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If you’re seeing more patients stuck in the revolving door of chronic vaginitis, stop the spinning by taking a hard look at your approach to the problem.
"That’s the red alert — when patients start in that revolving door to clinicians, the alarm should go off," asserts Mimi Clarke Secor, RNC, MS, MEd, FNP, family nurse practitioner at Bethel (AK) Family Clinic. "Treat the patient as a new patient, and take a full history head to toe, with review of all systems. That’s one of the biggest errors clinicians make. They don’t look for systemic clues, they don’t give the patient the amount of concentrated attention that they deserve, and they don’t question the diagnosis."
Secor, who has presented on the subject at several national conferences, says that if family planners want to become more expert in managing vaginitis, sharpening diagnostic skills and performing slow, deliberate physical exams will produce the desired results.
By implementing pH paper, whiff (potassium hydroxide), and wet mount testing in your exam, you can perform a three-step, three-minute test that will sharpen your diagnosis and help you prescribe the proper treatment. (See the resource list following this article to order the Association of Professors of Gynecology and Obstetrics’ free teaching module on the three-step, three-minute testing procedure.) Use a test of cure to see if your treatment was successful, and work in partnership with your patient to help her return to normal vaginal flora, the first defense against recurrent, or even primary, vaginal infections.
It is important that vaginal infections be detected early, with a normal pH balance re-established to fight off further infections, says Secor. (See handout on signs of vaginal infection, enclosed in this issue.)
"It’s been found that if women have a normal acid balance in their vagina, characterized by a normal amount of lactobacilli, they’re able to fight off infection better," she notes. "And that’s critical in this age of exposure of HIV."
Sharon L. Hillier, PhD, associate professor in the department of obstetrics, gynecology, and reproductive sciences at the University of Pittsburgh and director of reproductive infectious disease research at Magee-Womens Hospital in Pittsburgh, has conducted several studies exploring the relationship of lactobacilli in the vagina and infection resistance.
"One of the things that we’ve found in our studies is that women who have Lactobacillus in the vagina and have an acid pH in the vagina are less likely to acquire bacterial vaginosis," says Hillier.1 "We’ve also found that, in other unpublished studies, women who have prominent Lactobacillus vaginal flora that’s acid are less likely to have gonorrhea. Therefore, the idea is that a woman’s vagina in its healthy state [having an acidic pH] actually might play a role in protecting women against infection."
Many clinicians treat women with recurrent vaginal infections by giving them the same treatment again, she notes. "What we find is that many of these women, by the time they come in, have an extremely disrupted vaginal ecosystem," Hillier says. "So I agree that women need to have first of all, a careful, well-thought-out examination with pH paper, with a good microscopic exam, to determine the type of vaginal infection that exists, if any."
Clinicians need to make a specific diagnosis when dealing with vaginitis, then really focus on its underlying condition, be it bacterial vaginosis, trichomonas vaginitis, candidal vaginitis, or other infections, says Hillier.
"For example, if women really do have recurrent or resistant trichomonas, focus on applying remedies at higher doses or in different forms: that is, vaginally, plus orally, in order to try and eradicate them," she explains.
For women with frequent yeast infections, supply them with management strategies they can use themselves, to keep the recurrences less frequent, Hillier suggests. Have them reduce their dietary sugar intake, and offer them some relaxation exercises to lower their stress levels, says Secor.
"For women with recurrent bacterial vaginosis, we actually have, I think, fewer options," says Hillier. "At least we can explain to them that the cause is not that they’re doing something wrong in many cases, but they don’t have the right kind of vaginal flora."
It’s helpful for both the patient and the clinician when the patient keeps a diary of symptoms and activities, Secor suggests.
"One of the functions of a symptom diary for a patient, especially if they’re having any pain, is to be able to quantify objectively if they’re improving or not, she explains.
"If for example, they’re having pain in the vulval area and they record their pain level on a scale of one to 10, then over time you can see it’s not just dependent on their mood of the day," Secor says. "The other function of the diary is to help the clinician and the patient reflect on any pattern there might be in the symptoms. If patients record when they’re having sex and when they do this or that, then sometimes we can get an idea from the symptom diary."
Just because the symptoms have subsided, don’t be lulled into a false sense of security, Secor asserts. Bring the patient in for a test of cure to make sure the problem is solved, once and for all.
"Symptom relief is just that — it does not tell clinicians or patients if the infection has cleared up," Secor explains. "Unless we do a test of cure, we don’t know if it’s cleared up. When symptoms come back again, we don’t know if [the infection] was recalcitrant, meaning it never cleared up, or if it was recurrent, meaning there was a cure and the patient got the infection back again."
Sound like too much trouble? Calculate the amount of time spent doing a thorough exam and workup for accurate diagnosis with a test of cure vs. the endless whirl of "revolving door" patients.
"The more clinicians refine their basic skills in history taking, reading wet mounts, and performing physical exams, the better their diagnostic odds will be. Attention to basics is a huge part of managing these patients," Secor says.
1. Hawes SE, Hillier SL, Beneditti J, et al. Hydrogen peroxide-producing lactobacilli and acquisition of vaginal infections. J Infect Dis 1996; 174:1,058-1,063.