Vaginitis and PID –
The Basics
Wanda Ronner, M.D.
Vaginitis
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Disruption in the normal vaginal ecosystem
Alteration of vaginal pH
A decrease in lactobacilli
Growth of other bacteria
Normal physiologic discharge
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Cervical mucus
Endometrial fluid
Fluid from Skene’s and Bartholin’s glands
Exfoliated squamous cells
Normal pH: 3.5 – 4.5 during reproductive
years; 6 – 8 after menopause
Common Causes of Vaginitis
• Bacterial Vaginosis: 15 - 50% of cases; all
ages; anaerobic bacteria and Gardnerella
vaginalis
• Trichomonas: 15 - 20% of cases; 2045years; protozoan Trichomonas vaginalis
• Candida: 33% of cases; premenopausal
women: 90% caused by Candida albicans
Common Treatments
• Yeast: oral fluconazole 150mg single dose,
or clotrimazole, miconazole, or terconazole.
• Trichomonas: oral metronidazole 2 grams in
a single dose or 500mg bid for 7 days.
• Bacterial Vaginosis: oral metronidazole
500mg bid for 7 days, or vaginal
clindamycin cream or metronidazole gel.
Atrophic Vaginitis
• 40% of postmenopausal women
• Caused by estrogen deficiency
• Symptoms: dryness, itching, burning,
dyspareunia, pelvic pressure, yellowishgreen malodorous discharge
• Findings: pH > 5, decreased superficial
cells, WBCs
• Treatment: vaginal or oral estrogen
67 yr. old with vulvar/vaginal atrophy
Pelvic Inflammatory Disease
• Inflammatory disorders of the upper female
genital tract – endometritis, salpingitis,
tubo-ovarian abscess, pelvic peritonitis
• Organisms responsible: mainly Gonorrhea
and Chlamydia; anaerobes, G. vaginalis,
Haemophilus, enteric Gram-negative rods,
Streptococcus agalactiae.
PID – a public health concern
• Most common gyn reason for ER visits:
350,000/year.
• 70,000 hospitalizations/year.
• Most common serious infection of women
age 16 – 25.
• One in four women have significant
medical or reproductive complications.
Diagnosis of PID
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Cervical motion tenderness
Uterine tenderness
Adnexal tenderness
Temp > 101º F
Mucopurulent discharge
Abundant WBCs on wet mount
Elevated ESR, elevated C-reactive protein
GC or Chlamydia
Differential Diagnosis
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Ectopic pregnancy
Acute appendicitis
Functional pain (e.g. pain with ovulation)
Dysmenorrhea
Endometriosis
UTI/Pyelonephritis
Bowel disorders
Treatment of PID
• Need to provide empiric, broad spectrum
coverage of likely pathogens
• Must include treatment for GC and
Chlamydia
• See handout for April 2007 CDC treatment
regimens
CDC Recommended Regimens
• Parenteral: Cefotetan (2g IV every 6 hrs)
OR Cefoxitin (2g IV every 6 hrs) PLUS
Doxycycline (100 mg orally or or IV) every
12 hrs.
• Oral: Ceftriaxone (250mg IM in a single
dose) PLUS Doxycycline 100mg orally
twice a day for 14 days with or without
Metronidazole 500mg orally twice a day for
14 days
Why do we treat aggressively?
• Even mild cases may result in severe
damage: infertility, ectopic pregnancy, and
chronic pelvic pain.
Follow Up
• Improvement should be seen within 3 days
on oral meds – defervescence, reduction in
abdominal tenderness, uterine, adnexal and
cervical motion tenderness – if not –
HOSPITALIZE
• In no improvement after 3 days on
parenteral meds consider laparoscopy