LEUKORRHEA / WHITE DISCHARGE
LEUKORRHEA MEANS WHITE DISCHARGE. However, the color may very depending on the cause. Normally some amount of vaginal discharge is present in every woman. It is a mixture of cervical mucus, endometrial secretions, fluid from peritoneal cavity and fallopian tubes, and vaginal cells. Its amount varies with the phase of the menstrual cycle, being more at the time of ovulation (cervical mucus) and premenstrually (pelvic congestion). It does not have odor, and it many leave behind a brown stain on the underwear.
1. IF THE WOMAN HAS LEUKORRHEA AND ITCHING together, the cause is TRICHOMONIASIS or CANDIDIASIS. Wet smear, it is easy to differentiate the two in the majority of cases clinically and by wet smear. TRICHOMONIASIS is associated with thin, yellowish, frothy, abundant, foul discharge of pH 5 to 7. The underlying vagina is inflamed, with red spots on a hyperemic background. CANDIDIASIS causes thick, curdy, white discharge of pH 4 to 5.
2. A WET PREPARATION is made in all cases, because the nature of the discharge is misleading in some cases, and mixed infection is also possible. A drop of the discharge is placed on a glass slide and observed under a microscope. Trichomonads are seen to have flagellate motility, while the hyphae candida are not seen without special preparation. For that, the discharge is first treated with 10% KOH, which dissolves cells and tissue bebdis. Then India ink is added to the mixture. It stains the background black, and leaves the hyphae unstained.
3. If a diagnosis cannot be made by a wet preparation, a PAP SMEAR is obtained too. The smear shows trichomonads as indistinct, faintly grayish-blue cells with a variety of shapes. The epithelial cells stain red and often have perinuclear halo. Monilial hyphae stain red, are straight or curved, unbranched, and may occur in great numbers. The spores are small, rounded, red refractile bodies which are larger and thicker than cocci.Trichomoniasis can be treated by any of the following regimes. Both sexual partners are treated together Metronidazole 200 mg PO q8h X 7 days.
- Metronidazole 2 g PO once.
- Tinidazole 300 mg PO q12h X 7 days.
- Tinidazole 2 g PO once.
- Other agents: secnidazole, clotrimazole
- TREATMENT OF CANDIDIASIS is by any of the following regimes using pessaries at bedtime.
- Miconazole 200 mg qd PV X 7 days.
- Terconazole 80 mg qd PV X 3 days.
- Nystatin 100000 units qd PV X 14 days.
- Ketoconazole 100 mg PO q12h X 3 days.
- Fluconazole 150 mg PO qd once and repeated weekly.
- Gentian violet for local application X 7 days
4. If the woman does not have vulvar itching along with leukorrhea, a speculum examination is done to find a local cause.
CERVICAL EROSION is a velvety pink area of columnar epithelium in continuity with endocervical epithelium. If it is not due to pregnancy or use of combination contraceptive pills, and Pap smear is normal, it is destroyed with cryocauterization after doing colposcopy.
CERVICITIS causes diffuse redness of the cervix. It is treated by doxycycline (100 mg qd PO X 10 days) and vaginal povidone-iodine pessaries (200 mg qd PV X 10 days). Chronic cervicitis is treated like a cervical erosion.
NONSPECIFIC VAGINITIS is caused by BACTERIAL VAGINOSIS. It causes thin, grayish, watery, odorless discharge at pH 5 to 5.5, which produced "fishy odor" on mixing with 10% KOH. A wet preparation shows "clue cells", which are stippled or granulated epithelial cells (due to adhesion of the bacterial). A gram stain shows small gram -negative bacilli and a relative absence of lactobacilli. It is treated by one of the following regimes.
- Metronidazole 500 mg q8h PO X 6 days
- Metronidazole 2 g qd PO once (less effective)
- Watery cervical mucus in second half of menstrual cycle suggests anovulation.
- Carcinoma of cervix.
- Sexually transmitted diseases
- Foreign bodies: in adults forgotten menstrual tampon, ring or Hodge pessary may cause malodorous discharge. Treatment is to remove the foreign body.
- Atrophic vaginitis: lactating and postmenopausal women lack estrogen, so that the vagina becomes atrophic, and susceptible to trauma and infection. Treatment is local application of estrogen cream.