Three Difficult-to-Diagnose Forms of Chronic Vaginitis
Three forms of treatment refractory chronic vaginitis to consider: atrophic vaginitis, desquamative inflammatory vaginitis and genital graft vs. host disease
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Most commonly infectious in origin, vaginitis is a spectrum of conditions associated with vaginal itching, pain, burning and discharge, including candidiasis, bacterial vaginosis and trichomoniasis. In chronic vaginitis, the same symptoms last six months or more. Many times these issues become chronic because the symptoms may be intermittent, or the patient has self-treated with over-the-counter hydrocortisone creams and antifungal suppositories before seeing a physician.
These conditions are generally manageable once diagnosed, as they are often the result of a change in the normal balance of vaginal bacteria or reduced estrogen levels. The most common forms of chronic vaginitis are atrophic vaginitis (genitourinary syndrome of menopause) and desquamative inflammatory vaginitis. In rare circumstances, chronic vaginitis symptoms may indicate genital graft versus host disease.
Atrophic vaginitis is generally a post-menopausal condition related to declining estrogen levels, which leads to thinning and inflamed vaginal walls. Patients with atrophic vaginitis frequently feel vaginal dryness, itching, irritation, dyspareunia and burning with urination. When taking a patient’s history, it is important to discuss the subtle difference between burning during urination (which may indicate a urinary tract infection) and burning after urination. Many women with atrophic vaginitis will report burning with urination, and sometimes burning after urination, but have negative urine cultures.
A diagnosis of atrophic vaginitis is generally based on symptoms, though sometimes a urine culture, vaginal screen for infectious causes and vaginal pH may be indicated to help rule out other issues. Women with atrophic vaginitis will have a pH of >4.6.
Atrophic vaginitis is managed with either hormonal or non-hormonal treatments. For women seeking relief from dyspareunia, there are a number of over-the-counter vaginal moisturizers and lubricants available, including water- or silicone-based lubricants, extra-virgin coconut oil or olive oil.
Topical hormone therapy is the next step for patients who fail non-hormonal therapy, and may come in the form of a vaginal estrogen pill, cream or ring. All forms of intravaginal topical estrogen are comparable. Generally, this decision comes down to patient preference and insurance coverage. The only time I prefer cream is when the patient has significant vulvar atrophy and needs to apply cream on the urethra, vestibule and introitus.
Some patients will also benefit from selective estrogen receptor modulators (SERMs), which have been approved by the U.S. Food and Drug Administration for the treatment of moderate to severe vulvovaginal atrophy. In patients for whom estrogen is contraindicated, I recommend vaginal prasterone, which is a steroid—dehydroepiandrosterone (DHEA)—indicated for treatment of moderate to severe dyspareunia and atrophic vaginitis. Regardless of the hormone therapy suggested, I prefer topical treatment over oral for the management of genitourinary syndrome of menopause or atrophic vaginitis, as it has fewer systemic effects.
Patients for whom hormonal treatment is not an option or is ineffective may benefit from low-dose radiofrequency thermal therapy.
Approximately 8% of patients with symptoms of chronic vaginitis have desquamative inflammatory vaginitis. This condition is often missed or misdiagnosed as trichomoniasis, as it has similar symptoms, including yellow-greenish discharge, itching and burning (sometimes unrelated to urination), redness and dyspareunia. On physical exam, patients have purulent discharge that may be copious, redness of vulva and vagina, some contact bleeding with speculum insertion. The vaginal pH is >5. Saline microscopy reveals leucorrhea, which may obscure the vaginal epithelial cells, and parabasal cells (parabsasal cells are immature cells seen in hypoestrogenic patients).
It is a diagnosis of exclusion (infections should be ruled out), and most patients would have been treated for infectious causes multiple times with no or partial resolution of symptoms. Treatment for desquamative inflammatory vaginitis is a 4-6 week course of 2% intravaginal clindamycin. For patients with parabasal cells, introduction of vaginal estrogen—possibly compounded with the clindamycin—should be considered. The next line of therapy for patients failing this would be intravaginal 10% compounded hydrocortisone cream for 4-6 weeks. A few patients may relapse and require maintenance therapy of intravaginal hydrocortisone as well as vaginal estrogen. These patients should be referred to vulvovaginal experts.
Genital graft versus host disease is a common complication experienced by about 25%-50% of allogeneic blood and marrow transplant (BMT) recipients. It is important to inquire about vaginal symptoms, such as itch, dryness, dyspareunia and burning with urination, as patients may feel that these symptoms are minor when faced with such serious procedures. Physical findings include purulent discharge and changes from the normal vaginal anatomy. They may complain of vulva and vaginal itching and dryness, dyspareunia and contact bleeding. If left undiagnosed and untreated, genital graft versus host disease may lead to vulvovaginal atrophy, vulva synechaie and vaginal stenosis. Treatment includes: non-hormonal lubricants; topical and vaginal corticosteroids; topical, vaginal and sometimes oral estrogens; and patients with vaginal stenosis may sometimes require surgery. Patients should be referred to vulvovaginal experts.