This study is based on a real-life case.1 Some details have been altered to fit the format of this study to preserve the identity of the patient. All photos are stock photos, used for illustrative purposes only. Posed by models.
Hannah, an 18-year-old female college freshman, presents to the local clinic with a week-long history of vaginal discharge and itching.
Vaginal discharge, which is comprised of skin cells, bacteria, mucus, and fluid, helps protect the lower female reproductive tract and urinary tract by providing lubrication to the vaginal tissue and protecting against infections. Premenopausal women produce approximately 1/2 to 1 teaspoon (2–5 mL) of vaginal discharge each day. Discharge can be a completely normal finding in women, specifically if it is white or clear, thick, mucus-like, and odorless.2 However, when vaginal discharge presents with any of the following signs and symptoms, it’s abnormal and should be evaluated by a medical professional.2
In the exam room, the nurse collects medical and sexual history, including more information about Hannah’s chief complaint.3,4
Hannah shares that she has a new sexual partner. The nurse indicates that a urine sample is needed to ensure that Hannah is not pregnant and to conduct a urinalysis to screen for a potential urinary tract infection (UTI), which may also present with symptoms similar to those of sexually transmitted infections (STIs).5,6
Nurse: When did the discharge and itching start and how would you describe it?
Hannah: It all started several days ago. The discharge is more than what I usually have and is white-ish. The itchiness is something that I have never experienced before.
Nurse: Are you sexually active? If so, do you have any new sexual partners?3
Hannah: Yes, I broke up with my first partner a few months ago and I have since started seeing someone new. Our relationship turned into a sexual relationship a few weeks ago.
Nurse: If you use pregnancy and STI prevention methods, which ones do you use (e.g., condoms, oral contraceptives like birth control pills) and how often do you use them?3
Hannah: I’m on birth control pills, and although I take one every day, I sometimes forget to take it until bedtime when I usually take it first thing in the morning.7 Typically, my partner uses a condom, but there were a few times when we didn’t use one.8
What could be a potential infectious cause of the vaginal discharge and itching?
STIs (e.g, chlamydia, gonorrhea, trichomoniasis), BV, and VVC are all possible infectious causes of vaginal discharge and itching. Vaginal discharge that is foamy, green or yellowish, malodorous, blood-tinged, or accompanied by itching or redness of the vulva and vagina, pelvic or abdominal pain, dysuria (painful urination), or dyspareunia (painful sexual intercourse) is not normal and could be caused by a whole host of common infectious conditions:2,9,10
And less commonly by:
Common noninfectious causes can include the body’s reaction to a foreign body (e.g., tampon) and chemical or allergic reactions (e.g., to soap).2,10
Hannah collects the urine sample for in-house processing and prepares for the physical and pelvic exam by the physician.4
Vaginal swab is collected for lab analysis.1
According to the World Health Organization (WHO) Guidelines for the Management of Symptomatic STIs, all women who present with abnormal vaginal discharge should undergo a comprehensive medical and sexual history in addition to a physical exam, which should include a pelvic exam using a speculum to visualize the cervix.4
Although the definitive lab results are not yet available, the physician is considering empiric treatment for one or more STIs, citing that Hannah is considered high-risk for STIs. Based on Hannah’s medical and sexual history, do you think this is accurate?
Hannah is considered high-risk for STIs based on classification criteria from the American College of Obstetricians and Gynecologists (ACOG). The ACOG indicates that although anyone who is sexually active is at risk for STIs, some people may be classified as high-risk if they:
As part of the sexual history survey, Hannah indicated that she has had two sexual partners, one being a relatively new sexual partner.
The physician reviews Hannah’s case notes.
A definitive diagnosis from the lab test will likely not be available for several days, so the physician recommends presumptive treatment or syndromic management targeting the following three potential infections:1,4
Coinfection with both chlamydia and gonorrhea is common. It is estimated that 10–40% of people with gonorrhea have a concurrent chlamydial infection.20
Additionally, both chlamydia and gonorrhea have high rates of asymptomatic infections in women. In fact, 80% of women with chlamydia and 50% of women with gonorrhea are asymptomatic.21,22
PID, pregnancy complications (e.g., ectopic pregnancy, miscarriage), and increased risk of HIV acquisition are all potential complications of untreated STIs in women. Undiagnosed and untreated STIs can lead to many serious complications, including PID, pregnancy complications, and an increased risk of HIV acquisition, among others.4,25
PID is an inflammatory condition caused by microorganisms ascending from the vagina and cervix to the upper genital tract.26 It is characterized by endometritis, salpingitis, and/or pelvic peritonitis and can also cause abscesses in the fallopian tubes or ovaries. PID is a complication of STIs, especially chlamydia and gonorrhea, and approximately 50% of all cases of acute PID are attributed to STIs.18,26
Additionally, PID increases a woman’s risk of pregnancy or fertility related complications, including tubal factor infertility, ectopic pregnancy, and miscarriage.25,26 Adverse childbirth outcomes, including low birth weight and preterm delivery, are also associated with untreated trichomoniasis infections during pregnancy.25
An increased risk of HIV acquisition has been associated with chlamydia, gonorrhea, and trichomoniasis infections. Additionally, there is a heightened risk of maternal–child transmission of HIV in women who have HIV and are pregnant.25
The clinic receives STI lab results, which have been reviewed by the physician, and they confirm that Hannah does not have any of the STIs or other infections that were suspected (i.e., chlamydia, gonorrhea, or VVC), nor did she have BV or trichomoniasis.
The clinic attempts to contact Hannah several times before reaching her to inform her of the lab results. Hannah is instructed to discontinue treatment.
At this point, Hannah has had an intramuscular injection of ceftriaxone, a course of azithromycin, and five daily applications of intravaginal clotrimazole; all of which were not medically necessary in light of the lab results. The physician suspects a noninfectious cause and asks Hannah to schedule a follow-up appointment if symptoms persist.4
Under syndromic management, the WHO reports that there is considerable overtreatment of women presenting with vaginal discharge with antibiotics. Simple, rapid, and accurate Point-of-Care tests (POCTs) can greatly improve STI management by allowing a clinician to definitively diagnose and appropriately treat potential STIs.28,29
Let’s revisit Hannah’s story but see how differently it would go if the clinic was equipped with a rapid, highly accurate POCT, such as the Visby Medical Sexual Health Click Test…29
If this POCT had been used in the clinic, Hannah would not have received treatment for chlamydia and gonorrhea under a syndromic management protocol.4
Detection of organisms that cause BV and VVC are not part of the Visby Medical Sexual Health Click Test; an alternate diagnostic test would be needed for those two infections.
The Visby Medical Sexual Health Click Test is a POCT that enables result-driven, effective treatment delivery during a single clinic visit.