Am 8.45 policar vulvovag


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Am 8.45 policar vulvovag

  1. 1. Managing Vulvovaginal Disorders Michael Policar, MD, MPH Professor of Ob, Gyn, and Repro Sciences UCSF School of Medicine
  2. 2. • There are no relevant financial relationships with any commercial interests to disclose
  3. 3. Vulvovaginal Symptoms: Differential DiagnosisCategory ConditionInfections Vaginal trichomoniasis (VT) Bacterial vaginosis (BV) Vulvovaginal candidiasis (VVC)Skin Conditions Fungal vulvitis (candida, tinea) Contact dermatitis (irritant, allergic) Vulvar dermatoses (LS, LP, LSC) Vulvar intraepithelial neoplasia (VIN)Psychogenic Physiologic, psychogenic
  4. 4. CDC 2010: Trichomoniasis Screening and Testing• Screening indications – HIV positive women: annually – Consider if “at risk”: new/multiple sex partners, history of STI, inconsistent condom use, sex work, IDU• New assays – Rapid antigen test:  sensitivity, specificity vs. wet mount – Aptima TMA T. vaginalis Analyte Specific Reagent (ASR)• Other testing situations – Suspect trich but NaCl slide neg  culture or newer assays – Pap with trich  confirm if low risk• Consider retesting 3 months after treatment
  5. 5. Trichomoniasis: Laboratory TestsTest Sensitivity Specificity Cost CommentAptima TMA +4 (98%) +3 (98%) $$$ NAAT (like GC/Ct)Culture +3 (83%) +4 (100%) $$$ Not in most labsPoint of care•Affirm VP III +3 +4 $$$ DNA probe•OSOM Rapid +3 (90%) +4 (100%) $$ CLIA waivedNaCl suspension +2 (56%) +4 (100%) ¢¢ 1st linePap smear +2 +3 n/a Confirm if low prevalence Accuracy data: Huppert CID 2007
  6. 6. CDC 2010: Vaginal Trichomoniasis Treatment• Recommended regimen – Metronidazole 2 grams PO single dose – Tinidazole 2 grams PO single dose• Alternative regimen (preferred for HIV infected women) – Metronidazole 500 mg PO BID x 7 days• Metronidazole safe at all gestational ages – Limited pregnancy data on Tinidazole• Treat sex partner(s)• Targeted screening for other STIs: GC, Ct, syphilis, HIV
  7. 7. CDC 2010: VT Treatment Failure• Re-treat with either – Tinidazole 2 g PO single dose – Metronidazole 500 mg PO BID x 7 days• If repeat failure, treat with – Metronidazole 2 grams po x 3-5 days• If repeat failureTinidazole 2-3 g po plus 1-1.5 g vaginally x14 days• Arrange for susceptibility testing: Call CDC!! (770-488- 4115)
  8. 8. BV: Pathophysiology• Non-inflammatory bacterial overgrowth – 100 x increase Gardnerella vaginalis – 1000 x increase in anaerobes – More pathogen types (Mobiluncus, Mycoplasmas)• Suppression of H2O2-producing Lactobacillus crispatus and L. jensenii (L acidophilus is not present)• >50% women carry G. vaginalis in their vaginal flora in the absence of BV – Bacterial “C/S” of vaginal fluid doesn’t help in the diagnosis of BV….or of any other vaginal infection
  9. 9. BV: Sexually Associated or Transmitted?• “Sexually associated” in heterosexuals – Rare in virginal women – Greater risk of BV with multiple male partners – Condom use decreases risk, But – No BV carrier state identified in men – Treatment of partner does not affect recurrences• Women having sex with women (WSW) – Infected vaginal fluid between women causes BV – Studies of concurrence in lesbian couples suggest horizontal transmission
  10. 10. BV: Clinical Diagnosis• Amsel Criteria: 3 or more of – Homogenous white discharge – Amine odor (“whiff” test) – pH > 4.5 (most sensitive) – Clue cells > 20% (most specific)• Spiegel criteria, Nugent score: Gram stain with – Few or no gram positive Lactobacillus spp. – Excess of other gram negative morphotypes
  11. 11. Characteristic Discharge With BV
  12. 12. BV: Clue Cells on Saline Suspension >20% of epithelial cells are clues Reduced Lactobacilli Ragged cell border
  13. 13. BV: Laboratory TestsTest Sensit Specif Cost CommentNugent score +4 +4 ¢¢ Labor intensivePoint of care tests Affirm VP III +4 +3 $$$ DNA probe OSOM BV Blue +3 +3 $$ CLIA moderate G vag PIP +2 +3 $$$ CLIA moderatepH + amines +2 +2 $ CLIA waivedAmsel criteria +3 +2 ¢¢ 1st linePap smear +1 +2-3 n/a Coccobacilli
  14. 14. Who Should Be Tested for BV?• Routine screening (asymptomatic): not indicated• Standard diagnostic testing – Check discharge, amines, vaginal pH, clue cells• Microscopy not available or inconclusive – Affirm VP III – OSOM BV Blue – G vaginalis PIP, pH+amine test cards• “Shift in vaginal flora” on Pap – No consensus, but poor correlation with BV…most experts recommend no further follow up
  15. 15. CDC 2010: BV TreatmentRecommended regimens – Metronidazole 500 mg PO BID x 7 days – Metronidazole gel 0.75% 5g per vagina QD x 5 days – Clindamycin 2% cream 5g per vagina QHS x 7 daysAlternative regimens – Tinidazole 2 g PO QD for 3 days – Tinidazole 1 g PO QD for 5 days – Clindamycin 300 mg PO BID x 7 days – Clindamycin ovules 100 mg per vagina QHS x 3 days
  16. 16. CDC 2010: Recurrent BV• Consider suppression with metronidazole vaginal gel twice weekly for 4-6 months (after full initial treatment)• No evidence yet to support use of probiotics• Don’t douche…with anything!• Use of condoms by male partners may reduce recurrences• Clean sex toys (or use condoms) between uses• Avoid vaginal insertion after anal insertion of a finger or penis
  17. 17. CDC 2010: VVC Classification• Uncomplicated VVC (80-90%) – Sporadic or infrequent VVC, and – Mild-to-moderate VVC, and – Likely to be Candida albicans, and – Immunecompetant• Complicated VVC (10-20%) – Recurrent VVC, or – Severe VVC, or – Non-albicans candidiasis, or – Uncontrolled DM, immunosuppression, pregnancy
  18. 18. VVC: Laboratory• KOH suspension − C. albicans: pseudohyphae and blastospores (buds) − C. glabrata: blastospores only• NaCl suspension: many WBC, normal lactobacillus• pH: 4-6• Amine test: negative• Confirmatory tests - Point of care test: Affirm VP III - Candida culture (not: fungus culture) - Candida PCR
  19. 19. Treatments for VVC Drug Over the Counter PrescriptionLength of Treatment 7d 3d 1d 7d 3d 1dButoconazole XClotrimazole X X XMiconazole X X XTerconazole X XTioconazole X XFluconazole (PO) X
  20. 20. CDC 2010: Uncomplicated VVC Treatments• Non-pregnant women – 3 and 7 day topicals have equal efficacy and price – Offer either: 1 or 3 day topical or oral fluconazole • Topical: quickly soothing, but inconvenient • Oral: convenient, but effect is not immediate• If first treatment course fails – Re-confirm diagnosis (r/o dual infection) – Treat with an alternate antifungal drug – Perform Candida culture to confirm and speciate• No role for nystatin, candicidin
  21. 21. CDC 2010: Complicated VVC TreatmentSevere VVC• Advanced findings: erythema, excoriation, fissures• Topical azole therapy for 7-14 days, orCompromised host• Topical azole treatment for 7-14 days• Fluconazole 150 mg PO; repeat Q3 days 1-2 timesPregnancy• Topical azoles for 7 days
  22. 22. CDC 2010: Complicated VVC TreatmentRecurrent VVC (RVVC)• > 4 episodes of symptomatic VVC per year• Most women have no predisposing condition – Partners are rarely source of infection• Confirm with Candidal culture before maintenance therapy; also check for non-albicans species• Early treatment regimen: self-medication 3 days with onset of symptoms
  23. 23. CDC 2010: Complicated VVC Treatment• Recurrent VVC: Treatment – Treat for 7-14 days of topical therapy or fluconazole 150 mg PO q 72o x3 doses, then – Maintenance therapy x 6 months • Fluconazole 100-200 mg PO 1-2 per week • Itraconazole 100 mg/wk or 400 mg/month • Clotrimazole 500 mg suppos 1 per week • Boric acid 600 mg suppos QD x14, then BIW • Gentian violet: Q week x2, Q month X 3-6 mo
  24. 24. Vulvar Candidiasis• Vulva will be very itchy; often excoriated• Presentation – Erythema + satellite lesions – Occasionally: thrush, LSC thickening if chronic• Diagnosis: skin scraping KOH, candidal culture• Treatment – Topical antifungal therapy daily for 7-14 days, or fluconazole 150 mg PO repeat in 3 days – Plus: TAC 0.1% or 0.5% ointment QD-BID
  25. 25. Vulvar Candidiasis
  26. 26. Tinea Cruris: “Jock Itch”• Asymmetric lesions on proximal inner thighs – Plaque rarely involves scrotum; not penile shaft• Well demarcated red plaques with accentuation of scale peripherally; no satellite lesions• Fungal folliculitis: papules, nodules or pustules within area of plaque• Treatment – Mild: topical azoles BID x10-14d, terbinafine – Severe: fluconazole 150 mg QW for 2-4 weeks – If inflammatory, add TAC 0.1% on 1st 3 days
  27. 27. Intertrigo• Background – Occlusion, rubbing of skin chafing, inflammation – If moist, often superinfection with candida or tinea – May lichenify to LSC• Findings – Dull red, shiny skin fold; if moist, white surface – Follows clothing lines; under breasts, pannus – No satellites; border not sharp• Treatment – Keep skin clean and dry; use cornstarch – Reduce friction with bland emollient – Treat secondary infection with topical azole
  28. 28. Contact Dermatitis• Irritant contact dermatitis (ICD) – Elicited in most people with a high enough dose – Rapid onset vulvar itching (hours-days)• Allergic contact dermatitis (ACD) – Delayed hypersensitivity – 10-14 days after 1st exposure; 1-7 d after repeat exposure• ICD and ACD can present with – Itching, burning, swelling, redness – Small vesicles or bullae more likely with ACD
  29. 29. Contact Dermatitis• Common contact irritants – Urine, feces, excessive sweating – Saliva (receptive oral sex) – Repetitive scratching, overwashing – Detergents, fabric softeners – Topical corticosteroids – Toilet paper dyes and perfumes – Hygiene pads (and liners), sprays, douches – Lubricants, including condoms
  30. 30. Contact Dermatitis Symmetric Raised, bright red, intense itching Extension to areas of irritant contact
  31. 31. Contact Dermatitis• Common contact allergens – Poison oak, poison ivy – Topical antibiotics, esp neomycin, bacitracin – Spermicides – Latex (condoms, diaphragms) – Vehicles of topical meds: propylene glycol – Lidocaine, benzocaine – Fragrances
  32. 32. Contact Dermatitis: Treatment• Exclude contact with possible irritants• Restore skin barrier with sitz baths, compresses• After hydration, apply a bland emollient – White petrolatum, mineral oil, olive oil• Short term mild-moderate potency steroids – TAC 0.1% BID x10-14 days (or clobetasol 0.05%) – Fluconazole 150 mg PO weekly• Cold packs: gel packs, peas in a “zip-lock” bag• Doxypin or hydroxyzine (10-75 mg PO) at 6 pm• If recurrent, refer for patch testing
  33. 33. Why Not Steroid-Antifungal Combination Drugs?• Which products should be avoided? – Lotrisone: Clotrimazole and Betamethasone 0.5% – Mycolog II: Nystatin and Triamconolone acetonide• Why avoid them? – Inflammation usually clears up before fungal infection – Steroid overshoot  skin atrophy – Local immunosuppression (from steroid) may blunt antifungal effect
  34. 34. ISSVD 1987: Vulvar DermatosesType ISSVD Term Old TermsAtrophic Lichen • Lichen sclerosus et atrophicus sclerosus • Kraurosis vulvaeHyper- Squamous cell • Hyperplastic dystrophyplastic hyperplasia • Neurodermatitis • Lichen simplex chronicusSystemic Other • Lichen planus dermatoses • PsoriasisPre- VIN • Hyperplasic dystrophy/atypiamalignant • Bowen’s disease • Bowenoid papulosis • Vulvar CIS ISSVD: International Society for the Study of Vulvar Disease
  35. 35. ISSVD 2006 Classification of Vulvar Dermatoses• No consensus agreement on a system based upon clinical morphology, path physiology, or etiology• Include only non-Neoplastic, non-infectious entities• Agreed upon a microscopic morphology based system• Rationale of ISSVD Committee – Clinical diagnosis  no classification needed – Unclear clinical diagnosis  seek biopsy diagnosis – Unclear biopsy diagnosis  seek clinic pathologic correlation
  36. 36. ISSVD 2006 Classification of Vulvar DermatosesPath pattern Clinical CorrrelatesSpongiotic Atopic dermatitis, allergic contact dermatitis, irritant contact dermatitisAcanthotic Psoriasis, LSC (primary or superimposed), (VIN)Lichenoid Lichen sclerosus, lichen planusDermal Lichen sclerosushomogenizationVesicolobullous Pemphigoid, linear IgA diseaseAcantholytic Hailey-Hailey disease, Darier disease, papular genitocrural acantholysisGranulomatous Crohn diseaseVasculopathic Apthous ulcers, Behcet disease, plasma c. vulvitis
  37. 37. Lichen Sclerosus: Natural History• Most common vulvar dermatosis• Prevalence: 1.7% in a general GYN practice• Cause: autoimmune condition• Bimodal age distribution: older women and children, but may be present at any age• Chronic, progressive, lifelong condition
  38. 38. Lichen Sclerosus: Natural History• Most common in Caucasian women• Can affect non-vulvar areas• Part (or all) of lesion can progress to VIN, differentiated type• Predisposition to vulvar squamous cell carcinoma – 1-5% lifetime risk (vs. < 0.01% without LS) – LS in 30-40% women with vulvar squamous cancers
  39. 39. Lichen Sclerosus: Findings• Symptoms – Most commoly, itching – Often irritation, burning, dyspareunia, tearing – 58% of newly-diagnosed patients are asymptomatic• Signs – Thin white “parchment paper” epithelium – Fissures, ulcers, bruises, or submucosal hemorrhage – Loss of labia minora, fusion of labia and clitoral hood – Depigmentation (white) or hyperpigmentation in “keyhole” distribution: vulva and anus – Introital stenosis
  40. 40. Lichen Sclerosus: Treatment• Biopsy mandatory for diagnosis, unless classic findings• Preferred treatment – Clobetasol 0.05% ointment QD x4 weeks, then QOD x4 weeks, then twice-weekly for 4 weeks – Taper to med potency steroid (or clobetasol) 2-4 times per month for life – Explain “titration” regimen to patient, including management of flares and recurrent symptoms – 30 gm tube of ultrapotent steroid lasts 3-6 mo – Monitor every 3 months twice, then annually
  41. 41. “Early”Lichen Sclerosus Hyperpigmentation due to scarring Loss of labia minora
  42. 42. Later LichenSclerosus Thin white epithelium Fissures
  43. 43. “Late” Lichen Sclerosus Agglutination of clitoral hood Loss of labia minora Introital narrowing Parchment paper epithelium
  44. 44. Lichen Sclerosus: Treatment• Second line therapy – Pimecrolimus, tacrolimus – Retinoids, potassium para-aminobenzoate• Testosterone (and estrogen or progesterone) ointment or cream no longer recommended• Explain chronicity and need for life-long treatment• Adjunctive therapy: anti-pruritic therapy – Antihistamines, especially at bedtime – Doxypin, at bedtime or topically – If not effective: amitriptyline, desipramine PO• Perineoplasty may help dyspareunia, fissuring
  45. 45. Lichen Simplex Chronicus = Squamous Cell Hyperplasia• Cause: an irritant initiates a “scratch-itch” cycle• LSC classified as – Primary (idiopathic) – Secondary (superimposed upon lichen sclerosus, candida vulvitis; vulvar contact dermatitis)• Presentation: always itching; burning, pain, tenderness• Thickened leathery red (white if moisture) raised lesion• In absence of atypia, no malignant potential – If atypia present , classified as VIN
  46. 46. Lichen Simplex Chronicus
  47. 47. L. Simplex Chronicus: Treatment• Removal of irritants or allergens• Treatment – Triamcinolone acetonide (TAC) 0.1% ointment BID x4- 6 weeks, then QD – Other moderate strength steroid ointments – Intralesional TAC once every 3-6 months• Anti-pruritics – Hydroxyzine (Atarax) 25-75 mg QHS – Doxepin 25-75 mg PO QHS – Doxepin (Zonalon) 5% cream; start QD, work up
  48. 48. Lichen Sclerosus + LSC• “Mixed dystrophy” deleted in 1987 ISSVD System• 15% all vulvar dermatoses• LS is irritant; scratching  LSC• Consider: LS with plaque, VIN, squamous cell cancer of vulva• Treatment – Clobetasol x12 weeks, then steroid maintenance – Stop the itch!!
  49. 49. Vulvar Intraepithelial Neoplasia (VIN): Prior to 2004• Grading of VIN-1 through VIN-3, based upon degree of epithelial involvement• The mnemonic of the 4 P’s – Papule formation: raised lesion (erosion also possible, but much less common) – Pruritic: itching is prominent – “Patriotic”: red, white, or blue (hyperpigmented) – Parakeratosis on microscopy
  50. 50. ISSVD 2004: Squamous VIN• VIN 1 is not a cancer precursor…abandon the term – Instead, use “condyloma” or “flat wart”• Combine VIN-2 and VIN-3 into single “VIN” diagnosis• Two distinct variants of VIN – VIN, usual type • Warty type • Basaloid type • Mixed warty-basaloid – VIN, differentiated (simplex) type
  51. 51. ISSVD 2004:VIN, Usual Type• Includes (old) VIN -2 or -3• Usually HPV-related (mainly type 16)• More common in younger women (30s-40s)• Often asymptomatic• Lesions usually elevated and have a rough surface,• Often multifocal; multicentric in 50%• Strongly associated with cigarette smoking• Regression is less likely and progression to invasion more likely with the basaloid type
  52. 52. VIN, Differentiated (Simplex) Type• Includes (old) VIN 3 only• Usually in older women with LS, LSC, or LP• Not HPV related• Less common than usual type• Patients usually are symptomatic, with a long history of pruritus and burning• Findings – Red, pink, or white papule; rough or eroded surfaces – A persistent, non-healing ulcer• More likely to progress to SCC of vulva than usual VIN
  53. 53. White VIN,Usual (warty) type
  54. 54. VIN, usual (basaloid)type
  55. 55. VIN:warty-basaloidtype
  56. 56. Vulvar Intraepithelial Neoplasia• Precursor to vulvar cancer, but low “hit rate” – Greater risk of invasion if immunocompromised (steroids, HIV), >40 years old, previous lower genital tract neoplasia• Treatment – Wide local excision (few lesions), laser ablation – Topical agents: 5FU cream, imiquimod – Skinning or simple vulvectomy• Recurrence is common (48% at 15 years) – Smoking cessation may reduce recurrence rate
  57. 57. Genital Skin: Dark Lesions (% are in women only)• 36% Lentigo, benign genital melanosis• 22% VIN• 21% Nevi (mole)• 10% Reactive hyperpigmentation (scarring)• 5% Seborrheic keratosis• 2% Malignant melanoma• 1% Basal cell or squamous cell carcinoma
  58. 58. Vulvar Intraepithelial Neoplasia
  59. 59. HyperpigmentedVIN, usual type
  60. 60. Indications for Vulvar Biopsy• Papular or exophtic lesions, except obvious condylomata• Thickened lesions (biopsy thickest region) to differentiate VIN vs. LSC• Hyperpigmented lesions (biopsy darkest area), unless obvious nevus or lentigo• Ulcerative lesions (biopsy at edge), unless obvious herpes, syphilis or chancroid• Lesions that do not respond or worsen during treatment• In summary: biopsy whenever diagnosis is uncertain
  61. 61. References• Heller DS. Report of a new ISSVD classification of VIN. J Low Genit Tract Dis. 2007 Jan;11(1):46-7.• Siderite M, et al. Squamous vulvar intraepithelial neoplasia: 2004 modified terminology, ISSVD Vulvar Oncology Subcommittee J Reprod Med. 2005 Nov;50(11):807-10• Wechter ME, Management of Bartholin duct cysts and abscesses: a systematic review Obstet Gynecol Surv. 2009 Jun;64(6):395-404.• vanSeters, et al, Treatment of vulvar intraepithelial neoplasia with imiquimod. NEJM 2008;358:1465-73• De Simone P Vulvar melanoma: a report of 10 cases and review of literature. Melanoma Res. 2008 Apr;18(2):127-33
  62. 62. References• Lynch PJ, etal, 2006 ISSVD Classification of Vulvar Dermatoses. J Reprod Med 2007;52:3-9• ACOG Practice Bulletin #93. Diagnosis and Management of Vulvar Skin Disorders. Ob Gynecol 2008;111 (5);1243-1253• Smith YR, Haefner HK. Vulvar lichen sclerosus: pathophysiology and treatment. Am J Clin Dermatol. 2004;5(2):105-25.• Edwards L, Vulvar fissures: causes and therapy. Dermatol Ther. 2004;17(1):111-6.• Foster DC, Vulvar disease. Ob Gynecol. 2002;100(1):145-63.