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    Recurrent vulvovaginitis: Tips for treating a common condition

     

    Summary

    Both BV and vulvovaginal candidiasis are infections that are seen daily by most ob/gyns. It is important to recognize that many of the presenting symptoms overlap with one another and with other disease entities. Not all that itches is yeast. Clinicians must ensure that the diagnosis is correct through appropriate testing and examinations. Addressing other systemic comorbidities and giving appropriate counseling regarding contact irritants is time-consuming but necessary for proper therapy.

    Prompt evaluation and treatment can help resolve symptoms and ensure a correct diagnosis. Both infections, however, can pose a challenge to clinicians with their propensity to recur. Patient education about risk factors and identification of an appropriate treatment regimen are crucial to curing these problems.

    More data are needed on non-medicinal therapies aimed at prevention to minimize exposure to medications and improve the quality of life of affected women.

     

    References

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    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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