common causes of vaginal discharge

Common Causes of Vaginal Discharge Including Sexually Transmitted Infections

01/31/13

VETERANS HEALTH ADMINISTRATION

Objectives

By the end of this lecture, participants will be able to:

• Identify common causes of vaginitis

• Describe risk factors, symptoms, and appropriate patient education for common vaginal infections including those that are sexually transmitted (STIs)

• Understand the components of a good sexual history

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Vaginitis

• Most frequent reason why American women visit the doctor

− More than 10 million office visits per year

• Many are transmitted by sexual contact, but some infections are not

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Most Common Causes of Vaginitis• Overgrowth of vaginal flora

− Bacterial vaginosis− Yeast (candidiasis)

• Sexually transmitted infections• Non-infectious causes

− Leukorrhea (discharge occurring during pregnancy)− Atrophic vaginitis (dryness due to thinning tissue and

decreased lubrication)• Menopause, lactation, progestin-only contraception

− Reactions to deodorants, spermicides, latex, semen− Foreign bodies (e.g., retained tampons)

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Exam Assessment • Discharge:

− Color, viscosity, adherence to the vaginal walls− Presence of an odor

• Visualization of the cervix to rule out cervicitis• Specimen collection supplies needed

− Wet mount− Cultures− DNA probe (Affirm)− Rapid antigen test− Proline IminoPeptidase (PIP) activity test− BV-Blue

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Vaginitis/STI evaluations may include…

• HIV test

• Hepatitis B screen

• Chlamydia/GC culture

• VDRL/RPR

• HPV/DNA test (if not done at time of Pap)

• Wet mount supplies

• pH paper

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Common Causes of Vaginitis

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Bacterial Vaginosis (BV)

• Cause: lack of protective lactobacilli• Present in 29% of the female population• 30% of women have recurrence in 3 mo, 50% in 12• Most common cause of discharge and “fishy” odor, but >50% of

women are asymptomatic• Associated with

− Pelvic inflammatory disease (PID)− Increased risk of endometritis, cervicitis, post-op infections− Preterm delivery, ruptured membranes, low birth weight in

pregnancy• Has been identified in female same-sex partnerships

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Patient Education for Bacterial Vaginosis

• Associated with multiple partners, new partner, douching, lack of vaginal lactobacilli, shared sex toys

• Occurrence may be related to sex, but is not considered an STI• Use oral or intravaginal medication as directed

− OTC medicines for yeast or other vaginal products don’t work− Recognize potential for recurrence− Recurrence in 3-12 months is common− Treating male partner will not prevent recurrence − Avoid douches/feminine deodorant sprays to treat or prevent recurrence

• Reinforce abstinence, mutual monogamy, latex condom use, limiting number of sex partners

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Vulvovaginal Candidiasis (Yeast infection)• Overgrowth of yeast that is part of normal vaginal flora • Usually not transmitted sexually, but frequently diagnosed in

women being evaluated for STIs• 75% of women have it during lifetime; 50% have recurrence• Risk factors: diabetes, antibiotics, spermicide use, douching,

contraceptive devices, HIV, pregnancy, corticosteroid use

• Symptoms: Itching, redness, burning,odor-free “cottage cheese” discharge

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Patient Education for Candidiasis (Yeast infection)

• Lack of vaginal lactobacillus bacteria allows overgrowth of fungus− Yeast fungus can spread through oral-genital contact

• Associated with antibiotics, pregnancy, diabetes, impaired immune system, douching, sexual activity

• Use oral or intravaginal medication as directed • Avoid douches/feminine sprays to treat/prevent recurrence• Mineral-oil in topical antifungal preparations may erode latex

condoms /diaphragms. Use plastic/polyethylene condoms. • Reinforce abstinence, mutual monogamy, latex condom use,

limiting number of sex partners

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0 1 2 3 4 5 6 7

Number of cases (millions)

TrichomoniasisGenital HPV

ChlamydiaHerpes

GonorrheaHIV

SyphilisHepatitis B

7.4 mil

5.5 million

1.3 million 1 million

300,00035,000

40,000

38,000

Sexually Transmitted Infections in the USNew Cases, 2009-2010 (CDC data)

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Trichomoniasis

• #1 sexually transmitted infection in U.S.• Itching, burning, redness, pain during urination and intercourse

(but 85% women asymptomatic)• Frothy, thin, malodorous, yellow-green discharge• Risk factors: multiple partners, low socioeconomic status, history

of STIs, lack of condom use• Associated with PID, increased risk for HIV, tubal infertility, cervical

cancer, preterm delivery/ruptured membranes/low birth weight in pregnancy

• Can be transmitted between female partners

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• Without treatment, trichomonas can last for years• Be aware of medication side effects:

− Metronidazole can trigger cramps, nausea, vomiting, headaches and flushing if combined with alcohol. Avoid alcohol use during treatment and 3 days after. Metronidazole is should not be taken during first trimester of pregnancy.

• Avoid sex until patient and partner(s) complete treatment• Douching may worsen discharge• Trichomonas may facilitate HIV transmission• Recurrences/resistance happens - if s/s persist, re-evaluate• Reinforce abstinence, mutual monogamy, latex condom use,

limiting number of sex partners

Patient Education for Trichomonas

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Cervicitis

• Inflammation of the cervix (not always related to infection) • Most common causes

− Chlamydia and gonorrhea most common. Treat for both. − Foreign objects, radiation, malignancy

• Symptoms: Mucopurulent discharge, pain during intercourse, bloody vaginal discharge or spotting between periods. If urethra is also infected, may feel burning upon urination.

• Can spread to uterus, fallopian tubes, or ovaries, resulting in PID

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Gonorrhea

• Most commonly found in cervix and vagina • Also grows in urethra, mouth, throat, eyes, anus • Associated with ectopic pregnancy, PID,

infertility, Bartholin’s abscess

• Symptoms: painful urination, increased vaginal discharge, vaginal bleeding between periods (50% of women are asymptomatic)

Gonococcal cervicitis

Bartholin’s abscess

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Gonorrhea Diagnosis and Treatment

• Diagnosis− Endocervical culture

• Treatment− Dual antibiotic therapy with ceftriaxone and azithromycin− Retest at 3 months or whenever patient seeks medical care

in the next 12 months − Evaluate and treat partners

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Patient Education for Gonorrhea• In 15% of infected women, untreated gonorrhea spreads to

fallopian tubes and causes scarring and infertility• Can increase susceptibility to HIV infection• Use both medications as directed• Avoid sex until patient and partner(s) complete treatment• Some strains of gonorrhea are resistant to certain antibiotics. If

symptoms continue after completing course of treatment, another culture may be necessary.


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Chlamydia

• 1.3 million new infections yearly in U.S.

• Found in cervix, urethra, throat, rectum

• Symptoms: burning upon urination, frequent and urgent need to urinate, vaginal discharge, light bleeding after intercourse, pain in pelvis or lower abdomen (75% of women are asymptomatic)

• Associated with PID, infertility, ectopic pregnancy

• Perinatal transmission results in neonatal conjunctivitis in 30-50% of exposed babies

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Chlamydia Screening

• CDC and US Preventative Services Task Force recommend screening asymptomatic women…− Yearly for all sexually active women 24 and under− Yearly for sexually active women >24 years with risk factors

(African American, new male sex partner, two or more partners in preceding year, inconsistent barrier contraceptive use, history of prior STI)

− All pregnant women at the first prenatal visit

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Chlamydia Diagnosis and Treatment

• Diagnosis− Swab specimen from endocervix− Urine test

• Treatment− Antibiotics− Retest at 3 months or whenever patient seeks medical care

in the next 12 months − Evaluate and treat partners

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Patient Education for Chlamydia• 30% of women with chlamydia develop PID• Untreated chlamydia can lead to infertility, chronic pelvic pain,

tubal pregnancy. 50,000 women become infertile every year due to chlamydia.

• Use medication as directed• Avoid sex until patient and partner(s) complete treatment• Undergo screening for chlamydia at least once a year if under age

25 or if at high risk or if become pregnant• Pregnant women may need repeat testing 3 weeks after

completion of therapy• Reinforce abstinence, mutual monogamy, latex condom use,

limiting number of sex partners22


Human Immunodeficiency Virus (HIV)• Weakens immune defenses by destroying white blood cells that

guard body against infection. Eventually, white cells drop below level needed to defend against infections, and AIDS develops.

• Growing problem for women− 1985: 7% of US AIDS cases were women − 2004: 27% of US AIDS cases were women − Black and Hispanic women represent <26% of US women, but

account for 82% of female AIDS cases.• Of new HIV infections in 2004…

− 70% due to heterosexual contact− 28% due to IV drug use

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HIV• Risks:

− Women are 4x more likely to contract HIV through vaginal sex with infected men than men are to contract HIV through vaginal sex with infected women

− Unprotected anal sex is greater risk for women than unprotected vaginal sex

• Nonoxynol-9 spermicide may increase HIV risk (causes irritation and abrasions that allow virus to enter the body)

• Gender-specific complications− Recurrent vaginal yeast infections− PID− Increased risk of precancerous cervical changes

• Symptoms: 50-90% have flu-like illness in first few weeks

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CDC Screening Recommendations

• Screen all patients in all settings unless patient opts-out • Annual screening for persons at high risk:

− Unprotected vaginal and anal sex, abuse victims, multiple sexual partners, IV drug and other substance use, history of STIs, poverty, blood transfusions, occupational exposures to blood

• Separate written consent should not be required. General consent for medical care is considered sufficient to encompass HIV testing.

• Prevention counseling should not be required with HIV diagnostic testing or as part of HIV screening programs in healthcare settings

• Pregnancy: Include HIV in routine panel of prenatal tests

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Patient Education for HIV• Transmitted by vaginal/anal/oral sex, needle sharing, occupational

exposure, contaminated transfusion/transplant/artificial insemination. Passed from mom to baby during pregnancy/delivery/breastfeeding.

• HIV tests not accurate immediately after exposure to virus. Takes a few months to become positive.

• If results are positive, another test will measure amount of HIV virus in blood. A white blood cell count will confirm diagnosis.

• Cannot completely clear virus from the body. Goal of drug therapy is to suppress virus so it can’t be detected in blood, to increase white blood cell count, and to strengthen weakened immune system.

• Time of progression to AIDS depends on amount of HIV virus in blood (viral load) and response to drug therapy

• Inform all partners about HIV infection. Use latex condoms.26


Genital Herpes Simplex Virus (HSV)• 25% of US population has serological evidence • HSV-2 is most common subtype; present in 1 in 4 females and 1 in

5 males ages 15-45• Transmission: kissing, skin-to-skin contact, vaginal/oral/anal sex Can be transmitted when symptoms aren’t present• Primary outbreak usually occurs about 1 week after contact

− Fever, chills, headache, painful lymph notes in groin− Pain and itching may precede blisters, skin ulcers− 60% of those infected, have no symptoms

• C-section recommended for pregnant women with visible ulcers at delivery to prevent newborn infection

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http://en.wikipedia.org/wiki/Image:SOA-Herpes-genitalis-female.jpg


• Outbreaks :− Can reoccur 4-5 times per year− Most frequent in first year− After resolution of primary genital infection, asymptomatic

intermittent viral shedding occurs even in absence of genital lesions in up to 23% of people

− Daily antiviral medication can decrease recurrences by 75% for people with 6+ episodes per year

• Other complications− Herpes most common cause of viral encephalitis− 3rd most common cause of sexually transmitted proctitis

Genital Herpes

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• Diagnosis based on history and physical is often inaccurate − *Viral culture for active lesions− *PCR to detect asymptomatic virus shedding− Tzanck prep for lesion scrapings− Direct fluorescent antibody for clinical specimens

*Can determine herpes subtype • Treatment

− Antiviral medications to treat primary herpes and suppress recurrent outbreaks

− Topical treatments do not work

Genital Herpes

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Patient Education for Genital Herpes

• No cure. Symptoms can return periodically. Recurrence varies by person.• First attack is usually worst; 40% of people never have second outbreak.• Outbreaks can be related to menses, intercourse, sunbathing, stress• Abstain from sex when symptoms occur. Inform all partners about

infection. Even without symptoms, can be transmitted. Latex condoms.• People with herpes more likely to be infected if exposed to HIV through

sex. People with HIV and herpes more likely to spread HIV to others.• Take medication as directed to prevent symptoms from returning or to

make recurrences less severe• Topical treatments don’t work. Analgesics can help with painful lesions. • Inform provider if you become pregnant

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Syphilis

• Infection caused by bacterium Trepomema pallidum• 40,000 new cases each year

• Occurs in 3 stages− Primary: chancre or ulcer at infection site− Secondary: skin rash, lymphadenopathy− Tertiary: years later - neurological infection

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Syphilis Diagnosis and Treatment

• Diagnosis− Serologic test: Venereal Disease Research Laboratory (VDRL)

and RPR− Treponemal test (FTA-ABS ) to confirm diagnosis of syphilis

• Treatment− Single-dose benzathine penicillin− Late latent infection of unknown duration: benzathine

penicillin in 3 doses each at 1 week intervals− Clinical and serological test follow-up at 6 months and 12

months post-treatment − Treat partners presumptively

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Patient Education for Syphilis

• Comply with medications as instructed• Return for 6 and 12 month follow-up appointments• Avoid sex until patient and partner(s) complete treatment• Pregnant women should have blood test for syphilis to prevent

passing infection to baby • People with syphilis are more likely to become infected if exposed

to HIV through sex. People with HIV and syphilis are more likely to spread HIV to others.


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Hepatitis B Virus (HBV)

• 800,000 - 1.4 million people in U.S. chronically infected• 5-10% of infected adults become chronic carriers vs. 90% of infected

infants and 25-50% of children ages 1-5• Transmitted via intercourse, contaminated blood, mother to child,

occupational exposures• Incubation period 60-150 days• Symptoms: fever, fatigue, nausea, vomiting, malaise, loss of appetite,

jaundice, abdominal or joint pain, dark urine• Vaccine given in 3 doses over 6-month period• Multiple medications for treatment available• Adult recovery rate 95%. Acute infection more severe for adults over 60.

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Patient Education for Hepatitis B

• Get vaccinated. Don’t restart series if there is an interruption between doses; however, extra doses of vaccine are not harmful

• Vaccine is ok for pregnant, immunocompromised patients• HBV can survive outside body for at least 7 days; don’t share

needles, razors, toothbrushes, nail clippers, earrings • Vaccination within 24 hours of exposure can prevent infection. In

certain circumstances adding HBIG (hepatitis B immune globulin) increases protection.


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HPV-Related Genital Warts

• Most commonly caused by HPV types 6 and 11

• Flesh-colored spots that are raised or flat, orgrowths similar to cauliflower

• Can be found:− Inside or outside vagina/anus − On nearby skin− On cervix− On lips, mouth, tongue, throat

• Warts can take six months to develop; woman can be infected without symptoms

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HPV-Related Genital Wart Treatment and Follow-Up• Treatment

− Podophyllin applications, tricholoracetic acid, imiquimod 5% cream

− Cryosurgery, electrocauterization, laser therapy, surgical excision

− Examine partners; treat if warts identified• Follow-up

− Regular Paps − For warts on cervix, may need Pap smears every 3 to 6 months

after first treatment• Administer HPV vaccine for females ages 9-26

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Patient Education for Genital Warts

• Even though warts may be removed, viral infection can't be cured. Warts often return: benign but infectious.

• Don’t treat genital warts yourself with OTC drugs that remove warts on hands

• avoid sex until patient and partner(s) complete treatment• Get regular Pap smears• Best way to prevent genital warts is abstinence or sex with only

one uninfected partner. Condoms may help prevent infection, however, they can't always cover all affected skin.

• Gardasil immunization for uninfected partners <27 years of age

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Genital Ulcers

• Painless ulcers - think syphilis, but herpes can also present this way

• Multiple ulcers - think herpes, but could also be syphilis

• Diagnosis based on history and physical is often inadequate

• 25% of patients with a first episode of genital ulceration have no detectable cause despite a full diagnostic evaluation

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The Sexual History and Prevention Counseling

Source: CDC. A guide to taking a sexual history. CDC Publication: 99-8445.http://www.cdc.gov/std/see/HealthCareProviders/SexualHistory.pdf

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Two Ideas for Opening the Discussion

1. I am going to ask you a few questions about your sexual health and sexual practices. I understand that these questions are very personal, but they are important for your overall health.

2. Just so you know, we ask these questions to all adult patients, regardless of age, gender, or marital status. These questions are as important as the questions about other areas of your physical and mental health.

Add… Like the rest of our visit, this information is kept in strict confidence. Do you have any questions before we begin?

(Think of sharing these Interview questions with your Provider)

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• Provider should utilize the “Five P’s”− Partners− Prevention of pregnancy− Protection from STIs− Practices− Past history of STIs

• Questioning and counseling should be provided in a nonjudgmental and caring manner

Sexual History

Sexually Transmitted Diseases Treatment Guidelines, 2010 www.cdc.gov/mmwr

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1. Ask About Partners

Are your sex partners men, women, or both?In the past 2 months, how many sex partners have you had?In the past 12 months, how many sex partners have you had?

• One partner in last 12 months: ask about length of the relationship and partner’s risk factors (current or past sex partners, drug use)

• More than one partner in last 12 months: explore more specific risk factors (condom use, or non-use, and partners’ risk factors)

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2. Ask About Sexual Practices and Protection from STIs

• I am going to be more explicit about the kind of sex you’ve had in the last 12 months to better understand if you are at risk for sexually transmitted diseases.

• Do you use any protection against STDs? If not: Could you tell me the reason? If so: What kind of protection do you use?

• How often do you use this protection? If “sometimes”: In what situations or with whom do you use protection?

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3. Ask About Past History of STIs

• Have you ever been diagnosed with an STI? When? How were you treated?

• Have you had any recurring symptoms or diagnoses?

• Have you ever been tested for HIV, or other STDs? Would you like to be tested?

• Has your current partner or any former partners ever been diagnosed or treated for an STI? Were you tested for the same STD(s)?

− If yes: When were you tested? What was the diagnosis? How was it treated?

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4. Ask About Prevention of Pregnancy

• Are you currently trying to conceive a child?

• Are you concerned about getting pregnant?

• Are you using contraception or practicing any form of birth control?

• Do you need any information on birth control?

Think about sharing VA Maternity and Infant Benefits

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5. Assess HIV Risk

Assess for HIV risk• Injected drug use by her or her partner(s)?• Money or drugs exchanged for sex by her or her partner(s)?

Final probe• What other things about your sexual health and sexual

practices should we discuss to help ensure your good health?

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Be aware during history of these STI risk factors…

• Unprotected sex• Young age• Unmarried• Multiple sexual partners• History of a prior STI

• Illicit drug use• Contact with sex

workers• New sex partner in past

60 days• No vaccination (HPV,

hepatitis)

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Summary of STI Screening for Women

• HIV: screen all women ≤ 65 regardless of risk at least once; annual screen for those at increased risk

• Gonorrhea: women at high risk; consider those < 25

• Chlamydia: all women ≤ 24; all others at high risk

• Trichomonas: remember, this is #1 STI, women at high risk

• Syphilis: women at risk

• Hepatitis B: consider vaccinating women at risk

• HPV: encourage consideration of vaccination for women ≤26

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STI Summary

• STIs cost U.S. health care system $17 billion every year

• Young people represent 25% of sexually experienced population in U.S., but account for nearly half of new STIs

• Less than half of people who should be screened actually receive recommended STI screening services

• Providers are required to report gonorrhea, chlamydia, and syphilis to local or state public health authorities

− Nursing usually tracks and assists with this

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Helpful References

• CDC. A Guide to Taking a Sexual History. http://www.cdc.gov/std/see/HealthCareProviders/SexualHistory.pdf

• CDC Self Study STD Modules/Vaginitis http://www2a.cdc.gov/stdtraining/self-study/vaginitis.asp

• CDC. Sexually transmitted diseases treatment guidelines 2010. http://www.cdc.gov/std/treatment/2010/STD-Treatment-2010-RR5912.pdf

• Seattle STD/HIV Prevention Training Center. The Practitioner’s Handbook for the Management of Sexually Transmitted Disease. http://www.stdhandbook.org/

• Workowski KA, Berman SM. Centers for Disease Control and Prevention sexually transmitted diseases treatment guidelines. Clin Infect Dis. 2007;44(s3):S73-6

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Primary author: Catherine Staropoli, MD VA Maryland Healthcare System, Baltimore, MD

Contributors: Linda Baier Manwell, MSUniversity of Wisconsin Center for Women’s Health Research, Madison,

WI

Kathleen McIntyre-Seltman, MDVA Pittsburgh Healthcare System, Pittsburgh, PA

WH Nurse Reviewers: Barbara Palmer, MS, ANPRebecca Feria, RN, MSNJoan Galbraith, RN, MSN, NPCindy James, RN, MSNLaurie Pfeiffer, RN, BSNBarbara Polak, RN, MSN

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common causes of vaginal discharge

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