1. Vaginal Discharge

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

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

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

5. Commonest causes of altered vaginal discharge In women of reproductive age

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

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

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

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

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

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

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

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

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

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

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

21. 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

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

23. 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

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

25. 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

26. 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

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

28. Recurrent Vaginal Discharge • REFER TO THE GUM CLINIC

29. 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

30. 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

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

32. POLYCYSTIC OVARIES Prevalence 5-10%

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

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

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

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

37. 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

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

39. 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

44. 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

47. 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

48. 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

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

50. 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