Vaginal complaints are a common reason for women of all ages to visit their physician, with an estimated 3.2 million initial visits to physicians offices for this population in 1997 (8). Decreased estrogen production in the postmenopausal woman causes a number of changes in the vagina, which can lead to a variety of symptoms (21). The amount of glycogen in the epithelial cells diminishes, leading to a reduction in the lactobacilli population that help to protect the vagina from other bacteria by their production of lactic acid and hydrogen peroxide. The resulting increase in pH facilitates colonization of the vagina with coliform bacteria, streptococci, and staphylococci. The lack of estrogen also leads to thinning of the vaginal mucosa, loss of rugae, and a progressive loss of elasticity and vascularity. The vaginal vault shortens and narrows, and the vaginal introitus may also become contracted. These changes often lead to dyspareunia, vaginal dryness, itching, burning or pruritis, or vulvar symptoms. Physical signs of vaginal atrophy include pale, smooth shiny mucosa. In the case of atrophic vaginitis, signs of inflammation will also be present, such as erythema, petechiae, friability, bleeding, or discharge (21). It is important for the health care provider to recognize this condition not as an infection or STD but as a syndrome of hormone deficiency, as most women will respond to hormone replacement.
Bacterial vaginosis (BV) and candidiasis are not sexually transmitted infections, but may arise in older women because of the changes in the vaginal microflora that occur in the postmenopausal state. Because these conditions are not STDs, they are not discussed further here, but the reader is referred to the STD Treatment Guidelines for discussion on the diagnosis and treatment (10). Trichomoniasis, caused by Trichomonas vaginalis, is an STD, which in women can infect the vagina, cervix, urethra or bladder. Trichomoniasis is not a reportable disease, so accurate data on the incidence of this infection in older women are not available. Common signs due to trichomonia-sis include abnormal discharge, which is often discolored and/or frothy, vaginal erythema, and punctate cervical hemorrhages. Symptoms include discharge, itching, or burning of the vagina or vulva, but occasionally women will present with predominantly urethral complaints, such as frequency, urgency, or dysuria. Trichomoniasis, like other STDs, may also be carried asymptomatically for long periods of time, and the host factors that allow the asymtpomatic carriage have not been elucidated.
Trichomoniasis is diagnosed by seeing motile trichomonads on a saline preparation of vaginal secretions. In some cases, the trichomonads may not be readily visualized, so the clinician should suspect the diagnosis if the wet mount has numerous WBCs, the pH is highly elevated, and the "whiff" test (amine odor after addition of 10% potassium hydroxide to vaginal secretions) is mildly positive. A new commercially available culture system, called the InPouch TV test, is available for the diagnosis of trichomoniasis in patients with negative saline preparations. Trichomoniasis is easily treated with a single dose of 2 g oral metronidazole (10), and partner treatment is recommended due to the difficulty in diagnosing the infection in men.
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