D. Ashley Hill, MD

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Yeast infections are one of the most common infections occurring 			in women. Although they are rarely dangerous, they can be very bothersome and uncomfortable. A number of ways to 			prevent yeast infections are discussed here, as well as information on treating both acute and chronic yeast infections. 			Simply put, a yeast infection is an overgrowth of yeast that is normally found in the vagina. All people, no matter 			how "clean" they are, have bacteria, viruses, and yeast in their body. Some of these, like intestinal 			bacteria, are critical for our survival, whereas others, like the HIV virus that causes AIDS, can be deadly. Yeast 			infections are caused by a fungus, usually candida albicans, that grows rapidly, taking over the normal bacteria 			found within the vagina. Yeast infections are not so much "caught" (although they may be passed back 			and forth between sexual partners) as "grown" from one's own yeast cells within the vagina. The classic 			example of this is the increased chance of having a yeast infection after taking antibiotics. The antibiotics reduce 			the normal bacteria in the vagina, and the yeast seize the opportunity and reproduce rapidly, causing a yeast infection.
 
 We know that while some women simply get yeast infections once in a great while, others are susceptible to them 			because of certain risk factors. In the past birth control pills were thought to increase the chance of yeast infections, 			but current pills have much lower hormone doses than in the past, and are not thought to lead to yeast infections. 			Also, some women may feel that yeast infections imply they are not "clean enough down there" but this 			is not the case. Risk factors for yeast infections include:

Recent antibiotic use, for example for a urinary tract infection.

Wearing tight clothes, particularly non-cotton underwear or pants.

Wearing moist clothing for extended periods, such as workout or swimwear.

Having leukemia or AIDS, both conditions that damage the immune system. 				Obesity.

Most women know the common symptoms of a yeast infection, which include 			itching, burning, a white discharge, pain with intercourse or tampon use, or redness and irritation of the vulva 			(the outside "lips" of the vagina). Some women get all of these symptoms, while others have none. This 			is important now that there are over-the-counter medications for yeast infections. Medical studies have shown that 			most women misdiagnose their own yeast infections, and can miss other important vaginal infections, such as trichomonas, 			gardnerella, chlamydia, or gonorrhea that may produce somewhat similar symptoms. Therefore, unless one is absolutely 			certain of the diagnosis, a visit to a health care provider experienced in women's health is necessary.
 
 Diagnosing yeast infections involves a brief visit to your health care provider, who will perform a pelvic exam 			in order to look in the vagina. In many cases a small drop of vaginal discharge is taken and viewed under a microscope 			to look for yeast cells. Treatment for an acute yeast infection is rarely difficult and involves one of many oral 			or vaginal anti-fungal medications. There are many on the market. Most work equally well, but each patient's situation 			is different therefore your health care provider may want to try one versus another to treat your specific infection. 			Despite advertisements on television and in magazines, no one prescription is necessarily better than another. 			In all cases, however, the medication should be used completely as directed in order to "wipe out" all 			the yeast.
 
 Chronic infections or infections that recur frequently are often extremely distressing to the patient and frustrating 			to her health care provider. A systematic approach to these infections will usually yield appropriate treatment 			and relief of symptoms. Prevention, discussed later, is important, but if this is not successful, a thorough exam 			looking for diabetes or other causes is necessary. Furthermore, vaginal cultures may be necessary to determine 			if one's infection is caused by an unusual type of yeast that may be resistant to certain anti-fungal medications 			(such as candida glabrata or candida tropicalis). Treatment may require a long course of anti-fungal medications, 			painting the vagina and vulva with a purple medication called gentian violet, or using certain suppositories on 			a nightly or weekly basis. The treatment of chronic or frequently recurrent yeast infections involves a blend of 			the science and art of practicing medicine, and is rarely successful after only one visit. This will almost certainly 			require a number of visits to your doctor to "fine tune" the treatment, and may require careful monitoring 			for side effects. It is important to see a physician or other health care provider who is specifically comfortable 			and experienced managing complicated and chronic yeast infections. Unfortunately, treating the male partner, who 			may harbor yeast on his penis in about 10% of cases, does not seem to prevent recurrent infections in the female 			partner.
 
 Preventing yeast infections is obviously more desirable than treating them. Wearing loose clothing, cotton underwear 			(or at least underwear with a cotton crotch panel), removing damp clothing soon after swimming or working out, 			and carefully drying the vulvar area after bathing will all help prevent yeast infections. Some advocate using 			a blow dryer on warm to briefly blow dry the vulva after bathing to insure adequate drying. Others suggest using 			vaginal or oral yogurt, which is a controversial method of preventing yeast infections. However, there are articles 			in the medical literature that support eating 8 ounces a day of yogurt containing lactobacillus acidophilus, which 			may reduce the yeast infection recurrence rate by threefold. IF you choose to do this, however, please make sure 			the yogurt you buy specifically contains lactobacillus acidophilus, as many do not. Some also advocate taking anti-fungal 			medications intravaginally or orally at specific intervals to prevent overgrowth of yeast. In some diabetic patients 			this is very helpful. Yeast infections are common and sometimes difficult to treat, but with the appropriate evaluation 			and treatment they can be effectively treated. Any symptomatic vaginal discharge should be evaluated to ensure 			proper treatment.

Florida Hospital Family Practice Residency

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Yeast infections are one of the most common infections occurring in women. Although they are rarely dangerous, they can be very bothersome and uncomfortable.

Yeast Infections

Genital warts, also called condylomata, is a common infection of 			the female reproductive tract. There are a number of myths surrounding this complicated infection, and a discussion 			of genital warts, including the common symptoms, diagnostic tests available, and treatment options can help women 			gain the knowledge necessary to understand this condition.
 
 We are unsure of how many women are infected with the virus, HPV, that causes genital warts. Some medical studies 			show that 1 out of every 10 women has HPV, while others reveal an incidence of up to 1 out of every 2 (50%)! HPV, 			short for Human Papilloma Virus, is a virus that can infect humans through sexual contact, or, less commonly, through 			prolonged exposure to such things as shared underwear or swimming clothes. There are over 70 different types of 			this virus.
 
 Like most viruses HPV can infect someone without that person knowing it, and can "set up shop" inside 			their body for many years before causing symptoms. In some lucky individuals, HPV is present in their tissues but 			never causes symptoms. (In these people sophisticated and expensive diagnostic tests can sometimes reveal the presence 			of HPV). In others HPV causes abnormal Pap smears. This is the number one cause of highly abnormal Pap smears, 			although there are certainly other causes of abnormal Pap smears. Patients often have a difficult time understanding 			that HPV can cause abnormal Pap smears without any warts being present. In fact, this is the most common situation, 			and in my experience most women with bad Pap smears have never had a genital wart.
 
 HPV can also cause genital warts, which are usually small, wart like growths that can develop anywhere on the female 			genital organs. Warts may develop in the vagina, on the labia (lips of the vagina), or around the anus. In men, 			warts may develop on the shaft of the penis, in the hair at the base of the penis, or on the "head" of 			the penis. Again, it is extremely important to remember that many, if not most, women who are infected with HPV 			will never develop genital warts or any other symptoms. Of course, it is impossible to predict who will or who 			will not develop genital warts.
 
 Those women who get genital warts usually report one or more "bumps" on the vaginal lips or near the 			anus that are nontender and slightly raised. They look like warts that may occur elsewhere on the body. On some 			occasions the warts will brush against clothing and become irritated, causing bleeding or tenderness. While many 			women report only 1 or 2 warts, others will note numerous warts, or clusters of warts here and there. There are 			specific situations that may cause warts to grow to a large size, including during pregnancy or in women who have 			AIDS, leukemia, or other immune system illnesses. In some patients there are no external warts, but rather internal 			(vaginal) warts.
 
 Your physician or other health care provider will need to examine your pubic hair region, labia, anal area, and 			vagina. This is usually a painless exam. You may want to perform your own genital self examination with a mirror 			prior to visiting your health care provider, to help him or her locate all of the warts. In rare cases a biopsy, 			using Novocain and a small needle, will be necessary, but most health care providers who treat women are experienced 			at diagnosing this condition without a biopsy.
 
 There are a number of treatment options for genital warts. HPV can probably never be completely removed from the 			body, since viruses are extremely difficult to eradicate. However, warts can be treated using medications applied 			to them, or special injections at the base of the warts, or by removal. In some cases a laser can be used to remove 			the warts. The best treatment will depend on the number of warts and their location. If possible, your health care 			provider will try to apply an acid solution (called TCA) or a brownish liquid (called podophyllin) to the warts 			to "melt" them. This may take a few weeks of treatment. If this does not work, they can be frozen just 			like warts on other parts of the body. (Warts elsewhere on the body are usually caused by viruses other than HPV). 			Another alternative is to excise them using an electric wire or a pair of surgical scissors. The last two treatment 			options are more involved and more expensive. You doctor may choose to inject small doses of Interferon, a chemical 			that alters the immune system, into the base of each wart. This is expensive and is usually not the first choice 			for treating genital warts. Laser is also expensive, but is very useful for removing warts within the vagina or 			anal canal, or for patients with a large number of warts. This is usually done in the operating room under anesthesia. 			None of these treatments are necessarily "better" than another, but each patient will find that one works 			best for her individual situation.
 
 While warts can be treated, they may return in the future. If so, retreatment will take care of the problem. Women 			with genital warts require at least annual Pap smears and physical examinations. This will depend on your medical 			history and whether or not your Pap smears have been normal. As with most medical conditions, prevention is vitally 			important. Unfortunately, preventing genital warts is difficult. Latex condoms may prevent infection but are not 			guaranteed to do so. Choosing a monogamous partner is always a safe idea, and will certainly decrease the risk 			of exposure to HPV.
 
 If you believe you have genital warts please make an appointment with your physician or other health care provider 			for an examination and to discuss treatment options. With appropriate treatment it is almost always possible to 			remove these troublesome warts. Afterwards, you will want to examine yourself every month or so to make sure there 			is no recurrence of the warts.           

Genital warts, also called condylomata, is a common infection of the female reproductive tract.

Genital Warts

Although genital herpes is common there are a lot of misperceptions about this sexually transmitted infection. Genital herpes is caused by a virus, called Herpes Simplex Virus, or "HSV" for short. Viruses are different than bacteria. First, they are much smaller, and second, they are much harder to treat. For example, although antibiotics commonly kill bacteria they do not work on viruses. Because of this, there is no known cure for genital herpes. However, there are ways to prevent infection, and to treat infections once they develop.

Genital herpes is an extremely common infection. Some researchers estimate that 1 out of every 5 Americans have been infected with the virus that causes genital herpes! This represents 20% of the population, making genital herpes one of the most common sexually-transmitted infections.

There are 2 main types of herpes viruses, HSV-1 and HSV-2. HSV-1 usually causes "cold sores" or "fever blisters" around the mouth, and is not necessarily sexually transmitted. HSV-2 usually cause sores on the genitals and is sexually transmitted. However, it is quite possible to contract HSV-1 on the genitals, or HSV-2 on the mouth (through oral sex). In fact, any type of sexual contact, whether it's vaginal intercourse, anal sex, touching the genitals, or oral sex, can transmit the herpes virus.

Once HSV enters the skin and begins to reproduce. A very important point is that HSV in many cases never causes symptoms. It may simply invade the skin, reproduce, then lie dormant for many months, years, or sometimes even forever. Some very fortunate individuals may never even know they have contracted HSV, because they never get any symptoms. In other cases the virus reproduces and causes symptoms such as extremely painful blisters on the penis or the lips of the vagina (labia). The first time this infection develops the patient may have such severe pain and inflammation that he or she needs to be admitted to the hospital. Other conditions can cause small bumps on the genitals, but HSV almost always causes extremely painful sores that burn when touched. After a few days, these blisters become small, shallow ulcers with some redness around them. Finally, after a few more days, they crust over and are less painful. The entire first-ever infection usually lasts 1-2 weeks.

After a primary infection, the virus again lies dormant and may or may not ever recur. Some people have a recurrent infection as often as every month, while others get them only once every few years. (Some never get a recurrent infection again). The recurrent infections can be brought on by stress, other infections, irritation to the tissues, or exposure to the sun. Some patients notice a tingling or burning sensation around their penis or labia right before an outbreak of genital herpes. This is called a "prodrome" and is helpful since it can alert you that you need to abstain from sex, or to begin taking medication, if necessary. Recurrent infections are usually less painful and often go away more quickly than primary infections.

The diagnosis of genital herpes is made by a health care provider who has experience in genital infections. He or she will examine the genital organs and may take a swab of the blister or ulcer and send it for culture. You should make an appointment immediately after the blisters develop, since they may disappear after a few days which makes the diagnosis difficult.

Treatment depends on how painful the sores are and if you have other medical problems. Sometimes there is minimal pain and the patient is advised to abstain from sexual relations and other activity that may irritate the affected area until the sores go away. In other cases one may receive anti-viral medications such as valacyclovir, acyclovir, or famciclovir. These may help reduce the duration of the sores. If you are prescribed these medications for recurrent infections, please remember to begin taking them as soon as you notice the "prodrome" or blisters forming! (The medicine works best if it is taken as early as possible). People who have many recurrent infections, say 6 or more a year, might want to ask about taking an anti-viral pill once or twice a day to help prevent these recurrent infections. This can become expensive, but in some cases it is worth it to help prevent having genital herpes infections all the time. These treatments can help treat outbreaks, but unfortunately there is no way to completely rid the body of the virus once infection occurs.

A common question when a patient is diagnosed with their first-ever herpes outbreak is "does this mean my partner is having an affair?" Remember that this virus can "hang out" in your body for a long period of time, and may never produce symptoms. In other cases the first-ever outbreak may occur weeks, months or even many years after one was exposed. Thus, you or your partner may have been exposed many years prior but the virus only now has surfaced to create problems. Obviously, this makes it almost impossible for you or your health care provider to determine when you were exposed.

The only known way to prevent genital herpes is to not have sexual relations. Since herpes can be spread by vaginal, anal, or oral sexual activity, and sometimes even by touching the genitals, all of these activities can lead to an infection. It is easiest to contract HSV when there are sores present, but even without sores the virus can be passed to someone else during sex. This is called "asymptomatic shedding" of the virus, and for this reason one should strongly consider the use of latex condoms. Their use should be considered by anyone in a non-monogamous relationship and certainly anyone who has genital herpes. Married couples where one partner has HSV are also encouraged to use condoms. Even though condom use may not always prevent the other partner from becoming infected, it should help decrease the chances of this happening. Because genital herpes can affect each person differently and because in some cases the virus can cause severe symptoms, you should always tell your sexual partner that you have this condition and should encourage condom use in your relationship. Many couples have fulfilling sex lives when one partner has genital herpes. As with all aspects of a relationship, honest communication is important.

Many people have heard that HSV can cause problems in pregnant patients. Babies born to women who have blisters or sores on their genitals from HSV may become infected and may become extremely ill from this infection. When women are in labor but there are no sores present it is usually quite safe to deliver naturally, through the vagina. In women who are in labor and have sores present a cesarean section will often (but not always) prevent infection. Always tell your doctor or midwife if you have been diagnosed with genital herpes so that he or she can examine you during the pregnancy and especially when you go in to labor.

Genital herpes is a common and troublesome condition that can result in a number of other problems, such as depression, low self-esteem, and relationship problems. Although there is no known cure, there are effective medications to help reduce the symptoms and sometimes even prevent new outbreaks. Many couples make adjustments when one (or both) partners have HSV and continue in a loving relationship. Many cities have support groups, and one can obtain information from national organizations, medical libraries, the internet, and of course your doctor or health care provider.



Great article. Question:
Can HSV be detected in asymptomatic individuals by a blood test?

Roberta-



Yep. There is a fairly sensitive antibody test that will detect past exposure to HSV I or II. It is really only clinically useful in a research setting. For example, if you went the the local mall, set up a testing area, and tested the first 100 people that walked by, in some areas of the country you might find 20-40% with documented exposure to HSV II!! (Of course, almost all of us have been exposed to HSV I). As I said in the article, a number of people have been exposed, but never get herpes. They must either have a super immune system against HSV, or perhaps they only got a "small" viral load when first exposed. In any event, they're lucky, as it can be a very painful and chronic disease for women.

Herpes Simplex Virus - University of Cape Town


Herpes Simplex Virus (HSV) Infection (Images)




D. Ashley Hill, M.D.
Associate Director
Department of Obstetrics and Gynecology
Florida Hospital Family Practice Residency
Orlando, Florida


Although genital herpes is common there are a lot of misperceptions about this sexually transmitted infection. Genital herpes is caused by a virus, called Herpes Simplex Virus, or "HSV" for short.

Genital Herpes

Pelvic Inflammatory Disease, or PID, is an infectious disease that 			affects millions of U.S. women and girls each year.  Although usually surprisingly easy to treat, it can be 			hard to diagnose, and can lead to many long-term and troublesome complications. And, while PID is often a sexually 			transmitted disease (STD), in many cases it is caused by bacteria that are not necessarily associated with sexual 			activity.  Therefore, all women should understand the signs and symptoms of this illness, the diagnostic and 			treatment options available, the long-term effects of PID, and methods of prevention. 
 			
 			Simply put, PID is a specific set of symptoms caused by an infection of the upper parts of the female genital organs 			(uterus, tubes, or ovaries).  One or more bacteria travels from the vagina into and through the cervix (the 			opening of the uterus located at the very top of the vagina) then into the uterus.  The infection may "set 			up shop" in the uterus, or, more likely, continue up into the fallopian tubes through the tiny openings at 			the top of the uterus that lead to the tubes.  The tubes are extremely fragile and are easily damaged by bacterial 			infection.  If the infection ends at the tubes, we call this "salpingitis" which is another common 			term for PID.  If the infection spreads through the tubes and into the abdominal cavity, it is often called 			peritonitis.  Generally, the bacteria that cause PID can infect and inflame any or all of the organs they 			encounter although in most cases the fragile tubes bear the brunt of the infection and are the organs most commonly 			damaged. 
 			
 			PID can come from any of a number of common bacteria.  The sexually transmitted organisms chlamydia and gonorrhea 			are the most common "bugs" found in the tubes of women affected with PID.  However, PID is not necessarily 			a venereal disease, as other, non-sexual bacteria, have been isolated in the tubes of women with this disease.  			For example, in unusual cases  surgical procedures involving the uterus can lead to PID from the normal bacteria 			found in every woman's vagina.  In other cases chlamydia, gonorrhea, and the bacteria found normally in the 			vagina may work hand-in-hand to cause the infection.  Since we can only determine the exact bacteria by culturing 			the fallopian tubes, a difficult and complicated process, we treat PID by giving antibiotics that will kill all 			the possible bacteria that can cause the illness. 
 			
 			Certain activities place one at increased risk for PID.  The most important is unprotected sexual activity.  			It is simply impossible to tell if a sexual partner has chlamydia or gonorrhea, and every health care provider 			that cares for women has heard a patient with newly-diagnosed PID lament that "he seemed like such a nice 			guy."  Having multiple partners, early loss of virginity, or dating and sleeping with multiple partners 			at one time are all risk factors for PID (and other diseases, such as hepatitis, syphilis, herpes, HIV, genital 			warts, and abnormal Pap smears and cervical cancer).  Other risk factors include having a surgical procedure 			that involves penetration of the cervix, such as a D & C, endometrial biopsy, or IUD insertion).  To protect 			you from PID your health care provider will use sterile technique when performing the above procedures.  To 			protect yourself from PID you should strongly consider the use of latex condoms during sexual activity, especially 			when in a non-monogamous relationship! Furthermore, one should strongly consider being involved in a monogamous 			relationship, rather than being sexually active with more than one person. 
 			
 			There are many signs and symptoms of PID.  More common ones include lower pelvic pain.  In acute PID 			most patients report rapidly worsening abdominal pain, perhaps similar to appendicitis, that develops over a few 			days and often leads to a visit to the emergency room or your doctor's office.  Chronic pelvic pain, which 			occurs over many months, may also be due to "chronic" PID.  Other symptoms of acute PID may include 			fever, a vaginal discharge, pain with walking (sometimes called the "PID shuffle"), or irregular vaginal 			bleeding.  In severe cases the patient may report nausea/ vomiting and dehydration.   Obviously 			these symptoms need evaluation as soon as possible by a health care provider. 
 			
 			Your doctor or the emergency room doctor will want to perform a careful examination of your abdomen and genital 			organs.  This will usually involve looking inside the vagina with a speculum to take cultures of the cervix, 			and a bimanual exam involving one or two fingers in the vagina while feeling for tenderness around the ovaries.  			In many cases you will have blood drawn for a pregnancy test, a blood count, and perhaps blood cultures. Other 			tests may include cervical cultures and perhaps an ultrasound of the ovaries (if your ovaries are too painful to 			adequately examine with the bimanual exam) and evaluation for other sexually-transmitted infections (i.e. HIV, 			hepatitis, herpes, syphilis).  
 			
 			Treatment for PID is either outpatient, which usually consists of an antibiotic shot or pills, or inpatient, which 			consists of intravenous antibiotics, depending on the severity of the symptoms.  In some cases the diagnosis 			may be in doubt, and since conditions like appendicitis can mimic PID, your doctor may want you to undergo repeated 			exams or even a laparoscopy to pin down the diagnosis.  If an abscess develops around the ovaries, you will 			need prolonged hospitalization for up to a week .  Please remember to take all of the antibiotic pills that 			are prescribed to you, to prevent a recurrence. Furthermore, if your doctor suspects your case of PID is caused 			by a sexually-transmitted organism, your partner will need treatment to prevent further spread of this infection. 			
 			
 			There are many unfortunate long-term complications that can develop from PID, including infertility (an emotionally 			and financially devastating complication), chronic pelvic pain, scar tissue (called adhesions), and an increase 			in tubal ectopic pregnancies. These develop in at least 1/4 of patients who have PID.  Of course, having PID 			increases the chance of spreading this to sexual partners, which makes this a public health issue. Furthermore, 			some of the bacteria causing PID can cause complications to an unborn baby if not treated during pregnancy.  			PID itself is rare during pregnancy, but the two most common bacteria that cause PID, gonorrhea and chlamydia, 			both can cause problems if untreated during pregnancy.  Each of these complications discussed can produce 			severe symptoms and lead to numerous visits to the doctor and billions spent in annual health care costs. 1/4 of 			PID cases occur in teenage girls. Teenagers rarely consider the long-term consequences of their behavior, but they 			should. There are many women facing expensive and perhaps painful infertility treatments that wish they had been 			more careful about sexual activity when they were younger.  This is one of many reasons that parents must 			sit down with their pre-teen children and discuss sexuality issues.  Sexual activity in teenagers is no longer 			just an issue of morals and family values.   Probably all teenagers consider becoming sexually active, 			and while many do not, research has repeatedly shown that the majority of young women are experimenting sexually.  			Thus, teenage sexuality, a potentially life-threatening or life-altering activity, simply must be addressed before 			children reach an age where they start thinking about sexual activity.  Contact your health care provider, 			or look for one of many books available on this subject at your local library or bookstore.  If you are simply 			too uncomfortable discussing these issues with your child, please make an appointment with your doctor so that 			he or she can sit down with your child and have a confidential talk about human sexuality.  You may be asked 			to leave during this discussion, which I feel is appropriate, since you will certainly want your son or daughter 			to feel comfortable talking about these issues with a health care provider. 
 			
 			In summary, PID is a common but treatable infection that can usually be prevented by safe-sex practices.  			In cases where the infection is due to a medical procedure, rapid treatment will usually prevent long-term complications.  			Women who have had multiple sexual partners or who are in a non-monogamous relationship should consider visiting 			their health care provider for an evaluation and perhaps treatment.            

Pelvic Inflammatory Disease, or PID, is an infectious disease that affects millions of U.S. women and girls each year.  Although usually surprisingly easy to treat, it can be hard to diagnose, and can lead to many long-term and troublesome complications.

Author | D. Ashley Hill, MD

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