Improving women’s health: Does vaginal health need more focus?

Women’s health has been in the spotlight over the last few years, with a government women’s health strategy published and women’s health hubs established in many areas. While this focus is welcome, the strategy contains little about some important areas which impact the quality of life for many women.

Vaginitis is one of the most common conditions affecting women globally and affects women’s physical comfort and emotional wellbeing. Most women will experience at least one episode during their lifetime, with many facing recurrent infections.

It can be a challenge to accurately diagnose and treat vaginitis’s different causes with current diagnostic tools, leading to repeat GP appointments, inappropriate or unnecessary antimicrobial prescribing, and ongoing discomfort and distress for affected women.

Those whose condition goes untreated could also face more serious problems. For those requiring referral to specialist services, delays can further prolong symptoms and impact wellbeing.

What can be done to improve this? An HSJ roundtable, in association with Hologic, discussed some of the issues with a panel of experts.

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Ewa Craven, BMS menopause specialist and trainer, and GP with special interest in sexual health

Stephanie de Giorgio, GP with special interest in women’s health

Douglas Kirkwood, women’s health transformation lead, UK and Ireland, Hologic

Deepthi Lavu, Royal College of General Practitioners representative for women’s health

Catherine McClennan, director responsible for women’s health, Cheshire and Mersey Integrated Care Board

Aamena Salar, GP partner, Modality

Cara Saxon, British Association for Sexual Health and HIV president

Janet Wilson, consultant in sexual health, Leeds Teaching Hospitals Trust

Alison Moore, HSJ (roundtable chair)

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Vaginal health can be a taboo subject, inhibiting women from seeking help, sometimes putting it off until they are in crisis. Aamena Salar, a GP partner at Modality who also works in a women’s health hub, said: “There’s a trivialisation of this condition – [that’s] the elephant in the room,” she said. “It is extremely impactful on their lives, on their relationships.”

But when women do seek help, their local GPs’ surgery may not be the first port of call. They may buy over-the-counter products and tests from supermarkets, pharmacies, or online: many of these could be unsuitable. “If we had a good service in the NHS, there would be no need for women to waste their money,” said Janet Wilson, consultant in sexual health at Leeds Teaching Hospitals Trust. She added that some of the tests available outside the NHS were “absolutely useless” and some “treatments” could even be harmful.

Some women’s first point of contact with NHS services may be through a pharmacy. Thrush – one cause of vaginitis – is one of the conditions which can be diagnosed and treated through Pharmacy First, without needing to involve a GP.

“I think there is a real issue with Pharmacy First for vaginal symptoms,” said Stephanie de Giorgio, a GP with a special interest in women’s health. “That person may be brilliant at being a pharmacist, but they are not trained to take a vaginal/vulval history.”

Plus, women may find it embarrassing to talk about vaginal issues in a crowded pharmacy with a queue behind them and may not be prepared to talk about intimate details, such as symptoms.

But, even with a face-to-face GP appointment, the problems don’t end. Some GPs’ surgeries are ill-equipped for a vaginal examination, which involves a couch – ideally an electronic one which can tilt— and a decent light, said Dr Salar. “Some patients have to hold a mobile phone so we can look at their cervix,” she said.

Without appropriate equipment, examinations could be painful for women and a barrier to proper diagnosis.

But how equipped do GPs feel to diagnose vaginitis’s various causes? Deepthi Lavu, Royal College of GPs representative for women’s health, pointed out that underpressure GPs were often dealing with a difficult situation where they were trying to take a history of what could be years of vaginal health issues, examine the patient, and then decide on a diagnosis within a 10-minute consultation.

“We just need more time within appointments to deliver the care that patients want,” she said.

Dr de Giorgio said there was a particular issue with women living with obesity who might be reluctant to visit their GP and were sometimes treated badly. She cited the case of an obese woman who was made to have a cervical smear while lying on the floor. “I feel we are failing women even before they get to the right tests,” she said.

GPs may have access to some tests to determine the cause of vaginitis, but these can take time to come back from the pathology laboratory, so treatment may often be started while waiting for the results. And tests may be inconclusive, or the vaginitis may recur.

But referring a patient onwards can be challenging. There is no single standardised pathway for women with vaginitis, said Dr Salar. Where GPs needed to refer, there was little agreement on which specialty should be involved, and this might differ from area to area. This meant there was no common approach to testing. There could also be long waiting times to see a specialist, added Dr Lavu, and when patients were referred to a gynaecology service, some gynaecologists did not have good knowledge of vaginitis, added Dr Salar.

Dr de Giorgio said that if there was to be a different pathway, it was important to know who that led to – who the GP could refer to at the end of the pathway. “It might be a specialist GP, it might be sexual health, it might be all of us together, but at the moment, there is no place; it does not fit anywhere.”

Some women will end up at a sexual health clinic, but even there diagnosis of some of the causes of vaginitis can be challenging, said Dr Wilson. Microscopy may only pick up half or even fewer cases caused by some organisms, so additional tests will be needed.

Dr Wilson added that one consequence of this long path for treatment can be that by the time she sees women, their infection is resistant to some of the most commonly-used drugs – a problem which seems to be increasing, she added.

Changing pathways – whether working to a national specification or doing something more locally – will need greater acknowledgement of how much of an issue vaginitis is for women, added Catherine McClennan, the director responsible for women’s health at Cheshire and Mersey Integrated Care Board.

She believed ICBs could be persuaded to invest in improved pathways and better testing by both a strong business case and by hearing women’s lived experiences.

“You can’t just introduce a new test – you have got to start thinking about how you are going to educate the end user, in this case, the GPs,” said Mr Kirkwood, women’s health transformation lead, UK and Ireland, Hologic. He added that Hologic was looking at what it could do around this.

“It would be much more helpful if there was a national pathway,” said Ms McClennan, but added issues like this should be “front and centre” for neighbourhood health too.

But what women want needs to be considered. “As clinicians, we are not very good at understanding where the person is going,” said Dr Salar. “We try to mould services to make them come to us.”

Timely access to accurate testing that pinpoints the organism responsible for vaginitis is needed to ensure appropriate treatment and reduce the risk of drug resistance. But that does not always happen, contributing to the burden of vaginitis as women struggle with repeated or ongoing infections.

In some cases, doctors may not have access to testing. Dr de Giorgio said she had no access to testing while working in an urgent care centre, while Dr Salar, who works in a women’s health hub, said that the tests available to her there were those also available to GPs.

Taking a clinical history was key, but it needed to be backed up by good tests, said Dr de Giorgio. She raised concerns about other practitioners who were increasingly being used in general practice but might not have any gynaecology training. “You can end up with a paramedic doing remote care for vaginitis,” she said.

Some tests may only identify 20 per cent of cases caused by some organisms accurately, said Dr Wilson. She suggested that patients being able to do their own tests and send them in by post, as happens with some sexually transmitted infections, would help.

But getting better tests funded can be a challenge with panellists pointing to siloed funding in the NHS. Mr Kirkwood stressed the role that educating GPs could play in moving to a “test to treat” process where the clinician was prescribing knowing what they were treating, but that would mean women accepting they should wait for test results before starting antibiotics.

Women who contacted their GP could be asked to take a swab before an appointment, so that the GP would know who tested positive – and could then be sent a prescription – and who was negative and might need to be seen, he said.

“We do need to improve the diagnostic tests for everybody, and ideally we would make it so patients could do their own test and post it in… so women could see someone with a diagnosis,” said Dr Wilson.

“We must get the testing and tools right, but also the clinician awareness of these conditions,” said Cara Saxon, British Association for Sexual Health and HIV president. Education was needed so clinicians could be aware of differential diagnoses and also the possibility of two infections at once.

Do clinicians and the women they treat need more education on vaginitis and vaginal health? Many around the table felt they did.

It’s a condition which can affect girls who are pre-puberty right through to post-menopausal women, yet often gets little attention. Very often, there is an assumption that it is always thrush, said Dr de Giorgio.

Greater understanding could help prevent women getting vaginitis in the first place, said Ewa Craven, BMS menopause specialist and trainer, and GP with special interest in sexual health. She highlighted the role of vaginal oestrogen, which she said was underused.

Education around vaginal health could also help women realise that the products which surround them in supermarkets and other stores may not be good for their vaginal health, said Dr deGiorgio. Women may also be washing excessively as they see themselves as unclean and may be using over-the-counter products, as well as soaps and other products.

Women need to understand what is happening to their bodies and that it is not always thrush. Vaginitis can affect women of any age, from any culture, although Black women globally have a greater prevalence of bacterial vaginosis.

Ms McClennan said there was little about vaginal or vulval health in the women’s health strategy, but there is now an opportunity with the refresh of the strategy to tackle an issue which was not talked about.

For more information, you can contact Hologic’s Douglas Kirkwood: Doug Kirkwood, Hologic Women’s Health Transformation Lead - Linkedin