The Pearl index

The Pearl index is used to rate the effectiveness of a contraceptive method and is defined as the number of women who will become pregnant if 100 women use that form of contraception properly according to instructions for 1 year (or the percentage of women experiencing an unwanted pregnancy in 1 year of use). This is distinct from the actual failure rate, which is found with ‘typical use’ rather than ‘perfect use’ of the method. Table 9.1 shows the Pearl index for the different contraceptive options.

Table 9.1 Pearl index (the number of unwanted pregnancies per 100 women after 1 year of ‘perfect’ use of the following)

Poor compliance and incorrect use apply particularly to condoms, contraceptive pills and natural family planning, where the actual failure rates are 14%, 5% and 25%, respectively. Long-acting reversible contraceptives (LARCs) are encouraged for those women who need reliable contraception and where compliance with remembering to use a contraceptive may be poor. LARCs include the contraceptive implant and injection as well as the intrauterine contraceptive device (IUCD) and system.

History

The important factors to be considered in the history are:

The decision about contraception is always made between the doctor and the patient after explanation of:

Barrier methods

Hormonal methods

Levonorgestrel-releasing intrauterine system

This is a flexible intrauterine rod on a T-shaped frame, which releases 20 μg levonorgestrel every 24 hours. It is shown in Figure 9.1.

Figure 9.1 The levonorgestrel-releasing intrauterine system.

Mode of action

It thickens the cervical mucus and thins the endometrium, with inhibition of ovulation in some cycles for some women.

How to use

The LNG-IUS is fitted in the first 7 days of the cycle, or later if another contraceptive is used for 7 days after fitting. It can be inserted immediately after TOP or miscarriage and 6 weeks postnatally. Antibiotic cover is needed for insertion, as for other intrauterine devices. The intrauterine system should be changed after 5 years.

Most women have very light or absent bleeding after 2–3 months of irregular bleeding. Fertility returns immediately on removal. The LNG-IUS should be removed if pregnancy does occur as there is a theoretical teratogenic risk.

Benefits

Benefits are a reduction in bleeding, reduced dysmenorrhoea and reduced incidence of PID. There is also a significantly reduced ectopic risk and few progestogenic side effects, due to the local action. There is no significant effect of enzyme-inducing drugs.

Disadvantages

Disadvantages are irregular bleeding in the first 3 months (the commonest reason for early removal), increased risk of functional ovarian cysts, risks of expulsion and perforation. If progestogenic side effects do occur, they usually resolve within the first few months.

Contraindications

Contraindications are pregnancy, undiagnosed irregular bleeding, active liver disease, severe arterial disease, mechanical heart valves, untreated STI and a history of ovarian or endometrial carcinoma. Nulliparity is not a contraindication, though fitting may be less well tolerated.

Intrauterine devices

Used by about 5% of women, IUCDs are copper-containing devices on a T-shaped frame. They have two threads attached to the lower end, which protrude from the ectocervix and curl around the lips of the cervix and are grasped for removal. A frameless device is also available, which is attached to the uterine fundus by a knot.

Natural family planning

Sperm may survive for up to 7 days after intercourse and eggs survive for approximately 24 hours after ovulation. Therefore, the fertile period lasts for about 8 days. Natural family planning involves identification of the timing of ovulation to prevent contact between the egg and viable sperm during this time.

Natural family planning is only effective in women who have been properly taught the technique and have a regular cycle. Three methods are used, often in conjunction with each other, to identify the fertile time during which intercourse is avoided or a barrier contraceptive is used: (1) basal body temperature; (2) cervical mucus; and (3) time in cycle.

Lactational amenorrhoea

The lactational amenorrhoea method is the reliance on amenorrhoea during breastfeeding as contraception. It is effective in 98% of women who use the method. However, efficacy reduces as soon as:

Urinary hormone kit

A commercial kit uses urinary hormone changes to predict the fertile period. It is expensive, takes several cycles to be reliable and is not as effective as other contraceptive methods.

Emergency contraception

Permanent methods

Surgical sterilization (of the woman or her partner) is reported as the method of avoiding pregnancy in 23% of women in the UK. Approximately 45 000 tubal occlusions and 65 000 vasectomies are performed in England each year.

Contraception in teenagers

In the UK, the Fraser rules or Gillick criteria allow for contraception to be prescribed to girls under the age of 16, without parental consent, as long as the doctor is satisfied that:

Barrier contraception should be encouraged, often as well as hormonal, to prevent STI.

The age of the partner should be ascertained, as it is illegal to have intercourse with a girl under the age of 16. However, this law is generally only applied when the intercourse is non-consensual or the male partner is significantly older.

Contraception around the menopause

Fertility diminishes with age (10–20 pregnancies per 100 women over 45 years of age compared with 80–90 under 40 years). However, pregnancy in older women is more complicated, with much higher rates of termination, fetal abnormality, miscarriage and pregnancy complications, including maternal and fetal mortality. Therefore, effective contraception should be used for 2 years after the last period if the woman is under 50 years, or 1 year after the last period if she is over 50 years. The trend is towards greater use of sterilization as age increases.

The risks of oestrogen-containing pills increase with age. The POP is, therefore, commonly used after the age of 40 (or earlier in smokers). An IUCD inserted after the age of 40 years can be left in situ until 50 years old, as the risk of pregnancy is low.

Contraception and operations

Oestrogen-containing contraception increases the risk of postoperative thrombosis. It should be stopped 4 weeks before elective major or lower-limb operations and an alternative method used. For minor procedures, such as laparoscopy, it can be continued as long as prolonged immobilization does not occur. For emergency operations, the pill should be stopped on admission and extra thromboprophylaxis should be prescribed.

The COCP can be restarted 2 weeks after full mobilization.

Definitions

Female sexual problems are classified as:

Prevalence

Forty per cent of women experience some form of sexual dysfunction; 80% of these women complain of a loss of desire; and 12% of women do not experience orgasm. Of those who do, 25% of women achieve orgasm with penetrative sex and 75% need extra clitoral stimulation.

Aetiology

The aetiology of sexual problems is poorly understood, but psychological and physical factors may be involved. Table 9.3 outlines the main causes.

Table 9.3 Causes of psychosexual problems

TAH, total abdominal hysterectomy; BSO, bilateral salpingo-oophorectomy; GnRH, gonadotrophin-releasing hormone; COCP, combined oral contraceptive pill.

Clinical presentation

Women may present in a variety of ways, either directly with a problem or commonly by using another excuse for the consultation such as difficulty with contraception or dyspareunia. There is often difficulty discussing sexual problems both with partners and with health professionals.

Sexual problems may be situational, partner-dependent or occur all the time. They may be primary (since first sexual intercourse) or secondary (developed later). Some problems may not be perceived as a problem; for example, many women who never achieve orgasm still become aroused during sex and find it pleasurable and intimate.

Sexual difficulty can occur at any stage of the normal sexual response process, which involves sexual desire, arousal and orgasm, followed by a resolution phase. These physiological phases are independent of each other so, for example, a woman with loss of desire may still become fully aroused and achieve orgasm with sexual stimulation.

History

Examination

In many situations an examination is not necessary in the assessment of sexual problems. However, in some cases a full general examination is vital to exclude neurological or endocrine problems that may be suggested by the history. Genital examination is also useful in cases of dyspareunia, to diagnose any physical and treatable cause, and reassure the woman if the findings are normal. The reason for the examination must be carefully explained and it can be necessary to defer the examination if the woman feels nervous or uncomfortable at the first consultation. Occasionally, examination is performed under anaesthetic, for example where vaginismus is very severe and pathology has not been excluded.

Particular attention must be made to ensure privacy and a chaperone should be used for both male and female doctors.

Investigations

Urinalysis for glycosuria should normally be performed. Vaginal and cervical swabs should be sent where infection is suspected. Otherwise investigations are only indicated by findings in the history or examination.

Management

Incidence

One in 10 women under the age of 25 in the UK have Chlamydia (3–5% of the total female population of reproductive age) and most STIs are becoming more common, with double the incidence of gonorrhoea and six times the incidence of syphilis in the last 6 years.

Age

STIs occur most commonly in the 18–25-year age group.

Presentation

Women with STI may complain of symptoms or an infection may be found incidentally during investigation for pelvic pain or irregular bleeding. Alternatively, a woman may have been given a ‘contact slip’ by a partner who has been diagnosed with an STI. Many women attend genitourinary medicine (GUM) clinics for regular sexual health screens.

Clinical features

Presenting features for STIs in symptomatic women are vaginal discharge, postcoital bleeding, intermenstrual bleeding, itching, dyspareunia, abdominal pain, vulval irritation or blisters.

History

Women may find the sexual history or symptoms embarrassing, but they are more relaxed if the doctor is matter of fact in approach. In addition to a general gynaecological and obstetric history the sexual history must include:

Examination

Abdominal examination should be performed to check for tenderness or masses and for inguinal lymphadenopathy. The external genitalia may show signs of blisters (HSV), warts (HPV), excoriation or inflammation. Rarely, a syphilitic chancre or tropical ulcer may be identified.

Speculum findings may include discharge (note the amount, consistency and any odour), cervicitis (inflamed reddened cervix, possibly ‘strawberry cervix’ of Trichomonas), contact bleeding or vaginal warts. Bimanual examination should always be performed for cervical excitation, adnexal tenderness or pelvic mass suggestive of a possible abscess.

Examination findings are often unremarkable with Chlamydia and gonorrhoea, the commonest bacterial infections.

Investigations

Swabs

The technique of swab-taking is very important to the diagnosis of infection, particularly Chlamydia and genital herpes.

Vaginal and cervical swabs:

The following ‘triple swabs’ (Fig. 9.2) should all be taken for women suspected of any STI:

1. High vaginal for Candida, Trichomonas and bacterial vaginosis: swab gently in posterior fornix.

2. Endocervical swab for gonorrhoea: insert microbiology swab 1 cm into the endocervical canal and rotate gently to collect cellular material.

3. Endocervical for Chlamydia: swab must be inserted 1 cm into the endocervical canal and vigorously rotated (for about 10 seconds) to ensure cellular material is collected. The collection of discharge on the swab should be avoided by removing secretions first. The swab is transported in a specific medium.

Figure 9.2 (A) High vaginal swab for Candida, Trichomonas and bacterial vaginosis. Endocervical swabs for gonorrhoea (B) and Chlamydia (C).

Urethral swab for gonorrhoea and Chlamydia may pick up a few more cases, but is poorly tolerated and generally not carried out.

Women who have anal or oral sex should have additional rectal and throat swabs for gonorrhoea.

Viral swab

HSV is diagnosed by viral culture from a swab of the blister. It should be taken vigorously to obtain viral particles from the vesicle and base and the patient should be warned that this procedure is painful. The swab must be sent in viral culture medium.

Management

Women diagnosed with STIs should be encouraged to attend a sexual health or GUM centre with appropriate facilities for diagnosis and follow-up. Health advisors are specially trained in counselling and sexual health education. They can help with the anxiety associated with the diagnosis of a STI and help the woman to inform sexual contacts of any infection.

Women diagnosed with one STI must be screened for others, as co-pathology is common: up to 40% of women with gonorrhoea have coexistent Chlamydia infection.

Women should not have intercourse during treatment or until the cure has been confirmed and not until their partner has also been treated, to prevent reinfection.

Persistent positive tests for infection after treatment often represent reinfection rather than failure of the treatment, and this relates to sexual intercourse during treatment or failure of the partner to be treated.

Chlamydia

Chlamydia trachomatis is an intracellular bacterium that infects the endocervix and urethra. Factors associated with high risk of infection are age of less than 25 years, new sexual partner, lack of barrier contraception, women undergoing TOP and use of the COCP. Seventy per cent of women (and 50% of men) are asymptomatic, but symptoms may include discharge, lower abdominal pain, irregular vaginal bleeding or dyspareunia.

Examination may be normal or may show discharge, cervicitis, contact bleeding or adnexal tenderness.

Diagnosis can be made by culture, direct fluorescent antibody or enzyme immunoassay, from endocervical or urethral swab or enzyme immunoassay of a urine sample.

Antibiotic treatment for uncomplicated infection is governed by local guidelines and usually involve a combination like:

or

or

In pregnancy or breastfeeding doxycycline is contraindicated, but azithromycin and erythromycin are not known to be harmful.

As erythromycin is less effective (< 95%), a test of cure should be performed 3 weeks after treatment is completed in these women.

Complications of Chlamydia infection are PID (10–30%), ectopic pregnancy (Chlamydia is responsible for about 40% of ectopic pregnancies), chronic pelvic pain and infertility (half the cases of tubal infertility have positive chlamydial serology).

In pregnancy the prevalence of Chlamydia is around 6%. There is an associated risk of preterm delivery (odds ratio (OR) 1.6) and fetal growth restriction (OR 2.5) and low birth weight, with increased neonatal morbidity (conjunctivitis and pneumonia) and mortality.

The new national screening programme may help to reduce this risk.

Gonorrhoea

Neisseria gonorrhoeae is a Gram-negative diplococcus, which infects the mucous membranes of the endocervix, urethra, rectum, eye and throat. Fifty per cent of women are asymptomatic but the commonest symptoms are discharge, lower abdominal pain, irregular bleeding and dysuria.

Clinical findings may include discharge, cervicitis, contact bleeding or pelvic tenderness.

Diagnosis is by culture from an endocervical swab (swab, rotated 1 cm inside endocervical canal). In 90% of women the cervix is the only site of infection so urethral, rectal and throat swabs should be taken only if the symptoms or sexual history indicate.

Treatment involves:

or

However, sensitivity from culture should be checked to be sure the organism is not resistant.

In pregnancy or breastfeeding, ampicillin 2 grams orally or ceftriaxone 250 mg intramuscularly may be used.

A test of cure should be performed at least 3 days after treatment.

Trichomonas

Trichomonas is a flagellate protozoon that infects the vagina, urethra and paraurethral glands. Ninety per cent of women with vaginal infection also have urethral infection. Up to 50% of women are asymptomatic, but common symptoms are an offensive odour, itching, profuse discharge and dysuria.

Clinical findings are vulval excoriation, vulvovaginal inflammation, a profuse frothy yellow offensive discharge and ‘strawberry cervix’ (red and inflamed).

Diagnosis is made by high vaginal swab, with direct observation of flagellates on a wet smear at microscopy. Alternatively, swab culture detects 95% of Trichomonas infections. The diagnosis is sometimes made on midstream specimen of urine microscopy or as an incidental finding on cervical smear.

Twenty per cent of infections spontaneously resolve without treatment. However, treatment should always be given if the diagnosis is made:

or

If metronidazole is ineffective, a single dose of tinidazole 2 grams orally may be used.

Metronidazole and tinidazole are not recommended in early pregnancy and the high-dose metronidazole regime is not recommended at all in pregnancy, though there is no clear evidence of harm. Pregnant women should generally be treated with the 5-day metronidazole course, after the first trimester.

A test of cure is only needed if symptoms persist.

Genital herpes

Genital herpes is caused by HSV type 1 or 2. After primary infection the virus is latent in the local sensory ganglia and may reactivate, causing infectious viral shedding with or without symptoms. It usually presents with multiple small blisters around the labia, often associated with dysuria and vaginal discharge. The first (primary attack) is the most severe, often with general malaise, fever, anorexia and lymphadenopathy. Secondary attacks, if they occur, may be as frequent as every few weeks, or occur at times of stress, such as exams. Secondary attacks are generally minor and may be virtually unnoticed.

Multiple small labial blisters and lymphadenopathy may be present on examination.

Diagnosis is by viral swab from the base of a lesion. This involves vigorous rubbing over the lesion to de-roof it and is very painful.

Treatment involves general measures such as saline bathing, analgesia and topical anaesthetic agents. Admission is occasionally needed for systemic symptoms, urinary retention or meningism.

Genital herpes is usually self-limiting, but aciclovir (200 mg five times a day) or famciclovir (250 mg three times a day) for 5 days can be started within 5 days of the attack, to shorten the duration and severity, though it has no impact on the likelihood of recurrence.

Prophylactic aciclovir or famciclovir can be used for 6–12-month periods in women with more than six recurrences per year.

Counselling in a GUM clinic should be arranged to deal with the anxiety around the diagnosis of genital herpes and recurrences. Women can be infectious during recurrences and asymptomatic viral shedding is common in the first year. Condoms do not fully protect against transmission.

Pregnant women who develop a primary attack of HSV within 4 weeks of delivery should be advised to have a caesarean section as the risk of neonatal herpes infection is 50%. For those with recurrent attacks in pregnancy there is no evidence for caesarean section. Those with a recurrent attack and lesions present at the time of delivery have a very small risk of neonatal infection (0.25–3%) as the baby is generally protected by transplacental immunoglobulin G (IgG) from the mother. In this case the risks of caesarean section to the mother should be weighed against the risk of infection in the fetus.

In pregnancy there is no clear evidence of harm from aciclovir and it can be considered from 36 weeks to prevent recurrence around the time of delivery.

Genital warts

Clinical warts affect 1% of the population, most commonly involving HPV types 6 and 11. Lesions occur on the vagina, cervix, urethral meatus and anus. The lesions are usually painless, but unsightly and embarrassing.

On examination single or multiple irregular lesions may be seen, either broad-based or pedunculated, from 1 to 20 mm in size. Diagnosis is usually clinical, though biopsy is indicated if the lesion is pigmented, to exclude other pathology.

Treatment depends on the site, size and nature of the lesions, with various treatments available. All treatments have a high recurrence rate and expectant management is an option for non-troublesome warts. Options include:

or

or

or

In pregnancy, local pharmacological treatments are contraindicated because of the risk of teratogenicity.

Florid warts are common in pregnancy and reassurance should be given that spontaneous resolution usually occurs postnatally. Rarely, caesarean section is indicated in women with gross cervical or vaginal warts where haemorrhage at delivery is a potential problem.

Laryngeal papillomatosis is a very rare neonatal complication of maternal genital warts.

Molluscum contagiosum

Molluscum, caused by a poxvirus, is transmitted by direct skin contact. It is a common benign skin problem in children, with spontaneous resolution. In adults, genital infection from sexual contact occurs with multiple discrete pearly white smooth lesions up to 5 mm diameter, with an ‘umbilicated’ centre.

There are no symptoms except for cosmetic concerns. Diagnosis is based on the clinical appearance.

The lesions regress spontaneously over a few months, but treatment can be given for cosmetic indications:

Scabies

Sarcoptes scabiei is a mite that burrows under the skin to lay eggs. Infection causes intense itching. Clinical features are silvery lines of burrowing tracks and signs of excoriation, either genitally or between fingers.

Permethrin 5% cream or malathion 0.5% aqueous lotion is applied to the whole body and washed off after 12 hours, though the itch may persist for several weeks after treatment. Household contacts and partners should all be treated simultaneously.

Crabs (pubic lice)

Crabs are 2-mm crab-shaped lice found in pubic hair. The female lays tiny white eggs, which are seen tightly adherent to the hair shafts. Transmission may be by close physical as well as sexual contact. The predominant symptom is itching, but women may note the eggs or lice themselves, or find tiny brown specks in underwear (louse droppings). The diagnosis is usually clinical on identifying lice or eggs (confirmation under microscope is possible).

Malathion 0.5% aqueous liquid or permethrin 5% dermal cream is applied to all coarse hair (pubic and underarm) and left for 12 hours. The treatment is repeated after 7 days to kill any lice emerging from surviving eggs. Other sexual and family contacts should be screened and treated if infected.

Syphilis

Syphilis is caused by Treponema pallidum, a spirochaete. It is transmitted by sexual contact and has an incubation period of up to 90 days.

Tropical genital ulcers

Hepatitis B

Hepatitis B is caused by a DNA virus that is carried by up to 20% of people in South-East Asia. In the UK prevalence is 0.01–0.04% of the general population, but > 1% in homosexual men and drug users. Infection is sexual, parenteral (e.g. needle-sharing or blood products) or congenital. The incubation period is 40–160 days and infectivity is from 2 weeks prior to the onset of jaundice, if it occurs, until the surface antigen is negative.

Hepatitis C

Hepatitis C is caused by an RNA virus. It is found in 0.06% of blood donors and 60% of intravenous drug users. Transmission is generally parenteral, from shared needles, but 2–11% of long-term sexual partners will become infected.

HIV

HIV is an RNA retrovirus. It is transmitted, as for hepatitis B, by sexual contact, blood (e.g. shared needles, blood products prior to 1990) and vertical transmission. The incubation period is up to 3 months.

Definition

PID is infection of the pelvic organs almost invariably from ascending infection through the genital tract. Infection is most common in the fallopian tubes (salpingitis), but endometritis, parametritis, oophoritis, tubo-ovarian abscess and pelvic peritonitis also occur.

Incidence

The incidence of PID is unknown because non-specific or absent symptoms and signs mean that the diagnosis is probably often missed.

Age

PID is most common in 18–25-year-olds, but may occur earlier or even much later.

Aetiology

The commonest organism found is Chlamydia (50%), but PID can also be caused by gonorrhoea (14%), bacterial vaginosis and atypical anaerobes. Tuberculosis (TB) is a rare but important cause. In most cases a causative organism is not isolated.

Pathophysiology

Infection is largely by sexual contact. PID is very rare in non-sexually active women. The infection may be asymptomatic for some time (up to years) and be activated spontaneously or after instrumentation of the uterus.

Risk factors

Risk factors for PID include those for other STIs (see Chlamydia, above), insertion of an IUCD and smoking.

Clinical features

Abdominal pain is the main presenting feature of PID and women with acute infection are often systemically unwell with fever, vomiting, anorexia and malaise. Dyspareunia, postcoital or irregular bleeding, menorrhagia or dysmenorrhoea, discharge or back pain may also occur. Many women are asymptomatic, but have evidence of PID at later laparoscopy, for example for infertility.

Examination

General examination should be performed for temperature, pulse, blood pressure and signs of dehydration. Abdominal palpation typically reveals tenderness (usually bilateral). Peritonism is relatively common.

Speculum may show discharge and abnormal bleeding and typically bimanual examination reveals cervical excitation (pain on moving the cervix from side to side) and adnexal tenderness. Occasionally, a pelvic mass (e.g. tubo-ovarian abscess) may be palpable.

Investigations

A pregnancy test should always be performed to exclude the important differential diagnosis of ectopic pregnancy.

High vaginal and endocervical swabs (high vaginal for Trichomonas vaginalis, Candida and bacterial vaginosis, endocervical for gonorrhoea and endocervical for Chlamydia) should be taken, paying attention to using the correct technique.

Midstream specimen of urine should be sent for microscopy and culture.

Full blood count and C-reactive protein are important if the woman is systemically unwell, and urea and electrolytes should be analysed if she is vomiting.

Ultrasound scan will exclude a large tubo-ovarian collection, but is usually normal with PID except for possible free peritoneal fluid, which is a non-specific finding.

Laparoscopy is indicated if the diagnosis is unclear or there is no response to treatment after 48 hours.

Differential diagnosis

Other gynaecological causes of abdominal pain include ectopic pregnancy, miscarriage, ovarian cyst torsion, rupture or haemorrhage, endometriosis, fibroid degeneration and ovulation pain.

Non-gynaecological causes include adhesions, appendicitis, urinary tract infection or pyelonephritis, constipation, irritable bowel syndrome, inflammatory bowel disease and gastroenteritis. The pain may also be functional, often after a previous diagnosis of PID.

Management

The importance of education and advice is generally overlooked in gynaecological settings. The woman must be advised verbally and with clearly written advice:

Treatment involves analgesia, fluids and antibiotics. As the causative organism is not usually isolated, Chlamydia, gonorrhoea and anaerobic organisms must all be covered by treatment, and there should be a low threshold for treatment in view of the serious sequelae of untreated disease. Antibiotic regimens vary, but some recommended outpatient schedules are:

and

and

Criteria for admission for intravenous antibiotics and fluids are:

A suitable intravenous antibiotic regime is:

and

and

The intravenous treatment can be discontinued and changed to oral after 24 hours of systemic improvement and apyrexia.

Urgent laparoscopy is indicated where ovarian pathology (such as torsion) cannot be excluded or no improvement occurs after 48 hours of intravenous antibiotics. Infected tubes appear red, inflamed, congested and exudative. Laparoscopy can also be performed electively for persistent pain after treatment and may show peritubal adhesions and perihepatic adhesions (Fitz-Hugh–Curtis syndrome).

Tubo-ovarian abscess can be managed conservatively initially, but drainage by laparoscopy or laparotomy is indicated where there is no improvement after 48 hours or the patient is systemically unwell.

An IUCD should be removed if it has been inserted recently or if the infection is severe, as it may act as a focus of infection. However, possible pregnancy risk must be considered and emergency contraception given if necessary or the woman counselled about the risk of pregnancy if she has had intercourse in the last 5 days.

Complications

These include:

Pregnancy

PID is extremely uncommon in pregnancy, probably due to the mucous cervical plug and the pregnancy itself impeding passage of organisms into the fallopian tubes. In pregnancy or breastfeeding, penicillin or ceftriaxone can be used instead of ciprofloxacin. Erythromycin should be used instead of doxycycline or azithromycin, although azithromycin is not known to be harmful.

Follow-up

Women treated as outpatients should be reviewed after 72 hours to ensure improvement and for their microbiology results. This may be in a GUM clinic if the woman is given an appropriate referral letter and details. Further review is indicated 2 weeks after completing treatment to check response to treatment, check compliance with antibiotics, ensure partner(s) have been tested and treated and perform a full STI screen.

Candida (thrush)

Candida albicans is a very common cause of abnormal vaginal discharge, occurring at any age, more often during reproductive years. A total of 10–20% of women of reproductive age have asymptomatic Candida. It is more common in pregnancy, diabetes, after antibiotics and possibly with combined oral contraceptive use.

Bacterial vaginosis

Bacterial vaginosis is caused by an overgrowth of anaerobic organisms within the vagina, particularly Gardnerella vaginalis, Mycoplasma hominis and Mobiluncus species. It occurs and resolves spontaneously, though may occur more after sexual intercourse.