Advanced Video Vaginal Microscopy:
Everything You’re Itching to Know!
R. Mimi Secor, DNP, FNP, BC, NCMP, FAANP
Nurse Practitioner
Onset, Massachusetts
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Mimi Secor, DNP, FNP-BC, NCMP, FAANP
• FNP for 39 years specializing in Women’s Health
• NP at Just Us Women, N Attleboro, Massachusetts
• DNP 2015, Rocky Mountain University, Provo, Utah
• Lifetime Achievement Award, 2013 from Mass NP Coalition
• Advanced Health Assessment of Women: skills and procedures,
coauthor, Springer Publishing, 2014 (AJN Book of the Year)
• Fast Facts about the GYN Exam, coauthor, 2012
• Visiting Scholar - Boston College
• Fellow in AANP
• Owned practice for 12 years in Cambridge, Mass (1984-1995)
• Worked in Bethel, Alaska for 7 years (1992-1999)
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R. Mimi Secor, MS, FNP, FAANP
Disclosure
Speaker for:
GenPath Labs
Hologic
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Objectives
1. List indications for and describe the optimal procedure for
collecting, preparing & reading a wet mount. (Slides 6-44)
2. Discuss New CDC STI Vaginitis Diagnostic Guidelines.
(Addendum slides)
3. Explain new Treatment Guidelines for management of
vulvovaginitis.
(Addendum slides)
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TTT
• Test - often and early
• Treat - effectively
• Test - of cure, 1 month
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NEW National STI Survey
Often Asymptomatic, Underdiagnosed !
19 million new STIs yearly in US
• 50% in young 15-24 years old
• 25% of ALL teens have 1 > STI
• 50% of Black teens have 1 > 1 STI
www.cdc.gov/std/stats
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2010 STD Statistics- New National Survey
19 Million NEW STIs yearly = Syndemic
• STIs increasing: synergy risk, increasing in older adults
• Chlamydia: > females
• Gonorrhea: > Men having Sex w Men (MSM)
• Trichomoniasis: > teens 22/100 rate, high in older women too
• Herpes: Increases risk of HIV, highest prevalence
• HPV: highest incidence
• Syphilis: 15% incr. since 2003, 69% increase in women
• HIV: > in MSM (Screen all adults), 50,000 new cases yearly
• Hepatitis C: increasing esp. in older adults, 45-65 years old
(Screen all adults once)
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Krashin et al. Sex Transm Dis 2010 Mar 26 www.cdc.gov/std/stats
10Apr 16
MMWR Morb Mortal Wkly Rep 2010
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Clinical Presentations of STIs
1. Often asymptomatic
2. Infections in multiple sites are common
Cervix, urethra, vagina, anal, throat
3. Mixed infections common
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Vaginitis: Office Diagnostics
• Vaginal pH, good screening test (billing code 83986)
• Sensitive, not specific
• NEW: VS-Sense Swab Test, rapid acidity test, [email protected]
• KOH*Amine Whiff test (billing code 82120)
• Mix directly with vaginal sample, not saline
• Vaginal Microscopy (billing code 87210)
• Only 60% to 80% accurate
• Other tests:
• Pap, cultures unreliable per CDC 2010
• Affirm Test: yeast, trich, BV (must clinically correlate!)
• NEW PCR: One Swab, Multiple Detections (GenPath, MDL, Others)
• GenPath – Pap w/s HPV, STI, Vaginitis sx, asx
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*KOH=potassium hydroxide
PCR Testing: Features and Benefits
One Collection, Multiple Detections
— Simplicity of collection with 1 universal liquid vial
Convenience of Testing
— Pap, HPV, STIs, Vaginitis results from 1 lab (GenPath)
• STIs vaginitis (MDL)
— One easy-to-read report
Fast Turn-around Time:
— PCR method is significantly faster than culture
High Specificity, High Sensitivity
Clinically Relevant Profiles
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Vaginal Microscopy Indications
• Diagnosis of Vulvovaginitis
• Follow-up “Test of cure”
• With Pap smears
• With Gyn exams
• Maturation Index
• To assess hormonal influence
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TTT
• Test
• Early and often
• Treat
• Effectively
• Consider advantages of clindamycin for BV
• Vaginal therapies
• Test
• Of Cure
• 1 month post-treatment to verify cure
• Monitor until maintains cure
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Normal Flora
Lactobacilli
pH 4.0
Estrogen normal
< risk STIs
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Gardnerella
Mobiluncus
Atopobium
Mycoplasmas
anaerobes
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How Accurate is Vaginal Microscopy?
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Only 60-80% sensitive
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Key is
Quality of sample
Skill of viewer
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Wet Mount Preparation
Slide Method
2 frosted tipped slides
• 2 drops saline on front slide
• 2 drops KOH on back slide
or
1 slide
• Saline on left
• KOH on right side (keep separate)
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Wet Mount Preparation
Test Tubes
2 test tubes
• 1/2 cc saline in 1 tube
• 1/2 cc KOH in other tube
• Tube holder
• 2 dacron swabs used together
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Wet Mount Preparation:
Assemble Supplies
• Prepare pH paper, 1 inch strip
• Saline
• KOH 10 or 20%
• Tubes and/or slides
• Coverslips, 1 or 2 inch
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Vaginal pH Testing
• Sensitive
• But NOT Specific
• Proxy for normal estrogen
• Factors influencing pH
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Semen
Blood
Cervical mucus
Medications, etc.
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Wet Mount
•
E
r
y
t
h
e
m
a
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L
e
u
k
o
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h
e
a
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M
a
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i
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B
V
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O
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T
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h
Sample Side Wall
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Collecting the Sample
• Plastic spatula, or 2 swabs together
• Collect from lateral vaginal wall
• Or from speculum (blade edges)
• Check vaginal pH
• Before preparing slides
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• by Common Sense Ltd
• Rapid Results: 10 second test for BV and Trichomonas
• 90% accuracy
• CLIA waived
• 25 tests/box: $2.50 per test
• CPT code 83986: $5.13
negative
positive
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Vaginal pH Testing, CPT code 83986
• Nitrazine or phenaphthazine
pH range 4.0-7.5
Normal = 4.0-4.5
 BV
= > 4.5
Trich = > 4.5
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Vaginal pH Over the Lifespan
Premenarchal girls
pH 7
Reproductive aged women with estrogen:
Lactobacillus predominant
pH 4.0-4.5
Lactobacillus reduced or coitus in past 24 hours pH 5-4.7
BV
pH 4.7-5.5
Menses
pH 6.0
Reproductive aged women breastfeeding
pH 6.5-7.0
Post-menopausal and no HRT
pH 6.5-7.0
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Double Slide Holder
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2 frosted tipped slides
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Saline on the front slide
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KOH on the back slide
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Preparing the Sample
• Gently mix in saline, x1-2
Dilute (slightly opaque)
• Mix in KOH until white, x3-4
Concentrated (thick, white)
• Check Whiff immediately
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Sample Types
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Saline - well prepared
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KOH - well prepared
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Discard poor sample
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Repeat Smears
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Save the speculum
Sample from upper edges
If still moist
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pH, whiff may be repeated too
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Viewing the Smear
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View 12 fields minimum
Saline and KOH
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2 to 3 minutes until very proficient
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Microscopy Flow Sheet
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Date
HPI
LMP
Vulvo vaginal cervix findings
Vaginal mucus
pH
Whiff (KOH amine test)
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Flow Sheet – Saline: Low Power
 Quality of smear
●General impression
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KOH
Low Power
High Power
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Flow Sheet-Saline: High Power
• LB (lactobacilli)
estimate 0-3+
• Variable length rods are good bacteria
• Bacteria
0-3+
• Tiny, bad bacteria
• WBCs
estimate 0-3+
1+ ratio of WBCs to epi cells up to 3:1
2+ ratio of 5:1
3+ ratio of 10:1 or more
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Should I have another kid or two?
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White Blood Cells on Wet Mount
3 WBCs:1 epithelial cell….is normal Associated with
douching, intercourse, eversion, metaplasia, low estrogen,
etc.
5-10:1 ratio…....suggests inflammation
> 10:1 ratio.……likely inflammation
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Slide courtesy of David Soper, MD, Medical University of South Carolina
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Atrophic Vaginitis
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Vulva- ‘Sticky sign’
Erythema, mottling
Pallor
Flattening of rugae
• Leukorrhea variable
• Esp. amount
• May mimic BV, Trich, HSV
• Or other etiologies
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Maturation Index - Estrogen Influence
• Superficial, estrogenized cells - 95%
Large, cuboid, high ratio of cytoplasm to nucleus
Ratio 20:1
• Parabasal, intermediate cells
Medium round, lower ratio cytoplasm to nucleus
Ratio 10:1
• Basal cells, immature, unestrogenized
Small round, low ratio cytoplasm to nucleus
Ratio 5:1
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Flow Sheet - KOH
• Wet mount (20% KOH)
• Low (gross impression)
• High (detail including morphology)
• Assessment
• Plan
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Advantages of KOH
 Epithelial cells fade
 Yeast forms (hyphae & pseudo hyphae stand out)
 Buds (spores, conidia) still subtle
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KOH: Identifying Yeast Forms
• Dissolves epithelial cells (ghost cells)
• Morphology easier to identify
“Glass beads, circus balloons”
• Phase contrast adds dimension
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KOH: Ghost Cells
High Power
Low Power
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Identifying Yeast Forms
Secor RMC. Clinical Excellence for Nurse Practitioners. 1997;1:29-34.
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TTT
• Test - often and early
• Treat - effectively
• Test - of cure, 1 -2 months
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Clinical Presentation of BV
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Bacterial Continuum
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Normal, intermediate, abnormal = BV
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Differential Diagnosis
Purulent Vaginitis
• Trichomoniasis
• Gonorrhea
• Chlamydia
• HSV
• Cervicitis
• Retained tampon
• Atrophic vaginitis
• Crohn’s, Pinworms
• Idiopathic ulcers
HIV +
• Pemphigus entities
• Cancers
• Lichen planus
• DIV subgroups
• Group A Strept
• Rectovaginal fistula
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Slide courtesy of David Soper, MD, Medical University of South Carolina
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Differential Diagnosis Pearl
• Compare vaginal to cervical mucus
for greater # WBCs
• Indicates source of WBCs
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Atrophic Vaginitis
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Vulva- ‘Sticky sign’
Erythema, mottling
Pallor
Flattening of rugae
• Leukorrhea variable
• Esp. amount
• May mimic BV, Trich, HSV
• Or other etiologies
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Maturation Index - Estrogen Influence
• Superficial, estrogenized cells - 95%
Large, cuboid, high ratio of cytoplasm to nucleus
Ratio 20:1
• Parabasal, intermediate cells
Medium round, lower ratio cytoplasm to nucleus
Ratio 10:1
• Basal cells, immature, unestrogenized
Small round, low ratio cytoplasm to nucleus
Ratio 5:1
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Resources & Addendum Slides
• Studies
• Additional supportive content
• Helpful reference material
•
http://depts.washington.edu/nnptc/online_train
ing/wet_preps_video.htm
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Summary:
• Test
• often and early
• Treat
• effectively
• Test - of cure
• follow-up 1 month
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Thank you and Good Luck!
Mimi Secor, DNP, FNP,-BC, NCMP FAANP
MimiSecor.com
Twitter: @mimisecor, Facebook, YouTube,
LinkedIn,
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Artifact
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Note dark, rough edges
Non tubular quality
Like a "blade of grass"
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Types of Artifact
• Fibers: dark- rough edges, flat, non-segmented
• Hairs: dark edges, ragged ends, non-segmented
• Glove powder: gem-like, dark, +/- EC mimic
• Lipids: variable sized bubbles, 1 ring
• RBCs: all similar size, double ring
• Air bubbles: variable width, dark ring as focus
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Addendum Slides
Acute and Chronic Vulvovaginitis:
Update 2016
What Really Works?
R. Mimi Secor, DNP, FNP-BC, NCMP, FAANP
Onset, Massachusetts
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Disclosure for Mimi Secor, DNP, FNP-BC,
FAANP
Speaker:
• Hologic
• Shionogi
3 holes in one !!!
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Vaginitis Objectives
• Discuss NEW 2015 CDC recommended vaginitis
treatments focusing on minimizing chronic
recurrent infections
15 min
• Explain benefits and risks of various treatment
options re: prevention of chronic vaginitis
30 min
• Describe treatment challenges involving recurrent
infections and prevention of infections
15 min
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New CDC STI Treatment Guidelines:
June, 2015
• MMWR. (June 5, 2015). Sexually Transmitted Diseases Treatment
Guidelines, Volume 64 (3).
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Primary Genital Herpes in Women
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Handsfield HH. Color Atlas and Synopsis of Sexually Transmitted Diseases. 1992.
Genital Herpes Simplex Virus: Key Points
• Most transmission is asymptomatic = 70%
• Atypical symptoms are most common
• HSV increases HIV risk!
• HSV 1 = ~ 50% of Primary genital infections
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Genital Herpes Simplex Virus: Key Points
• Culture lesions with PCR (higher sensitivity)
• Serology IgG Type 1, 2, (IgM is NOT type specific)
• Offer episodal and/or suppressive therapy
• Highly stigmatized so Counseling is KEY
• Education
• Condoms help
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Vulvitis: Need to Clarify
Vaginal, Cutaneous Yeast, Contact, Allergic, Derm?
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Vulvar Symptoms
• Irritants, over cleansing
• Allergens
• Condom allergy is rare
• Infections
• Genital Herpes Type 2
• Skin conditions
• Lichen Simplex Chronicus/ LSC
• Lichen Sclerosis / LS
• Lichen Planus / LP
• Other
• Eczema, atrophy, etc.
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Vulvar Irritants, Allergens
• Soaps
• Pads
• Shaving
• Oral sex
• Spermicides
• Lubricants
• Underwear
• Dyes, fragrances
• Soap in undies
• Bubble baths
• Shampoo
• Hot tubs
• OTCs, Scripts
• Preservatives in these
• Over cleansing
• You name it...
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Personal or Family History
of Skin Sensitivities?
• Fair skin
• Light hair
• Sensitive skin
• Skin conditions
• Family history
• Sensitive vulva
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Vulvar Care Guidelines, “Less is More”
• NO SOAP: Wash with warm water only
• Soak and Seal
• Vaseline, mineral oil, or Crisco: to prevent & treat itching
• Avoid shaving, thong underwear and douching!
• Wear all cotton, white underwear (wide design)
• Wash underwear in very hot water
• Use ½ laundry soap, double rinse, do NOT hand wash
• Sleep without underwear, wear loose clothing
• Avoid sex if symptoms, pain, infection: for 1 week+
• Non-irritating lubricants: Standard KY, Femglide, Poise, Sliquid,
AVOID Astroglide, scented or warming products
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Normal Flora of Healthy Vagina
Gardnerella
Mycoplasmas
anaerobes
Mobiluncus
Others
Lactobacilli
pH 4.0
Estrogen
STI protection
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TTT
•Test - often and early
•Treat - effectively
•Test - of cure, follow-up
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NEW - 2015
VVC: Self Diagnosis per CDC
• “Women who have previously been diagnosed with VVC by a
clinician are NOT necessarily more likely to be able to diagnose
themselves;
therefore,
• If symptoms persist after using an OTC Rx
or
• If symptoms recur within 2 months after treatment for VVC
• Pt should be clinically evaluated and tested.”
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Vaginitis: Office Diagnostics
• Vaginal pH, good screening test (billing code 83986)
• Sensitive, not specific
• NEW: VS-Sense Swab Test, rapid acidity test,
[email protected]
• KOH*Amine Whiff test (billing code 82120)
• Mix directly with vaginal sample, not saline
• Vaginal Microscopy (billing code 87210)
• Only 60% to 80% accurate
• Other tests:
• Pap, cultures unreliable per CDC 2014
• Affirm Test: yeast, trich, BV (must clinically correlate!)
• NEW PCR: One Collection, Multiple Detections
- MDL, GenPath, Quest, Labcorp, etc.
*KOH=potassium
hydroxide
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Negative
Positive
VVC: What’s NEW?
Vulvovaginal Candidiasis
• Confirm if recurrent
• C. albicans, versus Non- C. albicans
• PCR (3-5 days)
• Non-PCR culturing (up to 2 weeks)
• Butaconazole (Gynazole) single dose
• Effective against C. albicans and non C-albicans
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Clinical Presentation of VVC:
Vulvovaginal Candidiasis
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Identifying Yeast Forms
Secor RMC. Clinical Excellence for Nurse Practitioners. 1997;1:29-34.
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Diagnostic Tests for Chronic VVC
• Wet Mount negative:
• CBC, TSH, Glucose, HIV, etc.
• Fungal culture and speciate!
• Non PCR: 1 week+ for results
• PCR: 3-5 days (NEW)
• Unilateral symptoms:
• Rule out genital herpes
• HSV Serology IGG for Type 2
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Treatment of Uncomplicated VVC:
Vaginal Options - Equal Efficacy !!!
Over-the-counter
• Clotrimazole (Gyne Lotrimin), 3, 7-14 day cream
• Miconazole (Monistat), 1, 3, 7 day creams, ovules
• Tioconazole (Vagistat 1), single dose ointment
Prescription
• Butaconazole (Gynazole), 5 gm single dose cream
- Bioadhesive, time released, albicans/non-albicans
• Terconazole (Terazol), 3 day ovules, 7 day cream
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Butaconazole (Gynazole) single dose:
is bioadhesive, time released…..
• Covers C. albicans
• And Non-C. albicans
• Consider if unable to culture
• Or chronic, recurrent sx
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Treatment of Uncomplicated VVC:
Oral Options- Fluconazole (Diflucan)
• Fluconazole 150 mg orally single dose (Category C)
• Limited effectiveness against Non-albicans species
• Delayed symptom relief (~24 hours)
• Warning May 2016:
Risk of spontaneous abortion, AVOID in pregnancy
• Defer breast feeding for 12-24 hours (Cat C)
• Drug-drug interactions
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Diagnostic Tests for Chronic VVC:
Vulvovaginal Candidiasis
• Wet mount negative:
• Fungal culture and speciate!
• Non PCR: 1 week+ for results
• PCR: 3-5 days (NEW)
• Unilateral symptoms:
• Rule out genital herpes
• HSV Serology IGG for Type1, 2
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Chronic VVC:
Rule out
• Diabetes
• Immunecomprimised
• Other conditions
• Stress, poor sleep
• Low Vitamin D?
• Mycoplasma species
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VVC: Recurrent
NEW 2015 CDC Guidelines!
• 50% of women with non-albicans have minimal sx, no symptoms or
treatment is challenging:
1. Rule out other causes of vaginal symptoms
2. Longer therapy (7-24 days) with non-fluconazole
3. Boric acid 600 mg vaginally at hs x 14 days
70% cure rates; Avoid in pregnancy, and ORAL
4. If HIV+, w C. albicans, fluconazole 200 mg po weekly
5. Referral to specialist !!!
NOTE: Optimal treatment remains unknown
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C. albicans Chronic:
Fungal Culture and Speciate
• ORAL:
Fluconazole 150 mg oral Day 1, 3, 6, total 3 doses
Culture negative, then 100/150/200 mg weekly x 6 mo
OR
• VAGINAL: 1-2x week x 6 months
Butaconazole (Gynazole) x 2 monthly? (no data)
Clotrimazole, tioconazole ointment (no data)
• “TEST-OF-CURE” 2 weeks post-treatment:
Then - monthly culture
CDC 2010, Sobel J. NEJM 2004:351:876-83
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Non-C. albicans Chronic:
Fungal Culture & Speciate
Longer duration Rx: 7-14 days
• Butaconazole (Gynazole) pv Stat x 1 weekly, x 2
• Boric acid suppositories pv qd x 14 days (600 mg), x2 weekly
• Max 6 months, safety/toxicity issues, AVOID oral & in Pregnancy
• Nystatin suppositories pv qd x 14 days (100,000 u), x2 weekly
• Unclear efficacy, but very safe
F/u: 1-2 weeks post-rx repeat culture: if negative
• Maintenance: 2 x weekly x 6 months+, monthly culture, PRN
• Butaconazole: x1 or x 2 monthly (lacking data)
REFER to specialist if symptoms recur
www.CDC.gov/stds 2010
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NEW: High Correlation with Yeast and
Mycoplasma Genitalium
• n - 516
• High correlation with yeast and M. genitalium
• P < 0.05
• Lesser association between C. trachomatis, and U.
urealyticum, no assoc. w N. gonorrhea
Kye Hyun Kim, Mi-Kyung Lee, Vaginal Candida and Microorganisms Related to
Sexual Transmitted Diseases in Women with Symptoms of Vaginitis, Korean J Clin
Microbiol Vol. 15, No. 2, June, 2012, http://dx.doi.org/10.5145/KJCM.2012.15.2.49
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Mycoplasma Genitalium
•
“Sexual
transmitted”
Tosh,A, Van Der Pol, Barbara et. al., Journal of Adolescent Health, 2007.
C Anagrius, B Lore´, J S Jensen, Sex. Trans. Infection 2005
• More prevalent than gonorrhea
• Less prevalent than Chlamydia
Manhart, Lisa, Holmes, King, et. al. American Journal of Public Health, June 2007.
• Urethritis: In men & women
• Cervicitis in women:
Role poorly understood
Still debated & more research needed
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Mycoplasma Genitalium:
• Spontaneous preterm delivery: Independent risk factor
Edwards, et.al. Journal of Maternal-Fetal and Neonatal Medicine, June 2006.
• PID: Frequently detected from cervix, endometrium
• Endometritis and PID treatment failure
persistent endometritis and continued pelvic pain.
• Cefoxitin, Doxycycline - may NOT be effective:
•
C.L. Haggerty, et. al. Sexually Transmitted Infections, 2008.
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Mycoplasma Genitalium:
Treatment
• NO cell wall, so B-lactam antibiotics NOT effective
• Only use: Tetracyclines, macrolides, fluoroquinolones
• Azithromycin 1 gm orally stat, partner too
• Azithromycin x 5 days: 500 mg po day 1, 250 mg day 25
• Moxifloxacin 400 mg orally x 14 days (PER CDC 2015)
• Consider testing, treating partner: per Dr. Gilbert, NYC
If patient symptomatic!
Role of Mycoplasma and Ureaplasma Species in Female Lower Genital Tract Infections
Patel MA, Nyirjesy P. Curr Infect Dis Rep (2010) 12:417–422
DOI 10.1007/s11908-010-0136-x
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BV: What’s NEW?
• Polymicrobial 100-1000x fold increase (abscess)
• Gardnerella, Atopobium, Mobiluncus, etc.
• Metronidazole resistance increasing up to 70%
• Avoid IUC esp. Copper (Paragard)
• Vitamin D !!!
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BV Linked to
Increased Risk of ObGyn Complications
• STIs
• Herpes HSV-2
• HPV
• GC and Chlamydia
• HIV (to male partners)
• PID and Infertility
• Cervicitis
• Cystitis
• Post-Gyn surgery and Postpartum infections
• Increases risk of Preterm delivery
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BV: Risk Factors
• Multiple Male or Female Partners
• New Sex Partner
• Douching
• Lack of Condom Use
• Lack of Vaginal Lactobacilli
• HIV+
• Rare in Virginal Women
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BV
Gardnerella vaginalis
Genital mycoplasmas
Anaerobes
Mobiluncus spp
35 bacterial species
Lactobacilli
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Diagnose BV per CDC
3 of 4 Amsel’s Criteria
• Coaty, white discharge: must correlate with other criteria
• Elevated pH > 4.7: sensitive but not specific
• KOH amine “whiff” test: predictive
• Clue cells: predictive
• Pap: DO NOT USE (low sensitivity/specificity)
• Gardnerella Vaginalis culture: is NOT specific
• Affirm: correlate with other criteria, pH, amine
• PCR: Gardnerella, Atopobium, Mobiluncus, etc.
• Lacking data on significance of this testing
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BV - CDC 2015 Guidelines:
Non-pregnancy and Pregnancy (NEW)
Recommended: Similar efficacy
• Metronidazole 500 mg orally bid x 7 days
• Metronidazole gel, 1 applic vaginally @hs x 5 days
• Clindamycin cream 1 applic vaginally @hs x 7 days
Alternatives: Similar efficacy
• Clindamycin 300 mg orally bid x 7 days
• Clindamycin Vaginal Ovules, 1 vaginally @ hs x 3 days
• Clindamycin 100 mg vaginal single dose
AVOID in Pregnancy:
• Tinidazole 2 g orally daily x 3 days (Cat C)
• Tinidazole 1 g orally daily x 5 days (Cat C)
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BV in Pregnancy:
NEW 2015 CDC Guidelines
Low and High risk for Preterm Delivery:
• Evidence insufficient to assess impact of screening for BV
• Evidence inconsistent if Rx of asymptomatic pt w BV reduces
adverse pregnancy outcomes
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BV: NEW 2015 per CDC
Must rule out other STIs
NEW:
• “ALL women with BV should be tested for HIV and other STDs.”
• Recurrent BV: Rule out HIV
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Chronic BV: Common & Complex
• 30% recur in 1-3 months, 80% at 9 Months
• Follow-up 1 month for Test of Cure: Amsel’s
• Condoms
• Avoid IUC: esp. Copper (Paragard)
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Recurrent BV: NEW
2015 CDC STI Guidelines- Rule out HIV !
• Same agent or
• Different agent
• Metronidazole 0.75% gel pv twice weekly x 4-6 months (may recur
after suppression discontinued)
• Metronidazole or Tinidazole 500 mg BID PO x 7 days
then
Boric acid 600 mg PV x 21 days then MTZ pv twice
weekly x 4-6
months
• Metronidazole 2 gm PO w fluconazole 150 mg Monthly!
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Chronic Bacterial Vaginosis: CDC & Not CDC
• Longer therapy: double initial therapy duration (CDC)
Metronidazole gel, Clindamycin, Tinidazole, Boric acid
• Test of Cure, 1 month
• 4 -6 months “intermittent” vaginal therapy; twice weekly (CDC)
Sobel et al, AJOG 2006;194:1283-1289. Metronidazole vaginal x 10 days, then x 4 months
• Condoms, No douching, avoid Copper IUC (Paragard)
Schwebke & Desmond. Clinical Infect Dis. 2007 Jan 15;44(2):220-221
• Reduce stress, no thongs, ? Comb Hormonal Contraceptives
• NEW: Low Vitamin D & BV: Bodnar, L. J Nutr. 2009;139:1157-1161
Vit D and DIV/LP, Vit D >50 ng/ml, Cutis 2010 July; 89
• NOT effective: LB supplements, yogurt, pH acidifying agents, H2O2
douches, treating male partner (Per CDC)
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Trichomoniasis: What’s NEW?
• 7 4 Million new cases a year in US
• Increased in Teens, & Women over 40 yrs old
• ORAL metronidazole or tinidazole 2 gms PO Stat,
• Partner Rx: PO tinidazole, Flagyl, www.cdc.gov/ept
• Men: Metronidazole x 7 days more effective than Single
Dose
• Follow-up: ALL Women (high recurrence rate)
151
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CDC Trichomoniasis Treatment NEW
High in Teens and Older Women Over 40!
• Common, often ignored, latent, no screening guidelines
• Not nationally reportable
• Risks:
HIV positive: Assoc. w/ incr. risk of Preterm Labor, PID
• Increased in women:
-
18-39 yrs
= 8-9%
> 40 yrs
= 11% !!!
Black women = 13%
Incarcerated = ~9% men, ~32% women
Most unscreened and untreated!
CDC 2014 Draft
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Trichomoniasis: Risk Factors
• HIV positive + (up to 53% infected with Trich)
• Patients in high prevalence settings:
- STI clinics
- Correctional facilities
• Patients at high risk:
- New or multiple sexual partners
- History of STIs
- Black women
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Diagnosing Trichomoniasis in Women
70-80% Asymptomatic
• Variable symptoms, discharge, itching, lesions
Strawberry cervix
• Vaginal pH: > 4.7
• Amine, Whiff, KOH: Negative
• Wet Mount: 60-70% accurate, read immediately
• Avoid hypersonic saline, or drying!
• Pap: NOT reliable
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Diagnosing Trichomoniasis in Women
Lab Testing: Rule out other STIs
• Culture: Gold Standard before molecular detection
75-95% sensitivity, up to 100% specificity (S/S)
• Aptima: 95-100% sensitivity & specificity = HIGH
• OSOM in-Office: S/S 95-100%
= HIGH
• Affirm VP III: S/S 63%, 99.9%
= LOW
• PCR: MDL, GenPath, Quest, Lab Corp
• Vaginal & Urine testing: ~100% concordance
• Pap: NOT reliable
• Rectal testing: not recommended (Research lacking)
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Trichomoniasis Treatment: NEW
2015 CDC STI Guidelines
• First Line: Equal efficacy
• Metronidazole 2 gms orally, (Category B), Avoid ETOH x24h
Safe anytime in pregnancy, avoid if breast feeding
OR
• Tinidazole (Tindamax) 2 gm orally (Cat C) Avoid ETOH x72h
Fewer side effects, better tissue penetration, $
• Alternative:
• Metronidazole, 500 mg orally BID for 7 days (HIV+) NEW
• Partner Treatment: Concurrent to patient treatment
• Expedited partner therapy (State specific)
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Trichomoniasis: NEW
Persistent or Recurrent?
• Metronidazole resistance 4-10%
• Tinidazole resistance 1%
• AVOID single dose for persistent infection (and HIV+)
• Metronidazole 500 mg oral BID x 7 days
• Tinidazole or metronidazole 2 gms oral daily x 7 days
• Consult CDC: tel 404-718-4141; website CDC.gov/sti
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Trichomoniasis: Patient Education
• Avoid intercourse or use condoms
• Until treatment is completed
• And/or symptoms are resolved
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Trichomoniasis: NEW 2015 CDC
Follow-up All Women !!!
• Due to high rate of reinfection among women:
17% within 3 months in one study!
• Re-testing is recommended within 3 months post Rx
Esp. for HIV+ women
• NAAT may be repeated as early as 2 weeks post Rx
• Data insufficient to support retesting MEN
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Vaginitis Summary
• Discuss NEW 2015 CDC recommended vaginitis
treatments
15 min
• Explain advantages and disadvantages of various
treatment options focusing on prevention of
chronic infections 30 min
• Describe treatment challenges and conundrums
involving recurrent infections
30 min
160
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Summary and Thank you
Mimi Secor, DNP, FNP-BC, NCMP, FAANP
www. MimiSecor.com, or Facebook
Check out my “Secor Initiative”
and
“Coach Kat and Dr Mimi” FB page
Text “Mimi” to 90407
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Bibliography
New Cervical Cancer Screening Guidelines
• www.asccp.org
2015 CDC STI Treatment Guidelines, Vol 64 (3), June 5, 2015.
http://www.cdc.gov/mmwr/pdf/rr/rr6403.pdf
Vaginal Microscopy Video
• http://depts.washington.edu/nnptc/online_training/index.html#clinicalslides
2012 US Medical Eligibility Criteria for Contraceptive Use (MEC per CDC)
• Http://www.cdc.gov/reproductivehealth/unintendedpregnancy/USMEC.htm
Source: MMWR 2012;61(24);449–452.
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Bib and Resources
• Fantasia, Secor. 2012. The GYN Exam for NPs. Springer pub.
• Carcio & Secor. 2014. Advanced Health Assessment of Women (3nd
ed). Springer publishing, NY.
• “Contraception” Journal with ARHP membership, ARHP.org
• Journal Watch Women’s Health
• www.jwatch.org
• Hatcher et al. 2010. Contraceptive Technology Update (20nd edition),
Ardent Press
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Bibliography
• http://depts.washington.edu/nnptc/online_training/index.html#clinical
slides
• www.cdc.gov/stds/treatment
• Centers for Disease Control and Prevention (CDC). (2009). Sexually
transmitted disease surveillance, 2007. Atlanta: U.S. Department of
Health and Human Services; Jan 2009.
(http://www.cdc.gov/std/stats07/toc.htm)
• Centers for Disease Control and Prevention (CDC). (2009). Trends in
reportable sexually transmitted diseases in the United States, 2007:
National surveillance data for chlamydia, gonorrhea, and syphilis.
Atlanta: U.S. Department of Health and Human Services; Jan 2009.
(http://www.cdc.gov/std/stats07/trends.htm)
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Bibliography and Resources
• cdc.gov/std/treatment (new 2015 guidelines)
• cdc.gov/std/hpv (Gardasil pt education)
• Herpesdiagnostics.com (Herpes-Select serology)
• Asccp.org, ACS.org, Digene.com (Pap guidelines)
• Asha.org (great patient education materials)
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Resources
•
•
•
•
•
•
STDcheck.org
ASHASTD.org
Herpeshomepage.com (inexpensive acyclovir)
Healthcheckusa.com (by mail serology testing)
Westoverheights.com (Terry Warren, NP website)
Webmd.com (Terry Warren, NP answers all HSV questions)
• The Good News About the Bad News, Terry Warren, 2009
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