Guest Author - Dr. Denise Howard
A 46 year old woman has seen several gynecologist and been given over 12 different medications but the discharge, genital irritation, burning and pain with intercourse is still present now after a year. After being treated for candidiasis, bacterial infection, trichomoniasis, atrophy, and even certain transmitted infections, she is quite distraught. What is left?
Desquamative genital infection is a condition that is infrequently discussed and often missed by the best gynecologist. It affects approximately 4% of women presenting with vulvitis symptoms that can be difficult to treat. The usual scenario is the one described above. A perimenopausal woman will develop a purulent discharge and severe pain during intercourse. It may take 15 months before a doctor figures out what is going on and then may take equally as long to get the symptoms under control.
The predominant symptoms and signs are purulent discharge, pain with intercourse and inflammation seen on examination. This has been described in 70-90% of women who has this problem. Even though the cause is unknown the symptoms can be found in other unusual genital disorders such as erosive lichen planus and pemphigus vulgaris.
This condition was first described in 1956 but even now the cause is unknown. It is more likely to occur in white women. A yellowish discharge, redness of the vestibule and rash along the birth canal walls are typically seen on examination. The doctor may also note erosions, a pH > 4.5 and the cultures are usually negative. Microscopic examination of the exudates reveals sheets of white blood cells and parabasal epithelial cells. The ratio of white cells to epithelial cells is 1:1 which is extremely high. There is a notable absent of lactobacilli and normal flora. This supports the impression that this is an inflammatory process and not an infectious one.
This isnít much written in the medical literature about this condition. The best available case series describes the use of 4-5 grams of 2% clindamycin cream or 3-5 grams of 10% hydrocortisone internally each day for 4-6 weeks. Alternatively hydrocortisone 25mg suppositories can be used internally. This provides relief for some women but the relapse rate is reported to be 32% at 6 weeks. At this point the options are retreatment with either or both of the described medications. Other therapies utilized include clobetasol which is a high potency steroid ointment, tacrolimus which is an anti-inflammatory ointment used for eczema and estrogen cream.
Definitive treatment is unusual. At 1 year, only 26% are considered cured, 58% are described as being controlled and the rest are poorly controlled. It is unlikely that a cure will be realized until an actual cause is found. This is an area that warrants in depth medical research.
This problem is not life threatening but it can be frustrating. If you think this describes you then it will be important to find a gynecologist who is familiar with this condition. The best place to start is at a University Medical Center and search for a doctor who has a special interest in vuvlar disorders. Typically this is a gynecologist but there are dermatologists who would also qualify.
I hope this article has provided you with information that will help you make wise choices, so you may:
Live healthy, live well and live long!