You see a 17-year-old female for a routine visit. She tells you she has been sexually active for 3 years and that her partners have used condoms, but not consistently. She has never had a Papanicolaou (Pap) test. You provide counseling regarding contraception and sexually transmitted diseases, and perform a gynecologic examination, including a Pap test (as insisted by the patient). The results of the test are reported as atypical squamous cells of undetermined significance (ASC-US).
According to the guidelines for Colposcopy and Cervical Pathology, which one of the following would be most appropriate with regard to the abnormal smear if HPV testing is unavailable?
Correct Answer A: The risk associated with abnormal results on cytologic testing vary with the age of the patient. Adolescents have a high prevalence of human papillomavirus (HPV) infection, but a very low risk for invasive cervical cancer. The vast majority of HPV infections will clear within 2 years after the initial infection, and have little clinical significance.
A 23-year-old woman presents with a chief complaint of foul smelling vaginal discharge. She is not sexually active. A wet mount and KOH prep are performed demonstrating clue cells.
What is the likely diagnosis?
Correct Answer B: Bacterial vaginosis shows clue cells on a wet mount (which are epithelial cells of the vagina that get their distinctive stippled appearance by being covered with bacteria). KOH prep would release a fishy odor.
Candida infection would present as thick, white, cottage cheese-like, non-odorous discharge. Diagnostic exam would show the yeast (hyphae and pseudo spores of Candida are visible) on the KOH prep.
Trichomonas is a sexually active disease. Presents with foamy, frothy yellow-green discharge, fishy/foul odor. A wet mount will show the Trichomonads, which are ovoid-shaped parasites, identified by their mobility.
You see a pregnant woman at 14 weeks gestation. She has a history of preterm labour in a previous pregnancy at 33 weeks. You perform a vaginal swab and it is positive for bacterial vaginosis, but she is asymptomatic.
What is the appropriate management?
Correct Answer A: There is significant evidence that links Bacterial Vaginosis with preterm labor. There have been many recent studies that have been conducted to verify this information and find a method of prevention. Other studies have also shown a possible link to miscarriages, low birth weight and premature rupture of membranes.
Treatment is highly recommended to avoid any chance of preterm labor. There are various treatments which include:
Tinidazole is not recommended for use during pregnancy.
Note: Clindamycin cream should be avoided during the second half of pregnancy because it can increase the risk of premature birth and other adverse outcomes. Use of Metronidazole is contraindicated in first trimester of pregnancy (1- 12 weeks).
A 26-year-old woman presents with vaginal discharge that has been smelly and bothersome. You perform a wet mount and diagnose bacterial vaginosis.
All of the following would be present, except:
Correct Answer D: Bacterial vaginosis will present with a thin, white, gray or yellowish cloudy discharge with a foul or fishy odor. Itching and irritation, gray discharge, pH > 4.5, fishy odor and clue cells will be seen on exam and testing.
A frothy discharge is more likely to be seen in a trichomonas infection.
Note: The normal vaginal pH is 3.8 to 4.5. Bacterial vaginosis, trichomoniasis, and atrophic vaginitis often cause a vaginal pH higher than 4.5.
Vaginal discharge which is fishy in odor and associated with > 20% clue cells on microscopy will not be associated with which of the following:
Correct Answer C: Bacterial vaginosis (BV) shows clue cells on a wet mount (which are epithelial cells of the vagina that get their distinctive stippled appearance by being covered with bacteria). Gardnerella vaginalis has been reported to occur in up to 100% of women with signs and symptoms of BV and in up to 70% of women with no signs or symptoms of BV. Vaginal odor is the most common, and often initial, symptom of bacterial vaginosis. Increased vaginal discharge is typically mild to moderate. Vulvar irritation is less common. Dysuria or dyspareunia occur rarely.
The normal vaginal pH is 3.8 to 4.5. Bacterial vaginosis, trichomoniasis, and atrophic vaginitis often cause a vaginal pH higher than 4.5.
Antibiotics are the mainstay of therapy for bacterial vaginosis. Medications include metronidazole, clindamycin oral or vaginal suppositories, and metronidazole vaginal gel. Asymptomatic women with Gardnerella vaginalis colonization do not need treatment.
→ Candida infection would present as thick, white, cottage cheese-like, non-odorous discharge. Diagnostic exam would show the yeast (hyphae and pseudo spores of Candida are visible) on the KOH prep.
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