Presentation on theme: "Genital Syndromes in Women"— Presentation transcript:
1 Genital Syndromes in Women Sexually Transmitted Diseases, Part II:Genital Syndromes in WomenDr. Devika Singh, MD, MPHJune 4, 2009Slides generously borrowed from mentor Jeanne M. Marrazzo, MD, MPH
2 STD as a Cause of Cervicitis and Ulcerative Disease Endocervicitis: ‘classic’ STD pathogensGonorrheaChlamydia trachomatisEctocervicitis: often associated w/ vaginitis:TrichomoniasisDiscrete lesions/Genital ulcerative disease/myriadHerpes simplex virusSyphilisChancroidHuman papillomavirusLGV
3 Things to Consider Age of patient Change in discharge: increased, malodorous, bloody, purulentAssociations: sexual activity/partnerships, cleaning the vagina (including douching/irrigation)Co-infections: HIV or non-HIVEpidemiology/exposures
4 Case I22 yo woman presents to your clinic. She endorses no particular symptoms.One male partner who is asymptomatic.Condoms used “sometimes”On no hormonal contraception
9 Chlamydia trachomatis Epidemiology Most common bacterial STD worldwide, with approximately 90 million cases each yearUro-genital diseaseOphthalmologicInvasive (Lymphogranuloma Venereum)
10 Clinical Syndromes Caused by C. trachomatis ConjunctivitisUrethritisCervicitisProctitisEndometritisSalpingitisPerihepatitisInfertilityEctopic pregnancyChronic pelvic painWomenConjunctivitis Pneumonia Pharyngitis RhinitisInfantsChronic lung disease (?)
11 C. trachomatis Cervical Infection Classic cause of endocervicitisMucopurulent dischargeFriabilityEdematous ectopyCervical signs occur in minority of patients (10-20%)Most (80-90%) infected women have normal cervix / no signs
12 General Characteristics of Chlamydia Superficial, mucosal: epithelial cellsOften no (or minimal) signs or symptomsChronic in women (months to years)Chronic inflammatory responseSerious reproductive sequelae inwomenReinfection common
13 Normal Fallopian tubes by Scanning EM Photos courtesy of Dorothy Patton, PhD
14 Fallopian tubes by EM after C. trachomatis infection Photos courtesy of Dorothy Patton, PhD
15 Chlamydia Tests Cell culture Antigen Detection Direct Fluorescent Antibody (DFA)Enzyme Immunoassay (EIA)Unamplified DNA Probe (Gen Probe PACE2)Signal Amplification Tests (Digene Hybrid Capture)Nucleic Acid Amplification (NAAT)Rapid Point of Care Tests
16 What is the recommended treatment for a pregnant woman with chlamydia? Erythromycin 500 mg po QID x 7 daysDoxycycline 100 mg po BID x 7 daysAzithromycin 1 g po x 1 doseLevofloxacin 500 mg po daily x 7 days
17 Chlamydia Treatment in Pregnancy 2006 Recommended regimensAzithromycin 1 g PO x 1Amoxicillin 500 mg PO TID x 7 dAlternative regimensErythromycin base 500 mg PO QID x 7 dErythromycin base 250 mg PO QID x 14 dErythro ethylsuccinate 800 mg PO QID x 7 dErythro ethylsuccinate 400 mg PO QID x 14 d
18 2006 CDC STD Treatment Guidelines: Uncomplicated Chlamydial Infection RecommendedAzithromycin 1 g PO, single dose, directly observedDoxycycline 100 mg PO BID x 7 dAlternativesOfloxacin 300 mg PO BID orlevofloxacin 500 mg PO qD x 7 dErythromycin 500 mg PO QID x 7 d
19 Counseling as Part of Chlamydia Treatment Abstain for at least 7 days and until partner(s) treatedConsistent condom useGet your partner treatedReturn if not improved over next 7-14 days
20 A Word about Screening UNITED STATES <24 years old: screen all sexually active women annually25 and older: Annual testing if ‘at increased risk’Defined liberally: inconsistent condom use, new or multiple partners, prior STD or CT, sex work, certain demographicsIf pregnant:<24 years old screen25 and older – only screen if “at increased risk”
21 LGV strains Severe Proctocolitis Blood, ulcers, pus Granulomas ChlamydiaProctitisLGV strainsSevereProctocolitisBlood, ulcers, pusGranulomasIncreased (>1/64)Non-LGVMildProctitisNormal, pusPMNsNormalSeverityExtentSigmoidoscopyBiopsyComp-fix AB
22 LGV (Serovars L1, L2, L3 of Chlamydia) Proctitis Biopsy showing crypt destruction by diffuse histiocytic and lymphocytic infiltrateSettings: developing context traditionally, but trendrecently has included West (MSM)DiagnosisCell culture OK if availableNAAT not cleared by FDA for rectal specimensCan be used if validated by local laboratoryID of LGV serovars requires culture serotyping or NAAT genotyping; neither widely availableSerologic tests: recommended, reference laboratories; titers notwell-defined for LGV proctocolitis and not highly predictive of infectionRatelle; Liu 2006
23 LGV (Serovars L1, L2, L3 of Chlamydia) Proctitis Consider presumptive treatmentDoxycycline 100 mg bid PO x 21 dRatelle; Liu 2006
24 Chronic lymphogranuloma venereum in female. Genital elephantiasis
25 Case II 33 yo woman presents with change in vaginal discharge. One new male sex partner for past three months. Previously was with one steady male partner x four years.
26 Regardless… ALWAYS do an examination Presumptive treatment is inappropriate
31 Purulent cervicitis When seen, tends to be MOST likely C. trachomatis N. gonorrhea
32 Gonorrhea Treatment, 2007Recommended regimens:Ceftriaxone 125 mg IM x 1Cefixime 400 mg PO x 1Ciprofloxicin 500 mg PO x 1Ofloxacin 400 mg PO x 1Levofloxacin 250 mg PO x 1Alternative regimens:Cefpodoxime 400 mg po x 1Cefuroxime 1 g po x 1Spectinomycin 2 g IM x 1: not availableSingle-dose injectable cephalosporin regimensSingle-dose oral quinolone regimensCo-treat for chlamydia unless ruled out with highly sensitive test (NAAT)MMWR April 13, 2007; 56 (14)
33 Case III37 yo woman presents with pain while having intercourse with her husband.She denies any vaginal discharge.He is asymptomatic.
37 Treatment Placement of Word catheter Culture/analysis fluid to ensure no co-infection or other findings (rarely, malignancy)Treatment is generally broad-spectrum (including for C. trachomatis and N. gonorrhea)
44 TrichomoniasisSingle-celled protozoan parasite, Trichomonas vaginalis.The vagina is the most common site of infection in women, and the urethra (urine canal) is the most common site of infection in men.
45 TrichomoniasisThe parasite is sexually transmitted through penis-to-vagina intercourse or vulva-to-vulva contact with an infected partner.Women can acquire the disease from infected men or women, but men usually contract it only from infected women.
46 TrichomoniasisSigns or symptoms of infection which include a frothy, yellow-green vaginal discharge with a strong odor.May cause discomfort during intercourse and urination, as well as irritation and itching of the female genital area. In rare cases, lower abdominal pain can occur. Symptoms usually appear in women within 5 to 28 days of exposure.
47 Trichomoniasis Treatment 2006 Recommended regimen:Metronidazole 2 g PO x 1Tinidazole 2 g po x 1Alternative regimen:Metronidazole 500 mg PO BID x 7dMetronidazole safe at all stages of pregnancy; tinidazole Category C (don’t use)Vaginal therapy is ineffectiveTreat sex partner(s): male and female
48 Case V28 y.o. woman comes to your clinic because she has noted increased, malodorous vaginal discharge for about a week.No history of known STD.In your history you note that she washes her vagina with a “special rinse” every monthShe has been monogamous with a male partner, who is asymptomatic, for 1 year.
49 Case VShe and her sex partner do not use condoms on most occasions but practice “withdrawal” method.
50 What do you advise?She probably has a yeast infection because she is at low STD riskShe probably has trichomoniasis, and you’ll call in a prescription for tinidazole/metronidazole.Come in for examination.Stop irrigating vagina
51 Rationale for office visit While most women with malodorous discharge have either BV or trichomoniasis, management of these two processes differBoth are treated with metronidazole, but need to know whether or not to treat partner(s)Therefore, specific diagnosis is usefulOverall, BV most commonUnfortunately, syndromic diagnosis of abnormal vaginal discharge is poorly predictive of the actual causeExamination required (vaginal pH at a minimum)
52 Bacterial Vaginosis: An Ecosystem Out of Balance Overgrowth of commensal anaerobic flora (classically defined as G. vaginalis, Prevotella, Mobiluncus, M. hominis) relative to H2O2-producing lactobacilli that predominate in the healthy vaginal ecosystemGram stain of normal vaginal fluid: many lactobacilli, normal epithelial cellsNugent Score: 0Gram stain of BV: no lactobacilli, many other bacteria, and clue cellsNugent Score: 10
54 Diagnosis of Bacterial Vaginosis Gram stain findings (Nugent scale): based on number of lactobacilli and other bacterial morphotypesClinical findings (Amsel criteria): 3 of the following must be present:homogeneous dischargepH >4.5clue cells (>20%)amine odor on addition of KOH (+whiff test)
55 BV Complications in Non-Pregnant Women PIDPost-abortal PIDPost-hysterectomy infection
56 BV and Adverse Outcomes in Pregnancy Data support that BV promotes:postabortal infectionspreterm labor and delivery*premature rupture of membranesintramniotic infectionhistological chorioamnionitispostpartum endometritisspontaneous abortion in first trimester (IVF)*infection implicated in up to 10% of cases
57 2006 CDC STD Treatment Recommendations Bacterial Vaginosis Nonpregnant WomenRecommended- Metronidazole 500 mg PO bid x 7 d- Metronidazole gel 0.75% intravag qHS x 5 d- Clindamycin cream 2% intravag qHS x 7 dAlternatives*- Clindamycin 300 mg PO bid x 7 dClindamycin ovules 100 g intravag qHS x 3 d* Metronidazole 2 g PO, single dose deleted
58 Normal Vaginal pH is Important! pH <4.7 favors growth of acidophilic organisms, inhibits growth of other organisms (residents and invaders)Maintained primarily by human Lactobacillus that produce hydrogen peroxideElevated vaginal pH associated with:loss of H2O2-producing lactobacillibacterial vaginosis, trichomoniasisenhanced transmission of HIVacquisition of gonorrhea
59 Case VI23 yo woman with HIV (last CD4 310) comes to see you with complaint of vulvar pain. She has no prior history of this.She has one male sex partner (also HIV positive). They have been together for about 3 months.They do not use condoms.
66 HSV: Clinical Features Many patients recognize subtle or non-ulcerative symptoms when educated (vulvar fissures; vulvitis; urethral irritation)Genital herpes due to HSV2 More severe primary infections, when they occurMore likely to recurPersistent subclinical shedding months-years post-infectionGenital-genital transmission usual route of acquisition
67 HSV: Clinical Features Genital herpes due to HSV1 Most don’t recur (1 at most); subclinical shedding does not persistOral-genital probably important route of transmission
71 HSV-2 Seroprevalence in the U.S. Seroprevalence strongly associated with increasing lifetime nos. of sex partners, female sex, black raceXu, JAMA 2006
72 Significance of Genital Herpes Physical and psychological concernsHSV-2 infection increases the risk of HIV-1 infection by 2-foldSource of transmission to uninfected partners89% expressed concern about transmitting to a partner in one study1. CDC Sexually Transmitted Diseases Guidelines2. Wald A, Link K. J Infect Dis. 2002;185:45-52.3. Catotti DN et al. Sex Transm Dis. 1993;20:77-80.4. Brown Z et al. JAMA. 2003;289:
73 Significance of Genital Herpes Transmission of herpes to newborn during pregnancy or deliveryOccurs in 1 per 3,200 live birthsMay lead to serious complications such as seizures, blindness, psychomotor retardation, spasticity, learning disabilities, and death1. CDC Sexually Transmitted Diseases Guidelines2. Wald A, Link K. J Infect Dis. 2002;185:45-52.3. Catotti DN et al. Sex Transm Dis. 1993;20:77-80.4. Brown Z et al. JAMA. 2003;289:
74 Which of the following statements is correct regarding diagnosis of genital herpes? Direct viral culture of a genital lesion can determine whether HSV-1 or HSV-2 is the etiology.Cytology (Tzanck versus Pap) is one of the most useful methods of HSV testing.The odds of getting a positive herpes test from a genital lesion increase the older the lesion gets.
75 Diagnostic Tests for HSV Culture: usual test of choiceWidely available, relatively inexpensiveDistinguishes HSV-1 and HSV-2Sensitivity declines as lesions agePolymerase chain reaction (PCR)Most sensitiveAntigen tests, e.g. direct FASensitivity similar to cultureOnly direct FA distinguishes HSV-1 from HSV-2
76 Diagnostic Tests for HSV Cytology (Pap, Tzanck preparation)Insensitive, nonspecific; no role in clinical managementSerologyDetects serum antibody
77 Uses of Herpes Serology Definite Indications:Diagnosis of genital ulcers or lesions, especially when lesions cannot be sampled or are unlikely to yield virusManagement of sex partners of persons w/ herpesImplications for counseling, antiviral therapy in infected partnerScreen persons at risk for HIV transmission (HIV+)Guerry CID 2005, Strick CID 2006
78 Uses of Herpes Serology Other Uses:Pregnant women and partnersPatient requestNot clear whether all sexually active persons should be screened (cost vs. benefit)BUT AVAILABILITY/COST are issuesGuerry CID 2005, Strick CID 2006
79 Genital Herpes: Prevention of Sexual Transmission, 2006 CDC STD Treatment Guidelines Antiviral treatment: valacyclovir 500 mg PO QDIndications may include:Discordant couples (the only evidence-based indication)Persons with multiple partnersMen who have sex with menHIV-infectedReassess discordant partner annually for seroconversionCounsel regarding condoms, disclosure, abstinence
80 2006 CDC STD Treatment Guidelines Genital Herpes: First Episode HIV- and HIV+ Acyclovir 400 mg TID x 7-10 dAcyclovir 200 mg 5x/d x 7-10 dFamciclovir 250 mg TID x 7-10 dValacyclovir 1.0 g BID x 7-10 dHHH /20/1998
81 Valacyclovir 1 gm bid x 5-10 d 2006 CDC STD Treatment Guidelines Genital Herpes: Episodic Treatment of RecurrencesHIV-infected:Acyclovir 400 mg TID x 5-10 dFamciclovir 500 mg bid x 5-10 dValacyclovir 1 gm bid x 5-10 dHHH /20/1998* 5x daily acyclovir regimen deleted
82 2006 CDC STD Treatment Guidelines Genital Herpes: Episodic Treatment of Recurrence HIV-negative:Acyclovir 400 mg TID x 5 dAcyclovir 800 mg BID x 5 dAcyclovir 800 mg TID x 2 d*Famciclovir 125 mg BID x 5 dFamciclovir 1 g BID x 1 dValacyclovir 500 mg BID x 3 dValacyclovir 1 g qD x 5 dHHH /20/1998* 5x daily acyclovir regimen deleted
84 * Studied in immunocompetent heterosexual adults Management of PatientsConsider daily suppressive therapy for patients who:Are bothered by their outbreaks, regardless of their relationship statusAre sexually active with an uninfected partner*Are newly diagnosed and concerned about transmitting genital herpes to their partner*Consider episodic therapy for patients who:Are not sexually active and not concerned about their outbreaksAre sexually active with a partner who has genital herpes* Studied in immunocompetent heterosexual adults
85 Subclinical Shedding: Key Points Frequency of shedding is not related to the frequency of symptomatic outbreaks (8% vs 7% of days by culture in people with 0-3 vs. 4-9 annual outbreaks, respectively)Up to 70% of transmission occurs during subclinical shedding periods (Mertz 1992)
86 Condoms Reduce HSV2 Transmission 528 monogamous couples discordant for HSV2 infection followed for 18 mos.Condom use for >25% of sex acts associated with 92% reduction in HSV2 acquisition for women1862 people in HSV2 vaccine study followed over 18 mos.Condom use for >65% of sex acts associated with 34% reduction in HSV2 acquisition in women and 41% in menWald 2001
87 A complete STD screen for a young, sexually active woman includes: All women:External genital and speculum examVaginal pH, KOH whiffCervical Pap if not done recentlyChlamydia testHSV serologyHIV serologyPregnancy testSelected patientsBimanual examVaginal fluid microscopyGonorrhea testSyphilis serology
88 A complete STD screen for a young, sexually active woman includes: Information on PREVENTION and CONTRACEPTION!
89 AcknowledgmentsJeanne MarrazzoHunter HandsfieldMatthew Golden
90 Listserv: firstname.lastname@example.org Next session: June 11, 2009Listserv:
91 New Tools for Cervical Cancer Prevention Next session: June 11th, 2009Jose JeronimoNew Tools for Cervical Cancer PreventionThank you for attending the session. Please type in again how many participants are at your site. We will answers to the questions that we were unable to get to today to the Distance Learning listserv. If you have additional questions, please them to the listserv. That listserv is:Please contact if you would like to get on this listserv or if you have any more topic suggestions for next year's series.
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