal fluid increases risk for BV; horizontally transmitted between women who have sex with women due to transfer of vaginal fluid to partner; clinical presentation — ≈50% asymptomatic; most symptoms unrecognized; profuse watery vaginal discharge with fishy, ­ammonia-like odor (especially after intercourse); few or no irritative symptoms; signs — white or slate gray homogeneous vaginal discharge; discharge may be bubbly; no redness or irritation; screening — not routinely performed; assess vaginal discharge in symptomatic women with amine KOH test, vaginal pH test, clue cells on microscopy (look for ragged border; ≥20% of epithelial cells); ­in-office tests (eg, Affirm VP III; OSOM BV Blue); result on Papanicolaou (Pap) testing stating “shift in vaginal flora consistent with BV” poorly correlated with BV; Amsel diagnostic criteria — ≥3 of 4; homogenous discharge; positive amine odor with KOH; vaginal pH >4.5; clue cells on microscopy; Spiegel criteria or Nugent score — based on Gram’s stain; highly sensitive and specific; inexpensive; ­labor-intensive; who to treat — symptomatic women; symptomatic pregnant women with history of preterm labor; women scheduled to undergo pelvic surgery (eg, abortion, hysterectomy, cervical procedure); no evidence supports BV screening or treatment before insertion of intrauterine device; treatment — controversial in women who have typical findings of BV during pelvic examination but do not notice their symptoms (discuss possible relationship with pelvic inflammatory disease [PID], recurrent bladder infections, and increased risk for HIV infection); oral metronidazole twice daily for 1 wk; metronidazole vaginal gel at bedtime for 5 days; clindamycin vaginal cream for 7 days; tinidazole regimens also acceptable; recurrent BV — ≥3 outbreaks per year; after typical treatment regimen, use metronidazole vaginal gel twice weekly; abstain from vaginal sex during treatment; avoid douching; condom use may reduce recurrences; women who have sex with women should clean sex toys in between use by partner and themselves; avoid anal insertion followed by vaginal insertion

Vaginal trichomoniasis (VT): diagnosis — sensitivity of saline suspension 60%, but specificity high; Aptima TMA (new test highly sensitive and specific; $40); ­point-­of-care tests include Affirm VP III, OSOM Trichomonas Rapid test, and saline suspension; Pap testing detects VT ≈50% of time, but highly specific; treatment — metronidazole and tinidazole equally effective, but fewer side effects with tinidazole; relative resistance to metronidazole reported; if infection persists after treatment, consider reinfection; retreat after treatment failure (if no response, use oral and vaginal tinidazole treatments concurrently); contact Centers for Disease Control and Prevention about resistant cases

Vulvovaginal candidiasis (VVC): species include Candida albicans and Candida glabrata; testing — ­point-­of-care office tests include KOH suspension (look for pseudohyphae and blastospores; in C glabrata infection, only spores may be seen, and patients more likely to have more burning than itching); Gram’s stain typically not highly helpful; amine test negative; polymerase chain reaction (PCR) laboratory testing or DNA probe testing used for diagnosis rather than screening; uncomplicated VVC — mild to moderate infection; likely C albicans; patient immunocompetent; complicated VVC — ≥3 episodes per year; uncomfortable and severe outbreaks; due to species other than C albicans; patient immunocompromised; treatment of uncomplicated VVC — ­3- and ­7-day topical antifungal agents equally effective (adherence higher with ­3-day therapy); use ­1- or ­3-day topical agent, or ­single-dose fluconazole (Diflucan; 150 mg highly effective); treatment of complicated VVC — topical azole therapy for 1 to 2 wk; treat immunocompromised women (eg, women with diabetes or HIV, or on chemotherapy) for 1 to 2 wk, or with oral fluconazole (150 mg every 3 days for 3 doses); avoid oral fluconazole in pregnancy (use topical azole for 1 wk); recurrent VVC — ≥4 episodes per year; most women do not have predisposing condition; 99% of time, species of yeast in vagina same as species in gut; maintenance therapy — confirm Candida infection with culture; for recurrent VVC, treat for 1 to 2 wk or with 3 doses of fluconazole, then give suppression therapy; suppression therapy — fluconazole (150 mg) twice weekly until controlled, then once weekly for 6 mo

Abnormal vaginal bleeding: determine whether patient pregnant; ovulatory — menorrhagia (regular but heavy menstrual periods); hypomenorrhea (regular but light menstrual periods); polymenorrhea (interval between menstrual periods <24 days); regular periods with intermenstrual bleeding or postcoital bleeding; anovulatory — metrorrhagia (irregular bleeding with no cyclicity); menometrorrhagia (heavy irregular bleeding); 5 to 6 periods per year; postmenopausal bleeding; ­work-up — patient history; physical examination; urine pregnancy test; if pregnant, determine cause of ­first-trimester bleeding; if pregnancy viable, perform ultrasonography (US); if not pregnant, perform pelvic examination

Nonuterine sources of abnormal vaginal bleeding: cervical — invasive neoplasms (eg, squamous cell carcinoma on exocervix, adenocarcinoma in canal); infections (eg, gonorrhea, chlamydia, or Mycoplasma); benign ectropion (fragile tissue; appears bright red and bleeds to touch; common cause of postcoital bleeding in teenagers and in women ­20-25 yr of age); vaginal — inflammation can cause intermenstrual bleeding or postcoital bleeding; VT; atrophic vaginitis leading cause of postmenopausal bleeding; trauma; foreign bodies (leading cause of vaginal bleeding in premenarchal girls; use nasal speculum to examine); vaginal neoplasms; postmenopausal bleeding — from urethra or anus; mainly postvoid bleeding; urethral caruncle (urethra turns inside out; appears bright red); squamous cell or transitional cell cancer of urethra; hemorrhoid or fissure; genital wart (rare); anal squamous cell cancer; thorough pelvic examination important

Structural conditions of abnormal uterine bleeding (AUB): women usually ovulatory with regular (usually heavy) periods; polyps — intermenstrual or postcoital bleeding mainly in women 30 to 50 yr of age; adenomyosis — burrowing of endometriosis into uterine corpus; symptoms include painful menstrual periods, painful intercourse, chronic pelvic pain, and menorrhagia; leiomyoma — intramural fibroid or submucous fibroid under endometrium; leads to menorrhagia, but never metrorrhagia; malignancy and endometrial hyperplasia — in perimenopausal and postmenopausal women, adenomatous hyperplasia progresses to atypical adenomatous hyperplasia, then endometrial cancer; in postmenopausal women, any abnormal vaginal bleeding is endometrial cancer until proven otherwise; determine whether woman has endometrial cancer (consider in women with postmenopausal bleeding, premenopausal women with recurrent perimenopausal metrorrhagia, or women with chronic anovulation); leiomyosarcoma (malignant variant of fibroid)

Nonstructural conditions of AUB: coagulopathy — clotting factor defect (eg, liver disease, Von Willebrand disease); platelet deficiency (start to see menorrhagia in patients with platelet count <20,000/mm3; always see menorrhagia when platelet count <10,000/ mm3); idiopathic thrombocytopenic purpura leading cause of thrombocytopenia in women of reproductive age; test blood coagulation in women with heavy menstrual bleeding since menarche, postpartum hemorrhage, unanticipated bleeding associated with surgery or dental work, or if woman has ≥2 signs (ie, bruising or nosebleeds >2 times/month, frequent gum bleeding, family history of bleeding symptoms)

Ovulatory dysfunction: anovulation — polycystic ovary syndrome (PCOS); stress; anovulatory episodes more likely at extremes of age (in, eg, girls ­12-13 yr of age or perimenopausal women ­49-51 yr of age); abnormal estrogen levels can result in estrogen withdrawal bleeding (irregular, heavy bleeding; menometrorrhagia classic finding in anovulatory bleeding episode); anovulatory bleeding can be related to ­adult-onset congenital adrenal hyperplasia or systemic problems (eg, renal or liver disease); hypothyroidism or hyperthyroidism — can lead to ovulatory defects; must be fairly severe and uncorrected (thyroid replacement or treatment of hyperthyroidism normalizes periods); luteal phase defect — corpus luteum lasts 1 wk instead of 14 days, resulting in ­21- or ­22-day cycles; primarily in women with short cycles and unexplained infertility (treat with clomiphene [Clomid, Milophene, Serophene]

Endometrial problems: idiopathic menorrhagia (no findings after complete ­work-up; common cause of menorrhagia in women ­40-50 yr of age; easy to treat with endometrial ablation); postpartum or postabortal endometritis; women with PID often have menorrhagia; in teenagers, chlamydial PID more likely to present with menorrhagia than with pelvic pain (women ­20-30 yr of age more likely to have pelvic pain)

Iatrogenic conditions: anticoagulants (eg, heparin, enoxaparin [Lovenox], warfarin [Coumadin, Jantoven]); contraceptives

Not classified: chronic endometritis; arteriovenous malformations within endometrium; myometrial hypertrophy

­Work-up of abnormal vaginal bleeding: urine pregnancy test; complete blood cell count; thyrotropin and prolactin if concerned about anovulatory bleeding; hemostasis evaluation; US for women with ovulatory bleeding, but not useful for looking for hyperplasia in premenopausal women; for evaluation of polyp or submucous fibroid, saline infusion sonography more helpful than pelvic US

Polycystic ovary syndrome: overlap between insulin resistance, hyperandrogenism, and chronic anovulation; clinical or biochemical hyperandrogenism and chronic oligoanovulation; clinical diagnosis (no specific laboratory diagnosis or tests available); in Europe, definition of PCOS includes ­polycystic-appearing ovaries on US; hyperandrogenism — hirsutism; acne; causes include ovarian ­androgen-secreting tumors, congential adrenal hyperplasia, Cushing syndrome, adrenal androgen tumors, exogenous androgens (rare), and idiopathic causes; laboratory tests may be necessary to differentiate PCOS from other causes of virilization or amenorrhea; screen for sequelae (eg, metabolic syndrome); consider endometrial biopsy in patients with ≥3 mo of anovulatory bleeding; choose optimal drug for ovulation induction; evaluation — check blood pressure, body mass index, and waist circumference; screen for diabetes; fasting lipid panel; pregnancy test; hematocrit; endometrial biopsy if hyperplasia suspected; total testosterone if patient has significant or ­rapid-onset hirsutism; if ­adult-onset congenital adrenal hyperplasia suspected, perform early morning ­17-­a-hydroxyprogesterone; if patient virilized, screen with dehydroepiandrosterone sulfate to look for adrenal tumor, and free or total testosterone to look for ovarian tumor; if patient has features of Cushing disease, check ­24-hr free cortisol or perform overnight dexamethasone suppression testing

Management of acute dysfunctional bleeding: bleeding lasting <1 wk — substitute luteal phase by giving progestin (eg, medroxyprogesterone [eg, Depo–Provera, Hematrol, Provera], ­10-20 mg for 10 days); natural or micronized progesterone (eg, Crinone, Prochieve, Prometrium) can be used for 10 days; moderate or heavy bleeding lasting ≥1 wk — use monophasic oral contraceptive pill (OCP; in women of average weight, twice daily for 7 days; in heavier women, 3 times/day for 7 days); ­high-dose OCPs 2 to 3 times/day for 7 days, then once daily for 1 mo; recurrent dysfunctional bleeding — clomiphene in patients interested in pregnancy; cycle with OCPs in women who need contraception; in women who had tubal ligation and have dysfunctional anovulatory bleeding, give progestin on days 1 to 10 of each calendar month; ­levonorgestrel-releasing intrauterine system (Mirena); consider endometrial ablation in women who have completed childbearing; recurrent menorrhagia — start with extended regimen of OCPs; nonsteroidal ­anti-inflammatory drugs (eg, naproxen, ibuprofen); Mirena approved by Food and Drug Administration for idiopathic menorrhagia; endometrial ablation; tranexamic acid (Lysteda) effective, and can be used up to 5 days in menstrual period

Postmenopausal bleeding: causes — hormonal withdrawal; anatomic (eg, atrophic vaginal changes); foreign bodies (rare); endometrial hyperplasia; endometrial cancer; cervical cancer; evaluation — if patient not on hormone therapy and bleeding >1 day, diagnose with endometrial biopsy or endovaginal US to assess endometrial stripe thickness (not hyperplasia if <5 mm); if using hormone therapy, then consider pharmacologic side effect; single episode — stimulated by stress; bleeding lasts only few days; biopsy not required unless bleeding persistent or repetitive

Menopause: time of last menstrual period before one complete year without bleeding; Women’s Health Initiative — found correlation between hormone therapy and increased cardiovascular risk applies mainly to women 60 to 70 yr of age; recent analysis found women who start hormone therapy at 50 to 53 yr of age soon after menopause do not have increased risk for myocardial infarction, and hormone therapy may be mildly cardioprotective; in women 50 to 60 yr of age (soon after menopause) with symptoms (eg, hot flushes, vaginal dryness), no concerns about additional risk for heart disease associated with menopausal therapy; use hormones for shortest time (2 yr) at lowest effective dose

Hormone therapy and breast cancer: attributable risk for breast cancer with combination of estrogen and progestin use at ≈4 yr (risk increases every year thereafter); with ­estrogen-only regimens, no increased risk for breast cancer; limit postmenopausal hormone therapy for hot flushes to 2 to 3 yr

Interventions for hot flushes: exercise; reduce room temperature at night; black cohosh; selective serotonin reuptake inhibitors and ­serotonin-norepinephrine reuptake inhibitors (eg, venlafaxine, paroxetine, sertraline, escitalopram [Lexapro]) not as effective as estrogen; gabapentin appears as effective as estrogen

Suggested Reading

Albers JR et al: Abnormal uterine bleeding. Am Fam Physician. 2004 Apr 15;69(8):­1915-26; Apgar BS et al: Treatment of menorrhagia. Am Fam Physician. 2007 Jun 15;75(12):­1813-9; Davidson KG, Dubinsky TJ: Ultrasonographic evaluation of the endometrium in postmenopausal vaginal bleeding. Radiol Clin North Am. 2003 Jul;41(4):­769-80; Dodson MG: Use of transvaginal ultrasound in diagnosing the etiology of menometrorrhagia. J Reprod Med. 1994 May;39(5):­362-72; Farrell E: Dysfunctional uterine bleeding. Aust Fam Physician. 2004 Nov;33(11):­906-8; Hayes LP et al: Use of gabapentin for the management of natural or surgical menopausal hot flashes. Ann Pharmacother. 2011 Mar;45(3):­388-94; Hurskainen R et al: Diagnosis and treatment of menorrhagia. Acta Obstet Gynecol Scand. 2007;86(6):­749-57; James AH: Von Willebrand disease. Obstet Gynecol Surv. 2006 Feb;61(2):­136-45; Kumar N et al: Bacterial vaginosis: Etiology and modalities of ­treatment-A brief note. J Pharm Bioallied Sci. 2011 Oct;3(4):­496-503; Lethaby A et al: Hormone replacement therapy in postmenopausal women: endometrial hyperplasia and irregular bleeding. Cochrane Database Syst Rev. 2004;(3):CD000402; Lethaby AE et al: Progesterone or ­progestogen-releasing intrauterine systems for heavy menstrual bleeding. Cochrane Database Syst Rev. 2005 Oct 19;(4):CD002126; Marret H et al: Clinical practice guidelines on menorrhagia: management of abnormal uterine bleeding before menopause. Eur J Obstet Gynecol Reprod Biol. 2010 Oct;152(2):­133-7; Munro MG et al: FIGO Working Group on Menstrual Disorders. FIGO classification system (­PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age. Int J Gynaecol Obstet. 2011 Apr;113(1):­3-13; Pinkerton JV: Pharmacological therapy for abnormal uterine bleeding. Menopause. 2011 Apr;18(4):­453-61; Sekhavat L et al: Oral fluconazole 150 mg single dose versus ­intra-vaginal clotrimazole treatment of acute vulvovaginal candidiasis. J Infect Public Health. 2011 Sep;4(4):­195-9; Sobel JD et al: Tinidazole therapy for ­metronidazole-resistant vaginal trichomoniasis. Clin Infect Dis. 2001 Oct 15;33(8):­1341-6; Strickler RC: Dysfunctional uterine bleeding in ovulatory women. Postgrad Med. 1985 Jan;77(1):­235-7, ­240-3, 246; Sweet MG et al: Evaluation and management of abnormal uterine bleeding in premenopausal women. Am Fam Physician. 2012 Jan 1;85(1):­35- 4. 3.

Readings

Albers JR et al: Abnormal uterine bleeding. Am Fam Physician. 2004 Apr 15;69(8):­1915-26; Apgar BS et al: Treatment of menorrhagia. Am Fam Physician. 2007 Jun 15;75(12):­1813-9; Davidson KG, Dubinsky TJ: Ultrasonographic evaluation of the endometrium in postmenopausal vaginal bleeding. Radiol Clin North Am. 2003 Jul;41(4):­769-80; Dodson MG: Use of transvaginal ultrasound in diagnosing the etiology of menometrorrhagia. J Reprod Med. 1994 May;39(5):­362-72; Farrell E: Dysfunctional uterine bleeding. Aust Fam Physician. 2004 Nov;33(11):­906-8; Hayes LP et al: Use of gabapentin for the management of natural or surgical menopausal hot flashes. Ann Pharmacother. 2011 Mar;45(3):­388-94; Hurskainen R et al: Diagnosis and treatment of menorrhagia. Acta Obstet Gynecol Scand. 2007;86(6):­749-57; James AH: Von Willebrand disease. Obstet Gynecol Surv. 2006 Feb;61(2):­136-45; Kumar N et al: Bacterial vaginosis: Etiology and modalities of ­treatment-A brief note. J Pharm Bioallied Sci. 2011 Oct;3(4):­496-503; Lethaby A et al: Hormone replacement therapy in postmenopausal women: endometrial hyperplasia and irregular bleeding. Cochrane Database Syst Rev. 2004;(3):CD000402; Lethaby AE et al: Progesterone or ­progestogen-releasing intrauterine systems for heavy menstrual bleeding. Cochrane Database Syst Rev. 2005 Oct 19;(4):CD002126; Marret H et al: Clinical practice guidelines on menorrhagia: management of abnormal uterine bleeding before menopause. Eur J Obstet Gynecol Reprod Biol. 2010 Oct;152(2):­133-7; Munro MG et al: FIGO Working Group on Menstrual Disorders. FIGO classification system (­PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age. Int J Gynaecol Obstet. 2011 Apr;113(1):­3-13; Pinkerton JV: Pharmacological therapy for abnormal uterine bleeding. Menopause. 2011 Apr;18(4):­453-61; Sekhavat L et al: Oral fluconazole 150 mg single dose versus ­intra-vaginal clotrimazole treatment of acute vulvovaginal candidiasis. J Infect Public Health. 2011 Sep;4(4):­195-9; Sobel JD et al: Tinidazole therapy for ­metronidazole-resistant vaginal trichomoniasis. Clin Infect Dis. 2001 Oct 15;33(8):­1341-6; Strickler RC: Dysfunctional uterine bleeding in ovulatory women. Postgrad Med. 1985 Jan;77(1):­235-7, ­240-3, 246; Sweet MG et al: Evaluation and management of abnormal uterine bleeding in premenopausal women. Am Fam Physician. 2012 Jan 1;85(1):­35- 4. 3.

Disclosures

In adherence to ACCME Standards for Commercial Support, ­Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, Dr. Policar and the planning committee reported nothing to disclose.

Introduction: vaginal discharge not always sign of infection; symptoms include irritation, itching, burning, and vaginal discharge; vulvar dermatoses — lichen sclerosis in older women; lichen simplex chronicus (hypertrophy of vulvar skin from scratching); contact dermatitis; vaginal discharge can be related to anatomic problems (eg, fistula, mucorrhea, mucopurulent cervicitis); physiologic or psychogenic

Bacterial vaginosis (BV): noninflammatory; decrease in normal vaginal flora (Lactobacillus crispatus or Lactobacillus jensenii); ­100-fold increase in Gardnerella (anaerobe normally found in vagina); ­1000-fold increase in anaerobes and more pathologic organisms that cause symptoms; since vaginal Gardnerella normally present in >50% of women of reproductive age, vaginal culture and sensitivity testing not performed in nonpregnant women; sexually associated, but not horizontally transmitted from men to women; rare in virginal women; multiple male sex partners increases risk; condom use decreases risk; no BV carrier state in men; treatment of male partners to reduce recurrences in women ineffective; exposure to seminal fluid increases risk for BV; horizontally transmitted between women who have sex with women due to transfer of vaginal fluid to partner; clinical presentation — ≈50% asymptomatic; most symptoms unrecognized; profuse watery vaginal discharge with fishy, ­ammonia-like odor (especially after intercourse); few or no irritative symptoms; signs — white or slate gray homogeneous vaginal discharge; discharge may be bubbly; no redness or irritation; screening — not routinely performed; assess vaginal discharge in symptomatic women with amine KOH test, vaginal pH test, clue cells on microscopy (look for ragged border; ≥20% of epithelial cells); ­in-office tests (eg, Affirm VP III; OSOM BV Blue); result on Papanicolaou (Pap) testing stating “shift in vaginal flora consistent with BV” poorly correlated with BV; Amsel diagnostic criteria — ≥3 of 4; homogenous discharge; positive amine odor with KOH; vaginal pH >4.5; clue cells on microscopy; Spiegel criteria or Nugent score — based on Gram’s stain; highly sensitive and specific; inexpensive; ­labor-intensive; who to treat — symptomatic women; symptomatic pregnant women with history of preterm labor; women scheduled to undergo pelvic surgery (eg, abortion, hysterectomy, cervical procedure); no evidence supports BV screening or treatment before insertion of intrauterine device; treatment — controversial in women who have typical findings of BV during pelvic examination but do not notice their symptoms (discuss possible relationship with pelvic inflammatory disease [PID], recurrent bladder infections, and increased risk for HIV infection); oral metronidazole twice daily for 1 wk; metronidazole vaginal gel at bedtime for 5 days; clindamycin vaginal cream for 7 days; tinidazole regimens also acceptable; recurrent BV — ≥3 outbreaks per year; after typical treatment regimen, use metronidazole vaginal gel twice weekly; abstain from vaginal sex during treatment; avoid douching; condom use may reduce recurrences; women who have sex with women should clean sex toys in between use by partner and themselves; avoid anal insertion followed by vaginal insertion

Vaginal trichomoniasis (VT): diagnosis — sensitivity of saline suspension 60%, but specificity high; Aptima TMA (new test highly sensitive and specific; $40); ­point-­of-care tests include Affirm VP III, OSOM Trichomonas Rapid test, and saline suspension; Pap testing detects VT ≈50% of time, but highly specific; treatment — metronidazole and tinidazole equally effective, but fewer side effects with tinidazole; relative resistance to metronidazole reported; if infection persists after treatment, consider reinfection; retreat after treatment failure (if no response, use oral and vaginal tinidazole treatments concurrently); contact Centers for Disease Control and Prevention about resistant cases

Vulvovaginal candidiasis (VVC): species include Candida albicans and Candida glabrata; testing — ­point-­of-care office tests include KOH suspension (look for pseudohyphae and blastospores; in C glabrata infection, only spores may be seen, and patients more likely to have more burning than itching); Gram’s stain typically not highly helpful; amine test negative; polymerase chain reaction (PCR) laboratory testing or DNA probe testing used for diagnosis rather than screening; uncomplicated VVC — mild to moderate infection; likely C albicans; patient immunocompetent; complicated VVC — ≥3 episodes per year; uncomfortable and severe outbreaks; due to species other than C albicans; patient immunocompromised; treatment of uncomplicated VVC — ­3- and ­7-day topical antifungal agents equally effective (adherence higher with ­3-day therapy); use ­1- or ­3-day topical agent, or ­single-dose fluconazole (Diflucan; 150 mg highly effective); treatment of complicated VVC — topical azole therapy for 1 to 2 wk; treat immunocompromised women (eg, women with diabetes or HIV, or on chemotherapy) for 1 to 2 wk, or with oral fluconazole (150 mg every 3 days for 3 doses); avoid oral fluconazole in pregnancy (use topical azole for 1 wk); recurrent VVC — ≥4 episodes per year; most women do not have predisposing condition; 99% of time, species of yeast in vagina same as species in gut; maintenance therapy — confirm Candida infection with culture; for recurrent VVC, treat for 1 to 2 wk or with 3 doses of fluconazole, then give suppression therapy; suppression therapy — fluconazole (150 mg) twice weekly until controlled, then once weekly for 6 mo

Abnormal vaginal bleeding: determine whether patient pregnant; ovulatory — menorrhagia (regular but heavy menstrual periods); hypomenorrhea (regular but light menstrual periods); polymenorrhea (interval between menstrual periods <24 days); regular periods with intermenstrual bleeding or postcoital bleeding; anovulatory — metrorrhagia (irregular bleeding with no cyclicity); menometrorrhagia (heavy irregular bleeding); 5 to 6 periods per year; postmenopausal bleeding; ­work-up — patient history; physical examination; urine pregnancy test; if pregnant, determine cause of ­first-trimester bleeding; if pregnancy viable, perform ultrasonography (US); if not pregnant, perform pelvic examination

Nonuterine sources of abnormal vaginal bleeding: cervical — invasive neoplasms (eg, squamous cell carcinoma on exocervix, adenocarcinoma in canal); infections (eg, gonorrhea, chlamydia, or Mycoplasma); benign ectropion (fragile tissue; appears bright red and bleeds to touch; common cause of postcoital bleeding in teenagers and in women ­20-25 yr of age); vaginal — inflammation can cause intermenstrual bleeding or postcoital bleeding; VT; atrophic vaginitis leading cause of postmenopausal bleeding; trauma; foreign bodies (leading cause of vaginal bleeding in premenarchal girls; use nasal speculum to examine); vaginal neoplasms; postmenopausal bleeding — from urethra or anus; mainly postvoid bleeding; urethral caruncle (urethra turns inside out; appears bright red); squamous cell or transitional cell cancer of urethra; hemorrhoid or fissure; genital wart (rare); anal squamous cell cancer; thorough pelvic examination important

Structural conditions of abnormal uterine bleeding (AUB): women usually ovulatory with regular (usually heavy) periods; polyps — intermenstrual or postcoital bleeding mainly in women 30 to 50 yr of age; adenomyosis — burrowing of endometriosis into uterine corpus; symptoms include painful menstrual periods, painful intercourse, chronic pelvic pain, and menorrhagia; leiomyoma — intramural fibroid or submucous fibroid under endometrium; leads to menorrhagia, but never metrorrhagia; malignancy and endometrial hyperplasia — in perimenopausal and postmenopausal women, adenomatous hyperplasia progresses to atypical adenomatous hyperplasia, then endometrial cancer; in postmenopausal women, any abnormal vaginal bleeding is endometrial cancer until proven otherwise; determine whether woman has endometrial cancer (consider in women with postmenopausal bleeding, premenopausal women with recurrent perimenopausal metrorrhagia, or women with chronic anovulation); leiomyosarcoma (malignant variant of fibroid)

Nonstructural conditions of AUB: coagulopathy — clotting factor defect (eg, liver disease, Von Willebrand disease); platelet deficiency (start to see menorrhagia in patients with platelet count <20,000/mm3; always see menorrhagia when platelet count <10,000/ mm3); idiopathic thrombocytopenic purpura leading cause of thrombocytopenia in women of reproductive age; test blood coagulation in women with heavy menstrual bleeding since menarche, postpartum hemorrhage, unanticipated bleeding associated with surgery or dental work, or if woman has ≥2 signs (ie, bruising or nosebleeds >2 times/month, frequent gum bleeding, family history of bleeding symptoms)

Ovulatory dysfunction: anovulation — polycystic ovary syndrome (PCOS); stress; anovulatory episodes more likely at extremes of age (in, eg, girls ­12-13 yr of age or perimenopausal women ­49-51 yr of age); abnormal estrogen levels can result in estrogen withdrawal bleeding (irregular, heavy bleeding; menometrorrhagia classic finding in anovulatory bleeding episode); anovulatory bleeding can be related to ­adult-onset congenital adrenal hyperplasia or systemic problems (eg, renal or liver disease); hypothyroidism or hyperthyroidism — can lead to ovulatory defects; must be fairly severe and uncorrected (thyroid replacement or treatment of hyperthyroidism normalizes periods); luteal phase defect — corpus luteum lasts 1 wk instead of 14 days, resulting in ­21- or ­22-day cycles; primarily in women with short cycles and unexplained infertility (treat with clomiphene [Clomid, Milophene, Serophene]

Endometrial problems: idiopathic menorrhagia (no findings after complete ­work-up; common cause of menorrhagia in women ­40-50 yr of age; easy to treat with endometrial ablation); postpartum or postabortal endometritis; women with PID often have menorrhagia; in teenagers, chlamydial PID more likely to present with menorrhagia than with pelvic pain (women ­20-30 yr of age more likely to have pelvic pain)

Iatrogenic conditions: anticoagulants (eg, heparin, enoxaparin [Lovenox], warfarin [Coumadin, Jantoven]); contraceptives

Not classified: chronic endometritis; arteriovenous malformations within endometrium; myometrial hypertrophy

­Work-up of abnormal vaginal bleeding: urine pregnancy test; complete blood cell count; thyrotropin and prolactin if concerned about anovulatory bleeding; hemostasis evaluation; US for women with ovulatory bleeding, but not useful for looking for hyperplasia in premenopausal women; for evaluation of polyp or submucous fibroid, saline infusion sonography more helpful than pelvic US

Polycystic ovary syndrome: overlap between insulin resistance, hyperandrogenism, and chronic anovulation; clinical or biochemical hyperandrogenism and chronic oligoanovulation; clinical diagnosis (no specific laboratory diagnosis or tests available); in Europe, definition of PCOS includes ­polycystic-appearing ovaries on US; hyperandrogenism — hirsutism; acne; causes include ovarian ­androgen-secreting tumors, congential adrenal hyperplasia, Cushing syndrome, adrenal androgen tumors, exogenous androgens (rare), and idiopathic causes; laboratory tests may be necessary to differentiate PCOS from other causes of virilization or amenorrhea; screen for sequelae (eg, metabolic syndrome); consider endometrial biopsy in patients with ≥3 mo of anovulatory bleeding; choose optimal drug for ovulation induction; evaluation — check blood pressure, body mass index, and waist circumference; screen for diabetes; fasting lipid panel; pregnancy test; hematocrit; endometrial biopsy if hyperplasia suspected; total testosterone if patient has significant or ­rapid-onset hirsutism; if ­adult-onset congenital adrenal hyperplasia suspected, perform early morning ­17-­a-hydroxyprogesterone; if patient virilized, screen with dehydroepiandrosterone sulfate to look for adrenal tumor, and free or total testosterone to look for ovarian tumor; if patient has features of Cushing disease, check ­24-hr free cortisol or perform overnight dexamethasone suppression testing

Management of acute dysfunctional bleeding: bleeding lasting <1 wk — substitute luteal phase by giving progestin (eg, medroxyprogesterone [eg, Depo–Provera, Hematrol, Provera], ­10-20 mg for 10 days); natural or micronized progesterone (eg, Crinone, Prochieve, Prometrium) can be used for 10 days; moderate or heavy bleeding lasting ≥1 wk — use monophasic oral contraceptive pill (OCP; in women of average weight, twice daily for 7 days; in heavier women, 3 times/day for 7 days); ­high-dose OCPs 2 to 3 times/day for 7 days, then once daily for 1 mo; recurrent dysfunctional bleeding — clomiphene in patients interested in pregnancy; cycle with OCPs in women who need contraception; in women who had tubal ligation and have dysfunctional anovulatory bleeding, give progestin on days 1 to 10 of each calendar month; ­levonorgestrel-releasing intrauterine system (Mirena); consider endometrial ablation in women who have completed childbearing; recurrent menorrhagia — start with extended regimen of OCPs; nonsteroidal ­anti-inflammatory drugs (eg, naproxen, ibuprofen); Mirena approved by Food and Drug Administration for idiopathic menorrhagia; endometrial ablation; tranexamic acid (Lysteda) effective, and can be used up to 5 days in menstrual period

Postmenopausal bleeding: causes — hormonal withdrawal; anatomic (eg, atrophic vaginal changes); foreign bodies (rare); endometrial hyperplasia; endometrial cancer; cervical cancer; evaluation — if patient not on hormone therapy and bleeding >1 day, diagnose with endometrial biopsy or endovaginal US to assess endometrial stripe thickness (not hyperplasia if <5 mm); if using hormone therapy, then consider pharmacologic side effect; single episode — stimulated by stress; bleeding lasts only few days; biopsy not required unless bleeding persistent or repetitive

Menopause: time of last menstrual period before one complete year without bleeding; Women’s Health Initiative — found correlation between hormone therapy and increased cardiovascular risk applies mainly to women 60 to 70 yr of age; recent analysis found women who start hormone therapy at 50 to 53 yr of age soon after menopause do not have increased risk for myocardial infarction, and hormone therapy may be mildly cardioprotective; in women 50 to 60 yr of age (soon after menopause) with symptoms (eg, hot flushes, vaginal dryness), no concerns about additional risk for heart disease associated with menopausal therapy; use hormones for shortest time (2 yr) at lowest effective dose

Hormone therapy and breast cancer: attributable risk for breast cancer with combination of estrogen and progestin use at ≈4 yr (risk increases every year thereafter); with ­estrogen-only regimens, no increased risk for breast cancer; limit postmenopausal hormone therapy for hot flushes to 2 to 3 yr

Interventions for hot flushes: exercise; reduce room temperature at night; black cohosh; selective serotonin reuptake inhibitors and ­serotonin-norepinephrine reuptake inhibitors (eg, venlafaxine, paroxetine, sertraline, escitalopram [Lexapro]) not as effective as estrogen; gabapentin appears as effective as estrogen

Acknowledgements

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CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

FP601001

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

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