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.
Pam, a divorced 46-year-old woman, presents to the clinic with complaints of malodorous 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.2
Vaginal discharge can be a completely normal finding in women, and the characteristics of normal discharge vary depending on factors such as diet, sexual activity, medication, and stress.3
Normal discharge is typically white or clear, thick, mucus-like, and odorless.2 However, in some cases, normal discharge can also be yellowish, slightly malodorous, and present with mild irritation,3 Medical evaluation is recommended when vaginal discharge presents with any of the following signs and symptoms:2,3
In the exam room, the nurse collects medical and sexual history.4,5
Pam recounts her symptoms, all of which started approximately I week prior:
Pam shares that she is sexually active.
She is in perimenopause based on her gynecologist’s assessment after she experienced hot flashes, night sweats, and sporadic and irregular menstrual cycles over the past 3 years.6
The nurse requests a urine sample to screen for a potential urinary tract infection and to confirm a negative pregnancy status.7
Nurse: When did the discharge and itching start and how would you describe it?
Pam: All the signs and symptoms started about 1 week ago. The discharge is foul-smelling, has a thin mucus-like consistency, and is off-white/gray in color. The vaginal itching is persistent and causing some irritation to that area.
Nurse: Are you sexually active? If so, do you have any new sexual partners?4
Pam: Yes. After my divorce, I re-entered the dating scene and have had a few sexual partners in the last few months.
Nurse: If you use pregnancy and sexually transmitted infection (STI) prevention methods, which ones do you use and how often do you use them?4
Pam: I stopped taking birth control pills when my (now) ex-husband had a vasectomy following the birth of our second child. Given my age and perimenopausal status, I’m not worried about pregnancy. My partners use condoms most of the time; there were only a handful of times when we didn’t use one.8
What age- or menopausal-related change(s) contribute to an increased susceptibility to sexually transmitted infections (STIs) in older women compared with younger, premenopausal women? Select all that apply.
Older, perimenopausal or menopausal women experience both a decrease in estrogen levels and a reduction in immune system function, which contribute to an increased susceptibility to STIs.
As women age and approach menopause, they may experience vaginal dryness and thinning of the vaginal mucosa due to a systemic decrease in estrogen levels. This thinning vaginal mucosa is easily inflamed and irritated, and microabrasions can occur from even the simple act of vaginal penetration. Microabrasions, or tears, create an opening for pathogens.9,10
Aging in general is linked to a reduction in immune system function. In addition to a reduction in cellular and humoral immunity, there is also a decrease in T-cell activity and immunoglobulin production. With a reduction in immune system function, it is harder for the aging tissues to ward off infections such as HIV and other STIs.10
Pam collects the urine sample and prepares for the physician’s physical and pelvic exams.5
Vaginal swab is collected for lab analysis.
Which STI is more prevalent among females in the 40- to 49-year-old age group?
Trichomoniasis is most prevalent in women 40-49 years of age.15
Trichomoniasis is unique in that its most affected population is women 40 years and older. One theory to explain this is that T. vaginalis may infiltrate the subepithelial glands and may only become detectable during hormone-induced or antibiotic-induced changes in the vaginal flora.16 Another possible explanation is that menopause-associated endocervical atrophy does not protect against T. vaginalis infection, which occurs in the vagina and cervix.17 The prevalence pattern for trichomoniasis is unlike most STIs that have the highest prevalence among younger individuals and decrease in prevalence with increasing age.17 For example, chlamydia and gonorrhea are most commonly seen in the 20- to 24-year-old age group, and their incidence rates decrease with increasing age.18,19
Based on the National Health and Nutrition Examination Survey (NHANES; 2013-2016), the prevalence of trichomoniasis was greatest among women aged 40-49 years (2.68% vs average prevalence in women of 2.1%)15
The physician reviewsPam’s case notes.
A definitive diagnosis from the lab test will likely not be available for several days, so the physician recommends empirical treatment (syndromic management) targeting the four potential infections shown in the table below.1,5
*Based on the Centers for Disease Control and Prevention (CDC) recommendations for BV treatment, metronidazole may alternatively be prescribed as a once-daily intravaginal application over a total of 5 days.22 However, intravaginal application is not recommended for trichomoniasis because this route of administration does not permit the drug to reach therapeutic levels in the urethra and perivaginal glands.22
Syndromic management is a strategy for identifying and treating STIs based only on the specific presenting syndromes, including symptoms identified by the patient and clinically observed signs of infection.
Black women are disproportionately afflicted by STIs compared with White women.28
The NHANES showed a higher prevalence of trichomoniasis among non-Hispanic Black women compared with non-Hispanic White women.15
In 2018, the CDC estimated that the overall rates of reported chlamydia and gonorrhea cases in Black women were 5 times and 6.9 times greater than the rates reported among White women, respectively.29
The significant racial disparity observed among Black women with STIs is likely multifactorial and may be attributable to:28
According to the CDC, approximately what percentage of all outpatient antibiotic prescriptions are deemed unnecessary?
The CDC estimates that 30-50% of all antibiotics prescribed in the outpatient setting are unnecesary.30
Overtreating or mistreating with antibiotics fuels the growing global health threat of antibiotic resistance. Antibiotics are also not taken without risks. They can cause many adverse side effects including nausea, diarrhea, disruption of the natural microbiome, and long-term effects on immunity and metabolism.1
Antibiotic stewardship is critical to minimizing unnecessary antibiotic use while balancing the need to treat STIs because without treatment, STIs can lead to serious medical consequences, including pelvic inflammatory disease, chronic abdominal pain, ectopic pregnancy, and neonatal complications.1
Seventeen days after the initial patient visit, the clinic receives the STI lab results, which have been reviewed by the physician, and confirms that Pam does not have any of the STIs or other infections that were suspected. Nor did she have VVC.
The clinic contacts Pam to inform her of the lab results, and she is told no treatment changes are applicable.
At this point, Pam has had courses of azithromycin, cefixime, and metronidazole, all of which were not medically necessary in light of the lab results. The physician suspects a noninfectious cause (e.g, a chemical or allergic reaction to soap, detergent, or feminine products).2,31 Pam is instructed to schedule a follow-up appointment if symptoms persist.5,22
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 during the patient visit.33,34
Let’s revisit Pam’s story, but see how different it would play out if the clinic was equipped with a rapid, highly accurate POCT, such as the Visby Medical Sexual Health Click Test...34
If this POCT had been used in the clinic, Pam would not have received unnecessary treatment for three STIs — chlamydia, gonorrhea, and trichomoniasis — yet she did receive unnecessary treatment under a syndromic management protocol.5,41
Note: 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 Test34 is a POCT that enables result-driven, effective treatment delivery during a single clinic visit.