Gina Kaye (Host): Welcome to Women's Health Perspectives. I'm your host, Gina Kaye. And we are here with Jennifer Price, a nurse practitioner with Capital Women's Care in Fulton, Maryland. Jennifer has joined us today to share her experience and expertise in chronic or recurrent vaginitis, a complex condition that presents diagnostic and management challenges for clinicians.

Jennifer has worked in fertility care and women's health for eight years, including at UCLA Medical Center in Los Angeles, California, and Massachusetts General Hospital in Boston. She recently earned her Master's of Science in Nursing from Georgetown University and is certified as a women's health nurse practitioner. Welcome, Jennifer.

Jennifer Price, CRNP: Thank you so much for having me.

Host: Great to see you here. Let's get started with some questions. So first off, what is chronic vaginitis and what pathogens can cause it?

Jennifer Price, CRNP: So, chronic vaginitis is a diagnosis of BV, yeast, or contact dermatitis three times in one year. So, that means that the patient is coming back to your clinic with recurrent symptoms. So, there's multiple pathogens that can cause BV. Of course, fungus for yeast. It can be Candida glabrata or Candida albicans. And contact dermatitis can basically be caused by anything, particularly fragrance.

Host: Sure. What are some other underlying conditions or scenarios that can contribute to chronic vaginitis?

Jennifer Price, CRNP: In my experience, chronic vaginitis can be caused by partner colonization, if the partner is carrying the same pathogen that's troubling the patient. And I see a lot of underlying subclinical ureaplasma infections, which alter the pH of the vagina and make the vagina much more susceptible to opportunistic infections like BV or yeast. There can be other comorbidities like diabetes or HIV that can make someone more susceptible to these types of infections as well.

Host: Which labs then should clinicians order for their patients?

Jennifer Price, CRNP: So, we always want to do a vaginitis. My go-to now is the ureaplasma mycoplasma. I've been picking up a lot of ureaplasma. And you can always do the STDs if you want to rule those out as well. And sometimes with post-menopausal patients, I will add in a genital culture, because sometimes their infections are GBS-related.

Host: How can you treat both male and female partners?

Jennifer Price, CRNP: So, I do like to treat the male partner with a combination of oral metronidazole twice a day for seven days and then topical clindamycin cream that he can put on at bedtime for seven nights. A female partner would be treated in the same way that your female patient would be treated.

Host: I know there's a three-pronged approach to correcting the biome. Can you walk us through that?

Jennifer Price, CRNP: Yes, this is my patented three-pronged approach for correcting the vaginal biome that I've kind of developed over time. So, I like to kill the offending pathogen with antibiotics. I like to make the vagina more acidic, which is protective for the vagina. And usually, I'll use boric acid for this, although you can also use vinegar or hydrogen peroxide.

And then, I like to introduce the appropriate bacteria, which is the lactobacilli. And so, I generally will advise ClairV intravaginally instead of orally or, you know, yogurt daily, or you can even use yogurt intravaginally like once a week to correct the biome with the proper bacteria.

Host: Interesting. So, first thing you said about your three-pronged approach was the antibiotic. So, what do you feel is the best antibiotic for chronic vaginitis and why?

Jennifer Price, CRNP: I love clindamycin cream. I feel like even if the cultures are negative, patients generally feel better on it. And studies have shown that you can use clindamycin cream for contact dermatitis or just chronic irritation. So, I do love clindamycin cream. It also doesn't usually cause a yeast infection in the same way that metronidazole oral or vaginal gel will.

So, we don't have that pendulum swinging back and forth between BV and yeast and BV and yeast, and the patient is just so uncomfortable. That way, we can at least avoid yeast if she doesn't have it by using clindamycin cream.

Host: Okay. And regarding the vaginal pH, what can the clinician do to correct it, and how is a healthy balance then maintained?

Jennifer Price, CRNP: So, I like to tell my patients they can use over-the-counter boric acid vaginal suppositories at bedtime. They can do that for maybe three or four nights in a row. And then, they can either use it after intercourse, after their periods, or once or twice a week as needed. Different people have different triggers for their vaginitis. Sometimes it's intercourse, sometimes it's the menstrual period. So, you're basically correcting the pH from semen, you know, making the vagina more basic, or blood making the vagina more basic, or neutral. And it kind of just brings that pH down. And so, some patients will have to continue using that maybe for three or four months, once a week, just to completely correct the pH.

Host: If one approach is reintroducing good bacteria, then talk to us about what that looks like.

Jennifer Price, CRNP: So, good bacteria is the lactobacilli. We're covered in it. It's all over our skin, it's in our gut, it's in the vagina. And when that dies, for whatever reason, you were on amoxicillin for a sinus infection or had a partner introduce some bad bacteria or maybe you're post-menopausal and you have a very low vaginal estrogen, or maybe you have a lot of sugar, because you're diabetic, and so you have a lot of yeast. So, we want to bring that lactobacilli back in.

And I am not a big believer in oral probiotics for vaginal health. I just, for the life of me, can't figure out how it gets there. So, I think that applying the probiotic directly into the vagina at bedtime once a week for several weeks is enough to reintroduce that good bacteria. You, of course, don't want to introduce it while you're on the antibiotic or you'll kill it, so you want to wait until you're done with the antibiotic.

Host: Okay. Okay. How long does that reintroduction process take in your experience then?

Jennifer Price, CRNP: Probably about three months. You have to tell patients to be patient. You know, they're uncomfortable and they want this to stop, and who knows how long it's gone on for before they've come into the clinic or how many other providers they've been to. So, you just have to tell them, "Have patience, this will work." And if it doesn't work, there's other things we can do. So, you got to give them a little bit of hope.

Host: Great. Hope is good.

Jennifer Price, CRNP: Yes.

Host: Okay. Our final question. Can you please discuss chronic yeast versus lichen sclerosis? And how do you recognize lichens and how do you treat them?

Jennifer Price, CRNP: So, I have many, many patients come in who have been treated for yeast over and over again or have self-treated with Monistat 7 over and over again. And then, when I look at the vulva, I can see that actually the problem is lichen sclerosus. So, lichen sclerosus is an autoimmune condition that causes intense itching of the vulva and the architecture of the external genitalia, because it's attacking that tissue. It's much more common in postmenopausal patients, but I do have some premenopausal patients with lichens. And you can get it anywhere. You can have it, you know, anywhere on your body. It's just I do GYN, so I see it on the vulva.

But If it's not managed over time, lichens will start to destroy the architecture of the vulva. So, you'll have a white appearance to the tissue, the labia minora, the clitoral hood, the clitoris might be gone, or parts of it might be gone. There might be light bleeding because of the destruction of the tissue. The itching is generally worse at night. So if I have a patient say, "At night, it's so, so bad, and I forget about it during the day," then my ears are pricked up. I'm thinking maybe this is lichens. So, you always want to get that culture. You want to rule out vaginitis. And then, you want to start her on clobetasol and vaginal estradiol cream, and then have her come back in in three months and see what's going on. You can even have her come back in in two months if you're the kind of person who likes to do a biopsy. I don't do that many biopsies anymore. I feel like I can eyeball lichens pretty well now. But you can always do a biopsy. But if they're losing that external architecture, if you see that change in color, particularly for women of color, if the vulva has lost its color and it's very pale, the first thing you need to think of is this lichen sclerosus.

Host: Okay. Very interesting information. Is there anything else that you would like to summarize or mention for the good of the group?

Jennifer Price, CRNP: So, I can't emphasize enough culturing for ureaplasma. Whenever I have a patient come in and she says, "I have BV almost all the time. I get my period and I get BV. Every time I have sex, I get BV," I would say 85% of the time she also has ureaplasma, and all you have to do is treat them with doxy, and then they generally lose that recurrent infection, because the vagina is now able to defend itself. So, I just get that ureaplasma if someone just keeps having problems. I would really encourage that.

Host: Thank you, Jennifer, for sharing your knowledge with clinician colleagues across the Unified community. For more podcasts and clinician-focused content, visit the Delivery Room intranet via the tile on your Okta dashboard. Thanks for listening to Women's Health Perspectives, presented by Unified Women's Healthcare.