Among patients receiving standard or high-dose chemotherapy for breast cancer, vulvovaginitis is a frequent reason for referral to the Gynecologic Oncology Center. Vulvovaginitis can occur during or after chemotherapy and is thought to result from an alteration in the vaginal ecosystem due to loss of normal ovarian function. Specifically, myelosuppressive chemotherapy can cause loss of normal ovarian function, which in turn can lead to a decrease in the vaginal epithelial glycogen content and an increase in the vaginal pH, and myelosuppressive chemotherapy can also cause neutropenia. Both higher pH and neutropenia may facilitate the pathogenic behavior of bacteria, fungi, and protozoans coincidentally present in the vagina.

Vaginal infections are usually accompanied by a discharge that is troublesome and noticeable to the patient. Patients describe the discharge as being increased,  offensive,  and associated with itching or a “burning” sensation at the introitus or urethra. The discharge resulting from vaginal infections is different from the normal physiologic discharge that many women experience, which is white but sometimes leaves a brownish stain on underclothing.  More than one type of vulvovaginal infection can be present at the same time, and therefore a careful work-up is essential.

Bacterial Vaginosis
Bacterial vaginosis is the most frequent type of vaginal infection, accounting for approximately 50% of all cases of vaginitis.

Bacterial vaginosis was previously also known as Corynebacterium vaginalis infection and subsequently as Gardnerella vaginalis infection after H. L. Gardner, the clinician who first described it. The pathologic state is believed to involve multiple bacteria, and the incubation period is usually 5-10 days.

The following bacteria are commonly found in the vagina (approximate frequencies of specific infections are shown in parentheses): gram-positive rods such as diphtheroids (40%); gram-positive cocci such as Staphylococcus epidermidis (55%), S. aureus (5%), ?-hemolytic streptococci (20%), and group D streptococci (55%); gram-negative organisms such as Escherichia coli (30%) and Klebsiella species (10%); and anaerobics such as Bacteroides species (40%),  Clostridium species (20%),  Peptococcus species (65%),  and Peptostreptococcus species (35%).

Women with bacterial vaginosis usually complain of a fishy malodorous discharge. The odor becomes more pronounced after intercourse and during the menstrual cycle because the alkalotic environment present at these times leads to the production of aromatic amines. The discharge is usually dark gray, with low viscosity and homogeneous consistency, and is primarily localized and adherent to the vaginal walls. Pruritus is not a common complaint. Three out of the following four criteria should be met before bacterial vaginosis is diagnosed: (1) there is a white or gray vaginal discharge of homogeneous consistency;  (2)  the pH of the discharge is greater than 4.5; (3) there is an amine-like odor when the discharge is mixed with potassium hydroxide (also known as a positive finding on a whiff test); and (4) at least 20% of the vaginal epithelial cells examined on the wet mount are “clue cells”-cells covered with clusters of cocco-bacilli, which give the cells a granular appearance.

Treatment options for bacterial vaginosis are shown in Table 15-1. Treatment of sex partners remains controversial. Most studies demonstrate no benefit from treating the partner after the first episode unless balanitis, inflammation of the glans penis,  is present.  However,  in patients with recurrent infections, treatment of the partner may be indicated.

Vulvovaginal Candidiasis
Up to 30% of healthy women harbor candidal organisms, but such women usually do not have symptoms. In contrast, patients with a history of diabetes or immunosuppression (e.g., because of HIV infection, malignancy, or chemotherapy)  are at high risk for the development of vulvovaginal candidiasis. In addition, up to 70% of patients who receive antibiotics for more than 10 days are affected by this infection.  Lactobacilli have been shown to regulate the growth of candidal organisms in the vagina. When the concentration of lactobacilli declines, the growth of candidal colonies increases. Vulvovaginal candidiasis is often recurrent.

It is important to note that vulvovaginal candidiasis is not associated with sexually transmitted diseases and is not itself considered a sexually transmitted disease.  Patients with this infection report a nonmalodorous discharge,  and many complain of a burning sensation of the vulva.  The symptoms may be worsened by intercourse.  Typically no discharge is present at the introitus. In the vagina, the discharge usually appears whitish and floccular, is very viscous, and adheres to the vaginal walls. Slight bleeding may occur when the discharge is removed. The vulva often becomes red and moist, with an inflammatory reaction that extends to the labial-crural folds, and cheeselike deposits are often present in the vagina.

The diagnosis of vulvovaginal candidiasis is made by inspection and may be confirmed using a potassium hydroxide slide preparation (vaginal discharge diluted with saline and 10% potassium hydroxide). In 70% of affected individuals, hyphae or budding yeast cells are seen when the slide is examined under a microscope.  Diagnosis by the above criteria is sufficient to warrant initiation of treatment;  cultures are occasionally needed if the patient does not respond to traditional treatment.

Treatment options for vulvovaginal candidiasis are shown in Table 15-1.

Cure rates are similar for the oral and vaginal treatments, so many providers inquire about patient preference before prescribing treatment. Cure is often aided by avoidance of tight clothing like pantyhose.

Table 15-1.  Treatment of Common Genital Tract Infections

Treatment of sex partners is unnecessary except in the case of uncircumcised partners, who may harbor the infection under the prepuce, and in cases of persistent or recurrent disease. In patients with four or more episodes in 1 year, 150 mg of fluconazole for 3 days followed by 150 mg of fluconazole weekly for 6 months has been shown to be effective.

Elizabeth R. Keeler, Pedro T. Ramirez, and Ralph S. Freedman
Committee on Gynecological Practice, the American College of Obstetricians and Gynecologists. Obstet Gynecol 2007

References