Infections and STD
Infections unique to the female underscore the specialized capabilities of her gender. Genital and urinary tissues interdigitate anatomically to provide sexual arousal and function, conception, reproduction, and elimination of waste. The immune response in the pelvis and external female genitalia is different from anywhere on or in the rest of her body. This is demonstrated by the ease with which herpes is acquired or warts develop only in some areas, yet episiotomies seldom get infected even though exposed to feces. Moles have a fivefold increased risk of becoming malignant on the skin of the vulva than anywhere else on her body, which is of course immunology. The vagina in particular presents a unique environment--not quite internal, not quite external. Because infections of different types often rage with the same symptoms, it is often a challenge for the gynecologist to sort out what is really going on. Sometimes this is with mixed success; nevertheless, there are protocols that will properly guide a woman to the proper treatment.
There's A Fungus Among Us
Yeast is a fungus--a living organism that is everywhere. It's in the air, on the soil, and probably on the clothes you're wearing. You breathe in buds of yeast at times. It's not a very aggressively infecting organism, but give it the right conditions and it'll take hold firmly. Any warm, moist place is a good site for yeast. Infants get it as diaper rash on their bottoms and as thrush on their tongues. Men get it as "jock itch."
In women it causes a burning, itchy sensation in the vagina and outside tissues. Many women are carriers anyway, an "infection" being nothing more than an overgrowth of their normal amounts of yeast. Conditions that make a woman a likely host are many. There are "good germs" called lactobacilli, bacteria that are normal for the vagina. They love to eat yeast and thereby keep the fungal population in check. Antibiotics, taken to kill bacterial infections elsewhere, also kill the lactobacilli, and suddenly the yeast have nothing to keep them in check. I often have prescribed anti-fungal pills, creams, or suppositories preventatively in women taking antibiotics.
Estrogen is conducive to yeast growth. That is why pregnant women and those on birth control pills are prone to infection.
Douching is probably the most worthless, damaging thing a woman can do to the delicate tissues of her body. It was probably invented by a man.
When a woman douches she leaves moisture in a dark environment and voila!--yeast. Besides that, she also washes away her body's natural defenses. Feeling temporarily refreshed, she's washed away the helpful lactobacilli, too. The women in my practice who have had the absolute least amount of problems with discharges or odor are the ones who have never douched in their lives. One must remember that the tissue of the vagina is identical to that inside the nose. No one makes a habit of squirting vinegar and water up her nose, even when it's bloody. The body has a way of cleansing itself, and douching defeats this ability.
Yeast infections can be particularly difficult to treat sometimes. Often the cream or suppository used is a harsh chemical itself, curing the infection but leaving a chemical irritation such that the woman feels the treatment was a failure. She feels the same symptoms, burning and itching, from the chemical and falsely assumes she still has the yeast. In these cases, oral anti-fungals can be used, pills that eradicate yeast over the entire body. Besides not burning the delicate vaginal tissue, they also can eradicate yeast in the rectum, a likely source of re-infection. Also, pills afford the gynecologist the opportunity to treat the husband, as yeast also can be sexually exchanged.
Yeast can't be diagnosed over the phone. There are a lot of things that feel the same and must be suspected with yeast symptoms or when a yeast infection fails to respond to anti-fungals.Bacterial vaginosis and Gardnerella vaginitis, two bacterial infections, can mimic a yeast infection. These need different medications, so it's prudent to have a gynecologist examine a smear under the microscope before having someone spend money on the wrong treatment. An error can add weeks to medical management, so like most things in life, an evaluation should be done right.
Doctors Lose Patients to Terminal Vaginitis--To Other Doctors
Some parts of our skin are tougher than others. Something like vinegar, a weak acid, will roll off the skin on our backs but will burn when splashing the cornea, a specialized "skin" over our eyes. Like the eye, there are other areas whose "skin" is composed of or includes mucous membranes. The vagina is one such organ, covered with a delicate type of skin called mucosa, a complex environment consisting of a fragile balance of bacteria and chemistry. It doesn't take much to alter it from the normal, and these alterations can cause a range of complaints, from a change of moistness to incapacitating pain.
During my training at Charity Hospital, I was taught that a yeast infection was treated with a certain cream product, and we seemed to have great success with this. Or so it seemed. Of course, the nature of the clinic design there was such that a doctor never saw the same patient twice. We were deceived--there was no follow-up. Yeast was a simple problem there, but when I came to private practice I became troubled with a new phenomenon--what I call Terminal Vaginitis. Patients presented with their yeast infections, were treated, but then they came back the next week with the same complaint. And then again the next week. How could this be? After all, I prescribed the right cream, just like I did back at ol' Charity Hospital, right?
Thus began a series of different prescriptions for this cream or that suppository, abstinence from sex, stopping douching, or allowing douching with a "medicated" douche. I understood when a patient finally left me to seek another gynecologist, because it was obvious I wasn't helping her. But then I'd find out that her very next doctor tried the very first thing I had prescribed and cured her. Doctor number two looked like Jonas Salk and I looked like a charlatan. What to do?
Years of private practice do impart a certain wisdom that residency can't provide. I'd like to share my observations.
Many women cured with the first cream or suppository prescribed persist in their symptoms because now they have suffered a chemical "burn" of the delicate vaginal mucosa from the very medicine used. The symptoms are the same, so the patients return. Under my microscope, the yeast is gone but a lot of inflammation remains. It's tempting to try something else at this point, but the right thing to do is to just back off and allow the mucosa to heal from the chemical we used on it.
All cases of vaginitis need to be properly investigated with a microscope. Could it be a bacterial infection instead of yeast? If so, all of the yeast medicine in the world won't help. Could there be a mixed infection? Inflammation caused by yeast can hide a secondary bacterial infection underneath--discovered with a post-treatment microscopic look.
Is there a reinfection problem? Often yeast can be exchanged between husband and wife. After all, it's a fungus, which is why we wear foot thongs in public showers. Reinfection can also occur by transmission from the rectum to the vagina. It's not that a woman's personal hygiend is bad, it's just that the rectum is close to the vagina. Vaginal cream application after application will do nothing to resolve yeast in the rectum, so an anti-fungal pill will make sense under such conditions. The pill should also be given to her husband in these situations to clear his rectum as well.
Does the patient take antibiotics frequently, killing off the normal bacteria that normally keep the yeast in check? Is the patient washing out all of her natural defenses by the worthless, voodoo practice of douching? Could there be an allergy to fabric softener, perfumed tampons or toilet paper? Has the patient been screened for diabetes, famous for causing yeast overgrowth? Menopause, pregnancy, birth control pills all alter the pH and environment of the vagina. So what are the hormonal considerations? All of these things go through my head when I evaluate a woman for "terminal vaginitis." And even with all of this acquired wisdom, I still "lose" a patient to another doctor who begins, once again--and succeeds-- with step one. And for every patient that leaves me I receive one in return, and of course I begin with and succeed with step one, too.
But by the time a patient has been telephone-prescribed a remedy without the benefit of a microscope, has been burned with harsh antifungal suppositories, has been further traumatically damaged by the mechanical act of intercourse the first day she feels any improvement--by all this time it's a real mess. It's hard for men to understand, unless of course they've put lit cigarettes out by shoving them up their noses. The pain of inflamed mucosa can be that bad, guys, really. So, what's a woman to do?
What's a doctor to do?
- First and foremost, never douche. Never. Let your body keep house for you.
- Second, get a gynecologist to look under a microscope before guessing with a prescription that may prove worthless and expensive. No telephone medicine here, please.
- Third, consider the new pill antifungals. They'll clear out yeast from the rectum as well as the vagina, the rectum being a source of reinfection. The mucosa is spared exposure to harsh chemicals. They can be given to the husband as well, and they can be taken preventatively if prescribed antibiotics by a family doctor.
- Fourth, allow the vagina time to heal--don't let mechanical trauma of intercourse delay a cure so carefully implemented.
- Fifth, consider the unusual things. A biopsy may be necessary to rule out autoimmune tissue disorders or even precancerous changes. An opinion by an allergist or dermatologist may be necessary to diagnose unusual conditions that may go beyond the field of gynecology.
Terminal vaginitis can be one of the most frustrating conditions for both the patient and the gynecologist. It's easy for a patient to get caught in a merry-go-round of different doctors all pretty much following the same protocols. And frankly, there will be some cases that cannot be treated, as well as some that will cure themselves in spite of our modern medicine failures. But the approach to treating this very perplexing condition should be as delicate as the mucosa afflicted.
It May Not Always Be Yeast
Bacterial Vaginosis and other vaginal infections
In every day in every gynecologist's office, many women make appointments for vaginal infections they just can't seem to cure on their own. Previously prescription strength anti-fungals have now gone "over the counter," meaning that they can be purchased without a prescription. Almost all women assume that their vaginal irritation, or vaginitis, is due to yeast, so many select and apply these remedies. Unfortunately, there are other things besides yeast infections that can cause their symptoms of burning and itching. Piled on top of these irritations, a "chemical burn" from these harsh anti-fungals can only make things worse.
It's no wonder why women try these remedies first. Certainly yeast is the very famous cause of vaginitis, always blamed first, and it makes sense to many women to attempt eliminating this with an over-the-counter remedy before the time and expense of a doctor's appointment. But the disadvantage is that by the time there's a treatment failure and possibly a reaction to the anti-fungal as well, a gynecologist's evaluation may only be partially diagnostic. This is because he or she must place a smear under the microscope to actually see what the infection is. If the slide is cluttered up with too many inflammatory cells because of a tissue reaction to a harsh cream, the real culprit may be hidden. This can result in a misdiagnosis or no diagnosis at all.
Bacterial Vaginosis is a new name. It's been called many things in the past, but now most gynecologists agree that this collective term is most appropriate for frequent causes of non-yeast vaginitis. Literally translated, it means a condition wherein there is bacterial overgrowth in the vagina. It must be remembered that like the colon and mouth, there are many normal bacteria in the vagina as well. In fact, one of the causes of a yeast vaginitis is when there is a decrease in the normal bacteria that eat yeast, which is why antibiotics are famous for causing yeast infections. But when there is an overgrowth of other types of organisms, many of which are present as a normal condition in smaller numbers, vaginitis of the non-yeast variety can occur. Rectal bacteria and a vaginal germ called Gardnerella vaginalis are the usual causes of Bacterial Vaginosis. All of the yeast medicine in the world will do nothing to eliminate this infection. For this condition, typically two prescription creams are used. Metronidazole, or "Flagyl," cream is one of the first choices. The other is Clindamycin, or "Cleocin." Both of these effect high cure rates. Studies have shown that treating a woman's sexual partner does nothing to change the cure rate, indicating that this is probably not a sexually transmitted disease.
How serious is this infection?
Actually, pretty harmless. Most of the concern seems to be centered about a woman's comfort. Being pretty harmless, and in fact probably being an overgrowth of what may be normal vaginal bacteria for some women, most recommend not treating it at all in women with no symptoms. But in pregnancy, since the all of the causes of premature labor have yet to be defined, bacterial vaginosis should be treated whether there are symptoms or not. Luckily, both of the above remedies seem to be safe in pregnancy under most circumstances.
So if a woman misdiagnoses her condition as a yeast infection, uses an anti-yeast over-the-counter cream, and is wrong, she has wasted her money (they're not cheap), done nothing to treat her infection, and may have possibly worsened her condition with a chemical irritation. Although it's true that a lot of cases of vaginitis are yeast and a woman may be right on target with her choice and averted a doctor visit, playing "catch up" with the symptoms by a gynecologist makes treatment more difficult in cases of Bacterial Vaginosis.
What Ever Happened To Herpes? What is the Cure for Herpes?
It's still out there. It's impossible to tell just how prevalent herpes infections are, but only the media appeal has diminished now that AIDS has replaced it as the sexual disease of the 90s. Herpes simplex ravages on, spreading by sexual contact, leading to a painful outbreak of ulcerations which begin as vesicles. It then goes on to live in the nerves, "migrating" back along the nerve from time to time to irritate the skin or mucous membranes supplied by that nerve. During this time viral shedding is its most obvious, and it used to be considered the only time a person was contagious. But the person spreading it, now it seems, may have absolutely no symptoms at all--a very frightening revelation and a rebuttal for the patient who has been strongly reassured by his or her sexual partner that the blame lies elsewhere. We gynecologists are now seeing reports about the "silent carrier" who can spread the infection while sincerely denying any personal lesions. So it seems there is no longer any "safe time" to be sexually active with someone who has it.
The current drugs of choice are acyclovir and other related antivirals. They come in creams and tablets. They are anti-viral agents indicated for genital herpes, but they have only seemed to help, not really being a cure for the disease. Many patients claim this medication leads to fewer recurrences, and the recurrences seem to be milder.
Women have an extra burden with herpes infections. Besides the discomfort and unpredictability, there is significant danger to babies born of mothers infected. Newer statistics are being investigated, but studies in the past indicated that of babies born of mothers with a primary (a first) genital herpes infection (herpes gestationalis), half got the infection, and before the antivirals, over half of these infected infants died! These terrifying numbers have decreased dramatically since the introduction of neonatal treatments using acyclovir. Nevertheless, the danger is an important one, and in obstetrics the physician must think of both patients, mother and child. Even though survival of an infant is now the norm, there may still be seizures, mental retardation, eye problems, or meningitis. Treating a patient for painful blisters is one thing, but serious danger to a baby is quite another.
We start talking C-sections when there are lesions at term. We used to do weekly herpes cultures near the due date to reassure us for a planned vaginal delivery, but these have been abandoned because of their unreliability. Now, if there are no active lesions at or near term, one can assume the reasonableness of a vaginal delivery. If there's an outbreak at term, a C-section is usually done.
Management of herpes is confusing with pregnancy, because C-section, used to prevent complications from herpes, has it's own set of complications which can thwart the best intentions. On top of that is the newest revelation of "silent shedding" (see below). In herpes, the gynecologist has a tough job, but the obstetrician has it harder.
STDs--The Gift from the Goddess of Love
We used to call them "venereal" diseases. The origin of this word comes from the goddess of love, Venus. Interestingly, so does the word, venerate. Today, gynecologists call them sexually transmitted diseases, or STDs.
Frequently a patient will come to my office requesting to get "checked out." A foolish, regrettable, unprotected sexual encounter with someone she didn't really know well will haunt her, and she'll ask me to check her out for everything imaginable that may be sexually acquired. Unfortunately, I don't have a tricorder like on Star Trek, so I set out to evaluate her according to the current standards so as to give her peace of mind. This type of work up is time-consuming and expensive. But now that unprotected sex may involve death-defying risks, it's worth it.
The first thing I do is perform the usual routine exam. I check for inflamed lymph nodes and push on her liver. Lymph nodes can enlarge with any infection from an area of the body that drains their way. The liver can indicate hepatitis, one of the deadliest risks from sexually transmitted disease. It's ironic that most people fear AIDS, because age-old hepatitis can be quite lethal. The pelvic exam is done to see if there's any undue tenderness, indicating possible infection in the tubes from gonorrhea or chlamydia. In the course of the pelvic exam, specific cultures for gonorrhea and chlamydia are taken as well, and a pap smear is done which could show infection with Human Papilloma Virus, or HPV. HPV, a sexually acquired virus, can lead to cancer of the cervix, especially in smokers.
After the physical exam, two cultures, and pap smear, I perform what's called a "wet prep." Vaginal smears are put on slides to study under a microscope. This is the same test that can see yeast, but it's also used to diagnose sexually acquired trichomonas, an organism that can lead to severe burning and vaginal discharge as well as be passed on to other sexual partners.
Finished yet? Not really.
Next comes blood work. Syphilis is making a big comeback. The initial lesion is painless and therefore often missed. If undiagnosed during its first stages, a patient leading what she thinks is a normal life may one day develop severe neurological dysfunction as an end stage of this easy-to-cure disease. As mentioned above, the risk of hepatitis lurks as well, and blood tests can tell whether there is an acute infection as well as indicate whether there is something chronic going on. HIV infection, the virus that causes AIDS, is also a blood test. All of these tests need to be repeated some time later, as these diseases may take some time to show up. Especially the new fear, hepatitis C, which can wait years to kill a liver.
The pap smear should also be repeated later, just in case a pre-cancerous lesion from HPV was too early to be picked up or even missed altogether.
Unless there's an obvious lesion, herpes can't be diagnosed without a positive culture. But herpes cultures are frequently unreliable. Blood work may show the body's reaction to herpes (antibodies), but this STD is a loose end that only time can diagnose or exclude. Besides herpes and syphilis, there are other nasty skin lesions.
Molluscum contagiosum is a little organisms that can cause raised bumps that need to be scraped off of the labia, thighs, or perianal areas. HPV, besides precancerous lesions of the cervix, can cause genital warts (condyloma, plural--condylomata) which can be very difficult to eradicate. More exotic diseases can involve severely ulcerating groin lymph nodes. Suddenly, condoms seem like a good idea. Always.
Occasionally I'll have a patient tell me "he" won't want to have sex if she were to insist on a condom. She underestimates the power of testosterone. If she were to insist that the late Frank Sinatra himself come back from the dead to serenade their foreplay, he'd be grave digging before the lights went down.
Sadly, even condoms are no guarantee, but they certainly help the odds with all of these different STDs.
Some STDs can be diagnosed quickly; others take longer. The wet prep will give an answer immediately on trichomonas. The blood work takes a couple of days. The cultures can take the better part of a week. So the important question is does a gynecologist start treating a patient immediately while waiting for all of these results to come back? The people in academics might say no; treat only when you have a clear indication based on a culture. In private practice, however, a place where we see the same patients over and over, there's a more sensitive feeling of responsibility on our part. We're probably more inclined to start antibiotics to guard for syphilis, gonorrhea, or chlamydia right away, knowing we can stop treatment if all turns up negative. Of course, with some treatments it's too late to stop a medicine, because many protocols involve single doses of a pill or a shot. This becomes a case wherein a patient was exposed to antibiotics unnecessarily, and the academicians groan about making the world less safe because of the needless sowing of these antibiotics in the environment that may reap resistant bacteria. We may reap what we sow, but this pales in comparison with what goes on in third world countries where antibiotics are sold over the counter. Meanwhile, I may have to face a patient with infertility one day who may want to know if those few extra days of treatment might have made the difference. Probably not is the phrase that would be the correct answer, but still there is some dividing line between when her infertility was preventable and when it was not. Also, some tests and cultures are just plain wrong.
I don't blame a woman who doesn't want to take even the slightest chance with her health--fertility or otherwise. We private clinicians have had a very honorable battle with the academicians for a long time--it's quite traditional. They espouse what's right, we individualize for what's right for our patients.
HPV, Not Frogs
Of all of the sexually transmitted diseases, the one that seems to get the least amount of media attention is the condyloma. This is what was once called a "venereal wart." Today we know it as the lesion caused by the body's reaction to the Human Papilloma Virus (HPV).
Besides the presence of warts, there is also the chance that the body may react to this virus by another type of change--cancer. The cervix (mouth of the womb) for some reason has a special attraction to this virus, and its cells react by growing abnormally (what is called "dysplasia"). Not all dysplasias end up as cervical cancer, but all cervical cancers begin with dysplasia. The warts are icky enough, but the cancer can kill you.
We gynecologists have grown to respect the lowly wart. Whenever a patient presents with one or several, many of us now insist on a colposcopy. A colposcopy is a microscopic evaluation of the cervix which can direct a physician to biopsy certain areas that may be suspected of harboring the effects of HPV. The colposcope can also look over the walls of the vagina to see if there are any warts there as well. Regardless of what the Pap smear comes back, I generally feel safer by doing a colposcopy on any patient with condylomata (plural). Unlike the obvious presence of the genital warts, dysplasia on the cervix is a microscopic lesion which can't be felt or sensed by a patient. HPV involvement there depends on the thoroughness of the doctor.
There is a feeling among gynecologists that the cervix will probably harbor a "mother wart" which will seed the external skin with HPV, creating recurrences of genital warts no matter how many times they're burned, frozen, or chemically eliminated. Colposcopy will save the patient many trips to the gynecologist by pointing out which patients need to have the cervix treated too. The cervix, however, is very rich in blood vessels, so one can't just paint on the chemicals that are used on the skin. With such a rich blood supply, these toxins may get absorbed and can theoretically prove toxic. Therefore treatment to eliminate HPV from the cervix is more involved.
Currently there are three types of treatment of the cervix. It must be remembered that the cervix is an organ pretty important to the continuity of the human race--it's what holds in a pregnancy until it's time to deliver a mature infant. This means that extreme caution must be used when destroying any tissue in the cervix.
Thankfully, the three most popular treatments for cervical dysplasia are sparing of the cervix's important role in pregnancy. Freezing the cervix, done right in the doctor's office without the need for anesthesia, is a six-minute office visit. Laser, done with anesthesia and/or sedation, is tidier, because it doesn't cause the prolonged, messy discharge that freezing does. The newest technique, LEEP (Loop Electrocautery Excision Procedure), which can be done in a doctor's office with a local anesthetic, uses a small electrified loop of wire that slices out the superficial portion of the cervix that contains the lesion. All of these methods, done properly, will not damage the function of the cervix, and they each have the same success rate--about 90%.
Of course this means that 10% will have a treatment failure, necessitating a repeat therapy. But most of the recurrences of dysplasia after one of these procedures are due to re-exposure to the virus. If a woman is sexually active with a man who has HPV, and then is treated, and then in turn has unprotected sex with him, she will be re-exposed to the virus and may develop dysplasia or warts again. The male partner, therefore, must be checked out for warts before resuming sexual intimacy with her. And it really should be by a dermatologist--someone who likes to look at skin.
Of the three treatments mentioned above, laser has the advantage of also being used to zap the external skin lesions. Although many women have only cervical involvement with HPV, still the others with genital warts may want to choose laser for this benefit. After treatment, it's not uncommon for a few warts to pop up--warts that were not quite evident even under the microscope at the time of the treatment. But with the "mother wart" tissue of the cervix treated, follow-up treatment can be continued with topical gels the patient herself can use externally on these last remaining hauntings of HPV.
One of the newer topical treatments is Condylox Gel 0.5%, by Watson Laboratories. Given to the patient, she can use it at home with repetitive bursts of applications--a series of attacks on the warts that only repetitive office visits could provide in the past. This is also an excellent prescription treatment when there are external genital warts, but the cervix is free of HPV involvement by colposcopy. There are other topical applications, including one that beefs up the immune system over the wart, but the Condylox is an extension of the standard agent used for a generation by gynecologists.
Viruses cause warts, whether they be on the hands, elbows, or genital areas. But the ones involving the genital skin and cervix may be of particularly virulence to cause the pre-cancerous changes of dysplasia. The treatment must be aggressive and persistent. For some reason, only certain areas of the genital tract are stimulated by HPV to cause warty change or dysplasia. Immunology no doubt plays a role. We have not been able to explain, for instance, why just destroying those areas that responded to HPV in these ways generally rids the patient of the risk forever, when we know there is still remaining virus. Is it that only certain areas are immunologically deficient and therefore undergo this deformation? Is that why destroying the tissue in only these areas works? There is still much to learn about viruses and immunology in general; but until the time that the secrets are deciphered, the trick-bag of treatments we have are excellent.
The American Social Health Association, under contract with the Centers for Disease Control and Prevention, operates the National STD Hotline where patients can call in anonymously to receive information and counseling. 1-800-227-8922