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Common Gynecological Infections in Women With HIV

October 1998

Most women experience occasional gynecological infections. Women with HIV experience more of these infections, and when they do the infections tend to be more serious and less responsive to treatment. Indeed, gynecological infections are the most frequently reported health problems in women who are living with HIV. Some of these infections -- vaginal candidiasis, or "yeast" infection, for example -- generally cause only minor discomfort and usually respond promptly to over-the-counter medications. Other infections -- pelvic inflammatory disease, or PID, for instance -- can cause symptoms so severe that the patient must be hospitalized. Recurrence is common with gynecological infections, and those repeat infections tend to respond less well to therapy. Indeed, women who experience several episodes of PID often develop chronic pain, and the scarring that results from these flare-ups can lead to tubal infertility.

Because all of these gynecological conditions pose particular risks for HIV-positive women, it is especially important that women with HIV -- and their regular care providers -- be especially vigilant about vaginal health. Recognizing the early signs and symptoms of the most common gynecological infections seen in women with HIV can help those women obtain treatment early -- when the infection is most responsive to therapy and the likelihood of lasting damage is smallest.

This vigilance is required at all stages of HIV infection, but it is particularly needed during the later stages of infection, when profound immune suppression leaves patients susceptible to a host of AIDS-related opportunistic infections. Women with advanced HIV disease do develop PCP, CMV retinitis, MAC, and all of the other OIs that are commonly seen in AIDS patients, but in addition they are susceptible to the infections listed on the table that appears on the next two pages.

This special Pull Out and Save feature, "Common Gynecological Infections in Women with HIV," identifies the signs and symptoms of these infections, describes how they are diagnosed and treated, offers alternative therapies, alerts care providers to potential problems that can occur when these treatments are administered, and suggests ways that providers and patients can work together to reduce the likelihood of recurrent infections. The box at the bottom of this page lists several organizations that specialize in providing treatment-update information to women who are living with HIV.

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All infections, including those listed in the table, are caused by one or more pathogens, or disease-causing agents. It is important to know what kind of pathogen -- viral, bacterial, fungal, or protozoal -- is causing a particular infection, because the choice of treatment is based on that information. It is possible to cure infections caused by bacteria, funguses, and protozoa. Viral infections such as herpes zoster infection can never be cured, but medication can clear up the symptoms and suppress viral activity, thereby reducing the likelihood of subsequent outbreaks.

As its name suggests, "Common Gynecological Infections in Women with HIV" covers only frequently seen vaginal infections in HIV-positive women. (It does not list the three most widespread sexually transmitted diseases -- syphilis, gonorrhea, and chlamydia -- even though these diseases can have gynecological manifestations, because these STDs are common in men as well as women. These STDs will be the subject of a future feature article in AIDS Care.) This special Pull Out and Save section offers readers another weapon in the ongoing battle against HIV infection and its manifestations. Familiarize yourself with the signs and symptoms of these common gynecological infections -- so that you can get early, effective help if you develop vaginal disease.


Note: The information contained in this special section is adapted from materials developed by Project Inform for that organization's discussion paper on women and HIV, and it is reprinted with permission. For more information, contact the Project Inform National HIV/AIDS Treatment Hotline: 1-800-822-7422.


Common Gynecological Infections in Women With HIV

Infection
Symptoms
Diagnosis
Treatments
Alternative
Treatments
Cautions
Other
Information
Bacterial Vaginosis

(BV or gardnerella)

Bacterial infection

Odorous, frothy vaginal discharge
  • Checking the vaginal pH

  • Mixing with potassium hydroxide solution and noting a characteristic odor

  • Looking at a sample of the discharge under the microscope
  • Metronidazole (Flagyl, MetroGel, and others)
    500 mg by mouth, twice a day for seven days
  • Metronidazole
    (MetroGel) cream
    (insert twice a day for five days)

  • Clindamycin (Cleocin) cream (insert once a day for seven days)

  • Herbal treatment with goldenseal (1Tbsp goldenseal in warm bath)
  • No metronidazole with alcohol

  • Herbal treatments should not be used by pregnant women, because they may not be effective (this may also apply to women with a history of PID)
  • Treat female sexual partners with the same regimen.

  • There is no evidence that BV increases risk for acquiring HIV infection.
  • Trichomonas

    (Trich)

    Protozoal infection

    Heavy, itchy vaginal discharge (sometimes a greenish-
    yellow color), usually with a fishy odor; can cause pain and soreness in and around the vagina; can cause extreme itching
  • Checking the vaginal pH

  • Microscopic examination

    Note: Trich may be noted on a Pap smear, but it is not diagnosed by a Pap smear.

  • Metronidazole 2 gm, taken by mouth in a single dose, cures 95% of cases as long as sex partners are treated at the same time
  • Metronidazole
    375 mg, taken twice a day by mouth for seven days

  • Garlic suppositories (insert a clove of garlic secured in gauze overnight for 10-24 days)
  • No metronidazole with alcohol
  • Treat all sexual partners

    Note: Women with HIV may require the 7-day regimen for effective treatment.

  • Vaginal Candidiasis

    (Yeast infection)

    Fungal infection

    Itchy, lumpy white or yellow discharge accompanied by rash and irritation
  • Checking the vaginal pH

  • Clinical signs during the speculum exam

  • Adding potassium hydroxide to the discharge and looking for the organism under the microscope

    Note: Yeast may be noted on a Pap smear, but it is not diagnosed by a Pap smear.

  • Fluconazole (Diflucan) 150 mg, taken by mouth in a single dose

  • There are a number of 7-day or 3-day creams and suppositories available by prescription or OTC
  • Single-dose creams are available by prescription

  • Douching with betadine or vinegar

    Note: Douching is not recommended for women who are pregnant or have any history of PID.

  • Yeast infections may be accompanied by a skin rash (much like a diaper rash). Treat it with creams such as clotrimazole, Desitin, vaseline, zinc oxide, or A&D ointment, all of which are available OTC. For more difficult rashes use prescriptions of clotrimazole (Lotrisone). Patients may be able to prevent recurrences by:

  • Decreasing sugar in the diet (including sweets and high-sugar-
    containing products like alcohol)

  • Eating lactobacillus-
    containing yogurt or taking acidophillus capsules daily

  • Taking fluconazole 100 mg by mouth once a week
  • Herpes Simplex Virus

    (HSV)

    Viral infection

    Painful blister-like sores in and around the vagina, rectum, and/or anus; painful urination; genital irritation, swollen lymph nodes in the groin, fever, headaches, muscle aches, fatigue Can sometimes be diagnosed by visual exam. Fluid from sores can be cultured to confirm infection.

    Note: Blood tests can confirm that a person is infected, but not if the infection is currently active.

  • Acyclovir (Zovirax) 200 mg, 5 times a day by mouth for 10 days during outbreak
  • Famciclovir (Famvir) 125 mg, taken by mouth twice a day for 5 days

  • Sores can be covered with facial clay or zinc oxide for comfort; valacyclovir (Valtrex) 500 mg, taken twice a day by mouth for five days for acyclovir-
    resistant HSV.

    Note: HSV can cause moderate to severe pain. Lidocaine (Xylocaine or Neosporin Plus) gel applied directly to the sores can help. Other pain relievers may be necessary.

  • The earlier the treatment is started, the more quickly symptoms will resolve. Recurrences may occur as rarely as every few years or as often as every few weeks. Low immune function usually means more outbreaks. In addition, outbreaks can lead to secondary bacterial skin infections Transmission is most likely during outbreaks, but it is also possible at other times.
    Human Papilloma Virus

    (HPV, genital warts)

    Viral infection

    Often asymptomatic; sometimes there are multiple tiny white spots (warts) on the vagina or around the anus; other symptoms include some vaginal discharge or, rarely, pain during intercourse Can often be diagnosed visually, but since warts may be associated with cancer or precancer anywhere in the genital tract, diagnosis should be made by biopsy whenever there is any question. Diagnosis is also made by Pap smear, but should be followed up with colposcopy. Multiple options including:

  • Trichloro-
    acedic acid

  • Electro-
    cautery

  • Cryotherapy
  • More treatment options: surgical excision, laser excision, and various chemicals that destroy warts. Recurrence of warts is very common, especially in immune-
    compromised persons.
    Prevention tips for patients:

  • Stop smoking (tobacco is associated with both warts and cancerous growths)

  • Practice safer sex (may help prevent passing HPV between partners)
  • Pelvic Inflammatory Disease

    (PID)

    Mixed microbial infection

    Lower abdominal pain and abnormal vaginal discharge; can also cause fever, pain in the upper-right abdomen, painful intercourse, and irregular menstrual bleeding as well as bleeding with insertive sexual activity. No clear-cut standards for diagnosis. Usually diagnosed by symptoms and pain on the pelvic exam. Sonogram may be performed; surgical diagnosis is occasionally required.
  • Treatment is usually at least two antibiotics that are effective against a wide range of infections since PID is probably the result of multiple pathogens; plus bed rest for 14 days.
  • Women with HIV and PID should be hospitalized for treatment with IV antibiotics. PID is usually caused by infection with gonorrhea or chlamydia, which spreads to the uterus, tubes and ovaries, carrying other pathogens and causing a mixed bacterial infection. In women with HIV, PID can occur without reinfection with an STD. Chronic pain is common after several episodes. PID can lead to tubal infertility.
    Molluscum

    Viral infection

    Tiny growths, most commonly found on the face, in the groin, or on genitals; may cause itching Usually diagnosed by visual exam. HPV should be ruled out.
  • No proven treatment

  • Some clinicians apply podophyllum to the lesions
  • Other caustic treatments may be used; consult a dermatologist. The infection is easily spread from person to person and it may disappear spontaneously. Immune compromise is associated with increased number of lesions and less likelihood of remission.
  • Not associated with cancer or any other complications

  • Some reports claim that molluscum disappear in patients who respond well to HAART

  • Resources for Women Living with HIV
    Project WISE. WISE Words, a treatment newsletter for women living with HIV infection, is published monthly by Project WISE, a division of Project Inform (which also publishes PI Perspective, a treatment-update newsletter for people with HIV). WISE was founded by Dawn Averitt, one of the guest editors of this special issue of AIDS Care. Project Inform's other services include an advocacy program, town meetings, a treatment hotline, and a Web site that offers interested parties an extensive resource directory. Contact: Project WISE, 205 Thirteenth Street, Suite 2001, San Francisco, CA 94103. Telephone: (800) 822-7422.

    Women Alive. Women Alive, a West Coast organization that pursues policy and treatment issues on behalf of women who are living with HIV, publishes a quarterly newsletter for HIV-positive women, runs a drop-in center, and provides peer counseling. Contact: Women Alive, 1566 Burnside Avenue, Los Angeles, CA 90019. Telephone: (213) 965-2564.

    WORLD (Women Organized to Respond to Life-threatening Diseases). WORLD, which publishes a monthly newsletter for women with HIV, also has a peer-advocate program, a treatment training program called HIV University, and several retreats every year for HIV-positive women. The newsletter is sent free of charge to prisoners and others who cannot afford to pay for it, but WORLD does ask individual subscribers to pay at least $20 per year. Care providers, professional groups, and corporations are asked to donate at least $50. Contact: WORLD, 414 - 13th Street, 2nd Floor, Oakland, CA 94612. Telephone: (510) 986-0340.

    Elizabeth Glaser Pediatric AIDS Foundation. The Pediatric AIDS Foundation advocates on behalf of infants and children with HIV infection and funds research studies aimed at improving the care of this patient population. Dr. Catherine M. Wilfert, the other guest editor of this special issue of AIDS Care, is the Scientific Director of the Pediatric AIDS Foundation. The foundation's trials hotline provides information on special treatment programs for HIV-positive infants and children. Contact: Elizabeth Glaser Pediatric AIDS Foundation, 1311 Colorado Avenue, Santa Monica, CA 90404. Telephone: (310) 395-9051.

    Families' and Children's AIDS Network. This Chicago-based organization offers family support programs, information, and special materials for children to anyone who is caring for an HIV-positive child. Contact: Families' and Children's AIDS Network, 721 North LaSalle Street, Chicago, IL 60610. Telephone: (312) 655-7360.

    National Pediatric and Family HIV Resource Center. NPHRC provides training and support to a national network of agencies that care for women and children infected with HIV.

    The Women's Initiative for HIV Care and Reduction of Perinatal HIV Transmission. WIN has projects in Florida, Louisiana, Maryland, Massachusetts, New Jersey, Pennsylvania, and Texas. Telephone: (301) 443-9051.





      
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    This article was provided by San Francisco General Hospital. It is a part of the publication AIDS Care.
     

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