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**Vaginitis**

**Trichomoniasis**

**Vulvovaginal Candidiasis (VVC)**

**Bacterial Vaginosis (BV)**

This module provides an overview of normal vaginal flora, common causes
of vaginitis, and general information on the diagnosis and evaluation of
vaginitis. The module covers trichomoniasis, candidiasis, and bacterial
vaginosis in detail.

\[Slide 2\]

I.  **Vaginal Environment**

    A.  The vagina is a dynamic ecosystem that normally contains
        approximately 10^9^ bacterial colony-forming units per gram of
        vaginal fluid.

    B.  The normal vaginal discharge is clear to white, odorless, and of
        high viscosity.

    C.  The normal bacterial flora is dominated by lactobacilli, but a
        variety of other organisms, including some potential pathogens,
        are also present at lower levels.

    D.  Lactobacilli convert glucose to lactic acid.

    E.  Lactic acid maintains an acid vaginal pH of 3.8 to 4.2.

    F.  The acidic environment inhibits the overgrowth of bacteria and
        other organisms with pathogenic potential.

    G.  Some lactobacilli also produce hydrogen peroxide (H~2~O~2~), a
        potential microbicide that kills bacteria and viruses.

\[Slide 3\]

II. **Vaginitis**

    A.  Vaginitis can be characterized by any of the following: vaginal
        discharge, vulvar itching, vulvar irritation, vaginal odor,
        dyspareunia, and dysuria.

    B.  The three most common types of vaginitis are: trichomoniasis
        (15%-20%), bacterial vaginosis (40%-45%), and vulvovaginal
        candidiasis (20%-25%). In some cases the etiology may be mixed,
        and there may be more than one disease present.

\[Slide 4\]

C.  Other causes of vaginal discharge or irritation may include:

    1.  Mucopurulent cervicitis\--may be related to *Chlamydia
        trachomatis* or *Neisseria gonorrhoeae* infection

    2.  Herpes Simplex Virus (HSV)

    3.  Atrophic vaginitis\--found in lactating and post-menopausal
        women and related to a lack of estrogen

    4.  Allergic reactions, e.g., spermicides, deodorants

    5.  Vulvar vestibulitis, lichen simplex chronicus, and lichen
        sclerosis (especially pruritis)

    6.  Foreign bodies, e.g., retained tampons

\[Slide 5\]

III. **Diagnosis and Evaluation**

     A.  Diagnosis of vaginitis

         1.  Patient history

         2.  Visual inspection of the external genitalia, vagina, and
             cervix

         3.  Appearance of vaginal discharge: color, viscosity,
             adherence to vaginal walls, odor

         4.  Collection of specimen: collect discharge from the lateral
             wall of the vagina; prepare specimen slide (wet mount) with
             a drop of .9% warm saline and a drop of discharge; place
             cover slip on slide and examine microscopically at low and
             high power.

         5.  The following diagnostic criteria can be helpful in the
             differential diagnosis of vaginitis:

             a.  Vaginal pH: determine vaginal pH with narrow-range pH
                 paper

             b.  Whiff test: assessment of a fishy odor after
                 application of 10% KOH to wet mount

             c.  KOH (wet mount): wet mount of discharge with 10% KOH

             d.  NaCl (wet mount): wet mount of discharge with 0.9%
                 normal saline

\[Slide 6\]

B.  Other available diagnostics for vaginitis evaluation

    1.  DNA probe for 3 organisms (*Trichomonas vaginalis*, *Candida
        albicans*, and *Gardnerella vaginalis*) is available.
        Sensitivity, specificity, and clinical utility are under
        investigation.

    2.  Cultures: not used routinely, but are available for both *T.
        vaginalis* and *Candida* *spp*. Culture may be useful in the
        management of persistent or recurrent vulvovaginal candidiasis.

    3.  New commercially available diagnostic tests for BV:

        a.  Fem Exam Test Card™: pH and amines

        b.  Fem Exam vaginalis PIP Activity Test Card™: detects enzyme
            breakdown from *G. vaginalis*

\[Slide 7\]

C.  Image: Wet Prep: Common characteristics

    1.  Note squamous epithelial cell, polymorphonuclear (PMN)
        leukocyte, red blood cells (RBCs).

\[Slide 8\]

D.  Image: Wet Prep: Lactobacilli and epithelial cells

    1.  Note lactobacilli and squamous epithelial cells.

\[Slide 9\]

E.  Vaginitis differentiation table: useful criteria for diagnosing
    vaginitis

    **Vaginitis**

    **Trichomoniasis *(Trichomonas vaginalis*)**

\[Slide 11\]

**Learning Objectives**

Upon completion of this content, the learner will be able to:

1.  Describe the epidemiology of trichomoniasis in the U.S.

2.  Describe the pathogenesis of *Trichomonas vaginalis.*

3.  Describe the clinical manifestations of trichomoniasis.

4.  Identify common methods used in the diagnosis of trichomoniasis.

5.  List CDC-recommended treatment regimens for trichomoniasis.

6.  Describe patient follow-up and partner management for patients with
    trichomoniasis.

7.  Describe appropriate prevention counseling messages for patients
    with trichomoniasis.

\[Slide 12\]

**Lessons**

I.  Epidemiology

II. Pathogenesis

III. Clinical manifestations

IV. Diagnosis

V.  Patient management

VI. Prevention

\[Slide 13\]

I.  **Epidemiology: Disease in the U.S.**

\[Slide 14\]

A.  Incidence and prevalence

    1.  Most common treatable STD.

    2.  Estimated 7.4 million cases annually in the U.S. at a medical
        cost of \$375 million.

    3.  Approximately 2%-3% prevalence in the general female population.

    4.  50%-60% prevalence in female prison inmates and commercial sex
        workers.

    5.  18%-50% prevalence in females with vaginal complaints.

    6.  Not routinely diagnosed in men. A 17% prevalence rate was seen
        in males attending an STD clinic in an urban city.

\[Slide 15\]

B.  Graph: Trichomoniasis and other vaginal infections --- Initial
    visits to physicians' offices: United States, 1966--2003

\[Slide 16\]

C.  Risk factors

    1.  Multiple sex partners

    2.  Low socioeconomic status

    3.  History of STDs

    4.  Some studies have found higher prevalence in African Americans,
        multiparous women, women married at an early age, and during
        pregnancy.

\[Slide 17\]

D.  Transmission

    1.  Almost always sexually transmitted; fomite transmission is rare.

    2.  *T. vaginalis* may persist from months to years in epithelial
        crypts and periglandular areas. Distinguishing persistent,
        subclinical infection from remote sexual acquisition is not
        always possible.

    3.  Males are less likely to be infected by *T. vaginalis,* but this
        pathogen, in the absence of treatment, can persist in the male
        urethra.

    4.  Transmission between female sex partners has been documented.

    5.  *T. vaginalis* can survive extragenitally, but fomite
        transmission is rare.

    6.  Survival: wet sponge (90 minutes), urine (up to 3 hours), wet
        cloth (up to 24 hours)

    7.  Contamination after use by infected women: bathtub (1%), toilet
        seat (13%)

> *Reference: Krieger & Rein (1996), Atlas of Infectious Diseases.*

\[Slide 18\]

I.  **Pathogenesis**

\[Slide 19\]

A.  Microbiology

    1.  Etiologic agent: *Trichomonas vaginalis* - flagellated anaerobic
        protozoa

        a.  The only protozoan that infects the genital tract

        b.  *T. vaginalis* has four free flagellae and one flagella
            embedded in an undulating membrane. The flagellae are
            responsible for the jerky motility of *T. vaginalis*.

    2.  Possible association with:

        a.  Pre-term rupture of membranes, pre-term delivery, pelvic
            inflammatory disease

        b.  Increased risk of HIV acquisition

\[Slide 20\]

Image: *Trichomonas vaginalis*

\[Slide 21\]

II. **Clinical Manifestations**

\[Slide 22\]

A.  Clinical presentation and symptoms in women

    1.  Vaginitis

        a.  Frothy gray or yellow-green vaginal discharge

        b.  Pruritus

        c.  Cervical petechiae (\"strawberry cervix\") - classic
            presentation, but occurs in minority of cases

    2.  May also infect Skene\'s glands and urethra, where the organisms
        may not be susceptible to topical therapy.

    3.  May be asymptomatic in women. Up to 50% of infected women are
        asymptomatic, although 30% of those who are asymptomatic will
        become symptomatic within 6 months.

\[Slide 23\]

Image: "Strawberry cervix" due to *T. vaginalis*

\[Slide 24\]

B.  *T. vaginalis* in males

    1.  May cause up to 11%-13% of nongonococcal urethritis (NGU) in
        males, but urethral infection is frequently asymptomatic.

    2.  Urethral trichomoniasis has been associated with increased
        shedding of HIV in HIV-infected men.

    3.  Frequently asymptomatic

\[Slide 25\]

III. **Diagnosis**

\[Slides 26-27\]

In the clinical setting, the diagnosis of trichomoniasis is made using
the following diagnostic methods:

A.  **Motile** trichomonads seen in saline wet mount (usual mode of
    diagnosis). Sensitivity varies from 42%-70% depending upon the
    experience of the microscopist and specimen collection technique.
    White blood cells are frequently seen. Microscopy should be
    performed as soon as possible after obtaining the specimen.
    Trichomonads, especially if the specimen is old, may closely
    resemble white blood cells. White blood cells can also be confused
    with trichomonads, so motility is a critical observation.

B.  Vaginal pH \>4.5 is often present.

C.  Positive amine (KOH) test (\"whiff\" test) in many cases.

D.  Culture (Diamond\'s media or InPouch TV) is the "gold standard."

E.  Pap smear has limited sensitivity and low specificity; therefore, it
    cannot be used to reliably diagnose trichomonal vaginitis.

F.  DNA probes (now available) may be more sensitive than wet prep, but
    are also more expensive and not widely available.

G.  Trichomoniasis in men is diagnosed by obtaining first void urine
    concentrated 10x and examining for motile trichomonads; a urethral
    swab or 10 cc of first-void urine may also be obtained for culture.

\[Slide 28\]

Image: Wet Prep: Trichomoniasis

\[Slide 29\]

IV. **Patient Management**

\[Slide 30\]

A.  Treatment

    1.  CDC-recommended regimen

        a.  Metronidazole 2 g orally in a single dose

        b.  Alternate regimen: metronidazole 500 mg twice a day for 7
            days

\[Slide 31\]

2.  Pregnancy: CDC-recommended regimen

    a.  Metronidazole 2 g orally in a single dose

    b.  No evidence of teratogenicity; treatment may be administered
        throughout pregnancy

    c.  No follow-up necessary

\[Slide 32\]

B.  Treatment failure

    1.  If treatment failure occurs after 1 treatment attempt with both
        regimens, the patient should be retreated with metronidazole 2 g
        once a day for 3-5 days.

    2.  If repeated treatment failures occur on higher dose regimen,
        contact Division of STD Prevention at CDC for
        metronidazole-susceptibility testing (404-639-8363).

    3.  Assure treatment of sex partners.

C.  Metronidazole has a 90%-95% cure rate. Metronidazole gel
    (intravaginal) is not efficacious for trichomoniasis and is not
    recommended for treatment.

D.  Consider testing for other STDs.

\[Slide 33\]

V.  **Prevention**

\[Slide 34\]

A.  Partner management

    1.  All sex partners should be treated.

    2.  All patients with trichomoniasis should be treated (whether
        symptomatic or asymptomatic).

    3.  Patients should be instructed to avoid sex until they and their
        sex partners are cured. In the absence of a microbiologic test
        of cure, this means when therapy has been completed and patient
        and partner(s) are asymptomatic.

\[Slide 35\]

B.  Patient counseling and education

    1.  Nature of the infection

        a.  Education regarding normal vs. abnormal discharge

        b.  *T. vaginalis* may persist for months or years in epithelial
            crypts and periglandular areas.

        c.  Both men and women can be asymptomatic.

        d.  *T. vaginalis* has been associated with adverse outcomes of
            pregnancy and PID.

        e.  Douching may worsen vaginal discharge.

    2.  Transmission issues

        a.  Trichomoniasis is almost always sexually transmitted. Fomite
            transmission is rare.

        b.  Sex partners should be treated.

        c.  Patients should abstain from intercourse until they and
            their sex partners are cured.

\[Slide 36\]

3.  Risk reduction

> The clinician should:

a.  Assess client's behavior-change potential.

b.  Develop individualized risk-reduction plans with the patient.

c.  Discuss prevention strategies such as abstinence, monogamy, use of
    condoms and limiting the number of sex partners. Latex condoms, when
    used consistently and correctly, can reduce the risk of transmission
    of trichomoniasis.

    **Vaginitis**

    **Vulvovaginal Candidiasis (VVC)**

    \[Slide 38\]

    **Learning Objectives**

Upon completion of this content, the learner will be able to:

1.  Describe the epidemiology of candidiasis in the U.S.

2.  Describe the pathogenesis of *C. albicans.*

3.  Describe the clinical manifestations of candidiasis.

4.  Identify common methods used in the diagnosis of candidiasis.

5.  List CDC-recommended treatment regimens for candidiasis.

6.  Describe patient follow up and partner management for candidiasis.

7.  Summarize appropriate prevention counseling messages for patients
    with candidiasis.

\[Slide 39\]

**Lessons**

I.  Epidemiology: Disease in the U.S.

II. Pathogenesis

III. Clinical manifestations

IV. Diagnosis

V.  Patient management

VI. Prevention

\[Slide 40\]

I.  **Epidemiology: Disease in the U.S.**

\[Slide 41\]

A.  Commonly called "yeast infection." Affects most females at least
    once during lifetime. Second most common cause of vaginal infection
    after bacterial vaginosis.

B.  Most cases of candidiasis are caused by *C. albicans* (85%-90%). *C.
    glabrata* and *C. parapsilosis* are responsible for 5%-10% of cases.

C.  Diagnosis and therapy costs estimated at \$1 billion per year.

D.  Frequent infections may be linked to diabetes, corticosteroids,
    repeated courses of antibiotics, pregnancy, or HIV disease, although
    most patients have no risk factors.

\[Slide 42\]

E.  Transmission: Candida species are normal flora of skin and vagina
    and are not considered to be sexually transmitted pathogens.

\[Slide 43\]

II. **Pathogenesis**

\[Slide 44\]

A.  Microbiology

    1.  Candida species are normal flora of skin and vagina. Candida
        species may be isolated from 20% of asymptomatic healthy women.

    2.  VVC is caused by overgrowth of *Candida albicans* or other
        non-albicans species.

    3.  Yeast grows as oval budding yeast cells and as chains of cells
        (pseudohyphae).

    4.  Symptomatic clinical infection occurs in the setting of
        excessive growth of yeast, which is usually kept in check by
        normal vaginal bacteria.

    5.  Disruption of normal vaginal ecology or host immunity can
        predispose to vaginal yeast infections (e.g., pregnancy,
        diabetes, HIV infection, or, in some women, antibiotic use).

\[Slide 45\]

III. **Clinical Manifestations**

\[Slide 46\]

A.  Vulvar pruritis is the most common symptom.

B.  Thick, white, curdy (\"cottage cheese-like\") vaginal discharge

C.  Erythema, irritation, occasional erythematous \"satellite\" lesion

D.  External dysuria and dyspareunia

\[Slide 47\]

E.  Image: Vulvovaginal Candidiasis

\[Slide 48\]

IV. **Diagnosis**

\[Slide 49\]

A.  History, clinical presentation, and symptoms

B.  Visualization of pseudohyphae (mycelia) and/or budding yeast
    (conidia) on 10% KOH wet prep examination (preferred), saline wet
    mount, or Gram stain

C.  pH normal (4.0 to 4.5). If pH is abnormally high (≥ 4.5), consider
    concurrent bacterial vaginosis (BV) or trichomoniasis.

D.  Cultures not useful for routine diagnosis, since positive cultures
    may be detecting colonization rather than clinically significant
    infections. Cultures may be useful to detect non-albicans species or
    resistant organisms in women with recurrent disease.

E.  DNA probe is available but expensive.

\[Slide 50\]

F.  Image: PMNs and yeast buds

\[Slide 51\]

G.  Image: PMNs and yeast pseudohyphae

\[Slide 52\]

H.  Image: Yeast pseudohyphae

\[Slide 53\]

V.  **Patient Management**

\[Slide 54\]

A.  Classification of VVC--uncomplicated or complicated

    1.  Uncomplicated VVC includes:

        a.  Sporadic or infrequent vulvovaginal candidiasis,
            mild-to-moderate vulvovaginal candidiasis, or vulvovaginal
            candidiasis in non-immunocompromised women

    2.  Complicated VVC includes:

        a.  Recurrent vulvovaginal candidiasis (RVVC), severe
            vulvovaginal candidiasis, non-albicans candidiasis, or
            vulvovaginal candidiasis in women with uncontrolled
            diabetes, debilitation, immunosuppression, or in those who
            are pregnant.

\[Slide 55\]

B.  Uncomplicated VVC

    1.  Mild to moderate signs and symptoms, sporadic, non-recurrent
        disease in a normal host with normally susceptible *C.
        albicans.*

    2.  75% of women have at least one lifetime episode.

    3.  Responds to all azole treatment regimens including short (3-day)
        and single-dose oral and vaginal therapy.

\[Slide 56\]

C.  CDC-recommended regimens for uncomplicated VVC

    1.  Intravaginal agents:

        a.  Butoconazole 2% cream, 5 g intravaginally for 3 days† or
            butoconazole sustained release single intravaginal
            application

        b.  Clotrimazole 1% cream 5 g intravaginally for 7-14 days†

        c.  Clotrimazole 100 mg vaginal tablet for 7 days

        d.  Clotrimazole 100 mg vaginal tablet, 2 tablets for 3 days

        e.  Clotrimazole 500 mg vaginal tablet, 1 tablet in a single
            application

        f.  Miconazole 2% cream 5 g intravaginally for 7 days†

        g.  Miconazole 200 mg vaginal suppository, 1 suppository for 3
            days†

        h.  Miconazole 100 mg vaginal suppository, 1 suppository for 7
            days†

        i.  Nystatin 100,000-U vaginal tablet, 1 tablet for 14 days

        j.  Tioconazole 6.5% ointment 5 g intravaginally in a single
            application†

        k.  Terconazole 0.4% cream 5 g intravaginally for 7 days

        l.  Terconazole 0.8% cream 5 g intravaginally for 3 days

        m.  Terconazole 80 mg vaginal suppository, 1 suppository for 3
            days

    2.  Oral agent: Fluconazole 150 mg oral tablet, 1 tablet in a single
        dose

> †Over-the-counter (OTC) preparations
>
> NOTE: The creams and suppositories in this regimen are oil-based and
> may weaken latex condoms and diaphragms. Refer to condom product
> labeling for further information.

\[Slide 57\]

D.  Complicated VVC -- Approximately 10% to 20% of women will have
    complicated VVC. VVC is considered complicated when the following
    exists:

    1.  Recurrent VVC (RVVC): four or more episodes in 1 year

    2.  Severe VVC: extensive vulvar erythema, edema, excoriation or
        fissure formation

    3.  Non-albicans species: requires longer duration of treatment
        (10-15 days) with topical azoles

    4.  Compromised host: women with diabetes, immunosuppression, HIV

    5.  Pregnancy

\[Slides 58\]

E.  Treatment of complicated VVC

    1.  Recurrent VVC (RVVC)

        a.  7-14 days of topical therapy, or 150 mg oral dose of
            fluconozole repeated 3 days later

        b.  While some women with RVVC have risk factors, most women do
            not. Recurrent disease may be more likely due to
            non-albicans species.

        c.  After an initial intensive regimen of 10-14 days, a
            maintenance regimen for at least 6 months is recommended.

        d.  Maintenance regimens:

            1.  Clotrimazole 500 mg dose vaginal suppositories once
                weekly

            2.  Ketonconazole 100 mg dose once daily

            3.  Itraconazole 400 mg dose once monthly or 100 mg dose
                once daily

        e.  RVVC should be confirmed by culture before initiating
            maintenance therapy. VVC diagnosis should also be
            periodically re-confirmed, and the presence of other
            contributory causes (new trichomoniasis or BV) assessed.

        f.  Patients with RVVC who are receiving treatment should
            receive regular follow up to monitor the effectiveness of
            therapy and the occurrence of drug side effects.

    2.  Severe VVC

        a.  7-14 days of topical therapy, or 150 mg oral dose of
            fluconozole repeated in 72 hours

        b.  In cases associated with severe vulvitis and intense
            pruritis, topical applications of low-potency corticosteroid
            cream or nystatin cream may be beneficial.

\[Slide 59\]

3.  Non-albicans VVC

    a.  Optimal treatment unknown

    b.  7-14 days with a non-fluconozole therapy

    c.  600 mg boric acid in gelatin capsule vaginally once a day for 14
        days

4.  VVC in a compromised host

    a.  7-14 days of topical therapy

5.  VVC in pregnancy

    a.  Fluconozole is contraindicated.

    b.  Use only topical agents.

\[Slide 60\]

VI. **Prevention**

\[Slide 61\]

A.  Partner management

    1.  VVC is not usually acquired through sexual intercourse;
        treatment of sex partners is not recommended but may be
        considered in women who have recurrent infection.

    2.  A minority of male sex partners may have balanitis,
        characterized by erythematous areas on the glans penis in
        conjunction with pruritis or irritation. They may benefit from
        treatment with topical antifungal agents to relieve symptoms.

\[Slide 62\]

B.  Patient counseling and education should cover the nature of the
    disease, transmission issues, and risk reduction.

    1.  Nature of the disease

        a.  Normal vs. abnormal vaginal discharge

        b.  Signs and symptoms of candidiasis

        c.  Maintain normal vaginal flora

        d.  Control of predisposing conditions

    2.  Transmission

        a.  Not sexually transmitted

    3.  Risk reduction

        a.  Avoid douching

        b.  Avoid unnecessary antibiotic use

        c.  Contact health provider if symptoms persist or recur within
            2 months

        d.  Complete course of treatment

            **Vaginitis**

            **Bacterial Vaginosis (BV)**

            \[Slide 64\]

            **Learning Objectives**

            Upon completion of this module, the learner will be able to:

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1.  Describe the epidemiology of bacterial vaginosis in the U.S.

2.  Describe the pathogenesis of bacterial vaginosis.

3.  Describe the clinical manifestations of bacterial vaginosis.

4.  Identify common methods used in the diagnosis of bacterial
    vaginosis.

5.  List CDC-recommended treatment regimens for bacterial vaginosis.

6.  Describe patient follow-up and partner management for patients with
    bacterial vaginosis.

7.  Summarize appropriate prevention counseling messages for patients
    with bacterial vaginosis.

\[Slide 65\]

**Lessons**

I.  Epidemiology: Disease in the U.S.

II. Pathogenesis

III. Clinical manifestations

IV. Diagnosis

V.  Patient management

VI. Prevention

\[Slide 66\]

I.  **Epidemiology: Disease in the U.S.**

\[Slide 67\]

A.  Most common cause of vaginitis. Occurrence of BV may be related to
    sexual activity, but BV is not considered an STD.

B.  Widely distributed. Prevalence varies by population: 5%-25% in
    college students, 12%-61% in STD patients.

\[Slide 68\]

C.  BV linked to premature rupture of membranes, premature delivery, and
    low birth-weight delivery, acquisition of HIV, and development of
    PID and post-operation infections after gynecological procedures.

D.  Organisms do not persist in the male urethra.

\[Slide 69\]

E.  More common in African American women, women who douche, women using
    IUDs, women with a new sex partner, women with more than two sex
    partners in previous six months, and women who lack peroxide
    (H~2~O~2~)-producing lactobacilli in their vaginal flora. Has also
    been identified in female same-sex partnerships.

\[Slide 70\]

F.  Acquisition: currently not considered a sexually transmitted
    disease, but it appears to be related to sexual activity.

\[Slide 71\]

II. **Pathogenesis**

\[Slide 72\]

A.  Overgrowth of bacteria species normally present in vagina, but at
    low levels, such as *Haemophilus*, *Gardnerella*, *Bacteroides*,
    *Mycoplasma hominis*, *Mobiluncus*, *Peptostreptococcus, Ureaplasma*

B.  BV correlates with the decrease or absence of protective
    lactobacilli.

    1.  Lactobacilli produce lactic acid through metabolism of
        glucose/glycogen.

    2.  Lactic acid keeps the vaginal pH acidic which inhibits growth of
        other bacterial species.

    3.  When lactobacilli are lacking, overgrowth of bacterial occurs.

    4.  Hydrogen peroxide-producing *Lactobacillus* spp. helps to
        maintain a low pH, which may directly inhibit some organisms.

    5.  Loss of protective lactobacilli may lead to BV.

\[Slide 73\]

C.  Hydrogen peroxide-producing lactobacillus

    1.  All lactobacilli produce lactic acid.

    2.  Some species also produce hydrogen peroxide.

    3.  Hydrogen peroxide is a potent natural microbicide.

    4.  Present in 42%-74% of females. The prevalence of BV in women who
        have H~2~O~2~ species is 4%.

    5.  Thought to be toxic to viruses like HIV and other bacterial
        species.

\[Slide 74\]

III. **Clinical Manifestations**

\[Slide 75\]

A.  50% report malodorous (fishy smelling) vaginal discharge, sometimes
    reported more commonly after vaginal intercourse and after
    completion of menses. Vaginal pruritis may also be present.

B.  50% are asymptomatic.

\[Slide 76\]

IV. **Diagnosis**

\[Slide 77\]

A.  Image: Bacterial vaginosis wet prep

\[Slide 78\]

B.  Bacterial vaginosis can be diagnosed using the following Amsel
    criteria. The presence of 3 of the 4 criteria is diagnostic:

    1.  Vaginal pH \>4.5 (most sensitive but least specific)

    2.  Presence of \"clue cells\" on wet mount examination (bacterial
        clumping upon the borders of epithelial cells). Clue cells
        should constitute at least 20% of all epithelial cells (an
        occasional clue cell does not fulfill this criterion).

    3.  Positive amine or \"whiff\" test (liberation of biologic amines
        with or without the addition of 10% KOH)

    4.  Homogeneous, non-viscous, milky-white discharge adherent to the
        vaginal walls

\[Slide 79\]

C.  Some experts use vaginal Gram stain to assist in the diagnosis of BV
    (Nugent criteria). A normal Gram stain would show lactobacillus only
    or lactobacillus with Gardnerella. When a more mixed flora is
    present (Gram-positive cocci, small Gram-negative rods, curved
    Gram-variable rods) and lactobacillus absent or present in low
    numbers, the smear would be interpreted as consistent with BV.

D.  Culture is not recommended.

E.  DNA probe\--Affirm™ V.P. III, may have clinical utility.

F.  Newer diagnostic modalities include FemExam™, PIP Activity
    TestCard™. These tests detect abnormal pH, and/or high levels of
    trimethylamine or *G. vaginalis*.

\[Slide 80\]

V.  **Patient Management**

\[Slide 81\]

A.  Treatment

    1.  CDC-recommended regimens (non-pregnant patients)

        a.  Metronidazole 500 mg orally twice a day for 7 days

        b.  Metronidazole gel 0.75% 1 applicator-full once or twice
            daily for 5 days. If once daily, administer at bedtime.

        c.  Clindamycin cream 2% 1 applicator-full intravaginally at
            bedtime for 7 days

    2.  Alternative regimens (non-pregnant patients)

        a.  Metronidazole 2 g orally single dose

        b.  Clindamycin 300 mg orally twice a day for 7 days

        c.  Clindamycin ovules 100 mg intravaginally at bedtime for 3
            days

\[Slide 82\]

B.  Treatment in pregnancy

    1.  All pregnant women with symptomatic disease should be treated.
        Recommended regimen: Metronidazole 250 three times a day for 7
        days or Clindamycin 300 mg orally 2 times a day for 7 days. Some
        experts suggest that treating early in pregnancy may actually be
        important in preventing adverse outcome.

    2.  Asymptomatic high-risk women (those who have previously
        delivered a premature infant) may be screened:

        a.  At first prenatal visit

        b.  Follow up 1 month after completion of therapy

\[Slide 83\]

C.  Screening and treatment in asymptomatic patients:

    1.  Asymptomatic screening of low-risk pregnant women is not
        recommended

    2.  Therapy is not recommended for male partners of women with BV.

    3.  Female partners of women with BV should be examined and treated
        if BV is present.

    4.  Screen and treat women prior to surgical abortion or
        hysterectomy.

    5.  Therapy may not be necessary for asymptomatic women with BV.
        Exceptions include asymptomatic patients with BV who are to
        undergo surgical abortion or hysterectomy. BV has been
        associated with endometritis, PID, or vaginal cuff cellulitis in
        women undergoing ambulatory invasive procedures. (endometrial
        biopsy, hysteroscopy, IUD insertions) and women scheduled for
        vaginal or abdominal surgery. However, data are insufficient to
        recommend treatment of asymptomatic patients prior to procedures
        other than surgical abortion or hysterectomy.

D.  Drugs **not** recommended for the treatment of BV include
    ampicillin, erythromycin, iodine, dienestrol cream,
    tetracycline/doxycycline, triple sulfa, and ciprofloxacin.

\[Slide 84\]

E.  Recurrence

    1.  20% to 40% recurrence rate after one month

    2.  Recurrence may be a result of persistence of BV-associated
        organisms and failure of lactobacillus flora to recolonize.

    3.  Data do not support yogurt therapy or exogenous oral
        lactobacillus treatment.

    4.  Under study: vaginal suppositories containing human
        lactobacillus strains

\[Slide 85\]

VI. **Prevention**

\[Slide 86\]

A.  Partner management

    1.  After multiple occurrences, some consider empiric treatment of
        male sex partners to see if recurrence rate diminishes. This
        approach has not been validated.

\[Slide 87\]

B.  Patient counseling and education---should cover the nature of the
    disease, transmission issues, and risk reduction.

    a.  Nature of the disease

        1.  Normal vs. abnormal discharge

        2.  Malodor symptomatology

        3.  Other signs and symptoms of BV

        4.  Association with sexual activity

    b.  Transmission issues

        1.  Not sexually transmitted

        2.  High association in female same sex partnerships

    c.  Risk reduction

        1.  Avoid douching

        2.  Limit number of sex partners

            **Vaginitis: Differentiating BV, Candidiasis, and**
            Trichomoniasis

+----------------+--------+-------------+-------------+---------------+
|                | **No   | **Bacterial | **Ca        | **Tri         |
|                | rmal** | Vaginosis** | ndidiasis** | chomoniasis** |
+----------------+--------+-------------+-------------+---------------+
| **Symptoms**   |        | Odor,       | Itch,       | Itch,         |
|                |        | discharge,  | discomfort, | discharge,    |
| **             |        | itch        | dysuria,    | 50%           |
| presentation** |        |             | thick       | asymptomatic  |
|                |        |             | discharge   |               |
+----------------+--------+-------------+-------------+---------------+
| ## Vag         | Clear  | Homogenous, | Thick,      | Frothy, gray  |
| inal discharge | to     | adherent,   | clumpy,     | or            |
|                | white  | thin, milky | white       | yellow-green; |
|                |        | white;      | "cottage    | malodorous    |
|                |        | malodorous  | cheese"     |               |
|                |        | "foul       |             |               |
|                |        | fishy"      |             |               |
+----------------+--------+-------------+-------------+---------------+
| ## Cli         |        |             | I           | Cervical      |
| nical findings |        |             | nflammation | petechiae     |
|                |        |             | and         | "strawberry   |
|                |        |             | erythema    | cervix"       |
+----------------+--------+-------------+-------------+---------------+
| **Vaginal pH** | 3.8 -  | \> 4.5      | Usually ≤   | \> 4.5        |
|                | 4.2    |             | 4.5         |               |
+----------------+--------+-------------+-------------+---------------+
| **KOH "whiff"  | Ne     | ## Positive | Negative    | Often         |
| test**         | gative |             |             | positive      |
+----------------+--------+-------------+-------------+---------------+
| **NaCl wet     | L      | # Clue cel  | Few WBCs    | #             |
| mount**        | acto-b | ls (≥20%),  |             |  Motile flage |
|                | acilli | no/few WBCs |             | llated protoz |
|                |        |             |             | oa, many WBCs |
+----------------+--------+-------------+-------------+---------------+
| **KOH wet      |        |             | ## Pseu     |               |
| mount**        |        |             | dohyphae or |               |
|                |        |             |  spores if  |               |
|                |        |             | non-*albica |               |
|                |        |             | ns* species |               |
+----------------+--------+-------------+-------------+---------------+

\[Slide 88\]

**CASE STUDY**

**Tanya Walters** is a 24-year-old single female who presented at her
HMO with complaints of a smelly, yellow vaginal discharge and slight
dysuria for one week.

\[Slide 89\]

**History**

-   Denies vulvar itching, pelvic pain, or fever

-   Has had 2 sex partners over the past 6 months---did not use condoms
    with these partners---on oral contraceptives for birth control

-   No history of sexually transmitted diseases, except for
    trichomoniasis 1 year ago

-   Last check up 1 year ago

\[Slide 90\]

**Physical Exam**

-   Vital signs: blood pressure 112/78, pulse 72, respiration 15,
    temperature 37.3° C

-   Cooperative, good historian

-   Chest, heart, breast, musculoskeletal, and abdominal exams within
    normal limits

-   No flank pain on percussion

-   Normal external genitalia with a few excoriations near the
    introitus, but no other lesions

-   Speculum exam reveals a moderate amount of frothy, yellowish,
    malodorous discharge, without visible cervical mucopus or easily
    induced cervical bleeding

-   Bimanual examination was normal without uterine or adnexal
    tenderness

\[Slide 91\]

1\. What is your differential diagnosis based on history and physical
examination?

-   Vaginitis\--Vaginitis is usually characterized by a vaginal
    discharge, vulvar itching or irritation, and a vaginal odor.

-   Chlamydia --Chlamydia is usually asymptomatic and cannot be
    diagnosed clinically. With the history of unprotected sex and the
    epidemiology of chlamydia, it must be considered.

-   Gonorrhea---Gonorrhea can be asymptomatic and cannot be diagnosed
    clinically. With the history of unprotected sex and the epidemiology
    of gonorrhea, it cannot be ruled out.

2\. Based on the differential diagnosis of vaginitis, what is the
etiology?

Unknown at this time. In addition to a physical examination and visual
inspection of the vagina, an appropriate evaluation of vaginitis
requires a collection of a specimen of the discharge for examination
under a microscope. It is premature to diagnose the etiology without
this missing piece.

Possible etiologic agents include the following. However, none of them
can be confirmed without examination of the discharge specimen.

-   *Trichomonas vaginalis*, which should be suspected in the presence
    of frothy gray or yellow-green vaginal discharge, pruritis, or
    cervical petuchae.

-   *Candida albicans*, which should be suspected in the presence of
    thick, white, curdy (cottage cheese-like) vaginal discharge. Vulvar
    pruritis, erythema, irritation, and an occasional erythematous
    "satellite" lesion may occur. External dysuria is another common
    symptom of VVC.

-   Bacterial vaginosis, which is associated with a malodorous vaginal
    discharge that is reported more commonly after sexual intercourse or
    menses.

3\. Which laboratory tests should be offered or performed?

Appropriate responses include the following:

-   Vaginal saline wet mount -- Vaginal saline wet mount could show
    trichomonads and clue cells.

-   KOH wet mount -- The KOH wet mount could show budding yeast hyphae

-   \"Whiff\" test -- The "whiff" test could elicit the fishy odor of
    amines.

-   Vaginal fluid pH -- Can help to rule out BV and possibly
    trichomoniasis.

-   Chlamydia -- A chlamydia test is appropriate because of the high
    prevalence of chlamydial infection in young women and its
    asymptomatic nature. CDC recommends that all sexually active women
    age 25 and under be screened for chlamydia on an annual basis, so
    testing this woman depends on when she was last screened and her
    risk assessment for recent STD acquisition.

-   Testing for other STDs - Depending on prevalence rates and the
    patient's behavioral risk factors, one may also consider screening
    for gonorrhea and syphilis and offering HIV testing.

-   Counseling and testing for HIV- The history of risky sexual behavior
    is an indication for offering HIV testing.

\[Slide 92\]

**Laboratory Results**

-   Vaginal pH\--6.0

-   Saline wet mount of vaginal secretions\--numerous motile
    trichomonads and no clue cells

-   KOH wet mount\--negative for budding yeast and hyphae

4.  What may one reasonably conclude about Tanya's diagnosis?

Trichomoniasis has been diagnosed and candida has been reasonably ruled
out. KOH prep will only detect fungal elements on average in 85% of
women whose vaginitis turns out to be yeast. The normal vaginal pH is
3.8--4.2.

5.  What is the appropriate CDC-recommended treatment for this patient?

Metronidazole 2 g orally in a single dose

\[Slide 93\]

**Partner Management**

Tanya has had 2 sex partners within the past year:

**Jamie**\
Last sexual contact: 2 days ago\
First sexual contact: 2 months ago\
Frequency, exposure type: Twice a week, vaginal sex

**Calvin**\
Last sexual contact: 6 months ago\
First sexual contact: 7 months ago\
Frequency, exposure type: 3 times a week, vaginal and oral sex

6.  How should Jamie and Calvin be managed?

Ensuring the treatment of male partners results in relief of symptoms,
microbiologic cure, and reduction of transmission. Trichomoniasis may be
asymptomatic in both men and women.

Jamie should be treated, and Tanya and Jamie should avoid sex until both
are cured (therapy is complete and they are asymptomatic).

Since Calvin and Tanya have not had sex in 6 months, Calvin is probably
not related to this infection.

\[Slide 94\]

**Follow-Up**

Tanya was prescribed metronidazole 2 g orally, and she was instructed to
abstain from sexual intercourse until her partner was treated.

She returned to clinic 2 weeks later. She reported taking her
medication, but still had persistent vaginal discharge that had not
subsided with treatment. She reported abstinence since her clinic visit,
and her partner had moved out of the area. Her chlamydia test was
negative. GC culture was negative.

The vaginal wet mount again revealed motile trichomonads.

7.  What is the appropriate therapy for Tanya now?

Metronidazole 500 mg twice a day for 7 days. If treatment failure occurs
with a recommended regimen, the patient should be retreated with this
regimen.

If treatment failure occurs after 1 treatment attempt with both
regimens, the patient should be retreated with metronidazole 2 g once a
day for 3-5 days.

8\. What are the appropriate prevention and counseling messages for
Tanya?

-   Patients should be instructed to avoid sex until they and their sex
    partners are treated and cured.

-   In the absence of a microbiologic test of cure, \"cured\" is when
    therapy has been completed and patient and partner(s) are
    asymptomatic.

-   Clarify that trichomoniasis is almost always sexually transmitted,
    and fomite transmission is rare.

-   Discuss individual risk reduction and prevention strategies,
    including abstinence, monogamy, and condoms.

-   Inform the patient that latex condoms can reduce the risk of
    transmission of trichomoniasis when used consistently and correctly.

-   Alcohol should be avoided when metronidazole is used for treatment.

-   Hormonal contraceptives offer no protection from STDs and HIV
    infection.

-   Offer HIV counseling and testing.

**TEST QUESTIONS**

1.  Which of the following statements is true about the vaginal
    ecosystem?

    a.  The normal vaginal flora is made up mostly of gardnerella.

    b.  Normal vaginal discharge is colorless, odorless, and has a low
        viscosity.

    c.  Lactobacilli convert glucose to ascorbic acid.

    d.  **Lactobacilli produce hydrogen peroxide which inhibits
        bacterial growth.**

2.  Which of the following types of vaginitis occurs most frequently?

    a.  **Bacterial vaginosis**

    b.  Candidiasis

    c.  Trichomoniasis

    d.  Atrophic vaginitis

3.  The diagnosis of vaginitis requires which of the following?

    a.  Patient history

    b.  Visual inspection of vaginal discharge

    c.  Collection of specimen of vaginal discharge for microscopic
        examination

    d.  **All of the above**

4.  The normal vaginal pH is:

    a.  **Acid with a pH of 3.8-4.2**

    b.  Alkaline with a pH of 5.0-6.0

    c.  Acid with a pH of 5.0-6.0

    d.  Alkaline with a pH of 2.5-3.5

5.  Which of the following best describes the signs and symptoms of
    trichomoniasis in women?

    a.  Foul fishy odor, and thick clumpy white vaginal discharge

    b.  **Malodorous, frothy yellow-green vaginal discharge**

    c.  Dysuria, and thin milky-white vaginal discharge

    d.  None, the condition is asymptomatic in women.

6.  Which of the following statements is **NOT** true about *Trichomonas
    vaginalis*?

    a.  **Fomite transmission is frequent.**

    b.  Sexual transmission is frequent.

    c.  Sex partners should be treated.

    d.  Patients are considered cured when patients and partners have
        been treated and are asymptomatic.

7.  The usual method of trichomoniasis diagnosis is:

    a.  Vaginal pH

    b.  KOH "whiff" test

    c.  **Motile trichomonads seen on a saline wet mount**

    d.  Pap smear

8.  The CDC-recommended treatment for trichomoniasis in non-pregnant
    women and in men is:

    a.  Miconazole 100 mg vaginal suppository, 1 suppository for 7 days

    b.  **Metronidazole 2 g orally as one-time single dose**

    c.  Metronidazole 500 mg orally twice a day for 7 days

    d.  Clindamycin 300 mg orally twice a day for 7 days

9.  The CDC recommends that pregnant women with trichomoniasis be
    treated with:

    a.  Miconazole 100 mg vaginal suppository, 1 suppository for 7 days

    b.  **Metronidazole 2 g orally as one-time single dose**

    c.  Metronidazole 500 mg orally as twice a day for 7 days

    d.  Clindamycin 300 mg orally twice a day for 7 days

10. When may sex partners resume sexual intercourse after treatment for
    trichomoniasis?

    a.  **When they are both cured or when therapy has been completed
        and both are asymptomatic.**

    b.  Six months after both have completed therapy and the microbial
        tests are negative.

    c.  Partners may continue sexual practices as long as both are being
        treated and they use appropriate barrier methods.

11. Most cases of candidiasis are caused by:

    a.  ***C. albicans***

    b.  *C. glabrata*

    c.  *C. parapsilosis*

    d.  *T. vaginalis*

12. Which of the following best describes the signs and symptoms of
    candidiasis in women?

    a.  **External dysuria, pruritis, and thick, clumpy white vaginal
        discharge**

    b.  Foul fishy odor, frothy yellow-green vaginal discharge

    c.  Malodorous and thin milky-white vaginal discharge

    d.  None, the condition is asymptomatic in women.

13. The preferred method for candidiasis diagnosis is:

    a.  KOH "whiff" test

    b.  Culture

    c.  **KOH wet mount**

    d.  Pap smear

14. Which of the following is recommended for the treatment of
    uncomplicated vulvovaginal candidiasis?

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a)  **Azole treatment regimen including 3-day and single-dose oral or
    vaginal therapy**

b)  Fluconazole 150 mg oral tablet repeated in 72 hours

c)  Itraconazole 100 mg daily for 3 days

d)  Ketoconazole 100 mg daily for 3 days

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15. Which of the following is true about treatment of male partners of
    women with candidiasis?

    a.  A majority of male partners have balanitis and should be
        treated.

    b.  Treatment of male partners should be topical.

    c.  **Treatment of male partners is not usually recommended.**

    d.  Oral regimens are more effective in men.

16. Complicated VVC is characterized by which of the following?

    a.  Sporadic and non-recurrent

    b.  Responds to all azole regimens

    c.  **Recurrent**

    d.  Mild to moderate symptoms

17. What is the recommended treatment for uncomplicated vulvovaginal
    candidiasis in pregnancy?

    a.  Fluconazole 150 mg in a single dose

    b.  **Topical agents only**

    c.  Itraconazole 100 mg in a single dose

    d.  Ketoconazole 100 mg in a single dose

18. Bacterial vaginosis may occur when there is a loss of protective:

    a.  Antibodies

    b.  **Lactobacilli**

    c.  Mucus

    d.  Antigens

19. Which of the following best describes the signs and symptoms of
    bacterial vaginosis in women?

    a.  External dysuria, discomfort, and thick clumpy white vaginal
        discharge

    b.  Malodorous, frothy yellow-green vaginal discharge

    c.  **Foul fishy odor and thin milky-white vaginal discharge**

    d.  None, the condition is asymptomatic in women.

20. Bacterial vaginosis has been associated with which of the following?

    a.  PID

    b.  Premature rupture of membranes

    c.  Acquisition of HIV

    d.  **All of the above**

21. The following statements are true for which type of vaginitis:
    "Approximately 50% of the time it is accompanied by a malodorous
    vaginal discharge; has a high recurrence rate; symptoms, if present,
    are more noticeable after sexual intercourse."

    a.  Trichomoniasis

    b.  **Bacterial vaginosis**

    c.  Candidiasis

    d.  Chlamydia

22. What is the recommended treatment for bacterial vaginosis in
    pregnant women?

    a.  Metronidazole 2 g orally in a single dose

    b.  Metronidazole 500 mg orally 2 times a day for 14 days

    c.  Clindamycin ovules 100 mg intravaginally at bedtime for 3 days

    d.  **Metronidazole 250 mg 3 times a day for 7 days**

23. What is the most likely vaginitis diagnosis based on the following
    criteria: pH 5.0; clue cells \> 20% per HPF; KOH "whiff test"
    positive; and homogenous discharge?

    a.  Trichomoniasis

    b.  Candidiasis

    c.  **Bacterial vaginosis**

    d.  Chlamydia

24. The Amsel criteria used in the diagnosis of bacterial vaginosis
    includes all of the following except:

    a.  Vaginal pH \>4.5

    b.  Presence of clue cells on wet mount

    c.  Positive "whiff" test

    d.  **Numerous WBCs**

25. Risk reduction messages for women with bacterial vaginosis would
    include which of the following?

    a.  **Avoid douching**

    b.  Treatment of all sexual partners

    c.  Consistent use of condoms

    d.  Annual screening of all women

**RESOURCES**

**Publications**

1.  American Social Health Association. Sexually transmitted diseases in
    America: How many cases and at what cost? Menlo Park (CA): Kaiser
    Family Foundation; 1998. Available from URL: 
    <http://www.ashastd.org/pdfs/std_rep.pdf>.

2.  Berger BJ, et al. Bacterial vaginosis in lesbians: a sexually
    transmitted disease. Clin Infect Dis 1995; 21:1402-5.

3.  CDC. Sexually transmitted diseases treatment guidelines 2002. MMWR
    2002;51 (No. RR-6). Available from URL:
    <http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5106a1.htm>.

4.  Hauth JC, et al. Reduced incidence of preterm delivery with
    metronidazole and erythromycin in women with bacterial vaginosis. 
    New Engl J Med 1995; 333:1732-1736.

5.  Hillier SL, et al. Association between bacterial vaginosis and
    pre-term delivery of a low-birth weight infant. New Engl J Med 1995;
    333:1737-1742.

6.  Holmes KK, Sparling PF, Mardh P-A, Lemon SM, Stamm WE, Piot P,
    Wasserheit JN (editors). Sexually transmitted diseases, 3rd ed. New
    York (NY): McGraw-Hill, 1999.  Chapters 42, 43, 45.

7.  Krieger JN. Trichomoniasis in men: old issues and new data. Sex
    Transm Dis 1995; 22:83-96.

8.  Larsson P-G, et al. Incidence of pelvic inflammatory disease after
    first trimester legal abortion with bacterial vaginosis after
    treatment with metronidazole: a double-blind randomized study. Am J
    Obstet Gynecol 1992; 166:100-103.

9.  Sewankambo N, et al. HIV-1 infection associated with abnormal
    vaginal flora morphology and bacterial vaginosis. Lancet 1997;
    350:546-550.

10. Skinner CJ. A case-controlled study of the sexual needs of lesbians.
    Genitourin Med 1996; 72:277-280.

11. Vasquez JA, et al. Karyotyping of *Candida albicans* isolates
    obtained longitudinally in women with recurrent vulvovaginal
    candidiasis. J Infect Dis 1994; 170(6):1566-9.

12. Wasserheit JN. Epidemiologic synergy: interrelationships between
    human immunodeficiency virus infection and other sexually
    transmitted diseases. Sex Transm Dis 1992; 19:61-77.

13. Weinstein L. Single oral dose fluconazole compared with conventional
    clotrimazole topical therapy of candida vaginitis. Am J Obstet
    Gynecol 1995; 172:1263-1268.

14. Wilson TE, et al. Testing for HIV and other STDs: implications for
    risk behavior in women. Hlth Psych 1996; 15:252-260.

15. Weinstock H, Berman S, Cates W Jr. Sexually transmitted diseases
    among American youth: incidence and prevalence estimates, 2000.
    Perspect Sex Repro Hlth 2004; 36 (1): 6-10.

**Websites and Other Resources**

1.  CDC, Division of STD Prevention:
    [www.cdc.gov/std](http://www.cdc.gov/std)

2.  National Network of STD/HIV Prevention Training Centers:
    <http://depts.washington.edu/nnptc/>

3.  2002 CDC STD Treatment Guidelines (including downloadable version
    for Palm devices): <http://www.cdc.gov/STD/treatment/>

4.  CDC National STD Hotline: 800-227-8922 or 800-342-2437

    a.  En Español: 800-344-7432

    b.  TTY for the Deaf and Hard of Hearing: 800-243-7889

5.  CDC National Prevention Information Network (NPIN):
    [www.cdcnpin.org](http://www.cdcnpin.org/)

6.  American Social Health Association (ASHA):
    [www.ashastd.org](http://www.ashastd.org/)