“Last hope” to end recurrent infections
Sandra, 46, makes an appointment to discuss her recurrent vaginal infections. In the past year, she has had numerous episodes of itching, burning, and abnormal discharge and has used “everything” to treat them. She has tried an array of antifungal and antibiotic preparations, but has experienced only transient relief. She says you are her last hope to break the cycle of recurrent infections.
How do you respond?
Although vaginitis is usually considered a minor nuisance, many women experience chronic symptoms that persist or recur after treatment. For patients such as Sandra, chronic vaginitis is a constant source of frustration and a serious threat to quality of life.
Careful diagnosis is the first and most important step to eradicate vaginitis, and this article describes the essential components—as well as common pitfalls. In some cases, high-dose therapy or maintenance regimens may be indicated; these strategies are also described in detail.
The usual suspects
Vaginitis is defined as inflammation of the vagina marked by pain, itching, and/or a purulent discharge. Depending on the population, the most common causes of infectious vaginitis are:
- bacterial vaginosis (BV) (22%–50% of symptomatic women),
- vulvovaginal candidiasis (VVC) (17%–39%), and
- trichomoniasis (4%–35%).1
However, vaginitis in 7% to 72% of women remains undiagnosed.1 Their symptoms may be caused by atrophic vaginitis, vulvar dermatological conditions, vulvodynia, or other entities.
The hazards of self-diagnosis
Although a wide range of pathogens can cause vaginitis and symptoms are often nonspecific, the trend in the past decade has been for women to diagnose and treat themselves for VVC. The reasons: availability of over-the-counter (OTC) antifungals, ability to rapidly initiate antimycotic therapy, empowerment of women, and the likelihood of reducing direct and indirect healthcare costs.2
Unfortunately, recent studies suggest that self-diagnosis may not be as beneficial as we thought. Ferris and colleagues3 studied 601 women in a variety of medical and community sites in Georgia and found that only 11% without and 34.5% with a prior diagnosis of VVC could accurately recognize it or bacterial vaginosis.
A later prospective study4 of 95 symptomatic women purchasing OTC antifungal agents found that only 34% had pure VVC; treatment with a topical antifungal would have been inappropriate or inadequate in the rest, many of whom had bacterial vaginosis.
A more recent longitudinal study5 of women who submitted yeast cultures every 4 months for a year found no correlation between antecedent Candida colonization and subsequent antifungal use.
Avoid telephone diagnosis, too. Although telephone conversations are useful for patient triage and treatment in many clinical situations, diagnosis of vaginal symptoms by telephone correlates poorly with the actual diagnosis.6
If it’s really VVC, it should respond to antifungals. Over-the-counter antifungals are as effective as their prescription counterparts, so women with VVC should respond to OTC therapy. If a woman reports a lack of response, question the initial diagnosis and offer a thorough evaluation instead of recommending further treatment as the initial step.
Even the pros can be wrong
In a review of 52 medical records of women referred to a tertiary-care vaginitis center, Wiesenfeld and Macio7 found that vaginal pH testing was performed at only 3% of office visits and that 42% of referring physicians failed to perform microscopy as part of their evaluation.
In a study of 61 women diagnosed with VVC after clinical examination and microscopy in a university-based outpatient gynecology clinic, Ledger et al8 found that 49% had a negative yeast culture and polymerase chain reaction.
Office-based tests, even when they are performed in the best of circumstances by personnel focused on vaginal symptoms, have relatively low sensitivity: 92% for bacterial vaginosis, 62% for Trichomonas, and a mere 22% for yeast.9
The right test matters
Given the nonspecific nature of vulvovaginal symptoms and the limitations of office-based testing, a few tests are nevertheless useful for patients with chronic symptoms or an unclear diagnosis.
Yeast cultures. When VVC is suspected, cultures increase sensitivity and allow for speciation of the organism. Speciation is crucial to choosing the proper antifungal drug.