Vaginitis is a common and frequent disease in obstetrics and gynecology. It is a general term for a variety of inflammatory diseases of the vaginal mucosa caused by different diseases.
However, the efficacy of vaginitis treatment is not satisfactory, the recurrence rate is high, and patient compliance is poor. The goal of vaginitis treatment is to effectively treat the clinical symptoms and reduce the recurrence rate. Rebuilding the vaginal ecosystem and restoring the vaginal defenses is the key. It is best to use drugs that are potent, fast, have a low recurrence rate and are safe.
The following are some common vaginitis treatments.
I. Trichomoniasis
90% transmitted through sexual intercourse by infected men. The typical signs/symptoms are: itching of the vulva, thin frothy leucorrhea, bleeding spots on the vaginal mucosa epithelium and strawberry-like cervix; the diagnosis can be confirmed by seeing trichomonas under microscopic examination. The most suitable pH for the growth of Trichomonas is 5.5-6. If the pH is below 5 or above 7.5, the growth of Trichomonas will be inhibited.
Recommended regimen: Metronidazole, 2 g, single oral dose or Tinidazole, 2 g, single oral dose.
Alternative regimen: Metronidazole, 400 mg, orally, 2 times/day for 7 days.
For those who cannot tolerate oral medication or are unsuitable for systemic medication, topical vaginal medication, metronidazole vaginal effervescent tablets 0.2 g, once a night for 7 days, may be used. However, the efficacy is lower than that of oral medication. Alcohol should be avoided within 24 hours of taking metronidazole or within 72 hours of taking tinidazole.
Sexual partners should be treated and advised to avoid unprotected sexual intercourse until cured. Follow-up is not required for those without clinical symptoms after treatment. If the initial treatment fails, the dosage and duration of treatment may be increased to metronidazole 2 g, once a night for 3-5 days.
Special management: Treatment regimen during pregnancy: Metronidazole 400 mg orally twice/day for 7 days is an option. Lactation: The regimen is the same as normal. Avoid breastfeeding for 12-24 hours after taking metronidazole; for tinidazole, avoid breastfeeding for 3 days after taking the drug.
Vulvovaginal pseudomyxomycosis
VVC is usually caused by Pseudomonas albicans, which is a conditional pathogen and occurs at least once in 75% of women. It occurs in vaginal environments with pH < 4.5. Typical symptoms are white curd-like or tofu-like discharge and intolerable severe itching, with swelling and ulceration of the vulva due to scratching. The diagnosis can be confirmed by microscopic examination of mycelium or spores.
VVC can be divided into: simple and complex (severe VVC, recurrent VVC, VVC during pregnancy, abnormal host, non-Pseudomonas albicans VVC. 10%-20% of women will develop complex VVC.
1. Simple VVC
Antifungal medication is used along with removal of the causative agent. Generally, there is no need to treat the sex partner at the same time, unless the partner has fungal glans. Give a short course of antifungal medication.
Miconazole suppositories 1.2 g single vaginal dose;
Miconazole suppositories 200-400 mg vaginally once a night for 3 d;
Clotrimazole suppositories 500 mg, single vaginal dose or 100 mg, twice daily for 3 d
Mycoplasma effervescent tablets 100,000 U vaginally once a night for 14 d;
Fluconazole 150 mg as a single oral dose.
2.Complex VVC
(1)Severe VVC
According to the table below, VVC with symptoms and signs score ≥ 7 is often poorly treated with a short course of treatment because of the severity of the symptoms. Topical application of low concentration glucocorticoid ointment or azole cream can be used to relieve symptoms. Preferred oral medication: fluconazole 150 mg orally once on days 1 and 4; combined with vaginal medication, the course of treatment can be extended to 7-14 days.
(2) Recurrent VVC
After treatment, clinical symptoms and signs disappeared and fungal tests were negative, women with VVC developed symptoms again and had four or more episodes of positive fungal tests within one year. Most of the pathogens are Candida albicans.
10%-20% are non-Candida albicans, including Candida smoothus, Candida klebsiella, etc. Treatment is based on secretion culture and drug sensitivity test. After intensive treatment to achieve fungal cure, consolidation therapy is given for six months.
Intensive treatment
Oral dosing.
Fluconazole 150 mg, repeated 1 time after 3 d;
Itraconazole 200 mg once/d for 2-3 days.
Vaginal medication.
Miconazole suppository 400 mg once a night for 6 d;
Miconazole suppository 200 mg once a night for 7-14 d;
Clotrimazole suppositories 500 mg, repeated once after 3 days;
Clotrimazole suppository 100 mg once a night for 7-14 d.
RVVC maintenance therapy
Currently, there is no proven protocol in China or abroad, and maintenance therapy may be ineffective in 30%-50% of patients. A low-dose, long-course regimen should be used.
Fluconazole 100-200 mg orally once/week for 6 months;
Miconazole suppositories 400 mg, 1 time/day, intravaginal, 3-6 d/month for 6 months;
Clotrimazole suppository 500 mg once/month for 6 months.
(3) VVC during pregnancy
The incidence of VVC in pregnant women is higher than that in non-pregnant women, and it is more difficult to treat and requires higher medication: no harm to mother and child, so medication should be used with caution during early pregnancy. Vaginal medication is preferred over oral antifungal agents. It should be noted that according to FDA, the commonly used clotrimazole and myclobutanil belong to class B drugs, while miconazole belongs to class C drugs.
(4) Patients with diabetes mellitus or long-term glucocorticosteroid application have poor response to a short course of treatment and therefore require an extended course of treatment.
(5) For non-Pseudomonas albicans VVC, the course of treatment needs to be extended: 7-14 days with non-fluconazole drugs. A fungal culture and drug sensitivity test are needed to help select the drug.
3. Bacterial vaginosis
Bacterial vaginosis is caused by a decrease or loss of vaginal lactobacilli and an increase in other related microorganisms. Patients may not have any symptoms. Those with symptoms complain of increased leucorrhea with a foul odor and mild vulvar itching or burning sensation.
BV can be diagnosed if 3 out of 4 items are met (with positive clue cells required).
(1) The vaginal discharge is a uniform thin leucorrhea;
(2) Vaginal pH > 4.5;
(3) Positive ammonia test;
(4) Positive clue cells ( > 20%).
Treatment
Preferred regimen: metronidazole 400 mg orally twice daily for 7 d; or metronidazole vaginal tablets (suppositories) 200 mg once daily for 5-7 d. Or 2% clindamycin cream (5 g) vaginally once nightly for 7 d. Alternatives: clindamycin 300 mg orally twice daily for 7 d.
Alternative regimen: Chlorhexidine 300 mg orally twice daily for 7 d.
It is important to note that BV may be associated with adverse pregnancy outcomes, so any symptomatic pregnancy and asymptomatic women with high-risk pregnancies should be screened and treated for bacterial vaginosis. Mostly oral metronidazole 200 mg 3-4 times/d for 7 d or clindamycin 300 mg 2 times/d for 7 d are used.
4. Geriatric vaginitis
Topical or systemic estrogen therapy can restore the vaginal environment, increase intracellular glycogen, establish normal vaginal flora, restore pH value, resist pathogenic bacterial infection, and improve vaginal and urinary symptoms.
Topical medications such as Ovidin or Pemetin ointment, 0.5-1 g daily, applied intravaginally, usually start to work within 36 h and normalize the vaginal mucosa within 2 weeks. Commonly used systemic medications include Nystatin, Levitra, Clomid, etc.
Since 97.2% of bacterial cultures of senile vaginitis have bacterial growth, both aerobic and anaerobic bacteria, it is advisable to use localized vaginal suppositories before using estrogenic drugs, and then use local estrogenic ointments after the inflammation is slightly controlled.