Do we need to treat vulvovaginitis in prepubertal girls?
BMJ 2005; 330 doi: https://doi.org/10.1136/bmj.330.7484.186 (Published 20 January 2005) Cite this as: BMJ 2005;330:186
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As a gp for 25 years(and father of three girls) the vast majority of
such cases seen in general practice are caused by the use of bubble baths
and soaps.the incidence is always higher after christmas following
presents of nice smelling preparations to girls.treatment is simple and i
advice mums to use barrier creams(eg any nappy cream) for afew days with
stopping bath time treats. This leaves the very infrequent child who
presents a diagnostic problem described in the article
Competing interests:
None declared
Competing interests: No competing interests
Dr Arnott’s asks for references for the carcinogenicity of
oestrogens. There are 129 publications by Regina Schoental in NCBI Pub
Med, mostly about her work on experimental carcinogenesis and the effects
of the oestrogenic mycotoxin zeralenone. Besides increasing the risk of
cancer, oestrogen exposures during childhood can also cause precocious
sexual development.1 Oestrogens caused breast cancer in experimental
animals in the 1930s.2 A range of cancers caused by hormones in animals
and humans is listed by Li.3
In 1974 Schoental published a new hypothesis, “The mode of action of
carcinogens which can induce tumours with a single dose”.4 She found that
oestrogenic mould in dietary corn, plus environmental oestrogens in
bedding, were causing spontaneous tumours in laboratory animals.5
Variations in the incidence of “spontaneous” tumours related to variations
in oestrogen exposures.6
Vulvovaginitis can be caused in animals by hyperoestrogenism due to
consumption of mouldy corn contaminated with zeralenone.7 The intake of
oestrogenic pesticides, and their long-term accumulation in body fat, can
be a reason why, along with high sugar diets and zinc deficiency, that Dr
Arnott and other GPs are asked to treat infantal vulvovaginitis. Zinc
cream would be a rational treatment for adhesions. The use of vaginal
oestrogen in very young girls adds insult to injury if oestrogen exposures
are the underlying cause. However because steroid sex hormone treatments
can suppress warning symptoms, superficial “beneficial effects” may be
easy to see. Unfortunately, the risk of numerous serious illnesses
increase, as has happened tragically with hormone use in pregnancy, OCs
and HRT since the late 1930s.
A few applications of oestrogen cream in childhood could soon be
followed by huge doses of even more immunosuppresive and carcinogenic
progesterones for emergency contraception in the early teens.
Schoental was very aware of the powerful immune system disruptive
effect of exogenous hormones. 8,9 Some of her work is about the
deleterious effects of likely increases in oestrogen exposures throughout
history, with papers on the Etruscans, the Bible and Moses, homosexuality
and AIDS. The increased use of progesterones and oestrogens in young girls
was a great concern to her.
Any refusal of parents to allow their children to be given
oestrogens, which could actually increase the risk of vulvovaginitis, is
very sensible. Refusing to give antibiotics a child is different and is
often stems from previous experiences of increased symptoms and thrush
after antibiotic courses because antifungal medication is not usually also
given. Pathogenic infections should be readily treatable with antibiotics
and antifungals.
Efficient and safe treatment of vulvovaginitis may also prevent
parents from being accused wrongly of child abuse.
1. Schoental R. Precocious sexual development in Puerto Rico and
oestrogenic mycotoxins (zearalenone) Lancet 1983; 1: 537.
2 Lacassagne A. Appearances of breast cancers in male mice injected
with folliculin. C R Hebd Seances Acad Sci 1932 ;195; 630-32.
3 Li JJ. Perspectives in hormonal carcinogenesis: animal models to
human disease. In Cellular and Molecular Mechanisms of Hormonal
Carcinogenesis. Environmental Influences. Eds J Huff, J Boyd, J Carl
Barrett. Wiley-Liss, New York 1996.pp 447-54.
4 Schoental R. Proceedings: The mode of action of carcinogens which
can induce tumours with a single dose: a new hypothesis. Br J Cancer 1974;
29: 92.
5 Schoental R. Proceedings: Zearalenone in the diet, podophyllotoxin
in the wood shavings bedding, are likely to affect the incidence of
"spontaneous" tumours among laboratory animals.
Br J Cancer 1974; 30:181.
6 Schoental R. Variation in the incidence of "spontaneous" tumours.
Br J Cancer 1979; 39: 101.
7 Aucock HW, Marasa WF, Meyer CJ, Chalmers P. Field outbreaks of
hyperoestrogenism (vulvo-vaginitis) in pigs consuming maize infected by
Fusarium graminearum and contaminated with zearalenone.
J S Afr Vet Assoc 1980 ; 51 :163-6.
8 Schoental R. Mycotoxins, pesticides and the immune system.
J Appl Toxicol 1989; 9: 359.
9 Schoental R. Trichothecenes, zearalenone, and other carcinogenic
metabolites of Fusarium and related microfungi. Adv Cancer Res 1985; 45:
217-90.
Competing interests:
None declared
Competing interests: No competing interests
The safety of short courses of low dose topical oestrogen in young
children is well established in the published literature. Low dose topical
vulval oestrogen has been employed in the treatment of paediatric hypo-
oestrogenic labial adhesions for at least three decades. I would obviously
scrutinise any research to the contrary and would be grateful if Dr Grant
could send this to me directly so that I can use this in shared decison
making with the patient. Topical oestrogen continues to be reported in the
mainstream published medical literature as safe when used as above. It has
been observed that the use of oestrogen appears to alleviate the
irritating symptoms of vulvitis in children and this treatment has been
reported in general practice. The dose of oestrogen is limited by
appropriate advice as I suggested in my initial correspondence. I agree
with Dr Rose that vulval hygiene advice is necessary at the outset and
that simple emollients could be advised. Some parents are averse to any
hormonal treatment in the same way that many are averse to antibiotic use
and I accept this. I also accept that there may be some debate as to where
to use oestrogen in a treatment algorithm. The reason for my initial
correspondence was to highlight the recognised role of oestrogen in the
treatment of paediatric vulvovaginitis, a not uncommon and rather
contentious area, and to help ensure that this is at least considered
within any further research proposal.
Topical oestrogen therapy for labial adhesions in children.
Br J Obstet Gynaecol. 1975 May;82(5):424-5.
Competing interests:
None declared
Competing interests: No competing interests
I agree with Joishy et al that this is the commonest gynaecological
presentation to a GP in prepubertal girls. Swabs are rarely taken in
primary care and the condition is often misdiagnosed- treatment for thrush
is a common prescription. I have found that an explanation to parents
about the aetiology of the condition and the use of emollients to reduce
symptoms is usually all that is needed.
I would suggest that renaming this condition 'juvenile
vaginitis'(c.f.senile vaginitis)would stress the hypo-oestrogenic
pathogenesis and would deter inappropriate treatments with antibiotics.
Competing interests:
None declared
Competing interests: No competing interests
The late Dr Regina Schoental's life’s work at the Royal Veterinary College in London concerned the effects of oestrogens. She discovered that one
large dose of oestrogen, especially during development, could be
carcinogenic when followed by numerous small doses of oestrogens. Even if
a child has not been exposed previously to exogenous maternal hormones in
pregnancy, as many have due to Pill failures or assisted conception
programmes, most children are exposed to daily doses of oestrogenic
pesticides in their food.
GPs like Dr Arnott, who are aware of the obvious effects of oestrogen
applications, seem unaware of possible long-term consequences.
In the experience of members of the British Society for Allergy,
Environmental and Nutritional Medicine vulvar irritation or leucorrhoea
are usually due to too much sugar and yeast in the child’s diet. They are
also usually signs of common nutritional deficiencies. Oral additive-free
nystatin gives excellent results both for vulvar irritation and eczema.
It is a pity that Nutritional Medicine does not feature as
prominently in medical education as the promotion of sex hormones to
females of all ages. Oestrogen users have increased risk of bacterial and
fungal infections and oestrogen should not be given if STDs are suspected
and have not been excluded.
The answer to “Do we need to treat vulvovaginitis in prepubertal
girls?”1 is “Yes, quite often, but preferably using safe non-hormonal
means”.
1 Joishy M, Ashtekar C S, Jain A, and Gonsalves R. Do we need to
treat vulvovaginitis in prepubertal girls? BMJ 2005; 330: 186-188
Competing interests:
None declared
Competing interests: No competing interests
Vulval irritation in girls aged between two and seven years is not
uncommon in UK general practice. I would say that out of 3000
consultations per year in a town practice in Scotland with a
demographically average population I might see 5-10 such cases.
I agree with the hard facts that are outlined in the overview by
Joishy et al but was surprised to see no mention of the use of local
oestrogen cream to the external genitalia. Despite the theoretical risks
of inducing breast engorgement, endometrial stimulation and withdrawl
bleeding through inadvertent prolonged use, I have found this to be an
excellent treatment used as a nightly application for 14 nights maximum.
With the knowledge of the child and family and after a careful history to
explore for the possibility of threadworms, foreign bodies such as sand
exposure recently or blood stained discharge I usually then check if any
obvious gaps in knowledge of vulval hygiene measures and then offer the
option of oestrogen cream versus the option to use penicillin orally with
oestrogen cream but tend to lead the patient to avoid antibiotics at the
outset. The pharmacist is instructed to remove the vaginal applicator from
the packet and the parent is instructed to apply the cream externally to
the vulva . It is also important to request a urine sample to exclude
urinary tract infection and to give advice specifically on vulval hygiene
including avoidance of soaps, shampoo running down to vulva from head and
basically any other potentially irritant applications to the vulva.
Special enquiry is made to check if topical applications such as sudocrem
or E45 cream are being used and these are stopped.
It is my experience that most children are cured by using oestrogen
which may in part be due to concomitant general hygiene advice. Follow up
is arranged and those who have not responded are examined intimately and
investigated to exclude unusual pathology.
I would welcome further comments regarding this approach as I feel it
works in every day general practice.
Dr Neil Arnott
General Practitioner
References:.
Manohara Joishy, Chetan Sandeep Ashtekar, Arpana Jain, and Rohini
Gonsalves
Do we need to treat vulvovaginitis in prepubertal girls? BMJ 2005;
330: 186-188
Jones R. Childhood vulvovaginitis and vaginal discharge in general
practice.. Fam. Pract.1996 Aug; 13(4):369-72
Competing interests:
None declared
Competing interests: No competing interests
This review of managing paediatric vulvovaginitis was, rightly,
cautious in mentioning sexually tranmissible infections (STIs) as a cause
for symptoms. It is concerning that insufficient guidance of how to
exclude such infections was given,particularly if therapy was to be
witheld.
It is well established that chlamydial, trichomonal and gonococcal
infections may cause vulvovaginitis in prepubertal girls.(1) These
infections may co-exist with threadworms and other minor pathogens, but
the paper did not consider this. The previous studies quoted are either
strictly concerned with bacterial microflora and do not mention specific
culturing attempts for trichomonas and/or chlamydia, or pre-date the
development of sensitive NAATS tests for chlamydia.
The management approach, with Gram staining and routine cultures for
bacterial infections and a sellotape test, cannot diagnose these STIs and
it is disappointing that appropriate methods for screening were not
mentioned. Culture methodologies and/or NAATS testing procedures for these
three important infections leading to a strong probability of sexual abuse
(2)must be considered in symptomatic children. If, as the title and
conclusion suggests, we may not offer treatment for vulvovaginitis, we
should be sure that screening protocols ensure the safety of that
decision.
1.Thomas A, Forster G, Robinson A, Rogstad K for the Clinical
Effectiveness Group. National guideline for the management of suspected
sexually transmitted infections in children and young people. Sex Transm
Infect 2002;78: 324-31.[Free Full Text]
2.The Royal College of Physicians of London, ‘Physical Signs of Sexual
abuse in children.
2nd edition (1997).
Competing interests:
None declared
Competing interests: No competing interests
Vulvovaginitis in prepubertal girls
EDITOR - I wonder whether the unexperienced physician will know how
to deal with a suspected vulvovaginitis in a young girl, after having read
the paper by Joishy et al1. Some of the statements made by the authors
can be disputed. There is no evidence whatsoever for considering that the
absence of pubic hair or the poor development of the labial fat pads
(labia majora) would put girls in this age group at greater risk. Nylon
underwear probably plays a role, if any, by altering the vulvo-vaginal
ecosystem due to its relative impermeability, rather than by irritation it
may cause. At any rate, young girls seldom wear nylon underwear !
One should not take vaginal swabs in prepubertal girls. The vaginal
mucosa being extremely thin is easily bruised by the cotton tip, and the
little girl may experience considerable pain and distress. A much better
method is to place the child in a slight Trendelenburg position, to
instill a few millilitres sterile saline in the vagina by means of a soft-
ended paediatric catheter connected to a syringe, to re-aspirate some of
the fluid, and to submit this latter to microbiological examination.
The reader is instructed by the authors to carry out a "sellotape
test" to rule out a threadworm infection, but is not told how to proceed.
Further, it is debatable whether the general gynaecologist is always
capable of dealing with a foreign body in the vagina of a little girl :
this practitioner often does not have a vaginoscope at his / her disposal.
Finally, the top figure in the paper by Joishy et al1 does not represent
an adult threadworm (which is 9 - 12 mm long !), as stated by the
authors, but instead the hatching of an egg, with a larva (140 - 150 µm
long) emerging from it.
Very briefly, practical guidelines might be the following.
1.
Inspect the child's stained underwear (that the accompanying person
frequently has brought to show) : blood stains mandatorily require further
investigation.
2. Carefully inspect the external genitalia, the skin of
the buttocks and the perianal area, the hymen, and the vaginal mucosa that
can be seen through the hymenal orifice.
3. Instill and re-aspirate
saline solution as described earlier, for microbiological examination of
the vaginal contents. If the culture would indicate that the beta-haemolytic
streptococcus of the group A is responsible for the vulvovaginitis, this
latter is preferentially treated by oral administration of 250 mg
penicillin V suspension three times a day for 10 days.
4. Flush gently
the vagina with 20-30 ml saline to wash out tiny foreign bodies (such as
fragments of toilet paper or wool from a carpet).
5. Instruct the parents
to inspect the perianal skin of the little girl, with the help of a torch,
around 11:00 PM, to rule out the presence of adult (female) threadworms,
which come out of the anus around that time to lay their eggs. If no
worms are seen on three consecutive evenings, the child may be considered
not to be infested by this parasite. If doubt should persist, the
adherent side of a piece of cellophane tape is pressed against the
perianal skin, in the morning after the child's awakening, immediately
removed, and stuck to a slide for microscopic examination. The treatment
of choice of a threadworm infestation consists of the oral administration
of mebendazole suspension.
6. If symptomatology persists, the child
should be referred for vaginoscopy to a paediatric gynaecologist.
Jean-Jacques AMY, professor and head
Department of Gynaecology, Andrology and Obstetrics,
Academisch Ziekenhuis, Vrije Universiteit Brussel,
Brussels, Belgium
cgynpnb@az.vub.ac.be
Competing interests : none, except for being the editor of a book on
paediatric and adolescent gynaecology.
1 Joishy M, Ashtekar CS, Jain A, Gonsalvez R. Do we need to treat
vulvovaginitis in prepubertal girls ? BMJ 2005; 330 : 186 - 8. (22
January.)
Competing interests:
Editor of a book on Paediatric and Adolescent Gynaecology
Competing interests: No competing interests