CHAPTER 16 Vaginal Health
During the reproductive years of a woman’s life, yeast infections are a common cause of vaginitis. One study estimated that by age 25, more than half of all college women will have had at least one episode of vulvovaginal candidiasis (VVC).1 Other researchers estimate that 75% of all women will experience at least one episode of VVC in their lifetimes and that 40% to 45% will have two or more episodes.2 Generally, yeasts are present as commensal organisms that proliferate when changes in the vaginal environment become conducive to their growth. Candida albicans is the species most abundant in the vagina; however, C. glabrata, C. tropicalis, C. krusei, and C. pseudotropicalis are often present.3 The blastospore and germinated hyphae are the two forms of C. albicans that infect the vagina. The blastospore attaches to the surface epithelial cells, whereas the hyphae invade the superficial layers of the vaginal epithelium, resulting in symptomatic vaginitis (Box 16-1).4
Box 16-1 Risk factors for vaginal candidiasis
Broad-spectrum antibiotics (penicillins, cephalosporins, tetracyclines)
Increased vaginal glycogen (pregnancy, high-dose oral contraceptives, diabetes mellitus)
Altered host immunity (acquired immunodeficiency syndrome, immunosuppressive drug therapy)
Local factors (increased vaginal warmth or moisture)
Increased urinary sugar (diabetes, excessive ingestion of dairy products and sucrose)
ORIGIN OF INFECTION
Many factors contribute to the proliferation of vaginal yeast. The use of broad-spectrum antibiotics reduces the number of beneficial lactobacilli in the vagina, yielding a favorable environment for the growth of Candida species.4 Pregnancy, diabetes, and high-dose oral contraceptives can all increase the vaginal level of glycogen, which has been associated with an increased number of vaginal infections. High levels of estrogen directly stimulate the growth of yeast; a cytosolic receptor for estrogen has been found within Candida species.5 Estrogen stimulates the germination of yeasts in vitro. Women may experience an increased incidence of vaginal yeast infections during the luteal phase of the menstrual cycle and pregnancy because of alterations in cell-mediated immunity. Individuals who are immunocompromised (as a result of medication or illness) are also at increased risk. Some researchers believe that sexual transmission plays a part in recurrent VVC (RVVC).6 It is not known whether treating the sexual partners of women with RVVC would reduce the rate of recurrence.
DIAGNOSIS
If a woman is having recurrent yeast infections (four or more infections in 1 year) a more complete evaluation is necessary to eliminate secondary causes (Box 16-2).
TREATMENT
Topical Antifungal Agents
Topical antifungal creams and suppositories that contain polyenes or imidazoles are the mainstay of treatment for VVC. The topical azole agents have been shown to be effective against C. albicans in vitro and are only minimally absorbed into the systemic circulation (Box 16-3).
Box 16-3 CDC 2002 guidelines for the treatment of sexually transmitted diseases: implications for women’s health care11
INTRAVAGINAL AGENTS FOR UNCOMPLICATED VVC
Butoconazole 2% cream or 5 g intravaginally for 3 days* or
Butoconazole 2% cream 5 g (butaconazole [sustained-release]), single intravaginal application, or
Clotrimazole 1% cream 5 g intravaginally for 7-14 days† or
Clotrimazole 100-mg vaginal tablet for 7 days or
Clotrimazole 100-mg vaginal tablet, two tablets daily for 3 days or
Clotrimazole 500-mg vaginal tablet, one tablet in a single application or
Miconazole 2% cream, 5 g intravaginally for 7 days† or
Miconazole 100-mg vaginal suppository, one daily for 7 days† or
Miconazole 200-mg vaginal suppository, one daily for 3 days† or
Nystatin 100,000-U vaginal tablet, one daily for 14 days or
Tioconazole 6.5% ointment, 5 g intravaginally in a single application† or
Terconazole 0.4% cream, 5 g intravaginally for 7 days or
Terconazole 0.8% cream, 5 g intravaginally for 3 days or
Studies note cure rates of 75% to 95% with clotrimazole (Mycelex), 63% to 91% with miconazole (Monistat), and 32% to 96% with nystatin.7 Terconazole (Terazol) has cure rates similar to those of clotrimazole.8
Topical agents have been used extensively and are relatively benign. Side effects, which are site-specific, include itching, stinging, and irritation. Approximately 7% of women using topical antifungal creams report treatment-related vaginal discomfort.9 Terconazole has been associated with rare side effects, such as fever and flulike symptoms, when used in high concentrations.10 The risk of drug-drug interaction is low with topical creams, but these agents may reduce the effectiveness of barrier contraceptive methods. Only topical azole creams, not oral agents, are appropriate for use in pregnancy.
Recurrent infection.
RVVC is typically defined as four or more episodes of VVC per year. It is estimated to occur in fewer than 5% of women. The pathogenesis of RVVC is poorly understood. Vaginal culture should be performed in patients with RVVC to confirm the clinical diagnosis and to identify unusual species, including non–C. albicans species, particularly C. glabrata. C. glabrata and other non–C. albicans species are found in 10% to 20% of patients with RVVC.11
Treatment with the standard antimycotic therapies is not as effective as for non–C. albicans species. Longer treatment with topical agents (7 to 14 days) or fluconazole given once and then repeated 3 days later may be sufficient for treatment; however, maintenance therapy may be necessary to prevent recurrence. Clotrimazole 500-mg vaginal suppositories may be used once per week as a first-line treatment. Fluconazole, 150 mg once per week, may be necessary. Although treatment with ketoconazole 100 mg/day is often recommended for as long as 6 months, caution must be exercised because this treatment causes hepatotoxicity in 1 patient per 10,000 to 15,000 people. Liver-function parameters must be regularly checked. Preliminary research suggests that boric acid is equivalent to the use of itraconazole for maintenance therapy in women with RVVC.12
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