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Approach to Case of Vaginal Discharge

Mar 10 | 1:30 PM

Although sexually transmitted infections do not majorly cause vaginal discharge cases, they cause swelling and pain around the vulva, acute itching, and a thick cheesy discharge. Recent breakthroughs have changed the investigation and management approach to vaginal discharge. Join Dr. Kohli live on Medflix as she walks through the new epidemiological data, the many presentations of vaginal discharge, and how to approach its management!

[Music] hello everyone a very good evening to all my respected doctors and beloved friends uh this is your host dr iris choudhury i'm a family medicine consultant a healthcare management person and a quality certified professional and it gives me immense pleasure on behalf of the entire team of netflix to welcome you to tonight's very interesting and yet a very common problem approach to a case of vaginal discharge and to do the honor we have a very respected and senior speaker and doctor among us dr as you can see in front of your screen she's a senior consultant gynecologist and ex-professor armed forces medical college owner before we hand over to mam i would like to say just two years two days before we celebrated uh international women's day on eighth of march so as a special honor attribute to women across all sectors of our society from diverse socio-economic backgrounds in whatever profession they are we assure all the best to all the women and specially to the doctors the female doctors because i'm also a doctor so i know that it is very tough how to balance family work and yet to give your best everywhere ah coming back to the topic you know approach to a case of vaginal discharge or we know that vaginal discharge or valve vaginal symptoms or vaginal problems as such do affect women at any one point time of their life and uh the problems are quite diverse the symptoms may be similar but the causes are quite varied so this means that the treatment protocol that the treatments are also quite valid so before we take our own calls and delay the thing and keep on being engulfed by the social stigma or mental barriers we should knock the door of the doctor at the right moment get diagnosed get evaluated and undergo the proper treatment to prevent a cascading series of recurrent infections and all this leads to a disturbance in the mental physical and social well-being of a female individual and hence her family her environment her work environment every wise so uh to enlighten us on this and to educate us further how to handle these patients how to develop a good patient-friendly relationship with these patients so that they open up they come up with their problems they do not hesitate and delay the entire process we have among us a very respected and esteemed doctor dr uttara is a senior consultant gynecologist and obstetrician with a vast experience of 20 years and above as you can see in front of your screen she has remained an ex-professor at afmc puna and she is also a senior teacher a pg teacher at command hospital in bangalore at the moment she's practicing in indiana in bangalore and her vast and vivid experience has enabled her to attain specialized skills especially especially around areas which are highly significant like high-risk obstetrics and something very interesting adolescent gynecology and preventive oncology stage wishing her and all women a very happy women's day today and every day thank you ma'am thank you very much dr iris uh for the great introduction so uh like mama's already told you all today uh good evening everybody good evening doctors uh today i have chosen a topic which necessarily may not come only to gynecologist but to all primary uh contact doctors because uh vaginal and vulnerable symptoms may be one of the most common symptoms that a lady may present with and so i thought that let us formulate an approach so that we there is one thing in medicine over a period of time i have realized that if we approach every disease in a systematic manner and no don't randomly treat we always have better outcomes and prevent recurrence drug resistant diseases so going further with this today we would like to know what is the normal vaginal physiology and the normal uh vaginal discharge because a lot of time 30 40 of the time a patient presenting with vaginal symptoms actually may be having just normal vaginal discharge how do we approach to the diagnosis and management of different age group when they present this age group is very important to the diagnosis you know over my period of practice i've had people referring 10 years old and 12 year old with symptoms saying oh patient has pid patient has infection so we have to see the age group and then decide what is the most likely cause then the etiology us actually speaking it's uh there are three major etiologies which we will see and the common infective causes will generally be discussing the management of those common causes treatment regimes how to how to go about it depending on the resources available to us in a syndromic approach so coming to what is the normal vaginal physiology so normally the vagina is not supposed to be dry it's supposed to be wet it has normal vaginal secretions and they consist of vulval secretions from sebaceous sweat bartholin skin glands translate from the vaginal wall exfoliated vaginal and cervical cells cervical mucus endometrial and oviductal fluid and some basic microorganisms and their metabolic products the normal commensals that are there in the vagina normally the channel situations are generally flocculated consistency white in color usually located in the dependent portion of the vagina and generally it is a mucoid clear fluid or lightly pale uh whitish it will not be associated with any other symptoms the amount may be determined by the biochemical processes and the hormonal effects so during pregnancy during higher estrogenic states mid cycle you may have excessive discharge so that may be normal normal vaginal flora is mostly aerobic and we all know that lactobacilli are important to the vaginal flora these lactobacilli break down the glycogen release lactic acid which maintains the vaginal ph to less than 4.8 normal vaginal ph is generally between 3.8 to 4.5 it maintains it below 4.5 excuse me i said 4.8 and they also have hydrogen peroxide which they produce and this hydrogen peroxide helps to destroy or you know prevent infection by other microorganisms now what is abnormal vaginal discharge abnormal vaginal discharge is obviously characterized by a change in color and consistency volume or odour of this particular normal discharge that we were talking about so it may be a slightly reddish shopping kitchen color it may be that maybe a premenstrual menstrual cause then it may be grayish in color gray color should suggest a bacterial vaginosis it may be thick white curdy cheesy appearance that is a yeast infection or fungal infection that we say generally candidiasis a yellowish green secretion should make us think of trichomonasis and a pinkish discharge maybe mid-cycle or a pink discharge persistent mid-cycle associated with other com problems like foul smell and all should make us think of other problems maybe in the menopausal age group of malignancy now it an abnormal vaginal discharge is more likely to be symptomatic than asymptomatic and generally the common problems that maybe will be itching soreness a dysuria which is typically not while passing urine but after passing urine or when the urine touches the vulva area because of the excoriations because of the erythema patient will have typically pain so generally you may miss that the patient will come and say i have pain and burning during urine so if we do not take a detailed history we may misjudge it as a urinary tract infection whereas it is actually the disuria is actually what she wants to say is that there is a burning in pain on the other hand there are some vaginal infections or stds that which may have co infection as a urinary tract infection also so the history becomes important here a pelvic pain if present should again make us think of a higher upper reproductive tract infection in the in in those cases we may have to consider pid and they also may have some form of intermediate bleeding or post fertile bleeding along with the discharge in those cases we definitely have to think of malignancy a polyp or something so that is important now important follow-up question to ask is whether the vaginal discharge is significantly altered from the woman's usual pattern that is very important a lot of time after delivery a normal thing that happens the cervix against you have something called ectopi or ectropion where a little bit of the colony epithelium is exposed and there is a little excessive discharge following delivery or paris ladies so whenever a lady says that she has excessive vaginal discharge or she has a pathological vaginal discharge it is prudent for us to see what is the type of discharge and if it is altered from her usual pattern now we all know it's one of the most common presenting symptom in uh gynopd in fact patients come with the diagnosis and say you you would have most of you would have said patient doesn't come into distress so that is the most common thing that they will say automatically now infective causes are almost 70 percent bacterial vaginosis vulgar vaginal candidiasis trichomoniasis our most common chlamydian donor may be would be there but not so easy to diagnose non-infective causes are something that a lot of us may not think of and that is why there is something we all should know about because you know visual discharge should not always be thought of as infective and specifically if somebody has recurring or you've treated and used to think so a reaction to allergen irritants are spermicides laundry hygiene products latex from condoms estrogen deficiency system especially in amino possibilities systemic diseases you know diseases connective tissue disorders are associated sometimes with vaginal symptoms after celsus so you have to think of that malignancies of course should be high on the list especially in the elderly age group retained foreign body is something you should think of and more so in the younger age group ulcerations following tampon use nowadays vaginal cups are used people you know if the size is not okay cups get stuck there is a kind of abrasion erosion to the vagina and then there is problem then lichen planus and hsv infection now coming to ecology i have like i would like to classify it as per the age group so neonatal i've just put because sometimes you'll find neonatals uh a very rare but you may have some mucinous mucoid discharge sometimes a little bit of spotting which is because especially in female units uh that is because of the effect of estrogen maternal estrogen withdrawal and okay so some amount of mucus charge would be there which is generally normal so nothing to be alarmed about childhood is something we should take care of in childhood the most common cause of discharge is only valvogenitis and mothers generally bring their child saying that the underwear has some discharge stain and we should not immediately jump to you know treatment we have to generally see what is it so then uh children may have because of the thinned thinned out hypo estrogenic state there is a mild erythema there is some smegma which may appear to people as candidiasis which may not be they are susceptible to chemical irritants because of the thin uh vulva skin the perennial skin also because of the small distance between the uh the vaginal and velvet opening the perineum and the anus a lot of time any form of perianal infection may also spread anteriorly so we have to always look at that in small kids very important is a child presenting with discharge especially basically if there is discharge always think of sex or bleeding we must always think of sexual abuse and foreign body children are very inquisitive occasionally you have cases of small toys and things being put this you have to be very careful pre-pubertal age group you will find velveitis is more than vaginitis because generally the hymen is intact and in the absence of sexual intercourse but in the absence of estrogen there is more predisposition to infections inflammation irrigate so uh if you actually think of an std you should think of a sexual cause a sexual abuse adolescence infections obviously are more common especially if they become sexually active reproductive age group vaginitis is more than valveitis and menopausal age group definitely consider malignancy rather than only infection value general conditions in childhood like i was already talking i'm just going to uh speak a little more on that so bulwark and it is is the most common uh gynecological problem of childhood like we said it is external remember that the unestrogenized vulva vestibule is mildly arithmetic and can be confused with infection smuggles magma in the interlabial sulci and beneath the clitoral produce may resemble patches of candida velveitis but it's just a little bit of the normal secretion it's not actually candida and the redness is normal so a lot of time or sometimes it's because of you know hygiene issues the underwear is not changed or it is wet a child has uh is wearing a wet underwear or has had an aberration like you know they run play cycle and then they may be local this thing so it's not always infection just because there's redness doesn't mean it's infection the vulva area is quite susceptible to chemical irritants so sometimes you know just because they're thinking that there's an infection you tend to wash extra with soap or use some kind of ointment or something which may add to the chemical irritation and one common thing i thought i'll put here which i have seen very frequently in very young kids generally is right from one year to three years of age or four years of age is labial agglutination that is the labial margins get stuck up i'll just show you a photo later and this generally occurs because of chronic inflammation inflammation it tends to adhere now the mother will come suddenly she will notice and or or if it is too much then the child will have problem in passing urine and mother will complain of dribbling she'll suddenly see it and then she'll get very worried that why is the passage blow so that's something uh you'll find uh non-sexually transmitted infections may be presenting as ulcers in the vulva region vulgar vaginal symptoms of any sort in a young child should prompt the consideration of possible sexual abuse so we must always ask about that in pre-pubertal girls inflammation and irritation are the commonest cause primary site is typically vulva in adolescence vaginitis is typically in the primary finding above vulvitis sexual abuse like i'm again and again saying should always be thought of especially in the pre-pubertal and the early adolescent age group and a persistent vaginal discharge after treatment or a discharge that is bloody or brown in color without other obvious external lesions should prompt vaginal irrigation of a gynoscopy to rule out a foreign body so how do we treat so in this figure you can see actually that there is the i i don't know if you can see it clearly there is uh if you pinch it zoom in you will find that the you will find that there is a agglutination and the probe has been passed there to show this so generally it is best to separate this under anesthesia the child will have a very traumatic experience and it can just gently with pressure be separated however following that separation you have to ensure that it doesn't um re reared here so for that uh use of topical uh uh local estrogen cream and an emollient an emollient means vaseline or normal petroleum jelly in day to day practice like we tell the parents or the ladies to just put normal petroleum jelly that keeps it lubricated prevents moisture from being there and prevents the the abrasions that occur from her day-to-day activities and from undergarments now where you suspect that there may be an infection of a general culture may be indicated you have to counsel about local hygiene vaginal irrigation may be done if you're thinking that there is some internal uh and it may also help in taking a saw and broad spectrum targeted a broad spectrum antibiotic can be started if you find that is a foul smelling discharge or you're thinking foreign body retained which is going to uh um the foul smell or the thing will uh if presence of fever or anything will tell us we start broad spectrum whenever we say broad spectrum i am sure you're all away so you have one gram positive gram negative and anaerobic coverage so generally ampy gentile is your most common thing when you say broad spectrum and then if you send the culture and something comes positive so obviously you treat accordingly in these patients a short course of local estrogen therapy helps local estrogen cream will help to prevent the thinning and the predisposition to infection and it will help in preventing reinfection now coming to adolescent vaginal conditions other than the infections you have to think of non-std related infections as well as sometimes you may have patients presenting with recurrent discharge recurrent itching you must think of volvo like in sclerosis adolescent girls who are screened for both chlamydia trachomatis and uti have high rates of concurrent disease uh especially if they have vaginal urinary symptoms they should be tested if they're especially both symptoms they should be tested for chlamydicomatase and uti these tests have been said but we don't frequently do clam idea testing because uh even a point of care test costs almost up to 1700 to 2000 rupees and we tend to empirically treat but uh however if you have a strong suspicion you should because chlamydia again has a tendency to progress to pid has long-term effect on fertility causing tubal damage and later affect the fear fertility of the patient in future this now a speculum examination where a person is sexually active or where you're very sure that there may be something called body should be advised or done unless the patient says that they're not willing for it however even if you cannot do a speculum examination a local examination is a must whenever a person presents with vaginal discharge at least a local examination you can at least examine the uh the perineum look for any signs of excoriation you can see the perianal region if there is a synov infection or any other uh skin exfoliation you may also find telltale signs of sexual abuse or trauma if you uh are worried about that as well as um uh where where it is required you will do a speculum examination so in adolescent uh conditions depending on their risk level you may have a ranging from your common diseases to anything but however the problem is in adolescence they may be scared to come up to the doctor or scared to tell anybody or at home there may be a lot of risk for self-treatment and self-treatment often is inadequate and which leads to recurrent symptoms now coming to the the main effective causes of uh the three main uh infective causes that we see when a patient has vaginal discharge which we see maximum in the reproductive age group and thereafter available vaginal candidiasis bacterial vaginosis and trichomonas so i will just speak a little more about these and how to treat these so uh while over general candidates is 80 of them most to 90 are caused by candida albicans now and candida albicans is or sometimes present as a norman commercial also it's uh but however when there uh there are certain circumstances where the ph changes or there is um uh immunocompromise or uh it tends to overgrow and that is one of the most common causes of vaginal candidiasis the most uh predominant symptom will be vulval pluritis that is itching and uh disuria which is typically perceived to be external or well-worn rather than urethral that was i was describing earlier also that means the patient will feel that there is a burning after she passes urine or while she's passing urine externally soreness irritation in case sexually wherever sexually active pain during sex dysphoronia the discharge is generally disliked described as thick curdy cheesy cottagey step of discharge normal when you examine the person you'll find that the ph is normal these uh when i summarize i'll tell you the ph is something that helps us differentiate between uh the type of infection that may be if where available see speculum examination you can see the pick here on speculum examination you will typically see these uh kerdi-type discharges which are white patches which should be adherent to the vaginal wall and if you try to remove it peel it you may find erythema below it or small bleeding punctations so that is typically uh a candidal infection and a wet mount preparation is something the best that we can do and if we do it or we put 10 potassium hydroxide we will be able to see under the microscope the yeast will be visible now well vaginal condition candidates is classified as uncomplicated and complicated depending on a sporadic infection infrequent with mild to moderate symptoms is likely to be candida albicans and it is present in immunocompetent women and it is uncomplicated now complicated is those which has recurrent symptoms and the symptoms are severe that means there is severe discharge patient has a lot of disuria pain she is uncomfortable because of intense itching and thus in complicated variety non-albicans candida may be growing now this is more common in immunocompromised ladies like diabetic women those with hiv and im those on immunosuppressive therapy and even pregnancy now when we decide for treatment in uncomplicated patients the treatment is simple you can either treat orally with a single dose of oral fluconazole tablet fluconazole tablet 150 milligrams one single tablet to be taken and you can use topical issues now topical is all like you have chloramizol uh fluke on uh micronus all you have lily cornosol if in case for external use you have these in cream and ointment forms which can be applied externally and for internally you have pessaries in the form of the candid pesticide pesticides you have micro nozzle pastries you can a patient can apply that vaginally at that time seven days and it should help now where there are the current symptoms severe non-albicans candida immunocompromised patient there you may have to give a little longer treatment so you give oral medication and sequentially repeat it after 72 hours and the topical regime has to be continued at least for 14 days now when pregnant women are there we prefer to use the topical because safety of fluconazole and pregnancy main is not been established so you prefer to use topical for at least seven days in case recurrent infections are there the current is described as four or more episodes in a year um initial induction therapy with fluconazole like we said 150 milligrams stat repeat after 72 hours for and this is for three doses followed by a maintenance flukes or therapy once per week for up to six months uh while i'm already speaking about this i can already uh some questions coming in the chat box was recurrently korea treatment of resistance type so i'll come back to it but like so here i've already said recurrent infection then you need to give the oral therapy for up to six months and recurrent is if more than four episodes in a year so this is something we should know and adjuvant therapy means that when the initially patient has severe itching and patient is very uncomfortable and what happens a lot of time because of the itching patient may end up scratching and there may be secondary infection so uh better is to give topical steroids for a short while short course like maybe uh two three days till the initial it the itching is uh reduced paretis is reduced and thereafter it should be stopped a lot of time what happens i have seen in practice is patients will you have these preparations of candid b which is you know a mixture of chlorotramazole and betamethasone and patient will buy that use it for two to three days symptoms will subside then stop using it and obviously the the the main culprit has not been treated because topical application at least for seven to 14 days should be given and then we'll have recurrence and again use the same steroid or use steroid for a longer duration and steroid will further end up thinning your uh your skin and make it more susceptible to infections further so uh this should be used with caution and only antifungal should be continued for a longer duration we should always if there is a intense erythema external probably you should uh differentiate with chronic atopic dermatitis and atrophic vulvovaginitis in menopausal ladies pregnancy and diabetes like we already said predispose to alvo general candidiosis and risk of alpha general candidacy can be reduced by avoiding unnecessary antibiotic use completing the course of treatment and not leaving it midway and it is not generally acquired through sexual intercourse so you don't necessarily have to test or treat the partner unless the partner is symptomatic a minority of male sex partners may have malinitis and they may benefit with topical antifungals so you have to ask the patient and they can accordingly get treated we should avoid anti-fungal treatment if there is no evidence of alveolar candidiasis and in case of resistant vulvogenic candidiasis there may be a role of doing a fungal culture so you have to take a slide send it for culture and find out the sensitivity this is generally for those which are highly resistant cases now coming next to bacterial vaginosis it is one of the most common type of vaginitis in women of childbearing age however it has long-term effects and it has uh and a lot of it may be asymptomatic also it represents a complex change in the vaginal flora characterized by a reduction in the concentration of the normally dominant lactobacilli and increase in the concentration of other anaerobes specifically garden elevation analysis it's associated with sql like increased risk of pelvic inflammatory disease poster bottle pelvic inflammatory disease post-operative cough infections after hysterectomy abnormal cervical cytology pregnant women and bacterial vaginosis have been found to be at increased risk for premature rupture of membranes preterm labor and delivery coriolinitis and post-therapy endometritis so um how do we diagnose this now there is something called absence criteria which is more of a clinical criteria at least three of these symptoms if they're present then we would think of actual vaginosis a fishy vaginal order which is particularly noticeable following intercourse vaginal secretions are gray and thinly coating the vaginal walls ph of these secretions is higher than 4.5 so usually 4.7 to 5.7 so one of the differential uh uh between a normal secretion and vaginosis will be that the ph will start getting higher than 4.5 now hanging drop preparation microscopy of the secretion will reveal something called clue cells so if you see this pic the normal the bottom pick is showing you normal uh leukocytes and normal cells from the cells of the vagina and on these you will find on these leukocytes you will find on the the upper peak you see that the the bacteria is attached to the borders making the water inconspicuous and these are called clue cells so these are seen in the hanging drop preparation and when you see clue cells it gives you the fact that the patient will be having bacterial vaginosis in addition to this when we make that preparation when we take the secretion when we add uh potassium hydroxide to it you will find uh it releases a fishy amine order which is called a vif test which also tells you that this may be pectile vaginosis treatment is pretty simple so we should be treating it metronidazole or flagella as we commonly know is the most uh potent treatment for it 500 milligrams twice daily taken orally for seven days you have metabolic gel which may be applied daily with generally for five days you can apply clindamycin cream and clindamycin ovules that is nowadays very commonly available clindamycin pessary it is i prefer that because uh of the most important thing is that we have better compliance because knowing maternity disorder it is the first line of treatment because of its side effects in the form of you know loss and taste metallic taste in the mouth and gi side effects so you may not have people so willingly taking oral preparations so a clinomycin pessary does help clinomycin tablet can be taken orally specifically for those who may be allergic to metabolic tinnitus all can also be used but it has to be avoided in pregnancy because it has been shown to have adverse effects in the in animal studies perioperative treatment of asymptomatic women who were to undergo uh any procedure like a hysterectomy or a mtp has been found to be you know useful it is more cost effective treating with one dose of maternal dissolve prior to surgery rather than doing a testing and seeing whether vaginosis bacterial vaginosis is there or not and then treating so that was one of the recommendations that's why whenever we do any vaginal procedure we like to cover up with metronidazole treatment of pregnant ladies reduces the risk of complications and recurrence of symptoms in 30 percent within three months and more than 50 percent experience a recurrence within 12 months so treat symptomatic relapse with a longer course of therapy using a different antibiotic for women who prefer preventive therapy instead of treatment of frequent episodes metronidazole gel for 10 days followed by twice weekly application for three to six months can be given metronome result oral therapy for a longer duration can also be given for those who are uh showing recurrent symptoms now trichomonas retinitis is uh recommenders vaginalis is a flagellated anaerobic protozoa we all know it and it is one of the only protozoa that you find it's sexually transmitted 70 contracted after single exposure it is often coexistent with bacterial vaginosis however the good thing is that the treatment for both the same so if you treat one of them the other gets treated that is metronidazole so it also has an association with the pre-term rupture of membranes and free term deliveries and post office cough cellulitis it is there is an increased risk of getting this in the presence of an hiv or other std risk factors a trichomonas comes under sexually transmitted diseases and risk factors obviously are multiple sexual partners it is seen more in lower economic status and those with history of prior stds lack of condom use it is uh that is the discharge you would see now is a profuse purulent maladras discharge which may be accompanied by vulvaritis and the discharge is typically very green yellow discharge and wherever the discharge is when you do a speculum examination when you try to remove the discharge remove it you'll find that there is a lot of erythema and inflammation along with that you'll also find something typically called strawberry cervix where there are punctate red patchy lesions on the cervix may be seen which is strawberry cervix is associated with trichomonovaginitis the ph of the vaginal secretions generally always higher than um five and the microscopy of the secretions by hanging drop will show us typically a you will find a flagellated uh protozoa will be seen in the hanging drop preparation the best thing is to make this preparation and seed within 10 minutes otherwise you will not see the motility it will like so you take a fresh vaginal secretion and make the and see it in the microscope you'll be able to see an active trichomonas uh protozoa will be seen and this is generally uh you may see a few clue cells also and viv test may be positive in this now treatment is metronome dissolved two grams orally in a single dose orton it in a single dose alternative of course 500 milligrams twice daily for seven days so we see that the treatment is almost same as bacterial vaginosis and we also know that the both coexist together but the good part is that both will be treated with one regime partner management in this case is important because it's a sexually transmitted disease so each sexual part sex partners should be treated and they should be instructed to avoid intercostal both the partners are cured otherwise reinfection will keep occurring now i don't think this is very clear you can pinch in and see if you can see it's just a summary of what we just said uh basically differentiating between the three common types where bacterial vaginosis trichomonasis and multiple candidaces based on their symptoms science the ph and the microscopy findings and need for further testing for std so we all know thin bubbly fishy order grace discharges vaginosis profuse frothy yellow green discharge should tell you trichomonasis thick white curdy discharge should think of alveolar candidaces and thick a thick curdy discharge which is greenish yellow in color should think of a mixed infection and science you will not find any signs of inflammation in bacterial vaginosis and that's why it's called vaginosis and not itis like we all know why it is inflammation trichomonasis you will find velveitis vaginitis strawberry cervix and in again you'll have velvet erythema edema and some lesions in the vagina in candidiasis itching will be intense in both trichomonasis and multivaginal candidiasis however there will be no such symptoms in bacterial vaginosis other than the discharge ph will be less than 4.5 that means the normal ph will be maintained in candidiasis however the ph will be more than 5 in trichomonasis and more than 4.5 in bacterial vaginosis and we need to test for other std specially if you have trichomoniasis and you need to do retesting after treatment the treatment as we have already discussed the same thing is summarized in this so the first regimetronic dissolve for bacteria vaginosis and trichomonasis and azoles for candidiasis and second treatment check alternate treatment clindamycin however for trichomonasis there is no alternate treatment other than metabolism so specifically when you have um metabolic resistance then of course we can try with clindamycin but there have been you know you have to really work around it right and it is all try the other thing and treat it and in severe cases where there is specifically recurrence occurring again and again so boric acid application vaginally has been found to have some help now the coming to the non-infective causes something called inflammatory vaginitis it's a disc formative inflammatory vaginitis in the clinical syndrome characterized by diffuse exudative vaginitis epithelial cell exfoliation and a profuse purulent vaginal discharge absence of normal lactobacilli they are replaced by gram positive cocci usually streptococcial and vaginal irritation and dysperunia less frequently uh vulnerable pluritis vaginal arrhythmia is present and they may be associated with ph is generally higher than 4.5 and treatment may be with two percent trinimyson cream so inflammatory vaginitis may be associated with non sexually transmitted or not some infection other than the common ones that we just saw but other than that sometimes uh connective tissue disorders or uh disc formation or uh injury which further you know gets infected may also lead to this form of inflammatory vaginitis now atrophic vaginitis is very common in post-menopausal age group and because there is a lack of estrogen the vagina becomes thinned out and then because of that they may be a burning patient may have sometimes general discharge they may have dyspareunia and this is treated with the local application of estrogen cream and generally we should first rule out an infection and any other condition before we start using the estrogen cream now sometimes the discharge may also be from the cervix and for this of course it's very important that we have done a speculum and we may find that the pyramidal discharge is coming from the endocervix or there's an endocervical discharge which which may be like mucopas now 50 of these cases may end up being gonorrhea or chlamydia and we have to test for the same and then treat treatment for gonorrhea is uh and these are all by the cdc the standard treatment protocol septrexon 250 milligrams i am in single dose or suffix in 400 milligrams in a single dose and alternate will be uh azithromycin one gram or really single dose similarly chlamydite recommenders the line of treatment is as a cycling hundred milligrams twice daily for seven days and azithromycin is second line specifically in pregnant ladies now because uh vaginal discharge is so common patients may be presenting in different kind of setups in a primary setup where you don't have things available in a treasury setup where you can do other inspections so uh then the who came up with the syndromic approach of a general discharge so the sign is discharge symptoms may be vulnerable general irritation dysphoria and the causes could be through vaginitis cervicitis so we follow a flow chart so patient comes abnormal discharge what do you do you see whether there's velvet itching burning you take a history to external examination then you check if there is lower abdominal tenderness if there is lower abdominal tenderness you treat as a case of pid now if there is vulval edema curd like discharge erythema exfoliation yes then you treat for candidiasis no then you do risk assessment risk assessment for std that means like what is the social setup what is the behavioral pattern with a periological situation if risk is there then you treat for bacterial vaginosis trichomyosis chlamydia gonococcal if no risk std risk is there then you treat only for bacterial vaginosis and trichomonasis you along with this you educate counsel uh promote the use of barrier contraception to provide a prevent reinfection and offer hiv counseling and testing if both facilities are available when you do a speculum examination and a people per vaginal bi-manual examination if you find that there is cervical motion tenderness it goes in favor of pid in case you find the same the discharge is sturdy discharge the same thing what i already said but if you find that the discharge is coming from the cervix you treat for gonococcal infection and chlamydia also now same thing again from the who manual patient complains of a general discharge you take a history you see if there is lower abdomen pain no pain then you go for pid if no pain you see whether cervical mucus burst is there or not if there then that means there is a high risk of gonorrhea or chlamydia trachomatis and if so you treat for that and if not then you put make a wet mount preparation and do gram staining when you or when you do a wet mount preparation you see motile trichomonas you see clue cells you see budding east or you see no abnormal finding in case you see no abnormal finding you educate and counsel the patient promote condom use and provide condoms and and offer a treatment if required and if you see any of these trichomonas vaginosis or candice you treat sim for that particularly so this is the same thing so if what i already said now coming to a clinical scenario now say you're alone somewhere and a lady presence with the history of discharge or she comes to you that i have vaginal discharge okay so how will we approach this patient most important is history now history of when was her last menstrual period that will help us know two things whether she is pregnant so accordingly a treatment will differ uh and causes of vaginal discharge will vary depending on pregnancy also last menstruation will tell you which part of her cycle is she in is she in the mid cycle hyper estrogenic phase so she may be having excessive discharge because of that so lmp is important then the character of the vaginal discharge you need to know what is the discharge what is the color what is the consistency is it a foul smelling is it associated with the other symptoms what is her sexual history what are the other medical and medical and drug history does she have any connective tissue disorder is she on any kind of drug which is immunosuppressant or is she having recurrent antibiotic use or recent antibiotic use which may predispose her to alveolar candidiasis what kind of contraception is she using s is for possibility of a foreign body in c2 there was any surgery instrumentation to the genital region use of tampons or depending on the age group then examination a standard practice is to do a vaginal and a speculum examination we should try not to avoid it is very common practice patient comes with the general discharge without anything we just write a kit uh you know you'll find in periphery these are these now they were in between they were marketed a lot uh kits which contain uh one one tablet of fluconazole 150 two tablets of azithromycin which amount to one gram of acetomycin and secondary dissolved two grams so fast kit or you had a microphone four kit which had fluconazole or on a dissolve and azithromycin so all these kids you know they were very um nowadays you will find again that the use has gone down but otherwise like patient comes with discharge without doing anything else for the patient the kit was just prescribed and the thing is whenever we do a over treatment or we treat without knowing what we're treating we may end up with a resistant or a recurrent disease so it's best to do a vaginal and specula examination unless of course the lady refuses or is she she is not fit candidate like sexually not active you would not want to do a speculum examination but you would still like to do a local examination to see others telltale signs and the type of secretion now ideally wherever available a microscopy should be done and we can make uh take take with a swap the vaginal secretion and place it in a drop of saline on a slide and see it under the microscope and we would get a good picture but if sometimes if not available we may be able to have point of care test kits but even if that is not available another very commonly and not so expensive method is a ph testing so you have these self ph testing kits where with the swap you can take the secretion and then along with the solution you mix it and then you put it on the thick card and you'll know what is the ph so if it is normal ph then other than a fungal infection you are not thinking of anything else so you would not unnecessarily treat with antibiotic in that case where uh infection foul smell is there you will definitely take a vaginal soft for culture and microscopy fever lower abdomen pain and tenderness mucopillon cervicitis cervical exertion then upper genital pathology suspected and she should be referred to a higher center or a gynecologist specifically after starting a broad spectrum antibiotic or as per pid regime now the main risk factor for sexually transmitted diseases are age less than 25 a new partner in last three months two or more partners in the last six months non-use of barrier contraceptives and symptoms of std in the partner so if any of these high risk symptoms are present then we have to obviously think of doing std testing for these patients also that means testing for gonorrhea syphilis and chlamydia now treatment obviously as per the finding that we get we already discussed the things so depending on whether we're suspecting bacterial vaginosis trichomoniasis candidiasis or all three we will do the treatment accordingly now std testing especially as i said in high risk you do and when should you refer to a gynecologist if there is a history of recent instrument instrumentation or surgery to the genital tract and the patient comes with discharge or these kind of symptoms you should definitely refer them to a gynecologist retained foreign body cervical ectopia or polyp or suspicion of tumor or malignancy and examination you should refer to a gynecologist if a woman with symptoms of upper genital tract infection recurrent infection or vulva general candidiasis is recurrent pregnant women with abnormal vaginal discharge and women who have failed routine treatment strategies that means you have you have diagnosed as per your all the abilities you have treated the patient but the patient has not responded then they should be referred to a gynecologist or to a higher center where cultures can be done and we can find now point of care testing just i made a summary of what we said so there are some these ph testing kits are available i think this is 149 rupees and you can test the ph as this is even home testing can be done you have rapid antigen testing kits for chlamydia syphilis syphilis is in blood and chlamydia and gonorrhea and the vaginal stops these vaginal swap are mixed with the reagent and then the solution is placed in the card and if it is positive you'll get to know and you have wet mount microscopy so if microscopy available but uh the fact of the matter is that we all work in a lot of times in such busy setups or if not so busy in such a primary setup that we may not have access to all of these but yes a speculum examination we should definitely have an access to it or at least try and have an access to it uh even if you don't have a speculum examination then a ph testing with a swap will help us at least to do the right treatment uh this is not a clear slide but it it a study was done in sri lanka and they for the primary setup you know they made a chart and with the common pictures and the a common questionnaire and the common diagnosis so it was easy for the periphery person so again if you pinch you'll find that vaginal discharge physiological what are the causes non-physiological what is it non-infective sexually transmitted and you will find the different types of discharges so in a periphery at least when the person is seeing or taking the history they will be able to come to most common cause out of all these so at the end of this i'd like to say that what we have realized today is that it is a common cause for vulvogenic conditions and discharge however a proper history and examination is very important it can help us reach a diagnosis and go for treatment in a systematic manner knowledge of the probable causes in different age groups is important because often we tend to just eat with antibiotics when it may actually be erosive or a local inflammatory cause in younger age groups and it may not be the fung antifungals unnecessarily should not be given to the patient when actually it may be a local bacterial infection or just excoriations these combined kids should be used judiciously unless you're thinking of a mixed infection they should not be used a syndromic approach is practical especially in low resource settings it is effective and affordable and may help in treating simple vaginal infection but they are not effective in covering asymptomatic women or covering uh they may end up over treating at times so we have to be careful so you cannot keep repeating you know what happens once you've given this uh a syndromic approach fine but if this patient really reports back to you with the same symptoms you cannot just again repeat the same treatment that's what happens very frequently that is when you have to do it again an evaluation check what it is and we will get to know so i have finished presenting uh i'm i would take your questions now mom uh thank you very much it was a very detailed and very informative session and uh it really gave us the comprehensive picture and a snapshot like how to approach that's a very basic thing i mean like any other clinical scenario taking a detailed history and evaluating before jumping to the treatment because many times it happens you know uh the patient comes and we start giving cloture muscle we start giving fluconazole and we start giving a steroid cream also because the patient is an utter discomfort due to itching and other conditions so you actually showed us a correct pathway how to approach the patient take the proper history and evaluate and approach age-wise that was very interesting that different age groups with these symptoms can you know give us to the leading diagnosis uh quickly you know and secondly with the very cost-effective point of testing because there are questions here in the you know comment box where people are saying that your doctors are saying that sometimes as you said ma'am in the primary health center we do not have all the state-of-the-art facility all the you know things at our disposal and especially sometimes uh money being a constraint i mean you know this economic uh keeping in mind the economic benefit so i think cost effectiveness of that ph testing you said rupees 49 i think something for you know for 149 149 kit is there yeah but it's still looking so less than 4.5 you go to these two diagnosis more than 4.5 along with the type color consistency age group history and are pregnant so you get a clear picture and you can guide your patients to a directed treatment quickly and how to treat resistant cases you know any immunocompetent individuals or otherwise you know that was also very nicely and more important is you need to know when you it is out of your you know first line treatment is definitely fine people have to know when they should stop treating and send to a higher center or another gynecologist or you know that you know there's something else that has to be done a culture has to be done or a swab has to be taken you know you cannot just keep repeating the same treatment yeah because that might have some side effects and adverse effects and that might not yield up in a potentially profitable i mean productive outcome also uh so ma'am we have some uh questions uh yeah i can see lot of questions yes ma'am they have said it's an excellent presentation which i also share i do agree it was so informative uh so uh regarding the questions ma'am uh dr jayadeep majumdar uh madam is in is it a good practice to refer to all uh patients to gynecologist for a better management what will be your suggestion in this case so um see i delete every patient but see if the patient has first come to you if you have the facility to do any of these immediate testing like a speculum examination or anything then it's you can do the first line treatment but if you think it's not possible or you think that the patient falls under any of the high risk groups high risk for std high risk for sexual abuse younger patient uh least you can do is at least a local examination but if you feel that it may be something more than that then it's better to and you have a gynecologist available okay so then you can definitely so it depends on where you are placed and how you are if a gynecologist is available definitely gynecologist will be more comfortable doing a speculum examination and doing it but uh like from my experience being in the armed forces i know there are so many of my colleagues youngsters who are sitting in places where they do not have an 150 kilometers away is the nearest ghana gynecologist so maybe further off so at least you cannot let the lady you know suffer or keep having her symptoms so at least you take the systematic approach so you can at least give her the first line treatment the and by just an external examination or if even if you don't do a speculum or a swap or you know just examine her undergarments for the type of secretion of the color of secretion you may at least be able to give her a first line of treatment and it's good to go one step at a time you know no right and then yeah exactly ma'am because uh many which is of india is a big country and we have diverse socio-economic beliefs cultural beliefs and people don't come first of all to the doctor at the right time okay and there's there's something that you know maybe some other senior gynecologist may not always agree with me but over my practice uh for some time i have seen that there is this uh crindamycin and chloramazole combination of pessary that is available so where you find there's a mixed discharge and you're not sure uh you know like we said metronome dissolved treats anyway both both these two conditions vaginosis and trichomonasis and clindamycin is the substitute for that and chloramine is all for uh candidates so where you think that there is a kerdi discharge you give the you give the pessary that has clindamycin and protramozole and if you find that there's no kerdi discharge but only itching or false smelling discharge you can give the kinder mess and pastry at least as a first line and you will find that the compliance to it is more because it doesn't have to be taken overly or it is not going to you know cause any oral systemic side effects so patients are more comfortable taking it so there's a lot of good comments ma'am dr sanjay singh says thank you ma'am for the very nice and informative lecture doctor if thanks ma'am uh dr gaurav das has a comment he's saying by speculum first and then treatment to be given so he will follow uh he would like to go with the speculum first examination and then yeah definitely speculum first you see if you're a gynecologist hundred percent speculum first hundred percent because a gynecologist practicing will have a speculum available so that is the least that you can do because you you as you have seen it the picture is obvious you know you will see kerdi discharge you will see that greenish discharge and trichomonasis you you'll see great discharge in bacterial vaginosis so even if you don't have all the other tests you will more or less with your smell and this thing you'll be able to give the correct treatment so definitely speculum would be a if available would be a good idea yeah that would be ideal uh yeah uh dr uh shivaji uh gamet gamet in which patients or females uh yeah ps examination should be avoided so generally uh speculum examination you would avoid in person who has an intact hymen that we are who's not sexually active and again when a person is not sexually active then the chances of sexually transmitted diseases are much rarer so you're not thinking of a cervical discharge or a deep adrenal discharge those patients are more likely to be having an external cause or more of alvinitis remember that so i of course those who are using tampons vaginal cups and all may have so you have to see and of course patient consent without that you cannot but you with generally just local examination gentle you will be able to see the outer vagina what it is and if you're suspecting something more then you will have to convince the patient or there is something called vaginoscopy that is done you know like your like a histoscope is there then you can put it into the so you have office this thing so it's it's less dramatic than anything but of course it's a larger procedure you'll irrigate the vagina and put the scope you can see for lesions but that is again it's only industry setups now you won't have a general vaginoscopy there is one question uh somebody has written the 20 year old unmarried female with profuse water the next question let me go to it now uh the next question is by doctor shruta vitti chennai and she wants to know uh how do you treat lichen sclerosis okay so like is ketosis and autoimmune disease so steroid is the main line of treatment and you have to be uh sure of the diagnosis you can do a skin reference dermatological referral you can do a skin biopsy and confirm if required and the typical the peas that you have in a purple pruritic so um that is for like sclerosis and then steroid topical steroids is the main line of treatment and you see the response yeah being a lichen sclerosis the topical steroids will be the first line of treatment yeah yeah um i'm coming back to the 20 year old question dr nancy r she says 20 year old unmarried female with uh one minute ma'am with profuse watery uh vaginal discharge with loss of weight with regular menstrual cycle what would be the management strategy ma'am in this case yeah so uh we will not go only by the unmarried part of it we have to see whether sexually active or not loss of weight is something uh see not uh just profuse vaginal discharge watery so is it uh is it foul smelling is it associated with itching or anything else uh there is something you know um such patients you may want to do an ultrasound abdomen so there are conditions in which uh you know she's a uh you make end up um like a collection some people have cervical stenosis something there may be a collection hydro the uterus inside the uterine cavity they may be fluid collected or discharged collected so that and weight loss is there tuberculosis so it's something an overall picture but more important it's where systemic effects are there like weight loss and um you know then you have to think of a systemic disease like tuberculosis a mere vaginal discharge will not cause that or something that has a systemic so you have to gen definitely evaluate systematically and hydrometer and that is uh fluid collection sometimes cervical steroids the normal secretions get collected but since she has regular menstrual cycles so that may may not be the thing profuse watery discharge again the history you know sometimes very ovulatory you have that uh discharge but if somebody is actually active and there is a cervicitis or cervical ectropion then also there is a what we discharge so uh a detailed evaluation is required in this page person and uh sexual history is also important and the history and the history also will give us good leads has posted the question earlier also so ma'am what is the mechanism by which hypo because you said in the beginning yeah yeah he's trojan withdrawal can lead to uh discharge so how come or what is the mechanism by which hypo estrogenism causes increased discharge since generally lack of estrogen makes a discharge quite quicker and less profuse could you please i i i think she misunderstood me i said hyper estrogenic states there will be increased discharge like pregnancy pose uh period tree that time there will be increased discharge so that is the hyper estrogenic states will cause more discharge and hypo estrogenic states are the ones like peri-menopausal or in people or young children where because of the um thinning of the uh in the absence of estrogen the mucosa as well as the skin and all become thin and they're more prone to injury abrasions and infections so that's of course yeah ma'am dr meghashinoy asks that we are recommending sometimes estrogen creams topically so what is the dosage and duration and is there any contraindication if so what are the contraindications yeah so so yes it's um yeah it's very important like i said whenever we start an estrogen cream we have to see few things that see in a young child say when i said you use topical estrogen in a case of labial fusion or in young children who are getting typically so that there we are using locally only for uh increasing the uh improving the skin health and the mucosal health so that the recurrent explorations are not taking place so there it is a short pose for say a month 15 days to one month and then followed by emollient so there we don't have to worry much about any contraindications but where we talk of atrophic vaginitis in the elderly age group where we are thinking of post menopausal ladies which require tropical estrogen therapy now these ladies before we add on estrogen we need to rule out uh estrogen sensitive tumors if any so like she should not have post menopausal bleeding she should not be in have a risk of endometrial hyperplasia so maybe we would want to do an endometrial thickness evaluation by ultrasound before prescribing a local estrogen cream secondly we would rule out any other infection other than that nothing to worry one gram of estrogen cream applied at bedtime every day so um generally as a as a rude when you say one pulp of your finger is generally approximately one gram so the patient they generally have applicators but applicators patients tend to injure themselves so you can use that and they can apply liberally inside at bedtime initially she should apply say every night for 15 days and following that you'll find that she is feeling already better then she can reduce the frequency but sometimes these two firms there is atrophic vaginitis that is because obviously or post menopausal the estrogen is not going to come from anywhere so then she can probably infrequently once or twice a week apply otherwise she'll again have in the absence of that but uh anybody who's on topical estrogen uh would have to be careful in case of any spotting bleeding then we have to look for any other especially if the uterus is inside there but this low doses uh vaginally generally would not lead to any to any kind of a major risk um i think doctor anjali dubai man is asking the next question i think this is partly answered but even though i'll go through it what should be the further approach uh to what should be the further approach to diagnose if trichomonas is seen in a urine microscopy and it's sometimes seen in with microscopy so what would we do yes approach such cases so same thing see you'll have to once you find it in the urine you'll also do a vaginal examination to see that and take a vaginal swab and check it also because generally they say that just based on the urine do not read but however you know ultimately if it is there in the urine it has come from the vagina also a likelihood so you should go ahead and treat but if you go by the books it will say that if you find it in the urine you should also do a general examination do a speculum examination take away channel swab see it in the vagina also and then treat so ultimately trichomoniasis treatment is metronome dissolved so you will have to treat with veterinary use uh the role of estrogen gel in labial adhesion uh well that's what i'd already actually had already told that so when we separate it's the main thing is again chronic inflammation because of the thinning of the labia because of the hypo estrogenic state right so uh for regeneration of the epithelium the endometrium helps so uh so estrogen helps sorry so that is why once you separate there is still raw area so by putting the estrogen you are kind of improving this uh the skin there the epithelial regeneration is taking place for a short course or 15 days you apply then it becomes okay and then further you just always use an emollient so that there is less chances of abrasions and re-adhesions so ma'am what i understood is only if there is a recurrence under resistant cases we should go for the long term things everywhere it is a small course and then follow up and then give emotions yeah that's what uh to avoid other you know side effects on the on the you know there is something um that we all uh should be generally advise our patients most people you would realize tend to use a lot of uh powder uh to you know prevent uh the people generally say okay moisture is there let's use a powder if there's a problem let's use powder but you will realize that if even even like if you see for diaper rash from newborns onwards for children so uh locally if you use emollients like petroleum jelly simple vaseline it it prevents it forms and you know when once you clean say after the bath for a child also even for uh other people so uh even those you know those who have local aberration additions uh because of pads men's at the time of menstruation uh petroleum jelly vaseline is very effective it forms a coating over the thing okay so then the moisture from the pad or the moisture from the undergarment or the moisture from sweat does not go to your skin and does not allow the abrasion it also forms like a layer to prevent this uh abrasions from your irritate local irritants like your skin and everything so so oh it's like kind of a myth people would say don't use it it's all you know so even if you sweat so for those who are athletic or those who go to the gym or you know run for them also using vaseline liberally before they go because then the sweating is there they will be chafing erosion local then secondarily there may be infection because of the abrasions and erosions thank you one question that i just said what's the role of robomycin uh robomyosin is not has does not have any role in the treatment of a general discharge it's a treatment for toxoplasmosis and we don't generally use it right so doctor you must have got the answer i was just following two comments ma'am we have covered so i guess but okay yeah we can wrap up the session and if i can see lot of thank you great session and it is fantastic thanks a lot uh there is one uh from dr just now uh if you could if you want to take up yeah the treatment of recurrent uti in post-menopausal okay so the most important is a lot of time post-menopausal ladies just because of the symptoms suggestive of uti treated recurrently for uti number one we must definitely have a culture proven uti to be treating and if the culture is suggesting obviously then we have to go ahead and treat for the specific uh organism as per the culture sensitivity secondly uh postmenopausal ladies are prone to utis again because of the same thing the thinning of the vagina the predisposition because of the hypoestrogenic state so sometimes local treatment with estrogen to the vagina for atrophic vaginitis helps in treatment of recurrent uti also again considering the age group in postmenopausal ladies they if you have to rule out other problems like diabetes any person with recurrent uti you have to rule out diabetes and ensure that and their local habits right uh recurring bacterial vaginas is that which the point you have covered in your presentation but if you want to just so same thing you know ensure the treatment is complete and if the recurrence is after say three months then you use the same regime but if you find that it's more like a treatment failure you've treated and still the patient is symptomatic or within a week the patient is symptomatic or in a short period two weeks three weeks patient symptomatic again then you have to see if i is your diagnosis correct or is there some other treat or is there some associated other infection or is it antibiotic resistant or you have to change so if you treat it with metronidazole the first time you treat with clindamycin or you add in a dissolve and then you may have to correct the ph yeah so not relevant to thank you mom for the answer or not relevant to the session but uh there is one interesting question uh role of calcium and associated drugs uh in post-menopausal so a lot of women suffer from arthritis and problems like that but with the pharmacological thing that calcium can change yeah so calcium supplement and vitamin d3 supplements are important because of and but and dietary supplements also so that'll require so yeah postmenopausal ladies require calcium but you know you realize it's very easy to prescribe medicines very difficult to take them ourselves and all doctors here in the group will agree that doctors make the worst patients so when you start taking treatment yourself you realize that it's not easy to eat a calcium morning evening every day so you have to basically tell a person you know i generally tell my patients which is obviously not evidence based or anything but it is more of common sense i tell them on your breakfast table keep a calcium supplement or a multivitamin supplement and at least once a day have one supplement you don't have to have calcium every day increase a little bit of your milk or milk products dairy products fruits in your diet which are calcium rich fruits calcium-rich foods in your diet and at least have a supplement once a day and more than any of the supplements what is important for bone health why do we give calcium is for bone health but what is the most important for bone health is exercise weight bearing exercise so whether you take supplement or not you please do weight bearing exercise all post menopausal ladies that's the only way you can prevent osteoporosis you can take all the calcium you want and not do exercise you will still have osteoporosis because weight bearing exercise is something that is going to prevent osteoporosis nothing else perfect yeah that also they'll have to set in the routine uh if it is a doctor because then that it actually doesn't get set like so so i think by the time doctors reach that age group they should reduce their workload and concentrate more on their own health i am trying to do that so i hope others also do that yeah thank you mom thank you for this wonderful advice and thank you for the session

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dr. Uttara  AiyerKohli

Dr. Uttara AiyerKohli

Senior Consultant Gynecologist | Ex- Professor AFMC, Pune

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dr. Uttara  AiyerKohli

Dr. Uttara AiyerKohli

Senior Consultant Gynecologist | Ex- Professo...

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