Abnormal vaginal discharge
BMJ 2013; 347 doi: https://doi.org/10.1136/bmj.f4975 (Published 13 August 2013) Cite this as: BMJ 2013;347:f4975
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As a GP I agree with the Chester Sexual Health specialists rapid response.
In the article I think that the comment “examination should always be offered” is unrealistic and defensive. GPs frequently treat symptoms of candidiasis by history only - with a consultation safety net for those who do not respond to clotrimoxazole 10% VC to explore alternative diagnoses and perhaps consider diabetes m.
I agree that "pH testing is not mandatory" in general practice - it is actually unusual practice. Guidelines for diagnosis of bacterial vaginosis based upon Amsel’s criteria are old fashioned and do not reflect current practice. Most GPs neither perform the whiff test (beyond their own and patient reported pungent observations for anaerobic organisms) nor do they perform pH testing; they rely on white/ grey thin discharge and fishy smell associated when swabbed with clue cells.
I also do not agree with the advice to “take endocervical swabs if there is a risk of STI.” The studies reported in the BMJ December 12th 2012 by the Leeds genitourinary team led by Sarah Schoeman found that self taken vulvovaginal swabs are significantly better than endocervical swabs at detecting Chlamydia and equivalent for the detection of gonorrhoea. Doctors may still wish to examine the patient in order to view the cervix and discharge but the swabs should be vulvovaginal whether patient or doctor taken. This is a real advance for the embarrassed female patient.
Competing interests: No competing interests
This otherwise sensible article missed the opportunity to re-emphasise that a low vaginal swab is the best investigation for gonorrhoea (GC) and chlamydia. The article suggests taking an endocervical swab. However, this would miss almost 10% of chlamydia.(1,2,3) Large studies have now shown that a self-taken swab, ie; vulvovaginal is superior to endocervical swabs. This also means that General Practice can do a full STD screen in total confidence. In General Practice, syndromic management is necessary and in a 29 year old woman in a stable relationship, a discharge if itchy is most likely due to candida. If it has an odour it is most likely due to bacterial vaginosis and the chance of gonorrhoea or chlamydia are slim but still need to be out-ruled. By getting the patient to do a self-taken vulvovaginal swab, the General Practice can be reassured that they have made sure they don’t miss that rare unexpected chlamydia or GC positive. If the test comes back positive, there can be enormous relationship implications involving contact tracing, etc, which really cannot be covered in a 10 minute consultation. Onward referral to Sexual Health Services who guarantee an appointment within 48 hours is then appropriate.
This also means that patients who have a self-taken AC2 swab done in General Practice or Community Clinics, can be reassured that they have had the best possible investigation, as some patients mistakenly think that a speculum-based examination is essential for a ‘proper’ screen.
Dr Colm O’Mahony, MD., FRCP., BSc., Dip.Ven.,
Consultant
Integrated Contraception & Sexual Health
Chester
Dr Nicola Mullin, FRCOG, MFFP
Consultant
Integrated Contraception & Sexual Health
Chester
References
1 Schoeman SA, Stewart, CMW, Booth RA, et al. Assessment of best single sample for finding chlamydia in women with and without symptoms: a diagnostic test study. BMJ 2012;345:e8013.
2 Stewart CMW, Schoeman SA, Booth RA, et al. Assessment of self-taken swabs versus clinician taken swab cultures for diagnosing gonorrhoea in women: single centre. Diagnostic accuracy study. BMJ 2012;345:e8017.
3 O’Mahony C, Vulvovaginal swabs are the best for chlamydia and gonorrhoea; let’s change practice. INT J STD & AIDS, 24(10)842.
Competing interests: No competing interests
Re: Abnormal vaginal discharge
I would like to underline and remind colleagues about the extremely powerful broad spectrum fungicidal and bactericidal activity, of carvacrol rich essential oil of oregano that has proved to be active, even against antibiotic and antimycotic resistant strains, without any side effects. [1][2]
Concomitant topical administration of carvacrol rich emulsions of essential oil of oregano, or other herbal monoterpenes, with current systemic pharmacologic therapies must be investigated and pursued, in order to achieve synergistic effects.
Carvacrol has also antinociceptive[5] and potent anti-inflammatory activity[3][4].
No bacterial resistance has ever been observed.
References
[1] http://www.bmj.com/content/317/7159/609/rr/634773
[2] http://www.bmj.com/content/337/bmj.39357.558183.94/rr/630538
[3] http://www.ncbi.nlm.nih.gov/pubmed/22363615
[4] http://www.ncbi.nlm.nih.gov/pubmed/22892022
[5] http://www.ncbi.nlm.nih.gov/pubmed/23146035
Competing interests: No competing interests