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Case 4.5 – Vulvovaginitis (Adolescence) [SDL]

Category: Endocrine & Reproductive Systems | Discipline: Obstetrics & Gynaecology | Setting: General Practice

Case

Joanna Grey is aged fifteen. She presents to her general practitioner complaining of a smelly vaginal discharge. She knows it smells because her brother has told her she 'stinks'.

Questions

1. Summarise the key steps in development in the following categories: breast, abdomen, uterus and tubes, ovaries, vagina, hymen, and vulva.

Breast (Thelarche)

  • Buds at birth
  • Occasional transient enlargement in response to in utero oestrogen - no investigations unless bilateral and PV bleeding
  • Biopsy of bud may lead to long term deformities
  • Tanner stages - 1 is 0-6 years of age and 5 is mature breast

Uterus and Tubes

  • At birth: Cx/Corpus ratio is 2-3:1
  • At puberty: Cx/Corpus ratio is 1:2
  • NB - may have withdrawal bleed in first 10 days of life due to withdrawal of (mother's) exogenous oestrogen

Ovaries

  • At birth - follicles <1cm but possible to have enlarged cysts (again - exogenous oestrogen withdrawal and postnatal surge of gonadotrophins)
  • About 5,000,000 follicles
  • Age 5 - ovaries begin to grow
  • Ovulation occurs after 12-15 cycles but beware not always! - think contraception

Vagina

  • Pre-pubertal vagina - 4 cm long, red (thin epithelium due to NO oestrogen), alkaline environment
  • Clear/pink discharge is possible and normal

Hymen

  • Prominent in newborn and well oestrogenised
  • Variety of canalisations
  • Puberty - will allow tampon entry (1cm canalisation)

Vulva

  • Hairless until adrenarche
  • Tanner stages 1-5 - significant racial differences in hair
  • At birth - prominent labia and clitoris but recedes until puberty (lack of oestrogen)
2. Describe the changes in appearance of cervical mucous through the menstrual cycle related to hormone changes.

Pre-ovulation

Nil until high levels oestrogen late in follicular phase and at ovulation. Mucous becomes copious, watery and stretchy resembling thin egg white.

Post-ovulation

Drop in oestrogen, rise in progesterone and mucous becomes thick and gelatinous.

3. List the infections that change the appearance of vaginal discharge and describe these changes and the treatment options.

Normal discharge: Clear to white. Normal amount of discharge varies.

Infection Organism Discharge Appearance Treatment
Candida (Yeast) Candida albicans White curd-like discharge - vulval pruritis
  • Nystatin vaginal creams/pessaries 7 days
  • Clotrimazole vaginal creams/pessaries
  • Oral antifungals
Bacterial Vaginosis Anaerobic - Gardnerella vaginalis, Bacteroides species Malodorous white-grey frothy discharge
  • Metronidazole oral/tinidazole
  • Vaginal clindamycin cream nocte 7 days
Trichomonas Anaerobic protozoon Trichomonas vaginalis Malodorous white to greenish frothy discharge
  • Single 2 gram dose metronidazole or tinidazole
  • Treat sexual partner
Chlamydia Chlamydia trachomatis Creamy cervical discharge/post coital bleeding
  • Single dose azithromycin 1 gram orally
  • Doxycycline 100mg BD 7 days (erythromycin 500mg BD in pregnancy)
  • Longer treatment if symptomatic
  • Treat partners in past 6 months
Gonorrhoea Neisseria gonorrhoeae Purulent cervical discharge
  • Single dose IM ceftriaxone 500mg
4. Taking into account the tone of her brother's comments outline the key steps in history, examination and investigation in this case.

History

  • Detail of discharge: smell, appearance and change through cycle
  • How long present, menstruation, menarche, intermenstrual and post coital bleeding
  • Follow up statement 'brother thinks she stinks'
  • Has there been inappropriate touching, sexual contact from brother or others?
  • Explore her knowledge of her own anatomy and its function
  • Violence against women can be overt as in sexual/physical abuse but also more subversive as derision towards menstruation, female genitalia
  • Has her self esteem been affected by the above?

Examination and Investigation

If sexually active:

  • Speculum examination of pelvis
  • Cervical, urethral and vaginal swabs
  • MC&S, Chlamydia PCR
  • Cervical Screening Test +/- cervical cytology (Co-test) if any IMB/PCB

If not sexually active:

  • First catch urine for gonorrhoea & chlamydia PCR
  • Vaginal swab without speculum
5. Outline the management options available when a woman reports past or present sexual or physical abuse.

Creating a Safe Environment

  • While taking a history, create an atmosphere of privacy, trust and empathy so a woman feels safe to discuss her situation
  • Be sensitive as this may be the first time in her life she has revealed these details
  • Do not be dismissive of her fears and explore the history she reveals

Safety Assessment

  • She may not be safe in her present environment
  • The police at her request may need to become involved

Referral

  • Referral to medical practitioner experienced in this area
  • Consider referral to appropriate support services and counselling