Types of Treatment

The type of treatment to be undertaken will depend on :

• General health of the patient.
• Age of the patient.
• Type of cancer.
• The stage of the cancer or the extent of spread at the time of detection.
• Size of the tumor.
• The wish to get pregnant.
• Whether the tumor is hormone dependent.
• Recurrence of cancer.
• Consideration of the side effects of various forms of treatment.

Surgery

Surgery is the mainstay of treatment for most types of female reproductive system cancers. The focus on treatment is to prevent pre-cancerous lesions progressing to invasive cancer. Pre-cancerous lesions may be treated with cold knife conization, laser conization, LEEP, laser vaporization, or cryotherapy. Women who have completed their family may prefer hysterectomy (surgical removal of the uterus). Women with early stage gynecologic cancer are usually treated with hysterectomy.

The types of surgery may include :

• Radical trachelectomy involves removal of the cervix, a portion of the vagina, and the pelvic lymph nodes. This method is preferred for women with small cervical tumors who wish to get pregnant in the future.
• Total hysterectomy is the removal of the uterus and cervix.
• Radical hysterectomy is the removal of the cervix and the tissues around it, uterus, and a portion of the vagina.
• Bilateral salpingo-oophorectomy is the removal of the fallopian tubes and ovaries on both sides. This may be done with total or radical hysterectomy.
• Lymphadenectomy is the removal of the lymph nodes near the tumor and may be done along with hysterectomy.
• Pelvic exenteration is the removal of most of the tissues and organs in the pelvis, including the bladder and rectum, along with radical hysterectomy.

Radiation Therapy

Radiation is a form of high-energy beam which is used to destroy the cancer cells or prevent it from multiplying. There are 2 types of radiation therapy which may be used alone or together. They are external beam radiation therapy, where the radiation is given by a machine from the outside, and internal radiation therapy (brachytherapy), where small devices containing radioactive material are placed near the tumor through the vagina.

Radiotherapy may be used alone or in combination with surgery or chemotherapy. It may be used at any stage of the disease. It is often used for treatment of recurrent cancers or as palliative therapy for giving relief from symptoms where a cure is not possible.

Chemotherapy

Chemotherapy uses anti-cancer drugs such as 5-FU, cisplatin, carboplatin, paclitaxel, and cyclophosphamide to destroy or stop multiplication of cancer cells. A single drug or a combination of drugs may be used, which may be given by mouth or through intravenous injections. Chemotherapy is more commonly used in the late stages of the disease when the cancer has spread to distant sites. It is also used for recurrent cancers and as palliative therapy. Chemotherapy may be used alone or in combination with surgery or radiotherapy.

Hormone Therapy

Hormone-dependent endometrial tumors may be treated with hormone therapy. Hormones or anti-hormones such as progestins, tamoxifen, gonadotropin-releasing hormone (GnRH) agonists, and aromatase inhibitors are used in the treatment of endometrial cancer.

Complications of Treatment

Complications of surgery may include general complications such as bleeding, infection, injury to adjacent tissues and organs such as the bladder and bowel, and anesthetic complications. After hysterectomy, a woman will not get her periods and will not be able to fall pregnant. Premature menopause, with hot flashes and other associated symptoms will occur with removal of the ovaries. Various emotional and sexual problems may arise following surgery. Intercourse may be difficult after treatment for vaginal cancer.

Complications of radiotherapy may include loss of appetite, fatigue, hair loss on treated area, diarrhea, nausea, skin reactions, and reduced white blood cells. Side effects will depend upon the amount of radiation and the site of treatment.

Complications of chemotherapy may include hair loss, tiredness, nausea, vomiting, diarrhea, fertility problems, and mouth and vaginal sores.

Complications of hormone therapy will depend upon the hormone used. Hot flashes, night sweats, weight gain, vaginal dryness, and osteoporosis are common side effects.

Diagnostic Methods

Ovarian cancer is often detected late because of the absence of symptoms in the early stages. Symptoms that are present are often nonspecific in nature. Also, there are no reliable early screening methods for detection of ovarian cancer and Pap tests can only detect ovarian cancer that has metastasized to the vagina or cervix.

Vaginal cancer is relatively rare and there may not be any symptoms in the early stages. The diagnosis of vaginal cancer is often missed or delayed since many of the symptoms are common to other gynecologic cancers and conditions such as fibroids or polyps. Diagnosis of vaginal cancer is usually made on routine pelvic examination or Pap test.

Early symptoms of cervical cancer such as abnormal vaginal bleeding and pelvic pain are often neglected. Regular Pap tests are very effective in detecting precancerous and early cancerous lesions of the cervix.

Uterine or endometrial cancer may be detected early by being alert to the signs and symptoms and by finding atypical endometrial cells on routine Pap tests. Yearly check-up from the age of 35 onwards is recommended for women at risk for hereditary nonpolyposis colon cancer (HNPCC).

Gynecologic History

The diagnosis of a female reproductive cancer begins with a gynecologic history and its evaluation. This includes menstrual history with special emphasis on abnormal vaginal bleeding. Pain related to menstruation or sexual intercourse, and sexual activities, pregnancy, and previous gynecologic disorders should be noted. Assessment of risk factors should be done.

Physical Examination

Physical examination should include a pelvic examination. A sample for Pap testing may be taken at this time. Any abnormality, growth, or tenderness may be observed during a pelvic examination. An abnormal growth in the back wall of the vagina may be detected by a rectovaginal examination.

Screening Tests

Screening tests may be done to look for cancers before the development of any symptoms.

• Papanicolaou (Pap) test – for detecting precancerous and cancerous lesions of the cervix.
• Screening for human papillomavirus (HPV) – a sexually transmitted disease which is considered a risk factor for vaginal and cervical cancer.
• Genetic screening – for women with personal or family history of breast, uterine, or colon cancer, or those with a close family member affected with ovarian cancer. Women with mutations in BRCA1 and BRCA2 are considered to be at high risk for developing ovarian cancer.
• Mammography – to exclude breast cancer, since there is a significant link between ovarian and breast cancer.

Diagnostic Procedures

• Colposcopy – an instrument with a magnifying lens (colposcope) may be passed through the vagina to view the vagina and cervix for any abnormalities. Endocervical curettage may be done during a colposcopy for obtaining tissue samples for biopsy.
• Biopsy – tissue samples are examined under the microscope for any cancerous changes. A biopsy can usually confirm or rule out the diagnosis of cancer.
• Ultrasound – to show presence of tumor and other abnormalities. A transvaginal ultrasound or a hydroultrasound may give better results.
• CT scan or MRI – may show in more detail the size of the growth. They are especially useful for detecting spread of cancer to lymph nodes and other organs.
• Positron emission tomography (PET) scan – to detect spread of cancer.
• Chest x-ray – to look for lung metastasis.
• Bone scan – when metastasis to the bone is suspected.
• Blood tests, especially to check for the tumor marker CA 125 which may be released into the blood stream by some ovarian and uterine tumors.
• Laparoscopy – proper visualization of the ovaries, uterus, fallopian tubes, and other structures within the pelvis and abdomen may be done through a laparoscope. Tissue samples for biopsy may be taken during this procedure.
• Hysteroscopy – to view the interior of the uterus and take samples for biopsy.

Causes of Premature Ovarian Failure

Under normal circumstances, the pituitary hormones FSH (follicle-stimulating hormone) and luteinizing hormone (LH) stimulate the ovaries to mature follicles. Although many follicles will mature simultaneously, normally one one will rupture to release an egg cell (ovum) into the fallopian tube. The ovaries produce estrogen and progesterone in preparation for pregnancy should the ovum be fertilized. If pregnancy does not occur, the estrogen and progesterone levels decrease, menstruation occurs and the entire menstrual cycle starts again.

The reason why the ovarian function ceases so early in life is not always clear. Women will experience a gradual decrease in ovarian function in the 30s which becomes prominent by the 40s. However, with premature ovarian failure there is a marked reduction in ovarian function before the age of 40. A hysterectomy is an obvious cause. Radiation therapy to the pelvis may cause damage to the ovaries that can lead to premature ovarian follicle. Other causes may not be as obvious. It is believed that a significant number of cases may be autoimmune in nature meaning that the body’s immune system is directed towards the ovaries as a result of antibodies formed against the ovarian tissue. There are several other risk factors that have also been identified and this includes :

• Family history
• Chemotherapy (cancer drugs)
• Pesticides
• Industrial toxins
• Cigarette smoking
• Genetic disorders like Turner’s syndrome

Signs and Symptoms

The symptoms are similar to menopause although periods may return and pregnancy is possible.

• Missed periods (amenorrhea) for months or even years.
• Diminished libido
• Vaginal dryness
• Hot flashes
• Night sweats
• Irritability
• Difficulty concentrating
• Sleeping problems

Premature ovarian function can also be associated with an increased risk of hypertension and other cardiovascular diseases, osteoporosis and hypothyroidism. The clinical features of these conditions may also be present.

Treatment

There is no specific treatment to restore ovarian functioning. By treating any underlying disorders the ovarian function may return. The aim of treatment is largely focused on preventing the complications associated with the low estrogen state. This can be achieved with estrogen-replacement therapy which may also involves the simultaneous administration of progesterone. Calcium and vitamin D supplements are essential to limit the reduction in bone density as osteoporosis is a major complication of premature ovarian failure. Infertility needs to be addressed separately but most conventional medication will not be effective and other options have to be considered.

Anatomy of the Vagina

The vagina is an elastic, muscular canal which connects the uterus and cervix to the outside of the body through the vaginal opening, which is partially closed by a thin fold of vascular tissue known as the hymen. The cervix protrudes inside and opens into the vault or upper part of the vagina. Most vaginal cancers occur in the upper third of the vagina. The vaginal wall is made up of the outer muscular layer and the inner mucosal layer. The mucosa of the vagina is lined by stratified squamous epithelium. There are no true glands in the vagina but the glandular or secretory cells in the lining of the vagina are responsible for producing and releasing secretions such as mucus.

Pathophysiology

Vaginal cancer usually begins on the surface of the vaginal epithelium. With time, as it invades the deeper layers of the vagina and the surrounding tissue, the bladder in front and the rectum behind may be affected by direct spread of the cancer. In later stages of the disease, spread to distant sites such as the lungs, liver, bone, and skin may occur through the blood and lymphatic vessels.

Types

More than 95% of vaginal cancers are squamous cell carcinomas, which are slow-growing cancers that originate in the squamous cells of the vaginal epithelium. These develop most often in women over the age of 60. Almost all other vaginal cancers are adenocarcinomas, which originate in the glandular cells. They occur more often in younger women and are likely to spread more rapidly than squamous cell carcinomas. The other rarer types of vaginal cancer are clear cell carcinoma (seen almost exclusively in women who have been exposed to DES while in their mother’s womb), melanoma, and sarcoma.

Causes and Risk Factors of Vaginal Cancer

The exact cause of vaginal cancer is not known. Women who may be more at risk are those over 60, infection with HPV, exposure to DES, and previous history of cervical cancer, vulvar cancer or ovarian cancer. Chemotherapy, radiation therapy to the pelvic area, immunosuppression therapy, and HIV/AIDS infection have been linked with development of vaginal cancer. Having multiple sexual partners, smoking, long-term use of vaginal pessary, and procidentia or complete uterine prolapse may be considered as other risk factors.

Signs and Symptoms of Vaginal Cancer

The diagnosis of vaginal cancer is often missed or delayed since there may not be any symptoms in the early stages. Also, some of the symptoms, when present, may be common to a number of other conditions. Quite often, vaginal cancer is detected during a routine pelvic examination or Pap test.

Abnormal vaginal bleeding is the most common symptom, of which postmenopausal bleeding is a common feature since vaginal cancer occurs most frequently in women over 60. Intermenstrual bleeding, post-coital bleeding, heavy menstrual periods, or vaginal bleeding unrelated to menstruation may be the other presenting complaints.

Other likely symptoms are abnormal vaginal discharge, painful intercourse, pelvic pain, or presence of a vaginal lump. Involvement of the bladder may give rise to urinary symptoms such as painful urination or blood in the urine, while rectal involvement may cause painful defecation and constipation.

Outlook

The outlook depends upon the type of cancer, age and health condition of the patient, and the stage and grade of the cancer when detected. Cancers detected while still confined to the vagina have better prognosis than those that have spread elsewhere.

Types of Abnormal Bleeding from the Vagina

There are different terms to describe the various types of vaginal bleeding that are considered to be abnormal.

• Metrorrhagia is the term for any bleed that does not occur at the time of menstruation. It is also known as intermenstrual bleeding.
• Menorrhagia is the term for prolonged menses or excessive.
• Polymenorrhea is the term for too frequent menstruation.

Causes of Abnormal Vaginal Bleeding

There are a host of possible causes and abnormal vaginal bleeding should be investigated further by a medical professional. The site of bleeding can be anywhere in genitourinary system and sometimes bleeding from the urethra is mistaken for a vaginal bleed. Some of the causes include :

• Gynecological Disorders
• Cancer of the vagina, cervix, or uterus
• Cervicitis
• Dysfunctional uterine bleeding (DUB)
• Endometriosis
• Foreign body in the vagina
• Injury of the cervix, vagina, or vulva
• Polyps of the cervix or endometrium (uterus)
• Polycystic ovary syndrome
• Uterine fibroids
• Vaginitis

• Non-Gynecological or Systemic Causes
• Hyperprolactinemia
• Hypothyroidism
• Bleeding disorders
• Medication like hormonal contraceptives and hormone replacement therapy.
• Intra-uterine devices (IUDs)

Pregnant Women

Vaginal bleeding is of greatest concern in pregnancy. It may be a sign of a threatened abortion or ectopic pregnancy if it occurs early in pregnancy. In late pregnancy, vaginal bleeding may be due to abruptio placentae or placenta previa which are very serious conditions that require careful monitoring or medical intervention. Sometimes a bleed in late pregnancy may occur with uterine polyps.

Babies and Young Girls

Vaginal bleeding in children is uncommon. When it does occur it infants it may be due to the estrogens from the mother’s circulation crossing the placenta and is then present in the baby after birth. This can cause vaginal bleeding in infants. In older children, vaginal bleeding should always be investigated first for the possibility of sexual abuse. Other causes may include vaginal or cervical warts, foreign bodies in the vagina or tumors. Sometimes puberty may occur at a much younger age than normal and this is known as precocious puberty.

Most cervical cancers are caused by the human papilloma virus (HPV), which is transmitted by sexual intercourse. Vaccines are available which can prevent infection with some strains of HPV responsible for cervical cancer. Practicing safe sex by using condoms can reduce the chance of HPV infection and other sexually transmitted diseases.

Early cases are treated by surgery, while more advanced cancer is treated better with radiation therapy, chemotherapy, or a combination therapy.

Anatomy, Physiology and Pathophysiology

The uterus is a hollow pear-shaped organ consisting of the body above and a narrow lower portion known as the cervix, which leads into the vagina. The upper portion of the cervix towards the uterus is the endocervix, while the portion protruding into the vagina is the exocervix.

The endocervix is lined by columnar cells while the exocervix is lined by squamous cells. The area where the 2 cell types meet, the squamocolumnar junction or transformation zone, is where most cervical cancers originate. 80% to 90% of cervical cancers are squamous cell carcinomas. Almost all other cervical cancers are adenocarcinomas, arising from the columnar cells of the endocervix.

In the precancerous stage the cells are in the transition phase from healthy to abnormal cells. This stage is known as carcinoma in situ, cervical intraepithelial neoplasia (CIN), dysplasia, or squamous intraepithelial lesion (SIL). If detected at this stage, timely treatment can prevent precancerous lesions from developing into cancer.

Invasive cervical cancer may present as cauliflower-like exophytic growths, firm nodular growths, infiltrative growths, or ulcerative growths.

Causes and Risk Factors of Cervical Cancer

• Infection with certain strains of HPV, which is spread through sexual intercourse, is a very important risk factor for development of cervical cancer.
• Age – precancerous lesions are more frequently detected in younger women, while invasive carcinoma is more commonly diagnosed in older women.
• Genetic – women with close relatives, such as mother or sister, who had cervical cancer.
• Race – African American women are at higher risk than Caucasians.
• Multiple sexual partners.
• Low socioeconomic status.
• Multiple childbirths.
• Smoking.
• Immunocompromised women, such as those suffering from HIV/AIDS.
• Sexually transmitted diseases, such as chlamydia.
• Long-term use of combined oral contraceptive pills.
• Daughters of women who took the drug diethylstilbestrol (DES) during pregnancy.

Signs and Symptoms

In the precancerous stage and in early invasive cervical cancer, symptoms are rarely present. Symptoms of cervical cancer are usually late to appear and even when it does, it is of a non-specific nature which may occur in other conditions such as uterine cancer, vaginal cancer, uterine fibroids, polyps, and other growths.

The common signs and symptoms are :

• The most common symptom of cervical cancer is abnormal vaginal bleeding, such as heavy bleeding, intermenstrual bleeding, post-coital bleeding or spotting. Also, postmenopausal bleeding in older women.
• Increased vaginal discharge, which may be watery, blood stained, or purulent, with a foul odor.
• Painful sexual intercourse.
• Lower abdominal or pelvic pain.
• Abnormal weight loss.
• Excessive fatigue.
• Loss of appetite.
• Anemia.
• Urinary problems.
• Rectal bleeding and pain.
• Constipation.
• Swelling of the legs.
• A lump felt in the cervix.
• Stony hard cervix.
• Cauliflower-like growth in the cervix which bleeds on touch.

Prevention

• Effective screening programs with regular Pap tests for all women starting from the age of 20.
• Screening tests for HPV.
• Vaccination against HPV.
• Use of condoms to prevent HPV and other sexually transmitted infections.
• Limiting number of sexual partners.

Outlook

Most cervical cancers are slow growing, so early detection and treatment can result in a high survival rate. Carcinoma in situ is totally curable.

Anatomy, Physiology and Pathophysiology

The uterus is a hollow pear-shaped organ which lies within the pelvis between the bladder in front and the rectum behind it. The broad upper part is the body of the uterus, while the narrower lower portion is called the cervix, which leads into the vagina. The body of the uterus consists of 2 layers, the inner lining known as the endometrium and the outer muscular layer known as the myometrium. Cyclical changes occur in the endometrium every month due to varying hormonal levels. During a normal menstrual cycle the endometrium thickens and is then shed every month, which is known as menstruation.

Hormonal imbalances, such as unopposed estrogenic stimulation, can lead to endometrial thickening, known as endometrial hyperplasia. Although reversible in the initial stages, persistent stimulation may lead to atypical hyperplasia, which may be a precursor of endometrial cancer.

Types of Uterine Cancers

Based on their outlook and underlying cause, endometrial cancer may be of 2 types. Type 1 cancers are caused by excess estrogen. They are slow-growing, with better prognosis. Type 2 cancers are not estrogen dependent. They are more rapid-growing, with prognosis not as good as type 1 cancers.

Causes and Risk Factors of Uterine Cancer

Although the exact cause of uterine cancer is not known, contributing factors may be

• Age – older women are more at risk.
• Changes in hormonal levels during menopause may put postmenopausal women at increased risk.
• Early menarche and late menopause.
• Family history.
• Obesity.
• Diabetes.
• High blood pressure.
• Persistently high estrogen levels.
• Never been pregnant.
• Women on hormone replacement therapy (HRT) with only estrogen.
• Use of the drug tamoxifen which is used in the treatment of breast cancer.
• Women with hereditary nonpolyposis colon cancer (HNPCC).
• Past history of breast cancer or ovarian cancer.
• Endometrial hyperplasia with atypical hyperplasia.
• Polycystic ovarian syndrome (PCOS).
• Estrogen-producing tumors.
• Pelvic irradiation.

Signs and Symptoms of Uterine Cancer

Abnormal uterine bleeding is the commonest presentation of uterine cancer, of which postmenopausal bleeding is the most common symptom. There may be thin white or blood-tinged vaginal discharge in postmenopausal women. Bleeding in between periods (intermenstrual bleeding) and after or during intercourse (post-coital bleeding) is common. Prolonged, heavy periods may be present.

There may be lower abdominal or pelvic pain, painful urination, or pain during sexual intercourse. Other signs present may be unintentional weight loss and detecting a mass in the lower abdomen or pelvis.

Complications of Uterine Cancer

Complications are more likely to occur if the cancer has been detected late. Urinary or bowel obstruction and bleeding from the vagina, rectum, or bladder may be due to spread of cancer to nearby structures. Spread to distant organs can cause breathing difficulty, persistent cough, and collection of fluid in the abdomen. There may be complications of treatment following surgery, radiotherapy, chemotherapy, and hormone therapy. Psychological complications such as depression are common.

Outlook of Uterine Cancer

Since uterine cancer is usually detected early, the outlook with proper treatment is very good. When diagnosed in the late stage, with spread to distant organs, the survival rate falls drastically.

Basic Anatomy and Physiology

The ovaries are a pair of small, oval organs on either side of the uterus, close to the pelvic wall. They belong to the female reproductive system and are responsible for producing ova (eggs), as well as producing and secreting the female hormones estrogen and progesterone. These hormones help in developing sexual characteristics of a woman and in regulating menstruation and pregnancy. With menopause, the ovaries stop producing eggs and there is a decline in hormone production as well.

Causes and Risk Factors of Ovarian Cancer

The exact cause of ovarian cancer is not known. Various factors that have been linked to its development are :

• A faulty genetic factor which involves mutations in BRCA1 and BRCA2 genes.
• Close family history.
• Repeated ovulation.
• More common in postmenopausal women.
• Never having children.
• White women seem to be more at risk than African American women.
• Long-term use of fertility drugs such as clomiphene citrate.
• Obesity.
• Women on long-term hormone replacement therapy with estrogen alone.
• Pelvic irradiation.

Types of Ovarian Cancer

There are different types of ovarian cancers, depending upon the cells from which they originate.

Primary tumors of the ovary, which originate in the ovary itself, are of 3 main types :

• Epithelial tumors are those that arise from the surface epithelial cells. These make up almost 90% of all ovarian cancers and are more common in older women.
• Germ cell tumors arise from cells that produce ova. They occur more frequently in young women.
• Sex cord and stromal tumors are those that arise from connective tissue cells.

Secondary tumors of the ovary occur due to spread of cancer or metastasis from other primary sites such as cancers of the breast, uterus, stomach, and colon.

Spread of Ovarian Cancer

• By local extension to the adjacent tissues and organs.
• Intraperitoneal dissemination by shedding of cancer cells into the peritoneal cavity.
• Spread by lymphatic vessels to distant sites.
• Rarely, spread through blood vessels.

Signs and Symptoms of Ovarian Cancer

In the early stages, the complaints are usually vague and often mimic symptoms of digestive disorders such as nausea, indigestion, poor appetite, fullness after a meal, bloating, abdominal distension, and altered bowel habits.

Gynecological problems may include abnormal vaginal bleeding, menstrual irregularities, and painful sexual intercourse. Androgen-producing tumors may cause virilization. A mass may be felt on pelvic examination or a large tumor may be felt through the abdomen.

Other complaints include excessive fatigue, unexplained weight loss, abdominal pain or discomfort, feeling of weight in the pelvis, urinary problems, rectal discomfort, and back pain.

Outlook of Ovarian Cancer

The stage and grade of the disease at the time of detection determines largely its outcome. As most ovarian cancers are detected after the cancer has progressed beyond the ovaries, the outcome is usually poor. The prognosis also depends on the type of ovarian cancer, age of the patient, general health condition, type of treatment and the response of the patient to it.

Causes of Bacterial Vaginosis

The exact reason why the bacterial population grows out of control is unclear. It is not associated with hygiene. Excessive washing and vaginal douching can in fact promote overgrowth of bacteria as it disturbs certain aspects of the micro-environment in the vagina like the pH. Multiple species of anerobic bacteria proliferate in the vagina with bacterial vaginosis but there is a decline in the lactobacilli. It may be some factor that disturbs the lactobacilli which allows for the other types of bacteria to grow out of control.

Apart from douching, cigarette smoking and multiple sex partners may be other risk factors for developing bacterial vaginosis. However, with the latter it must be noted that bacterial vaginosis can even occur in girls or women who are not sexually active. Furthermore bacterial vaginosis is not a sexually transmitted infection. Hormonal changes with the menstrual cycle, pregnancy and menopause and the use of an intra-uterine device (IUD) may also contribute to the development of bacterial vaginosis.

Signs and Symptoms

The signs and symptoms of bacterial vaginosis are not signficantly different from other types of genitourinary infections in women. Most women with bacterial vaginosis, however, have no symptoms (asymptomatic). An abnormal vaginal discharge with a fishy odor are the main symptoms. Usually there are no other symptoms as is seen with other infections. Pain, burning, itching of the vagina and so on should raise the awareness about some other infection as these are not typically seen with bacterial vaginosis.

Developing bacterial vaginosis will increase the susceptibility to contract other infections, including sexually transmitted infections. The signs and symptoms of these infections may then be superimposed over the underlying bacterial vaginosis.

Diagnosis

A medical history indicating the typical signs and symptoms and the absence of other infectious symptoms in conjunction with a pelvic examination may be sufficient for a diagnosis. However, it is advisable to follow up with further investigation like testing the pH of the vagina and examining the vaginal discharge under microscope.

Treatment

Many cases of bacterial vaginosis may resolve spontaneously meaning that it eases without any treatment. Identifying any risk factors and preventing or removing it will allow the bacterial populations to return to normal. Drugs may be taken orally and/or applied topically. This includes the drugs metronidazole, tinidazole and clindamycin. Although bacterial vaginosis can be successfully treated, it is not uncommon for it to recur usually within 3 to 6 months. Therefore women need to be aware of the risk factors and take the necessary measures to prevent  it.

Causes of Trichomoniasis

Trichomoniasis is caused by the single-celled parasite (protozoan) Trichomonas vaginalis. It is transmitted through sexual contact, particularly vaginal intercourse. It can also be transmitted among homosexual women bu vulva-to-vulva contact. Since the parasite cannot survive in the mouth or rectum it is not seen with oral or anal intercourse respectively. The parasite has a flagellum which is a tail-like protrusion that allows it to travel around the tissues of the vagina and urethra. It directly injures the tissue and causes the formation of tiny ulcers. As with most sexually transmitted infections, the risk of contracting trichomoniasis increases with having multiple sexual partners and unprotected sex. Those with a history of STDs including trichomoniasis are also at a greater risk. The infection is more commonly seen in females under the age of 35 years.

Signs and Symptoms

Trichomoniasis is similar in clinical presentation to other genitourinary infections. The signs and symptoms include :

• Abnormal vaginal discharge with a foul-smelling odor.
• Itchy and burning genitals
• Redness and swelling of the external genitalia.
• Pain during intercourse.
• Painful urination.

Some women are asymptomatic meaning that there are no signs and symptoms. The infection can extend all the way to the cervix where it causes inflammation (cervicitis) and may pass beyond the endocervical canal. In pregnant women this can lead to serious complication and cause preterm labor.

Diagnosis of Trichomoniasis

There are several methods to diagnose trichomoniasis. This includes a microscopic evaluation of a vaginal swab, pH testing, Pap smear and a culture. This allows for the Trichomonas vaginalis parasite to be identified and the infection differentiated from bacterial and fungal infections that may cause similar symptoms. Women with untreated Trichomonas vaginalis infection are at a greater risk of contracting viral infections like HIV. Therefore it is advisable to conduct HIV testing.

Treatment of Trichomoniasis

The antibiotic metronidazole and antiparasitic drug tinidazole are usually sufficient for successfully treating trichomoniasis. Systemic treatment through oral administration of these drugs is the most effective measure although there are topical applications for trichomoniasis. Alcohol should not be used when taking these drugs as it can cause severe adverse effects similar to those seen with certain drugs used for treating alcohol addiction. Patients need to be educated on effective measures to prevent infection or re-infection not only of trichomoniasis but also of other sexually transmitted infections. Sexual partners should also be treated to prevent re-infection.