Vaginal Thrush and Bacterial Vaginosis (PHAR2921) PDF

PHAR2921 Vaginal Thrush and Bacterial Vaginosis Dr Jack Collins Sydney Pharmacy School [email protected] The University of Sydney Learning objecti...

PHAR2921 Vaginal Thrush and Bacterial Vaginosis Dr Jack Collins Sydney Pharmacy School [email protected] The University of Sydney Learning objectives – Describe causes, risk factors, and signs and symptoms of vaginal thrush, including making a differential diagnosis from similar conditions – Describe the different treatment options for vaginal thrush and when each may be used – Select appropriate treatment and provide advice on the selected treatment – Describe non-pharmacological management of vaginal thrush – Describe causes and signs and symptoms of bacterial vaginosis, including making a differential diagnosis from similar conditions The University of Sydney Page 2 Strongly recommended reading Library link: https://sydney.primo.exlibrisgroup.com/permalink/61USYD_INST/1c0ug48/alm a991031707799205106 The University of Sydney Page 3 Vaginal thrush The University of Sydney Page 4 Outline Overview of Vaginal thrush Pharmacological Non- vaginal thrush symptoms Referral points management pharmacological Bacterial vaginosis management Scope of lecture History taking and Points for referral Evidence base Overview of non- Overview Epidemiology reaching a diagnosis Choosing a product pharmacological Signs and symptoms Pathogenesis Symptoms Creams management Management Differentiating from Pessaries similar conditions Oral The University of Sydney Page 5 Anatomy recap Typical internal and external anatomy of people assigned female at birth Source The University of Sydney Page 6 Overview of vaginal thrush – Vaginal thrush (vulvovaginal candidiasis) is a common fungal (yeast) infection – Approx. 75% of women* will have vaginal thrush at least once in their lifetime – Commonly (>80%) caused by overgrowth of Candida albicans (natural flora) – Opportunistic pathogen The University of Sydney Page 7 Overview of vaginal thrush – Other Candida species, Nakaseomyces glabrata, or Saccharomyces cerevisiae may also be implicated – Thrush may present as an isolated incident, or may become recurrent (4 or more incidents in a year) – Vaginal swabs may be taken by physicians; however, thrush is commonly self-diagnosed and managed in the pharmacy without microscopy The University of Sydney Page 8 Overview of vaginal thrush Thrush is not a sexually transmitted infection but can (uncommonly) be sexually transmitted The University of Sydney Page 9 Risk factors – Poorly controlled diabetes – Hormonal changes (hormonal contraception, pregnancy) – Immunosuppression (e.g., HIV, immunosuppressive drug therapy) – Vulvar dermatosis – Use of antibiotics (esp. broad spectrum) – Changes in vaginal pH The University of Sydney Page 10 Signs and symptoms – history taking – Often present self-diagnosed – Important to ask adequate questions to ensure differential dx – Remember to be cognisant of privacy and framing of questions! – Consider using consult room or ensuring there is adequate privacy The University of Sydney Page 11 Signs and symptoms – history taking – Acknowledge that this may be an uncomfortable experience for some people – If you’re uncomfortable the consumer is likely to be as well – Ask purposeful questions, enough to ensure safe and adequate use of treatment and/or referral The University of Sydney Page 12 Signs and symptoms – what not to do The University of Sydney @milligram96 Page 13 Signs and symptoms Sign/symptom Thrush Other conditions Comments Discharge appearance Thick and white (‘cottage White-grey thin discharge: BV Normal discharge varies in cheese’) Profuse, green-yellow and frothy: consistency, is clear or white Trichomoniasis Pus (purulent): Gonorrhoea, Chlamydia Discharge odour Minimal, slightly ‘yeasty’ Strong odour (‘fishy’): BV, Normal discharge is not Trichomoniasis malodourous Itch (pruritis) Present, may be quite Itch present in Trichomoniasis and itchy Vulvovaginal dermatitis Redness/swelling May be present May be present vagina/vulva Dysuria, pain during May be present May be present, classified as intercourse superficial or deep Vaginal pH 4.5: BV, Trichomoniasis Normal pH is ~3.8-4.5 Onset The University of Sydney Acute Slower Page 14 Classification Uncomplicated Complicated Sporadic or infrequent Recurrent: 4+ episodes in 12 months Mild-moderate Recurrence within 2 months Likely due to C. Albicans Severe infection Not associated with risk factors Infection with species other than C. Albicans Infection during pregnancy Infections with immunocompromise, poorly controlled diabetes, etc. The University of Sydney Page 15 Referral – Cases falling into ‘complicated’ category – Unable to reach a clear diff dx or sx consistent with different infection, e.g., strong odour – OTC treatment failure – Aged 60 as vaginal thrush not common The University of Sydney Page 16 Treatment – Main treatment options are creams, pessaries, oral capsules – Creams and pessaries need to be inserted into the vagina (not used just externally) – Varying duration of treatment, etc. – Largely driven by patient preference – S3 medicines The University of Sydney Page 17 Treatment - creams – Contain clotrimazole (imidazole) or nystatin – Clotrimazole the most common/largest market share – Topical imidazoles have cure rates of 85-90%, comparable to oral therapy – Nystatin considered second-line in eTG The University of Sydney Page 18 Treatment - creams – Come as a ‘once’, 3-day, 6-day treatment (varying concentrations) – Creams include an applicator to aid use – not the same as regular cream – May also be applied externally to provide comfort The University of Sydney Page 19 Treatment - creams – May cause vaginal irritation, weaken condoms – Symptoms may take 2-3 days to resolve – 6 days may be preferred for recurrent infections or pregnant The University of Sydney Page 20 Treatment - creams (available formulations) Formulation Directions for use Example product Clotrimazole 1% vaginal cream 1 applicatorful intravaginally once Canesten® 6-day cream daily at bedtime for 6 nights Clotrimazole 2% vaginal cream 1 applicatorful intravaginally once Canesten® 3-day cream daily at bedtime for 3 nights Clotrimazole 10% vaginal cream 1 applicatorful intravaginally once at Canesten® ‘Once’ cream bedtime Nysatatin 100,000 units/5 g vaginal 1 applicatorful intravaginally once Nilstat® vaginal cream cream daily at bedtime for 14 nights The University of Sydney Page 21 Treatment - pessaries – Contain clotrimazole (imidazole) – 1-day or 6-day treatment – Vaginal irritation may occur – Similar in terms of principles and use to creams The University of Sydney Page 22 Treatment - pessaries The University of Sydney Page 23 Treatment - pessaries (available formulations) Formulation Directions for use Example product Clotrimazole 100 mg pessary 1 pessary intravaginally once daily at Canesten® 6-day pessary bedtime for 6 nights Clotrimazole 500 mg pessary 1 pessary intravaginally once at Canesten® ‘Once’ pessary bedtime The University of Sydney Page 24 Treatment - oral capsule – Stat dose of 150 mg fluconazole (triazole) – May be used by people who cannot tolerate creams/pessaries or would prefer oral option – Symptoms may not resolve immediately, available in combination with a cream for external comfort – Used to manage recurrent infections The University of Sydney Page 25 Treatment - oral capsule – May cause some gastrointestinal upset – Single dose unlikely to be problematic in breastfeeding, best avoided in pregnancy – CHECK PSA Protocol The University of Sydney Page 26 Non-pharmacological advice – Wear loose-fitting clothing – Wear cotton underwear (more breathable than synthetic) – Wipe ‘front to back’ – Avoid soaps, fragrances, douching, bubble baths, etc. – Wash your hands before touching your genitals – No evidence for yoghurt or other intravaginal probiotics The University of Sydney Page 27 Non-pharmacological advice – Avoid ‘feminine’ products as disrupt vagina pH and natural balance The University of Sydney Page 28 Bacterial vaginosis The University of Sydney Page 29 Bacterial vaginosis – overview – Common vaginal infection (approx. 35% of people with a vagina will have at least one episode) – Up to 50% asymptomatic – Often recurrent – Currently examining if relevant to treat sexual partners (especially if partner has vagina) The University of Sydney Page 30 Bacterial vaginosis – overview – Lactobacillus species produce hydrogen peroxide and dominate the vaginal normal flora – BV often associated with decreased Lactobacilli and overgrowth of anaerobic bacteria such as Gardnerella vaginalis in a biofilm – Much like thrush, is NOT an STI – May have significant impacts on self-esteem, etc. The University of Sydney Page 31 Bacterial vaginosis – identification – If symptomatic, typically identified by ‘fishy’ odour – Discharge may be grey-white (significant amount) – pH of the vagina will be increased The University of Sydney Page 32 Bacterial vaginosis – management – Symptomatic infections should be treated with antibiotics The University of Sydney Page 33 Bacterial vaginosis – management – New S3 product which contains Astodrimer sodium (not an antibiotic) – Believed to disrupt biofilm – Used once at night for a week – Evidence limited and does not appear in guidelines – Marketing? New guidelines? Watch this space. The University of Sydney Page 34 Questions? The University of Sydney Page 35