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    Recurrent vulvovaginitis: Tips for treating a common condition



    A variety of oral and topical preparations are available for treatment of uncomplicated yeast infections (Table 4). These are appropriate if the infections are infrequent, symptoms are mild-moderate, the infection is likely C. albicans, and the patient is not pregnant. An uncomplicated yeast infection can be treated with either oral or topical therapy. Studies show comparable cure rates for oral and topical agents with equal relief of symptoms and a negative post-treatment culture in 80% to 90% of patients.18


    Patients seem to prefer oral dosing for convenience, however, time to relief of symptoms may be slightly longer. Topical treatments tend to have fewer side effects. These factors support using patient preference and cost to guide treatment decisions.

    Many of the medications used are over-the-counter and these can be effective methods of treatment, especially in uncomplicated infections. Guidelines from the Centers for Disease Control and Prevention are a good resource on first-line therapies for vulvovaginal candidiasis.

    Complicated yeast infections are defined as recurrent infections, oc currence in immunocompromised patient, severe symptoms, occurrence in pregnant patients, or non-albicans species. These patients may be appropriate candidates for extended dosing of topical therapies or repeated oral doses. When a patient has more than 4 episodes of vulvovaginal candidiasis in a year, a more thorough examination of risk factors should be done.22

    Women should be advised to eliminate all contact irritants, douching, and products that have allergens. Vulvar skin care guidelines should be implemented. A test of cure should be done after the treatment to ensure eradication. If the culture is positive after initial treatment, prolonged therapy is indicated in the symptomatic patient. A culture has been recommended in the case of recurrence to isolate the yeast strain for appropriate therapies. Non-albicans strains like C. glabrata may require the use of gentian violet or boric acid to treat.23 When a patient has had recurrence or is at high risk of recurrence, maintenance therapy may be reasonable. Weekly fluconazole has been shown to be effective in preventing recurrence but care should be taken with extended use due to possible liver complications. Maintenance therapy has been shown to reduce the risk of recurrence at both 6 months and 1 year.24 Vaginal therapies have few risks other than burning and irritation.25

    Oral therapy, especially ketoconazole and itraoconazole, may have other drug interactions and may affect liver function. Fluconazole appears to have a better safety profile and its use does not automatically require laboratory monitoring. Data are lacking on use of probiotics. More studies are needed to demonstrate improvement and to direct dosing and route of administration.19

    The question of treating sexual partners is somewhat controversial. If reinfection seems to be linked directly to sexual exposure, evaluation of the partner may be warranted and if no overt infection exists, a culture of oral or ejaculate specimens can be done.19 Recurrent yeast infections also tend to recur once suppressive therapy has been stopped. The rate may be as high as 30% to 40%. When that occurs, treatment may need to be episodic to prevent recurrences.

    Because there is concern about fluconazole-resistant Candida, new therapeutic options are needed.17 Several non-conventional options for recurrent vulvovaginal candidiasis exist including lactobacillus and tea tree oil, which have potential but study of them may be difficult due to dosing and administration constraints.26


    Merida Miller, MD
    Dr. Miller is Associate Professor of Obstetrics and Gynecology, University of Iowa, Iowa City.


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    • Dr. Neil S. Gladstone
      I appreciated Dr. Miller's discussion of a common and vexing problems for both patients and clinicians. For 45 years, I have seen more unhappy patients with BV than any other condition including malignancies. At least with cancer, there is hope of a cure. With BV it never goes away. The two most important tools for the clinician in diagnosis BV are pH paper and a microscope. After the history, which is predictable, and after my vaginal exam. I do a pH on the discharge taken from the upper aspects of the vagina. The pH helps to direct what comes next. If the pH is in the acidic range the differential diagnosis is either Candida (yeast) or leucorrhea. If the patient presents with a history suggestive of yeast and she has a "Typical" cottage cheese discharge, and we are not dealing with multiple recurrences, I elect to treat with either topical or oral agents. For problem cases I will use a NAAT testing procedure. If the pH is in the alkaline range, I do a wet smear. If there is no evidence of Trichomands and with presence of Clue Cells, I make the diagnosis of BV. My treatment is two fold: I take the time needed to explain to the patient what are the triggers for BV, that the bacteria that cause the BV symptoms are residents of the vagina and can not be totally eliminated, and the change in pH temporarily eliminates the beneficial action of Lactobacillus. In this environment it is the anaerobes that were listed in the article that predominate. I encourage all patients to use condoms at all times and to use tampons to get rid of menstrual blood as quickly as possible. Instead of continually prescribing Metronidazole or Clindamycin orally, I use Boric acid vaginal suppositories 600 mg for at least one week. Patients do not like the topical antibiotics as the perception these measures do not work. They are unhappy because the oral antibiotics do not work because the "infection" keeps reoccurring, I never reference BV as a STI,but I also talk about keeping the environment of the vagina healthy by keeping out the offending substances and restoring the pH. The suppositories help with Candida as well. One part of therapy most clinicians especially non OBGYNS fail to do is to use a steroid and antifungal topical combination for the skin of the vulva. This maneuver provides relief for the irritated itchy skin. Each patient gets a written information about BV and I always offer to discuss the diagnosis with reluctant partners. This approach is not the panacea for BV , but I think it is more successful than the manner most people treat BV.This is anecdotal information, but I think it would merit someone with the time and patients to do a RCT. Also, I am very liberal in ordering STI panels including the use of NAAT panels. Neil S Gladstone, MD, FACOG,CCD


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