polypi there is increased secretion of mucus from the cervix, sometim with a little bleeding. Early cervical cancer may cause postcoital bleedin but advanced cancer will give rise to offensive, purulent and blood-stain discharge.

The menopausal patient

After the cessation of menstruation slow atrophy occurs in the vulva an vagina. There is thinning of the vulval and vaginal epithelium, loss 0 glycogen in the vaginal epithelial cells and a fall in acidity. Local resistan to infection is further diminished by the reduced blood supply.

Atrophic vaginitis

Vaginitis in postmenopausal women was formerly termed senile vaginif but the term atrophic vaginitis is preferable. It is not due to any specifi organism. The patient complains of a profuse purulent and sometim blood-stained discharge, which produces discomfort and soreness at vulva. The vaginal walls are inflamed. There may also be atrophic end metritis and if this occurs discharge will be seen coming from the cervix. vaginitis has been present for some time, desquamation of the epitheli of the vagina may lead to the formation of bands and adhesions.

1 t is important to remember that this condition can be accompanied malignant disease of the uterus. If the slightest doubt exists -for inst

if there is bleeding or improvement does not rapidly follow treatment diagnostic curettage must be performed.

Treatment

When malignant disease has been excluded as a cause of the discharge, vaginitis is treated with oestrogens such as ethinyloestradiol 0.01 mg mouth twice a day for 14 days. Rapid regeneration of the epithelium of vagina and an increase in blood supply are to be expected, but unfortuna endometrial bleeding may also occur. Unless this is of short duration not recurrent, diagnostic curettage must be performed. The possibility bleeding may be reduced, but not entirely eliminated, by administe the oestrogen in the form of pessaries or creams which act locally on vaginal epithelium.

Vulvovaginitis in childhood

Because vaginitis in children is usually accompanied by secondary vui . the term vulvovaginitis is often used. Protection of the non-oestroge . vagina by the hymen is usually effective, but infection may occur result of poor hygiene, of insertion of a foreign body by the child, or sexual interference. A few instances of streptococcal infection appear be associated with infections of the throat or scarlatina. Candidiasis trichomoniasis are uncommon, but infection may be carried from an a if the family standard of hygiene is poor. Gonococcal infection may 0

Vaginitis and vaginal discharge 113

The child usually complains of soreness and discomfort on micturition. The vulval skin is reddened, and discharge may be evident; but sometimes the 'discharge' is only a slight stain on clothing noticed by an anxious mother -she, rather than the child, may require reassurance. A copious purulent discharge suggests the presence of a foreign body. Anal thread- worms may cause pruritus and scratching.

Advice on hygiene may be necessary. The vulval region should be bathed daily, but irritant antiseptics should not be added to the water, and care must be taken to rinse out detergents from clothing. It is seldom necessary to give an anaesthetic for examination; a small wire loop or pipette may be passed into the vagina to obtain discharge for bacteriological examination. A foreign body may be felt by rectal examination, or possibly seen with the aid of a small nasal speculum. Oestrogens may be tried (ethinyloestradiol 5 micrograms daily by mouth for a small child) or dienoestrol cream locally before any more thorough investigation. Tri- chomoniasis is treated with oral metronidazole but with half the adult dose. Candidiasis is treated with oral nystatin suspension (400 000 units

three times daily).

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