Infections and STD
Overview
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.
Yeast
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.
Terminal Vaginitis
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? 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.
Herpes
What Ever Happened To 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