LEUKORRHEA  (Vaginitis)

2. LEUKORRHEA  (Vaginitis) GENERAL CONSIDERATION

     Leukorrhea is not a disease but the manifestation of ovulation or of a local or systemic disorder. It may occur at any age and affects almost all women at some time. The most common cause is infection of the lower reproduction tract; other causes are inflammation, estrogen or psychic stimulation, tumor and estrogen depletion.
     Leukorrheic discharge is usually white because of the presence of exfoliated or inflammatory cells. The persistence of some vaginal mucus is normal. Nevertheless, when soiling of the clothing or distressing local symptoms occur, the discharge must
be considered abnormal.
     Excessive moisture may add to normal body odor and may be a source of self-consciousness. Frequent bathing and drying of the parts should suffice. In
Contrast, a strongly offensive odor may be an indication of genital infection.
     The disease is termed "Dai Xia" (vaginal discharge) in traditional Chinese
medicine.
CLINICAL MANIFESTATIONS
     Vaginal discharge with or without discomfort may be associated with itching
when urine contaminates the inflamed introitus. The patient may complain of pudendal irritation, proctitis, vaginismus and dyspareunia.
     Inflammation or ulceration of the vulvovaginal surfaces or cervix and a copious, white or coloured, usually odorous, discharge are usually present.
DIAGNOSIS
     Cytologic study of a smear of vaginal secretion is indicated for all parous
patients and others who are sexually active or whenever cancer is suspected. The same preparation can be stained to show trichomonads, candida, or other organisms.
Motile trichomonads are often seen in freshly voided urine contaminated with leukorrheic discharge. If these organisms are noted in a catheterized specimen,
urethral and bladder involvement by the flagellate is likely. Culture of the trichomonad is difficult but may be successful when trichosel medium is used.
     Leukorrhea associated with positive serologic tests may be a result of syphilis; a positive complement fixation test suggests lymphogranuloma venereum.
     Inspect a fresh wet preparation of the vaginal fluid first for motile trichomonas vaginalis. Look for heavy clouding of the spread and especially the covering of epithelial cells ("clue cells") by myriads of small bacteria; these will probably be chlamydia trachomatis or gardnerella (haemophilus) vaginalis, previously termed corynebacterium vaginale. Then add 5% potassium hydroxide to lake blood cells as an aid in visualization of candida hyphase and spores. Examination of a gram-stained smear may identify intracellular gram-negative diplococci, other predominant bacteria and helminths. If possible, culture the vaginal fluid anaerobically and aerobically to identify bacterial pathogens. Thioglycolate medium is most useful in the culture of Gardnerella organisms.
TREATMENT
I. Treatment in Western medicine.
     1. General measures
     Utilize internal menstrual tampons to reduce vulvar soiling, pruritus, and odor. Coitus should be avoided until a cure has been achieved. Trichomonal and candidal infections require treatment of the sexual partner also. Relapses are often reinfections. Re-treat both parties.
     Antipruritic medications are disappointing unless an allergy is present.
     2. Specific measures
     A. For trichomonas vaginalis vaginitis.
     Metronidazole. 2g in a single dose at bedtime. The physician should treat the
sexual partner similarly during the same interval. Insist upon condom protection
against reinfection during coitus until both partners are free of T vaginal organisms.
     Aminocrine hydrochloride. Allantion and sulfanilimide creams used vaginally
twice daily for 1 week are not as effective as metronidazole.
     B. For candida albicans.
     Discontinue oral contraception; substitute condom protection temporarily. Vaginal clotrimazole, one 100mg tablet or one applicatorful of miconazole nitrate 2% in an aqueous cream at bedtime for 7 nights, is effective for vaginal candidiasis.
     C. For Gardnerella vaginalis and chlamydia trachomatis vaginitis.
     Metronidazole, 2g orally at bedtime.
     Tetracycline, 500mg orally 4 times daily for 5 days.
     Sulfathiazole, sulfacetamide, and benzoylsulfanilamide in cream form (sultrin), I  application daily for 10 days.
     D. For atrophic (senile) vaginitis.
     Diethylstilbestrol, 0.5mg vaginal suppository, 1 every third day for 3 weeks.
Omit medication for 1 week; then resume cyclic therapy indefinitely unless contraindicated.
     Dienestrol vaginal cream, one application for 1 week, then resume cyclic
therapy.
     Premarin, 0.625mg orally daily for 3 weeks each month. After 1 to 3 months of
treatment, perform an endometrial biopsy to rule out carcinoma or atypical hyperplasia that could become cancerous.
     E. For gonorrheal vaginitis.
     Aqueous procain penicillin G, 4.8 million units injected.
     3. Local measures
     Occasional warm saline or acetic acid douches may be beneficial in the treatment
of leukorrhea.
     4. Surgical measures
     Cauterization, cryosurgery, conization of cervix, incision of Skene's glands, or bartholinectomy may be required. Cervical, uterine, or tubal disease (tumors, infection) may necessitate laparotomy, irradiation, or other appropriate measures.
II. Treatment in traditional Chinese medicine.
     1. Herb therapy
     A. For leukorrhea due to the loss of normal function of the spleen. The excessive
thready discharge from the vagina is white and mucoid, like egg white because the
pathologic changes due to abnormality of digestive and transporting functions of the spleen, so the symptoms are decreased appetite, abdominal distension, sallow complexion, emaciation, weakness of the limbs, and edema. The treatment is intended to strengthen the spleen and excrete the dampness with Wan Dai Tang Jia Jian.
     Constituents:
     Dangshen  12g
     Largeheaded atractylodes  15g
     Root of herbaceous peony  30g
     Chines