Vaginal Discharge and

Vulvar Disease
MELODY NOLAN, MD, FACOG
Disclosures
I have no financial relationships or affiliations to disclose.
Objectives
Vulvar Hygiene and Normal Vaginal Flora
Vulvovaginal Candidiasis
Bacterial Vaginosis
Trichomoniasis
Atrophic Vaginitis
Vulvar Care
Vulva – Mons, labia majora, labia minora, the
clitoris, urethral and vaginal openings and the
perineum
Daily habits can irritate the vulva causing itching
and burning
Scratching, frequent washing, over the counter
products can worsen itching and pain
Urinary incontinence can irritate the vulva
Prevention: stopping the offending product or
habit
Vulvar Care continued
Bathing – use hands only to wash, pat dry; unscented soaps, no bubble baths; avoid baby wipes,
personal wipes, sprays/perfumes, avoid douching
Menses – avoid pads/panty liners every day; if not option use unscented products only
Clothing – unscented laundry detergent; cotton underwear; loose fitting clothing; consider no
underwear at night
Avoid scratching the area
Petroleum jelly on vulva after bathing or sitz-bath for comfort; (do not use with condoms);
Prescribe antihistamine to prevent itching
Normal Vaginal Flora
Vaginal Microbiome
In prepubertal and postmenopausal women the vaginal epithelium is thin and pH of the vagina
is >4.7
During reproductive years the presence of estrogen increases glycogen content in epithelial cells
– encouraging colonization of lactobacilli; pH <4.7
Evaluate: focused history on vaginal symptoms
Physical Exam: evaluate vulva and speculum exam
◦ Samples for vaginal pH, Amine “whiff’ test, saline (wet mount) and 10% potassium hydroxide
microscopy
◦ Samples collected from mid-portion of vaginal side wall
◦ Test for chlamydia and gonorrhea
Vulvovaginal Candidiasis
Symptoms – itching, burning, irritation,
whitish thick discharge
Visualize pseudo hyphae on saline or 10% KOH
microscopy
Candida albicans,
C. glabrata
C. tropicalis
Vulvovaginal Candidiasis
Classification of Candidiasis
Standard Treatment Topical clotrimazole (2%), miconazole (1%) for 7 days; Oral fluconazole
150mg x1

Complicated Treatment: 150mg fluconazole with repeat dose 3 days later, increases cure rate
from 67% to 80%.
Recurrent Treatment: 150mg Fluconazole once weekly for 6 months; successfully treat 90% of
symptomatic episodes and lead to prolonged protective effect in 50% of women
Vaginal Boric Acid 600mg capsules daily for 14 days – effective in treating azole failures
Bacterial Vaginosis
Polymicrobial infection marked by a lack of
hydrogen peroxide-producing lactobacilli and
overgrowth of facultative anaerobic organisms
Associated with infections of the female
reproductive tract: pelvic inflammatory
disease, post procedural gynecologic
infections and acquisition of HIV and herpes
simplex virus infections
Symptoms: abnormal discharge, fishy odor,
grayish discharge
Bacterial Vaginosis
Amsel’s Criteria
- Abnormal gray discharge
-pH >4.5
-positive amine test
->20% of the epithelial cells are clue cells

Treatment:
Metronidazole – 0.75% gel, 5gm daily for 5 days
500mg PO, 500mg twice daily for 7 days
Clindamycin – 300mg PO, 300mg twice daily for 7 days
2% cream, 5gm daily for 7 days
Trichomoniasis
Very common STD – abnormal discharge, itching,
burning and postcoital bleeding
Pale green, watery discharge
Vulvar erythema, cervical petechia
Wet mount sensitivity (55-60%); trichomonas
culture and antigen testing (~90%)
Motile, pear-shaped, flagellated protozoa
Trichomoniasis
Treatment for patient and her partner
Metronidazole 500mg, 4 tablets x1
◦ 500mg, twice daily for 7 days

Tinidazole 500mg, 4 tablets x1

Adverse pregnancy outcomes: preterm delivery,

premature rupture of membranes, low birth
weight
Atrophy
Most common in postmenopausal women,
symptoms of discharge, dryness, itching,
burning or dyspareunia. Found in women with
prolapse
Elevated vaginal pH and presence of parabasal
or intermediate cells on microscopy; negative
amine test
Most likely cause of postmenopausal bleeding
Atrophy
Atrophy Treatment
Moisturizers and lubricants
◦ Replens, Vagisil Feminine, Feminease, K-Y Silk-E
◦ Water soluble – Astroglide, Slippery Stuff, K-Y Jelly
◦ Silicone and Oil based

Mechanical Measures – sexual activity and vaginal dilators

Vaginal estrogen therapy
◦ Cream – Premarin, Estrace

Other
Smoking cessation
Oral Vitamin D
Case 1
22 y/o G1 presents to the office for her first prenatal visit. Her last menstrual period was 11
weeks ago. She has concerns with more than usual vaginal discharge and itchiness. You perform
a speculum exam showing discharge that is frothy yellow-green. Cervical petechial is also noted.
What do these findings suggest?
Bacterial Vaginosis
Vulvovaginal candidiasis
Normal discharge
Trichomoniasis
Case 2
A 25 y/o female presents with recurrent vaginal discharge. She has been treated for Bacterial
vaginosis for four times in the past year, and you have a high suspicion for BV as her current
diagnosis.
BV recurs in 1/3 of women within 3 months of treatment and ½ of women after 6-12 months.
Recurrent BV is defined as greater than or equal to 3 episodes of BV in a year.

Name three risk factors of acquiring BV.

When a patient has BV, which STIs is she at greater risk acquiring?
BV Suppressive Therapy
Following treatment per CDC :
Intravaginal boric acid 600mg daily for 21 days
Metronidazole 0.75% gel twice weekly for 4-6 months
Monthly oral metronidazole 2gm administered for fluconazole 150mg for 6 months

Limited data on optimal management

Case 3
A 45 y/o woman, G2P2 with most recent HbA1c of 8.5% presents with vaginal discharge,
irritation and itching for 4 days. She reports pain with sex.
Physical exam demonstrates swelling of the vulva, erythema and thick, white, curdy vaginal
discharge.

What is your diagnosis?

What test would you perform to confirm this diagnosis?
What are risk factors for complicated vs uncomplicated?
Vulvar Disease
Manifest in vulvar pain, pruritus, erythema, bleeding, dystrophy or lesion

Differential Diagnosis Extensive:

•Blemishes and Cysts
•Infections
•Inflammatory Diseases
•Vulvar cancer
•Pain syndromes
•Ulcers
Blemishes and cysts
Epidermal cysts
Bartholin’s cyst
Skene’s Duct cyst (paraurethral)
Moles/varicosities
Cysts – Epidermal, Bartholin’s, Skene’s
Moles, Varicosity
Infections
Genital warts
Herpes simplex
Tinea cruris
HPV Genital Warts
Estimated lifetime risk of visible genital warts in women is 4.2%
Rough, scaling surface, skin colored or slightly brown;
◦ Four types: keratotic (square shaped); filiform (taller than wide); Flat-topped (wider than tall) and
nodular (spherical)
◦ Easily recognizable, biopsy flat-topped and nodular types or warts to ensure no dysplasia;

Evaluation of cervix, vagina and anal verge especially in immunocompetent and

immunosuppressed patients
HPV 6 and 11 account for >90% of external genital warts
Treatment with Podofilox, imiquimod, podphyllin, trichloroacetic acid
Procedures: cryotherapy, excision, electro-surgery, laser ablation
Herpes Simplex Virus
HSV Type 1 and 2 responsible for oral and genital lesions – significant stigma and
embarrassment
Sexually transmitted, 50 million people in the US are affected
The virus may shed during a symptomatic outbreak, but shedding has been detected in
asymptomatic women with history of genital HSV on about 5% of days when no lesions are
present
Primary HSV exhibits widespread vesicles and erosions which may occur on the vulva, vagina,
cervix; significant pain, swelling, and inability to urinate; bilateral lymphadenopathy, fever,
myalgias and headache; May take 2 weeks for blisters to heal
Recurrent HSV – prodromal symptoms (tingling, burning, itching) followed by red vesicopapules
and vesicles lasting 3-5 days
HSV
Diagnosis:
◦ HSV culture – unroof blister and collect
◦ PCR for HSV

Treatment:
◦ Place foley, topical lidocaine, Valacyclovir 1gm BID
for 7-10 days;
◦ Acyclovir 400mg TID for 7-10 days

◦ Recurrent episodes
◦ Acyclovir 400mg TID 5 days
◦ Valacyclovir 1gm Daily for 5 days
Tinea Cruris
Cutaneous fungal infection of hair bearing skin
Red, well-demarcated, scaling plaques on thighs, extending to buttock
and mons
Confirmed on microscopic exam of KOH, culture or response to
therapy

Mild disease without fungal folliculitis – any azole cream twice daily
until clear
More extensive disease, presence of folliculitis – fluconazole 100-
200mg weekly for 2-4 weeks; ketoconazole 200mg daily until clear

Restart topical cream at first sign of recurrence

Inflammatory Vulvar Disease
Lichen Simplex Chronicus/Sclerosus/Planus
Pemphigoid gestationis
Pemphigus vulgaris
Eczema and psoriasis
Hidradenitis suppurativa
Lichen Simplex Chronicus
Intractable itching/scratching; evidence of nighttime scratching; visible excoriation,
psychological factors may play a part (stress exacerbates)
Rule out underlying dermatoses and vulvar intraepithelial neoplasia; with biopsy rule out
psoriasis
Remove environmental triggers, symptoms will wax and wane over months to years if left
untreated; while treatment is successful, recurrence is likely after therapy stopped
Treatment: bathtub soaks/lubrication; mid-high potency topical steroids, hydroxyzine in evening,
consider systemic steroids, consider daytime SSRIs
Lichen Simplex Chronicus
Lichen Sclerosus
- common disease in 3% of incontinent women, affects mainly postmenopausal women
- Itching, frequently excoriation and excoriations on the skin produce tearing and abrasions
- Sharply well-demarcated plaques, white, affects clitoris, vulva, perineal body and perianal skin;
usually spares the vestibule;
-Pathognomonic ‘crinkling of the skin’ or ‘cellophane paper-type’ appearance;
-Scarring and lichenification occur
-Associated with vulvar squamous cell carcinoma (up to 5% of women develop)
Lichen Sclerosus
Lichen Sclerosis
Treatment: Clobetasol propionate ointment
Apply sparingly to affected area twice daily
until skin texture normalizes – may take 3-4
months
When skin texture normalizes decrease use to
twice weekly
Tacrolimus is an alternative – no atrophy,
steroid dermatitis or rosacea; ease and use of
compliance; may burn with application, slower
onset of action
In postmenopausal women consider premarin
In prepubertal girls, limit
ultra-potent topical
corticosteroids; in eroded
or excoriated skin treat if
there is bacterial or fungal
infection
Biopsy all hyperkeratotic
lesions – tendency to
evolve into squamous cell
carcinoma
Lichen Planus
Occurs in 1% of people and approximately 57% of women with oral lichen planus exhibit
vulvovaginal disease
Mucous membrane demonstrates erosions, white, reticulate lacy striae, solid white epithelium
More extensive, affecting all areas of the vulva and extending into hair-bearing skin
Most common in postmenopausal women
Lichen Planus
Lichen Planus
Avoid irritants to include topical anesthetics and washing too frequently
Topical corticosteroids twice daily to vulva;
Prevent and treat yeast when needed
Systemic therapy includes hydroxychloroquine (Plaquenil) 200mg BID – easy to administer and
monitor, methotrexate, azathioprine
Additional of topical estrogen cream 3-4 nights weekly can minimize discomfort and scarring;
use vaginal dilators if not sexually active
Initial close interval follow up for treatment and develop of side effects
Pemphigoid gestationis
Rare autoimmune bullous disease, 1 in 40,000-60,000 pregnancies;
Occasionally associated with trophoblastic tumors, hydatidiform mole and choriocarcinoma
9wks gestation to 1 week postpartum
Diagnosis – Vesiculobullous eruption on urticated erythema, papules and plaques
◦ Conspicuous abdominal involvement with umbilicus
◦ No association of skin lesions to striae
◦ Postpartum flare 75%, neonatal skin involvement 5-10% (usually mild and transient)
Pemphigoid gestationis
Treatment – relieve pruritus and suppress blister formation

Pre-bullous stage – topical corticosteroids, antihistamines

Bullous stage – high-dose systemic corticosteroids; increase dose immediately following

delivery to prevent postpartum flare

Risk of flare with COC use and may recur in subsequent pregnancies
Pemphigus vulgaris
Autoimmune blistering disease, common in
middle-aged women
Affects mucous membranes; lesions appear as
superficial erosions then become thin roofed
blisters, causes scarring of the vulva
Confused with lichen planus and blistering
erythema multiforme
Diagnose: routine and direct
immunofluorescence biopsy
Treatment: systemic and topical steroids
Psoriasis
Disease of autoimmune etiology affecting 1-
3% of the population
Occurs in all ages, races; obesity and
alcoholism are more prevalent in patients with
psoriasis
Intense itching, fissuring and cracking of the
skin; well demarcated shiny plaques
Thickened skin of psoriasis appears white in
skin folds, mimics candidiasis
Treatment with topical steroids, systemic
medications in severe cases
Hidradenitis suppurativa (HS)
Chronic follicular occlusive disease – recurrent
deep-seated papules, nodules and abscesses
located primarily in the axillary,
inframammary, genitocrural, perineal and
perianal regions
-inflammatory, erythematous, severe cases –
sinuses and fistulae development as well as
hypertrophic scarring
-1% of the population, more frequent in
African Americans than Caucasians, more
common in females
HS Treatment
Stage 1: topical and oral antibiotics 1% Stage 3 - systemic steroids prednisone 20-
clindamycin lotion BID; tetracycline, 40mg daily, cyclosporine 4mg/kg daily, surgical
doxycycline, clindamycin; excision of affected skin with primary closure
of flap
Zinc gluconate 50mg/day for prevention
Yasmin or spironolactone
Loose clothing, smoking cessation, weight loss,
avoidance of environmental irritants, dietary
changes
Stage 2: higher dose antibiotics for at least 3
months; intra-lesional triamcinolone, surgical
unroofing
Cancer
Basal Cell
Squamous
Melanoma
HPV – covered in infections
Basal Cell Cancer
Most common cancer occurring in humans, nearly all cases on sun exposed skin
Vulvar basal cell - account for 3% of vulvar cancers, average age at diagnosis is 70; average size is
2 cm, symptoms include mass, itching – ulceration/pain and bleeding when cancer progresses
Predisposing factors: exposure to ultraviolet light, chronic irritation, prior radiation therapy,
immune deficiency and genetic component
Treatment: wide local excision
Prognosis is good with rare metastasis
Basal Cell Carcinoma
Squamous cell cancer
Accounts for 5% of genital cancers in women, incidence has risen
Develops in the setting of VIN – vulvar intraepithelial neoplasia; scaling or crusted plaques and
nodules, ulceration is very common; Lesions are 1-4 cm at the time of diagnosis
Associated with lichen sclerosus or lichen planus
History of CIN, HIV and other immunosuppression also a risk factor
HPV related about 20% occurs in younger women with warty or basaloid VIN precursor lesion
Non-HPV related about 80% occurs in older women and associated with lichen
Squamous Cell Cancer
Melanoma
2nd most common vulvar malignancy,
decreasing in incidence
More common in white women, ages 50-80
Pigmented, elevated, polypoid nodules,
ulceration, decreased pigment and multifocal
lesions may occur
Most found on clitoris, labia minora and inner
aspect of labia majora
Melanoma
Prognosis is poorer with 5 year survival rate of 25-50%,
dependent on the depth of invasion and node
involvement;
Depth <1mm – average for cutaneous while 3mm for
vulvar
Therapy – excision with 1-2cm margins, risk of
recurrence is high; sentinel node biopsy also helps
determine prognosis
Pain syndromes
Vulvodynia
Vaginismus
Vulvodynia
Women report burning, stinging, stabbing/tearing; pain with intercourse, tight clothing, wiping,
tampon insertion
Pain ranges from mild to severe
Physical exam demonstrates erythema of the vulva but is otherwise unremarkable
Classified as provoked and spontaneous
Exclude diabetic neuropathy, postherpetic neuralgia and pudendal neuralgia
Pathogenesis multifactorial: neurologic abnormalities, pelvic floor dysfunction, irritant contact
dermatitis, inadequate estrogen effect and psychosexual factors
Vulvodynia treatment
Nonspecific therapy
◦ Patient education, National Vulvodynia Association
◦ Counseling
◦ Avoidance of irritants and unnecessary topical agents
◦ Lidocaine jelly 2% or ointment 5%

◦ Medication: Amitriptyline/gabapentin/venlafaxine
◦ Pelvic floor physical therapy
◦ Surgery with removal of the vestibule if medical treatments have failed and pain only at the vestibule
Ulcers
Aphthous ulcer
Behcet’s Disease
Aphthous Ulcer
Oral aphthous ulcers common with a lifetime incidence of 60%;
Risk factors: white race, family history, psychological stress
factors, vitamin and iron deficiency
Most vulvar are herpetiform aphthous ulcers – multiple, cluster,
shallow and small 1-3mm
Individual lesions are round to oval but may coalesce with
neighbor lesions; very painful , take 2-3 weeks to heal
Aphthous Ulcer
Apply lidocaine or silver nitrate for pain
Topical (0.5% clobetasol) or intra-lesional
(10mg/mL triamcinolone) steroids
Only 5% of patients respond satisfactorily to topical
agents
With systemic therapy, 88% of their patient
achieved 50% or greater improvement
Oral prednisone 40mg every morning for 7 days
Behcet’s Disease
Extremely rare; higher rates in Eastern Mediterranean and Asia
Criteria:
◦ Recurrent genital ulceration
◦ Eye lesions (anterior or posterior uveitis)
◦ Skin lesions

May also be associated with inflammatory bowel disease, lupus and other autoimmune diseases
Therapy for oral and genital lesions the same as that for complex aphthosis
Questions?
 Resources
American College of Obstetricians and Gynecologists. Guidelines for Women’s Health Care: A
Resource Manual. 2014.
American College of Obstetricians and Gynecologists. Vaginitis. ACOG Practice Bulletin Number 72,
May 2006; reaffirmed 2017.
Obstetric and Gynecologic Dermatology. 3rd edition. 2008.
http://www.midwife.org/ACNM/files/ccLibraryFiles/Filename/000000002192/Vulvar%20Care.pdf