Chronic Vaginal Infections


I’m at 2016 ACOG!

I recently heard an informative lecture at the 2016 ACOG Annual Clinical Meeting about new research and treatment of chronic vaginitis. Dr Chemen Tate from the Indiana University School of Medicine spoke about the different causes of chronic vaginal infections. While most people associate vaginal infections with yeast, the actual leading cause of vaginal infections is Bacterial vaginitis, which comprises 50% of infections, compared with only 25% for yeast.

Bacterial vaginitis causes an increased discharge with a bad smelling odor. It is usually not associated with inflammation. There is found to be a reduction of the amount of lactobacilli, which usually serve to protect the vagina. (Those are the same helpful bacteria that are found in yoghurt). BV can weaken the body’s defenses and promote other infections including herpes, chlamydia, trichomonas, HIV and gonorrhea. It is highly recurrent, and 30% of women who are treated for it will have a return of symptoms within 3 months, or 3 to 4 episodes a year. This can be very distressing. Return of symptoms may be due to reinfection or a failure of treatment. Why does this happen?

Research has determined that bacterial biofilms are organized microcolonies on a surface that create a protective mode of growth allowing for survival in a hostile environment. For example, electron microscopy of the surfaces of infected medical devices have shown the presence of large numbers of slime-encased bacteria. Tissue taken from chronic infections have shown the presence of biofilm bacteria surrounded by a protective exopolysaccharide matrix. Other examples of biofilm infections include dental carries, prosthetic device infections and cystic fibrosis lung infections.

Biofilm infections are resistant to antibiotics and host defense mechanisms. Antibiotic therapy typically reverses the symptoms caused by the infection but may fail to kill the biofilm. Bacterial Vaginosis is a biofilm infection. An adherent vaginosis biofilm persists on the vaginal epithelium after standard treatment with oral metronidazole. What new treatments can be successful against this resistant infection?

We should council our patients that in many cases bacterial vaginitis is chronic and will come back. When the infection returns treatment needs to be adjusted to be more effective. New recommended treatment is longer treatment, and includes Metrogel, oral metronidazole, tinidazole, or clindamycin vaginal for two weeks. For a patient who has a previous history of long term symptoms, the two week treatment is to be followed by once weekly Metrogel, or twice weekly oral metronidazole or tinidazole for six months. Using the appropriate treatment for this chronic problem can be expected to cure it 80% of the time. Investigation is ongoing in this field and future therapies that attack biofilms directly may show even better results.

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Zika was reported in May 2015 in South America and since then has spread throughout the Americas. The CDC and Pan American Health Organization (PAHO) websites maintain and update the list of areas where Zika virus transmission has been identified.

The virus spreads to humans primarily through infected Aedes aegypti mosquitoes. ZikaOnce a person is infected, the incubation period for the virus is approximately 3-12 days. Symptoms of the disease are non-specific but may include fever, rash, aching in joints, and eye inflammation. It appears that only about 1 in 5 infected people will have these symptoms and most will have mild symptoms. It is not known if pregnant women are at greater risk of infection than non-pregnant.

Zika during pregnancy transmissionhas been associated with birth defects, specifically significant microcephaly (small fetal head). Transmission of Zika to the fetus has been documented in all trimesters; Zika virus RNA has been detected in fetal tissue from early miscarriages, amniotic fluid, babies and the placenta. However, much is not yet known about Zika virus in pregnancy. Uncertainties include the incidence of Zika virus infection among pregnant women in areas of Zika virus transmission, the rate of transmission to the fetus, and the rate with which infected fetuses have complications such as microcephaly or demise. The absence of this important information makes management in the setting of potential Zika virus exposure (i.e. travel to active areas) or maternal infection, difficult. Currently, there is no vaccine or treatment for this infection.

Prevention Guidance:Protect yourself

  • Avoiding exposure is best. Pregnant women should delay travel to areas where Zika outbreaks are ongoing when possible. Women considering pregnancy should discuss with their obstetricians the advisability of travel. See the CDC and PAHO websites for updated lists of affected countries.
  • When traveling to areas where Zika has been reported, women should take all precautions to avoid mosquito bites including the use of EPA-approved bug spray with DEET, covering exposed skin, staying in air-conditioned or screened-in areas, and treating clothing with permethrin.Repellents
  • Sexual transmission of Zika virus has been reported in a few cases but the frequency and efficiency of this route of infection is uncertain. Based on limited data, there is a theoretical risk of sexual transmission through exposure to semen of males with Zika virus disease. Given the potential risks of maternal Zika virus infection, pregnant women whose male partners have traveled to countries in which Zika is reported or have Zika virus infection should consider using condoms or abstaining from sexual intercourse.

Summary of Updated Guidance:

  • Antibody testing for Zika virus is now recommended for all pregnant women who have traveled to or lived in affected area regardless of the presence of clinical illness.
  • Physicians should discuss reproductive plans, including pregnancy planning and timing, with women of reproductive age considering the potential risks associated with Zika virus infection.
  • Women of reproductive age with current or previous laboratory-confirmed Zika virus infection should be aware that there currently is no evidence that prior Zika virus infection poses a risk of birth defects in future pregnancies.
  • Although the presence of Zika in breast milk has been reported, it is in very small amounts and unlikely to be harmful for the neonate. The benefits of breastfeeding likely outweigh the potential neonatal risks. Therefore, the recommendation is that women should continue to breastfeed.


If you are pregnant or planning for pregnancy check with us before traveling to areas of the American tropics and strictly follow steps to avoid mosquito bites during your trip.

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Improving Your Sexuality

sex6I recently attended the Annual Clinical Meeting of the American Congress of Obstetricians and Gynecologists, and heard a very nice talk from Dr. Maureen Whelihan who is a sex therapist in West Palm Beach, Florida. She talked about how to maintain a good sexual relationship. Her are some of her tips:

Orgasm: 90% of her patients have had an orgasm, and most have them at least 50% of the time. In most cases clitoral stimulation is needed to achieve orgasm – manual, oral or vibration. An inexpensive vibrator she recommends is the Oral B pulsar toothbrush. sex5Use the back (smooth) side for clitoral stimulation. Lelo is another brand of vibrator, better made, unbelievably powerful, available in many versions (some remote controlled, waterproof, USB rechargeable) and available online at 10% of women can have a vaginal orgasm-a much deeper, whole body orgasm that is difficult for most to achieve. In menopause orgasm gets less intense. Laying a warm wet washcloth across the vulva for 10 minutes before sex can increase the blood flow.

Kissing: The most important sexual activity, Dr. Whelihan calls it “the key to getting women naked.” It’s the number one thing that turns you on. It signals a wanting or craving that will make your partner think about you differently. Married couples should try to kiss at least for one minute a day! Make it a good kiss too! Having good oral hygiene is important. Use a mouthwash or brush your teeth if you have bad breath; avoid cigarettes and chewing tobacco.

Male Partner: Doctors should ask about the male partner. Erectile dysfunction is common in older men and very manageable with Viagra or Levitra. sex8Helping men to maintain an erection longer gives women more time to enjoy an orgasm instead of rushing it. Premature ejaculation can be due to anxiety condition, and an antianxiety medication can help. Low testosterone is common in aging and can decrease desire in men. All women need to understand that men need sex. It is number one throughout their life. If the woman loses her enthusiasm for sex, the man does not understand. It is a need and ignoring it can lead to an unhappy end to the relationship.

Children: Will suck the life and energy from women. Recommend that any 2 nights a week the partner is responsible for “kid duty” all the way until bedtime. She has a free evening to exercise, get her nails done, have a glass of wine or read a sexy book and she will meet you in bed and have sex. “I can’t believe he did all those things just to have sex with me!” It teaches mutual respect for the work the other partner is doing. You must respect the other’s role in the relationship. You can also try to desensitize the kids that mom and day can be alone in their bedroom without interruption. sex4First go into the bedroom for 1 minute and lock the door. Tell them “it is a private time for parents, please do not knock on the door.” You can gradually increase that alone time and get the kids used to not interrupting you and wondering what’s going on in the bedroom. Finally you get 15 minutes and that’s all the time you need to get sex done if you are married and motivated.

Medications: Don’t discount the negative effects of some medications on sex drive. Birth control pills and other hormones may decrease desire. Opiates are sex inhibitors. Get a good night’s sleep.

Lubes: Sex is friction in inadequately aroused women. Silicone lubes stay on the surface longer. Wet Platinum, Eros, Astroglide and Pre-Seed (for women trying to conceive) are recommended. Coconut oil, olive oil and vegetable oil work fine especially with a glass of wine and sex in the kitchen! Be very careful to not slip if it gets on the floor!

Gay sex: assuming people are straight and finding out they are not embarrasses us. We should think of “partner” instead of “husband.” The more comfortable we are with asking, the more likely patients are to tell. We need to be in a judgment-free zone.

Books: “The Guide to Getting it on” by Paul Joannides is an all-encompassing guide. “Best of Best Women’s Erotica” by Marcy Sheiner is a good collection of female erotica. “How to be a Great Lover” by Lou PagetGreat Lover is a great book about improving sex technique from the female point of view. “Every Man Sees You Naked” by David Mathews is a great guide for women about why men behave the way they do.

Incorporating Technology: Podcasts: – “Speaking of Sex” is fun, direct, and informative. It can be uploaded and sent to your lover to let them know what is on your mind. Apps: “Pocket Kamasutra” gives ideas (visual cartoons) on sexual positions and sex games. Upload to a text or email and let your lover know what you want to try next.

Final Thoughts: sex2Doctors need to let patients know that they are interested in their sexual concerns. We should promote sexual pleasure as another component of overall wellness and good health. Your patient will be forever grateful.

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Getting Pregnant!

Fertility FriendBecoming pregnant can be fun, happy, exciting, or sometimes unplanned. Knowing how it happens is very useful information to make it easier to achieve when desired, and to be avoided if that is the goal.


The average menstrual cycle lasts for 28 days and can range from 21 to 35 days. In an average cycle ovulation occurs on day 14. Signs may include a cramp in the lower abdomen or back, breast tenderness, increase in a clear vaginal discharge, or an increase in sexual desire.


SpermFor pregnancy to happen, sperm must be present in the fallopian tubes and meet with an egg. When a man climaxes during sex millions of sperm go into the vagina and some can make their way through the cervical mucus and into the uterus and from there into the fallopian tubes. Sperm can live inside a woman’s body for 3 days or more, but an egg’s life is much shorter, only 1 day. So pregnancy can occur if an egg is already present when you have sex, or if you ovulate within a day or two after you have sex. This means that your fertility time is limited. You are fertile from 3-5 days before ovulation to 1 day after ovulation. Trying to time intercourse so that you have sex just before ovulation seems to be a good way of thinking about it. There is also a new theory that ovulation is not just a random event. Research has discovered a special protein in semen that can actually cause ovulation.


Knowing when you are fertile can be a challenge. There are different methods to predict it. For planning purposes, there are phone apps that can be helpful such as Fertility Friend or My Days. These apps calculate your expected next period and make predictions based upon it. The predictions are less accurate if your cycles are less regular. You can also go to the drug store and purchase an ovulation predictor test kit such as Ovutime or Ovutest. These urine tests indicate when the hormone LH becomes present. When LH rises in your circulation it causes ovulation and this hormone can be detected in your urine. When the ovulation test turns positive, this means you should have intercourse that day and the next day for best results. You may also notice changes in your cervical mucus where it becomes increased in amount and more clear and watery in quality. To promote pregnancy you should time intercourse to be daily or every other day when good quality cervical mucus is present. It should not be less often than every other day or more frequent than once a day for the best fertility results. You can also track your temperature with a special thermometer to measure your basal body temperature. Your temperature rises after you ovulate and stays up by a small amount for 2 weeks. This method is not that useful in that by the time you discover you have ovulated, it’s already too late for timing of sex.


You can start trying for pregnancy soon after you stop using a birth control method, but not too soon. If you are using the pill or a similar hormonal birth control method, it is a good idea to wait at least a month or two to allow your body to return to normal. If you get pregnant in the first cycle after stopping the pill you will have double the chance of having twins. While that may sound exciting, having one baby at a time is a much safer way to go, and much more manageable for taking care of children later on. We recommend stopping the birth control method, waiting 1-2 months before trying for pregnancy, and being on vitamins that contain iron, folic acid and DHA. In a given cycle the chance of success is only 20%, and it is normal to take months for pregnancy to happen. Do not be discouraged if it does not happen right away. With normal fertility you will become pregnant within 1 year, and 85% of couples will be successful in having this happen. 15% of couples will take longer than a year (that is called infertility), but only 1% of couples are unable to conceive. If you are trying for pregnancy and it seems to be taking too long, don’t worry about it. Sometimes you can be trying too hard for pregnancy. Increasing your anxiety about it is not helpful for fertility. Relaxing and having a good time is usually the best recipe for success.


First signs of pregnancy include feeling very tired, feeling nauseous, having breast tenderness, and your period being late. If you think you may be pregnant, doing a home test is helpful. If positive, these tests are usually reliable. If a test is negative it may be accurate or not. Sometimes the level of pregnancy hormone is elevated by too little to be detected by the urine method. If you really need to know (for example when a tubal pregnancy is suspected), then a blood test is much more reliable to detect an early pregnancy. Blood tests and ultrasound are also very helpful if you are bleeding and concerned about a possible miscarriage.


When you have a positive test, call us to make an appointment to come in and confirm your pregnancy. If you are at least six weeks and one day from the first day of your last period, we should be able to see the fetus and its heart beat by ultrasound. Once we see the fetal heartbeat the chance of successfully having a baby goes up to 85%! Then you are on your way to having a new life in your family. Good luck!


This article is partially based on information in ACOG’s book, Your Pregnancy and Childbirth, Month to Month.Your Pregnancy and Childbirth

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Menopause and Hormone Therapy – What’s New?

estrogen replacementIt was only about 100 years ago that the average woman’s life expectancy increased to the extent she would live past the time of menopause. Now with the average life expectancy into the 80’s, a woman may live more than 1/3 of her life in the menopause. The number of women in the menopause is increasing and expected to go up even more. The consequences of menopause include hot flashes, night sweats, insomnia, skin changes, mood changes, depression, anxiety, irritability, loss of libido, vaginal atrophy, cardiovascular disease and weakened bones. How can hormone therapy be safely used to help treat this problem affecting so many women?

We need to put hormone therapy in perspective, and also consider risks and benefits of treatment. Although there is a lot of controversy in the media, patients look to their doctors to be their advocates and give good advice about treatment. It’s our duty as doctors to be informed and advocate for our patients. We need to treat disease in a preventive way, rather than wait for the damage to be done. Disease often starts off in a pre-clinical way, and with some diseases it can be difficult to detect early on. Many diseases that occur have their roots decades before they can be detected, and similarly their treatment may take time to demonstrate a benefit.

Menopausal symptoms

Hot flashes are one of the most bothersome symptoms of menopause. 50% of women have them longer than 4 years, 23% more than 13 years. Temperature regulation helps your body maintain the proper temperature by causing sweating when you are hot and chills when you are cold, thus maintaining a neutral zone of comfort. Hot flashes are a disturbance of this system which are thought to be due to a change in the temperature regulatory system where a decrease in estrogen causes a decrease in the size of the normal thermo-neutral zone in-between sweating and shivering. The end result can interfere with your sleep and your comfort.

Benefits and risks of treatment

Combination estrogen and progestin therapy is FDA approved to treat menopausal hot flashes, prevent osteoporosis, treat vaginal atrophy, and provide other benefits to reduce insomnia, irritability and short-term memory loss. Hormone therapy is highly effective to relieve hot flashes, both their amount and intensity. In women who have a uterus, estrogen alone therapy can increase the risk of uterine cancer, but the increased risk is removed once progesterone therapy is added to estrogen. In 2002 the Women’s Health Initiative study came out and revealed risks of this treatment, including an increased risk of heart disease, stroke, blood clots and breast cancer when both estrogen with progesterone are taken. This had the effect of scaring women into avoiding estrogen therapy even though the absolute risk was only 8 per 10,000 women and the study was based on doses higher than are in use today. This risk is roughly equivalent to the risk of dying in a car accident, and is relatively rare. Rather than being misled by percentages of change, it’s more scientific to consider the absolute risk, and when the risk is less than 1 per 1000 you must weigh that small risk against the improvement in relieving symptoms you get with the right treatment. Other variables to consider include age and method of treatment. Women receiving hormones in the age group of 50-59 have a much less risk of coronary heart disease, stroke, and breast cancer than those in the 70-79 age group. Also women who receive estrogen through a transdermal patch have a significantly reduced risk of a blood clot compared with oral treatment, possibly due to a more stable delivery system and avoiding metabolism by the liver where clotting proteins are made.

Having a uterus makes a difference

Having had a hysterectomy means that hormone replacement therapy need only include estrogen, which is the hormone that conveys most all of the benefits and very little risk. This good hormone decreases the risk of heart disease, protects against breast cancer, and reduces damage to blood vessels with benefits in the brain leading to less risk of Alzheimer’s disease. Women who don’t have a uterus are in a much better position because the only major risks to consider are those related to blood clots and much of this risk can be reduced by getting estrogen through transdermal medications that don’t affect the liver where clotting proteins are made. There are benefits in vaginal lubrication, increased vaginal thickness, better sexual function, better support of the bladder, improved bone strength and decreased cancer of the colon.

Having a uterus makes treatment more complex, because an progestin needs to be added to treatment to decrease the risk of uterine cancer. But what if there were a medication available that can still provide estrogen benefits without the progesterone risk? Well, there is a new type of estrogen now available called a SERM, or selective estrogen receptor modulator, and when combined with a traditional estrogen, its called a TSEC, or tissue selective estrogen complex. The new estrogen has been designed to have some progesterone-like beneficial effects on the uterus (but without a progestin) and also when combined with a traditional estrogen conveys an improved quality of life, more satisfaction with treatment, improved vaginal health, improved sleep, improved bone density, significantly less hot flashes, with less breast pain and less bleeding. The new medication, Duavee, combines an estrogen with a synthetic “designer” estrogen called Bazedoxifene and represents an improved hormone therapy for those women who have a uterus.

While combined traditional hormone replacement therapy can still be used for the majority of women being treated, there are groups of women who are particularly good candidates for this new approach, including women with a family history of breast cancer, women who have had a problem with combined therapy such as tender breasts, those with increased breast density, or if they have had bleeding issues.


We need safe and effective treatment for menopausal symptoms. The risk of breast cancer is slightly increased with hormone therapies that combine estrogen with progesterone, but not with estrogen alone or in combination with a new estrogen (called a SERM). TSECS combine an estrogen with a SERM to provide relief of menopausal symptoms without the increased risks caused by progestins and offer a new, safer treatment for menopause. These new developments in hormone therapy are just the beginning of designing new safe treatments that provide more benefit at less risk.

This information is from a course “Menopause and Hormone Therapy” given at the 2015 ACOG Annual Clinical Meeting and was presented by Drs Hugh Taylor and JoAnn Pinkerton.

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