Case 9 A 22-year-old woman presents with vaginal discharge

 Case 9 A 22-year-old woman presents with

vaginal discharge

Morag is 22 years old and works in a grocery store. She has

noticed in the last week or so that she has vaginal

discharge. She has never had this before and she is worried

about the colour and smell. She is too embarrassed to speak

to her mother or her best friend. An article in her favourite

magazine suggested that she get swabs taken at her GP

clinic or local sexual health clinic.

What other information do you need?

Vaginal discharge is a common symptom with a number

of different causes. Some are benign and some are potentially life - ruining or life - threatening. Formulating a differential diagnosis will help focus your line of questioning.

What is your differential diagnosis?

• Physiological

• Non - infective:

 bacterial vaginosis (BV)

 vulvovaginal candiasis (VVC)

• Sexually transmitted infection (STI)

 Chlamydia

 gonorrhoea

 Trichomonas vaginalis

• Cervical lesions (ectopy, polyp)

• Foreign body

What further questions would help to

pinpoint the diagnosis?

Physiological

Physiological discharge is the most common cause of

discharge in women of reproductive age. However, it is

a diagnosis of exclusion, meaning you have to exclude

other causes first. The clue is that it is usually cyclical in

nature.

Iatrogenic

You need to ask Morag about contraception. The combined oral contraceptive (COC) or the patch predispose

to cervical ectopy. All contraceptive methods can give

unpredictable bleeding which may be misconstrued as

discharge. Intermenstrual bleeding is common with the

intrauterine device.

Cervical ectopy

Ectopy is the physiological response to oestrogen. An

ectopy is the appearance of the exposed glandular epithelium of the endocervix canal extending on to ectocervix

(Plate 9.1 ). It is associated with increased oestrogen

(puberty, pregnancy and taking exogenous oestrogen,

e.g. COC). Mucous glands in the glandular epithelium

produce increased discharge.

Bacterial vaginosis

BV is characterized by a grey discharge with a fishy smell.

The use of vaginal douches or deodorants will predispose

to BV by lowering the pH of the vagina.

Vulvovaginal candiasis

VVC is characterized by a thick white discharge and

itching, redness and soreness of the vulva, vagina and

anus. Pregnancy, diabetes and a recent history of antibiotics or steroid use can predispose.

Chlamydia, gonorrhoea and Trichomonas

You need to take a sexual history from Morag, specifically

asking her about any episodes of unprotected sex. A

history of a new sexual partner in the past 3 months or

more than one partner in the past year increases the risk

of STI. All three STIs can give symptoms of dysuria and

dysparunia. T. vaginalis can cause soreness or itching in

the genital area. A recent history of intermenstrual bleeding, breakthrough bleeding on contraception or postcoital bleeding would suggest Chlamydia or gonorrhoea.

Remember to ask about symptoms associated with upper

genital tract infection (pelvic pain, deep dysparunia).

Obstetrics and Gynaecology: Clinical Cases Uncovered.

By M. Cruickshank and A. Shetty. Published 2009 by Blackwell

Publishing. ISBN 978-1-4051-8671-1.Case 9 73

PART 2: CASES

Cervical polyp

Cervical polyps are usually asymptomatic but can cause

intermenstrual or postcoital bleeding.

Foreign body

This is associated with offensive discharge. Ask specifically about tampon use and foreign body insertion.

Morag tells you that she uses ‘the Pill’ and tampons. She

admits to only occasional condom use. She had thrush a

couple of times in the past but her symptoms seem different

and she has little in the way of itch. She has had five sexual

partners in the past year and three of these were new

partners. She has a vulval soreness but has not noticed any

lumps. Sex has not been painful and she has no pelvic pain.

She had her first smear about a year ago and the result was

negative.

KEY POINT

You will not know the sexual history unless you specifically

ask (Box 9.1). The questions are embarrassing but can be

asked in a sensitive manner. The patient’s response will

guide you on what tests, advice and treatment are most

appropriate.

Box 9.1 Example questions to elicit a female

sexual history

Have you had any major health problems in the past?

Have you had any sexually transmitted infections in the

past?

Have you ever injected drugs?

Have you a current or past sexual partner who has injected

drugs?

Have you a current or past sexual partner who is HIV or

viral hepatitis positive?

Have you a current or past sexual partner who is bisexual?

Have you a current or past sexual partner from outside the

UK? If yes, which country?

Have you had medical treatment outside the UK? If yes,

which country?

Have you had a non-professional body piercing or tattoo?

Have you had sexual contact with the commercial sex

industry?

Have you ever been sexually assaulted?

Have you ever had an HIV test?

Have you had a new sexual partner in the past 3 months?

How many sexual partners have you had in the past 12

months? How many were new partners?

Regarding sexual contacts in the past

3–6months, ask about

Date of contact

Name (if known)

Duration of contact

Sexual activity (e.g. oral, vaginal, anal, sex toys)

Condom use (never, sometimes, always)

Nationality

Does she need to be examined?

Morag can be treated empirically for VVC or BV without

an examination, if she gives a clinical and sexual history

that is:

• Consistent with a non - infective cause for her

discharge

• Low risk for STIs

• She has no symptoms indicative of upper genital tract

infection

• She is able to return for follow - up if symptoms do not

resolve

You should ‘ safety net ’ in these circumstances by

saying if her symptoms do not settle or if they re - occur

she should make an appointment for swabs. In this case,

as her history is not typical of VVC or BV and she gives

an increased risk of STI, she should be examined.

What should you look for

on examination?

You need to inspect the vulva, perineum and anus for

swelling, redness or fissures. You need to take note of any

fishy or offensive smell.

Speculum examination

You will see a cervical ectopy or polyp is present. There

may be a lost condom, tampon or another foreign body.

You will be able to view the discharge and assess its consistency and colour. As Morag has no upper genital tract

symptoms, you do not need to perform a bimanual

examination.

Morag does not have enlarged inguinal lymph nodes. Her

vulva looks a bit red and swollen and you identify small

warty lumps at the introitus. There is a definite fishy odour.

On speculum examination she has a cervical ectopy. There is

creamy discharge and the cervix looks inflamed.74 Part 2: Cases

PART 2: CASES

What further investigations might help

to distinguish the possible diagnoses?

• Assessment of vaginal pH using narrow range (pH

4 – 7) litmus paper is cheap and helpful if there is no

onsite microscopy. Test secretions swabbed from the

lateral vaginal walls. A pH ≥4.5 would suggest BV or T.

vaginalis rather than VVC, but cannot distinguish

between the two.

• A high vaginal swab (HVS) taken from the lateral and

posterior vaginal fornices can be used for both dry and

wet microscopy and direct bacteriological plating. This

will test for BV, T. vaginalis and yeast.

• An endocervical swab to test for gonorrhoea.

• An endocervical swab will test for Chlamydia. This is

usually a nucleic acid amplification test (NAAT).

• Some microbiology laboratories can test for both Chlamydia and gonorrhoea from the same sample so check

with your local laboratory.

• Warts are a clinical diagnosis and a biopsy is rarely

necessary.

Many young women are embarrassed or

frightened of intimate examinations. If

Morag refused to be examined what

could you do to aid the diagnosis?

You could ask Morag to take her own swab for BV, T.

vaginalis and yeast. It might also pick up gonorrhoea, but

an endocervical sample is more sensitive. For Chlamydia

she could do a self - obtained low vaginal swab (SOLVS) or

first void urine (FVU). An FVU sample is used as it provides a vulval wash with the highest bacterial load for DNA

amplification. Patients need to be warned that repeat

testing may be required if the result is indeterminate.

Chlamydia DNA test POSITIVE

Please treat and refer to GU clinic

for contact tracing

----------------------------------------------------------------

Page: 1 u/k = Unknown Sample Time: 9:30

Laboratory Number: 103456 Report Time: 12:19

Specimen: Endocervical swab

Figure 9.1 Morag’s test results.

KEY POINT

Take the gonorrhoea swab first as you want to sample

discharge. Then take the Chlamydia swab as you want to

collect cells as Chlamydia is an intracellular organism.

KEY POINT

If you are performing a test you must have consent and

confirm how to contact the patient if their result comes

back positive.

KEY POINT

Non-invasive tests are particularly useful if a patient is

asymptomatic or does not need to or wish to be

examined.

With diagnoses of cervical ectopy,

genital warts, BV and Chlamydia, what

treatment would you suggest?

Results usually take a few of days to process. If the history

and examination point to a specific diagnosis, there is

merit in starting treatment empirically. This is particularly

relevant if the wait for laboratory confirmation could

result in ascending infection to the upper genital tract.

Upper tract infection is called pelvic inflammatory disease

(PID) and the tubal damage can lead to ectopic pregnancy,

tubal factor infertility and chronic pelvic pain.

Morag ’ s test results are shown in Fig. 9.1 .

Can you now make a diagnosis?

Clinical examination of Morag confirms the presence of

a cervical ectopy and vulval warts. Microbiological tests,

reported 2 days later, confirm coexisting Chlamydia

and BV.

Are these diagnoses expected?

A cervical ectopy is common in COC users. Genital warts

and Chlamydia are common STIs in Morag ’ s age group

and Morag has put herself at risk of an STI by changing

sexual partners and not practising safe sex.Case 9 75

PART 2: CASES

Cervical ectopy

Cervical ectopy often does not need treating as the glandular epithelium will undergo metaplasia to squamous

epithelium with time. In Morag ’ s case, conservative management would be appropriate. If her discharge continues, you could offer cryocautery or suggest a change to a

progesterone only method of contraception or a barrier

method. However, she may not like the change and could

risk an unplanned pregnancy.

Genital warts

This is an incidental finding. Treatment is for cosmetic

reasons and aims to destroy the warts and assist the

patient ’ s immune system to stop producing more. Treatment options for warts include:

1 Freezing with liquid nitrogen.

2 Podophyllotoxin cream or solution is applied at home

twice daily for 3 days per week.

3 Imiquimod cream is a non - specific immune system

modulator. It is applied on alternate nights for a

maximum of 16 weeks. It is expensive and except in the

case of anal warts, should be used third line when previous treatments fail.

Bacterial vaginosis

This is not an infection but an overgrowth of the bacteria

normally found in the vagina. This is why it is an ‘ - osis ’

not an ‘ - itis ’ . BV only needs treatment if the woman is

symptomatic or pregnant. Treatment is usually with

metronidazole either one dose (2 g) or twice daily dose

(400 mg) for 5 days. Patients should not drink alcohol

during treatment and for 24 hours after as it reacts with

alcohol. BV is not an STI and partners do not need treatment. Recurrence is common.

Chlamydia

Chlamydia is an STI and treatment is a one - off dose of

azithromycin (1 g).

Morag will be asked to abstain from sex for 1 week or

until 1 week after her regular sexual partner has been

treated. Chlamydia infections are asymptomatic in 50%

and 70% of males and females, respectively. Chlamydia

is most common in under - 25 - year - olds and those who

do not use condoms.

Would your management be different if

you thought Morag had an upper

genital tract infection?

If she had upper genital tract symptoms (pelvic pain and/

or dyspareunia) the diagnosis is PID and she needs a

different course of antibiotics:

• Doxycycline 100 mg twice daily for 14 days and metronidazole 400 mg twice daily for 10 days

• If gonorrhoea is suspected or present, add ceftriaxone

250 mg IM once

Warn her about the side - effects of doxycycline –

nausea on an empty stomach and photosensitivity (no

sunbeds) – and the interaction between metronidazole

and alcohol.

Morag is shocked to be told that she has two STIs and starts

crying. She is devastated that her boyfriend has cheated on

her.

What would you say to her?

Most patients find the diagnosis of STI distressing but it is

better to know and be treated so that potentially life - ruining

sequelae can be averted. These diagnoses do not confirm

infidelity in her current relationship. In the case of genital

warts, 70% of a sexually active population will have a genital

human papilloma virus (HPV) infection at some stage, but

only 1 in 5 develops warts. Because of its asymptomatic

nature, she could have picked up Chlamydia from a previous sexual partner or her current partner may have brought

it into the relationship from a previous partner.

You succeed in settling Morag down. Is

there anything else you should discuss

with her?

• Partner notification and health advisor support

(Box 9.2 )

• Information leaflets

• Safe sex

• Retesting for Chlamydia

Morag should ask her partner to attend a local genitourinary medicine (GUM) clinic or his GP for testing and

treatment.

KEY POINT

You should have a low threshold for empirical treating

women at risk of STI.

KEY POINT

To avoid reinfection, current sexual partner(s) should be

tested and treated.76 Part 2: Cases

PART 2: CASES

At the GUM clinic, her partner ’ s sexual history will be

taken and he will undergo urethral swabs for Chlamydia

and gonorrhoea or FVU for Chlamydia. He has about a

70% chance of being positive for Chlamydia and most

GUM clinics would treat him empirically with azithromycin (1 g). The couple would be asked to abstain for 1

week. He would then see the health advisor for partner

notification, information and support.

What safe sex advice do you give?

The best way to prevent STIs is to practice safe sex. This

means using a condom for all untested sexual partners.

Condoms should be used for oral, vaginal and anal sex.

Non - penetrative sex (massage, masturbation) is safer.

Most GUM and family planning clinics offer free

condoms.

What about retesting?

Morag needs to be retested for Chlamydia at 3 or 6

months in case treatment has failed or she has a reinfection. It can be performed non - invasively using a SOLVS

if the patient is asymptomatic.

Which other STI tests might be

recommended?

• HIV

• Syphilis

• Hepatitis B

• Hepatitis C

The decision to offer each test depends on Morag ’ s

sexual history (Fig. 9.1 ).

Morag is not keen on a HIV test as she does not consider

herself to be in a high risk group.

HIV

It is estimated that 1 in 3 of those infected with HIV in

the UK are unaware of their positive status. HIV is on the

increase in the UK and the majority of diagnoses are

in heterosexuals. Most heterosexual acquisition is from

outside the UK, mostly Africa. Most UK acquired infections are in men who have sex with men. An HIV test is

a blood test that looks for antibodies to HIV. There is up

to a 3 - month window period for the test as most people

take approximately 6 weeks before developing antibodies. Patients may therefore have to return for a repeat test.

Syphilis

Most cases of syphilis occur in men who have sex with

men (hence the question about bisexual partners in the

sexual history) or in men who have had sex with someone

who is from outside Europe. Syphilis is highly infectious

during its second and third stage. Third stage or latent

syphilis can cause gummatous syphilis, cardiovascular

syphilis and neurosyphilis which result in serious damage

to the heart, brain, bones and central nervous system.

Routine testing is also carried out antenatally because of

potential serious affects to the fetus. Testing is by a swab

that collects a sample of fluid from any ulcer or, more

commonly, by a blood test.

Hepatitis B

Hepatitis B is highly infectious, 100 times more so than

HIV. Morag is at risk of hepatitis B because of her history

of unprotected sex. You should ask about any risk factors

that may increase her risk of contracting hepatitis B (Box

9.3 ). One in four carriers of hepatitis B develop severe

liver disease leading to chronic hepatitis, cirrhosis and

cancer. Hepatitis B is detected by a blood test looking for

antibodies and you need to ask for hepatitis B core antibody on the request form.

Box 9.2 Health advisor

The health advisor is specifically trained in partner

notification. It is their job to identify potentially infected

individuals and break the infection chain. They will trace

contacts anonymously if the patient feels unable to do

this. Ideally, they would see both Morag and her partner(s)

individually and identify any other sexual partners from the

past 3–6 months. This can be a difficult job as many index

cases (positive patients) are too embarrassed to give names

or do not know the name of casual sexual contacts.

KEY POINT

Retesting before 3 weeks will yield a false positive result as

the amplification process will amplify dead chlamydial

bacteria.

Morag agrees to speak to the health advisor on the

telephone who agrees to contact Morag’s other recent

sexual partners as Morag does not have any contact.

Sexually transmitted infections commonly occur

together. While gonorrhoea and T. vaginalis have been

ruled out, there are other STIs that Morag may have

contracted.Case 9 77

PART 2: CASES

Hepatitis C

Hepatitis C is rarely contracted through sex. The main

risk factor is injecting drug use and it is estimated that

50 – 80% of past and current users are infected.

Is there anything else that could be

offered to Morag in way of prevention?

Safe sex and the use of condoms have already been discussed with Morag. Another option is hepatitis B

vaccination.

Morag’s sexual history revealed multiple sexual partners in

the past year but all from the UK. There was no history of

injecting drug use or high risk partners. She had never been

outside the UK, had never been sexually assaulted, and had

only professional piercings and tattoos. She was deemed

low risk for blood-borne virus infections, but testing for HIV

and hepatitis B was recommended. These came back

negative.

Box 9.3 Risk factors for hepatitis B

• Intravenous drug use

• Current or past partner with hepatitis B

• Current or past bisexual partner

• Family relatives with hepatitis B

• Health care occupation

• Contacts with prison (self or partner)

• Travel or work in countries where virus is endemic such

as South-East Asia, Middle and Far East, south Europe

and Africa

CASE REVIEW

This 22 - year - old woman presented with the common

complaint of vaginal discharge. A careful history, asking

targeted questions, will help home in on a differential

diagnosis. Most women of this age will be sexually

active, meaning that iatrogenic contraceptive causes and

STI infections should be high up on your diagnosis

list. Chlamydia is found in 10% of sexually active

25 - year - olds.

BV is a non - infective cause of vaginal discharge which

is very common. Her symptoms were typical of BV and

she could have started treatment for this on history alone.

Normally, there should be a low threshold for performing

a vaginal examination. In this case, taking genital swabs

was useful as she was found to be Chlamydia positive. Most

STIs, except genital warts and herpes, benefit from partner

notification, testing and treatment.

A useful routine to follow is to take a HVS from the

posterior and lateral fornices to test for yeasts, BV and T.

vaginalis. Then take an endocervical swab for gonorrhoea

and endocervical NAAT for Chlamydia. If she had refused

examination, a self - obtained high vaginal swab and low

vaginal NAAT swab could be collected. FVU is an alternative sample for Chlamydia testing. Evidence of her risky

sexual behaviour gave an opportunity for education about

safe sex, the offer of hepatitis B testing and vaccination,

and the provision of free condoms.

KEY POINTS

• Women under 25 are often sexually active and this is a

good opportunity to discuss both contraception and STI

risk

• A sexual history is intrusive but can provide key

information for the differential diagnosis, inform on

appropriate testing and sampling sites, aid the partner

notification process and focus education and prevention

strategies

• There should be a low threshold to perform a vaginal

examination if symptoms are present

• Always offer a chaperone for any intimate examination

• Swabs should include an HVS and two endocervical swabs

• If you are performing a test you must have consent and a

means to contact the patient if their result comes back

positive

• VVC and BV only need treatment if the patient is

symptomatic and testing and treatment of male partners

is not routinely recommended

• Partner notification is recommended for all STIs except

genital warts and herpes

• Unprotected sex increases the risk of blood-borne viruses

such as HIV, syphilis, hepatitis B and C

• Education, condom use and hepatitis B vaccination can

reduce the risk of acquiring an STI78 Part 2: Cases

PART 2: CASES

Further reading

Faculty of Family Planning and Reproductive Health Care Clinical Effectiveness Unit. FFPRHC and BASHH Guidance. The

management of women of reproductive age attending non -

genitourinary medicine settings complaining of vaginal

discharge, January 2006 [ http://www.fsrh.org/admin/

uploads/326_VaginalDischargeGuidance.PDF ] Accessed

April 2, 2008.

The British Association For Sexual Health website ( www.bashh.

org ) has a comprehensive list of clinical effectiveness guidelines on all sexually transmitted infections, common presentations and other aspects of sexual health.