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Women’s Health - Vaginitis, Sexually Transmitted Infections, Pelvic Inflammatory Disease - Fast Facts | NEJM Resident 360

The CDC Sexually Transmitted Diseases Treatment Guidelines, 2021 is the most comprehensive resource for screening, diagnosis, and treatment of STIs and includes recommendations for STIs not covered in this rotation guide (including hepatitis C, hepatitis B, genital herpes simplex virus, lymphogranuloma venereum, Mycoplasma genitalium, and viral hepatitis). See the Summary of CDC STI Treatment Guidelines, 2021. 

Vaginitis

Presentation, Causes, and Diagnosis

• Presentation: Vaginitis is a common complaint in the primary care setting. When a woman presents with vaginal irritation and discharge, it is critical to identify the etiology in order to prescribe the appropriate therapy and quickly alleviate symptoms.

• Causes: The most common causes of vaginitis are bacterial vaginosis (BV; usually caused by Gardnerella vaginalis), vulvovaginal candidiasis, and trichomoniasis.

• Diagnosis: The gold standard test to differentiate between these common etiologies is microscopy or a “wet mount” to look for clue cells (BV), hyphae, or Trichomonas. Some point-of-care diagnostic tests are available for diagnosing BV and trichomoniasis, but these are not available in typical primary care offices.

See JAMA Rational Clinical Exam series for a table of causes, symptoms, and signs of vaginitis and a review of the sensitivity, specificity, and likelihood ratios of various signs on exam and microscopy.

Sexually Transmitted Infections (STIs)

Recommendations for STI Screening, Diagnosis, and Treatment

The following organizations provide summaries of screening, diagnosis, and treatment recommendations for STIs:

• Centers for Disease Control (CDC)

• World Health Organization (WHO)

• U.S. Preventive Services Task Force (USPSTF)

Screening

For otherwise healthy women, screening recommendations are as follows:

• Chlamydia and gonorrhea: Screen women in the following groups annually:

• • all sexually active women aged <25 years

  • all sexually active women aged ≥25 years at increased risk, including those with:

    • a new sex partner

    • more than one sex partner

    • a sex partner with concurrent partners

    • a sex partner who has an STI

  • Note: A pelvic exam is not required for testing. USPSTF guidelines recommend nucleic acid amplification testing from urine, vaginal, or cervical specimens.

• Syphilis: There is no recommendation for routine screening for healthy nonpregnant women at average risk. Pregnant women, women with risky sexual behaviors, men who have sex with men (MSM), and patients with HIV should be screened. See USPSTF guidelines.

• HIV: Testing should be offered at least once to all patients ages 13–64 years on an opt-out basis. See the HIV/AIDS section in the Resident 360 Infectious Diseases rotation guide for more information about screening.

Note: The screening recommendations listed above do not apply to patients who have symptoms (discharge, dysuria, dyspareunia, abnormal bleeding, or any other new symptoms), are pregnant, or have HIV or other immunodeficiency.

Expedited partner therapy (EPT**):**EPT is important in the treatment of patients with chlamydia or gonorrhea. EPT is the practice of simultaneously treating patients and their sex partners by providing prescriptions or medications for the patient to take to his or her partner. EPT is a “useful option” according to the CDC and is legal in most states.

Treatment

Recommended Treatment Regimens for STIs

	Bacterial Vaginosis	Trichomoniasis	Chlamydia	Gonorrhea
Recommended regimen	Metronidazole
(500 mg orally twice/day for 7 days)

OR

Metronidazole gel
(0.75%, one applicator [5 g] intravaginally, once/day for 5 days)

OR

Clindamycin cream
(2%, one full applicator [5 g] intravaginally at bedtime for 7 days) | Metronidazole

• Women: (500 mg orally twice/day for 7 days)

• Men: (2 gm orally in a single dose)

OR

Tinidazole
(2 g orally in a single dose) | Doxycycline (100 mg orally twice/day for 7 days)

OR

Azithromycin (1 g orally in a single dose ORlevofloxacin 500 mg orally once/day for 7 days

• Pregnancy: azithromycin (1 g orally in a single dose)

| Ceftriaxone (500 mg IM in a single dose) for uncomplicated infections of the cervix, urethra, and rectum, or pharynx in adults and adolescents

OR

Gentamicin (240 mg IM in a single dose) PLUSazithromycin (2 g orally in a single dose) in patients with cephalosporin allergy

Cefixime (800 mg orally in a single dose) if ceftriaxone administration is not available or feasible

• Pregnancy: ceftriaxone (500 mg IM in a single dose)

| | Notes | Avoid alcohol consumption during treatment with nitroimidazoles | Avoid alcohol consumption during treatment with nitroimidazoles | Consider concurrent treatment for gonococcal infection if patient is at risk for gonorrhea or lives in a community with a high prevalence of gonorrhea | If chlamydial infection has not been excluded, treat for chlamydia with doxycycline (100 mg orally twice/day for 7 days)
For persons weighing ≥150 kg: 1 g ceftriaxone should be administered | | Treatment of sexual partners | Not recommended | Recommended: Avoid sexual contact until treatment is completed and symptoms have resolved | Recommended: Avoid sexual contact until treatment is completed, symptoms have resolved, and all sexual partners have been treated | Recommended: Avoid sexual contact until treatment is completed, symptoms have resolved, and all sexual partners have been treated |

Abbreviations: IM, intramuscularly

(Reference: Sexually Transmitted Diseases Treatment Guidelines, 2021. Centers for Disease Control STI treatment Guidelines, 2021.)

Pelvic Inflammatory Disease (PID)

PID occurs when the female upper reproductive tract (endometrium, fallopian tubes, ovaries) becomes infected, usually with sexually transmitted organisms. PID can lead to infertility, ectopic pregnancy, and chronic pelvic pain.

Diagnosis

• Who’s at risk? PID is most commonly seen in sexually active adolescents and young women, who present with pelvic or lower abdominal pain, discharge, bleeding, and dyspareunia (pain with sex).

• Clinical diagnosis: To diagnose PID clinically, you should note signs of upper genitourinary tract involvement (cervical motion tenderness, adnexal tenderness) on exam. You may also note evidence of lower genitourinary tract involvement (cervical purulence and/or cervical friability or easy bleeding, or white blood cells on wet mount).

Diagnostic Algorithm for PID*

*Some patients may not willingly disclose information about sexual activity.

• Testing: All patients with suspected PID should undergo:

  • testing for Neisseria gonorrhoeae and Chlamydia trachomatis (with nucleic acid amplification testing [NAAT] from cervical or vaginal samples)

  • pregnancy test to rule out ectopic pregnancy

  • HIV testing (presence of HIV increases the risk of tubo-ovarian abscess), and syphilis testing if community prevalence rates are high

Treatment

(Source: Pelvic Inflammatory Disease (PID). Sexually Transmitted Infections Treatment Guidelines, 2021. Centers for Disease control and Prevention 2021.)

• Antibiotics: According to the CDC, all regimens used to treat PID should also be effective against N. gonorrhoeae and C. trachomatis because negative endocervical screening for these organisms does not rule out upper reproductive tract infection. Therapy always involves at least two antibiotics (usually a third-generation cephalosporin and doxycycline) given at the same time, even if the woman was recently treated for chlamydia. In a recent study, the addition of metronidazole to treatment regimens for PID resulted in a reduction in anaerobes and pelvic pain at 30 days, compared with regimens without metronidazole.

• Expedited partner therapy (EPT): EPT is the practice of treating sex partners of patients diagnosed with chlamydia or gonorrhea by providing prescriptions or medications for the patient to take to his or her partner. 

• Treatment of PID in women with an IUD: If a woman has an intrauterine device (IUD), it does**not need to be removed when she is diagnosed with PID. Most infections can be treated through the IUD to maintain placement of the highly effective contraception. If there is no clinical improvement within 48 hours and/or if you suspect complicated infections (e.g., tubo-ovarian abscess or perforation), recommend urgent referral to an OB/GYN specialist.

• Retesting: All women who have received a diagnosis of chlamydial or gonococcal PID should be retested 3 months after treatment, regardless of whether their sex partners have been treated. If retesting at 3 months is not possible, these women should be retested whenever they next seek medical care <12 months after treatment.

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