National Clinical Training Center for Family Planning



Recurring Vaginal Infections: Strategies for Success!TranscriptDr. Susan Hoffstetter:Hello. My name is Susan Hofstetter. I'm a women's health nurse practitioner and professor at St. Louis University School of Medicine. My clinical practice is in vaginal and vulvar disease at the SLUCare Vulvar and Vaginal Disorders Center.Dr. Susan Hoffstetter:Our topic today is Recurring Vaginal Infections: Strategies for Success.Dr. Susan Hoffstetter:Objectives are to describe how to make appropriate diagnoses for recurrent vaginal infections, for candidiasis and bacterial vaginosis. To understand the risk factors associated with [inaudible 00:00:50], identify patterns or triggering events that contribute to recurrent symptoms, and identify appropriate treatment strategies.Dr. Susan Hoffstetter:Before we start talking about recurrent infections, I think it's important that we reflect on the healthy vaginal microbiome. To the right of the screen, you can see a very clean and healthy looking squamous epithelial cell. There's a listing of the typical microbiota that we see in the vaginal microbiome, listed on the left. It's important to realize what's normal, what can be there, as we go through the process of trying to understand recurrent infections. A healthy normal vaginal microbiome should have a pH range from 4.0 to 4.5.Dr. Susan Hoffstetter:The general topic of vaginitis, I think is something we all see in our clinical practices on a daily basis. At least 10 million GYN visits a year have been documented, and that's including bacterial vaginosis, candidiasis and trichomoniasis. If women are symptomatic, candidiasis will be between 17 and 39% of those infections, BV, 22 to 50%, with trichomoniasis 4 to 35%.Dr. Susan Hoffstetter:Today, we're only going to be talking about candidiasis and bacterial vaginosis. It is important to remember that, for a lot of women, their vaginitis problems remain undiagnosed.Dr. Susan Hoffstetter:When we talk of recurrent infections, you have to wonder, what is wrong? Why does this happen for some women and not others? Is the recurrent infection a relapse of their initial infection? Is it a new infection? Is it the result of treatment failure? Noncompliance to a treatment regimen? Or for some, is it really an infection at all?Dr. Susan Hoffstetter:Some women find that any discharge is perceived as abnormal. That can be increased or intensified if they have no vulvar hair from waxing or lasering or recurrent shaving. Women often are unaware of their cyclic changes in their vaginal secretions. I see commonly women who have been on hormonal contraception. They stop. They begin to have a normal monthly cycle, and then believe they're having an infection when what's happening is the normal changes in their secretions, based on their menstrual cycle. So it is important to understand what is their perspective, where they're coming from, and then also to understand what is going on with previous treatments,Dr. Susan Hoffstetter:Making the diagnosis is critical. We want to get a good history of vulvar vaginal symptoms, description, location, and duration. Their sexual history is very important. Number and gender of their partners, sexual practices, any self treatments.Dr. Susan Hoffstetter:The internet is full of ideas for treating the vagina, making things better. Sometimes they can make things worse. But lots of ideas out on the internet. Prescription treatments. We have a lot of patients who really don't want to come into the office for an evaluation. They know what they have. They want you to call in treatments for them. And in our busy practices, we actually enable this to happen. And that can also lead to problems for patients and for us.Dr. Susan Hoffstetter:What are their vulval, vaginal hygiene practices? Women do a lot of things for the vagina, to the vagina, to the vulvar skin. Sometimes they're not the best, and we really need to understand what are the things that they routinely do. Does the woman have any other medical conditions? Diabetes? Any immune status challenges? Bladder and bowel diseases? And then understanding triggers, patterns or cycles that she has identified.Dr. Susan Hoffstetter:Women who have recurrent infections really spend a lot of time thinking about their problem, trying to understand the problem, trying to solve their issues, before they ever come to us. So they've usually have some good ideas or thoughts about what they think their unique problem is.Dr. Susan Hoffstetter:Then it comes time for examination. Certainly we're going to take a look at the outside. We're going to look at structures. We're going to look at pigmentation. Are there color changes? Are there any lesions or growths? Papules? Plaques? Does she have any edema? When we use that speculum, what does the discharge look like? Let's look at those vaginal walls of the [inaudible 00:06:02]. Is there odor? The consistency. Those things are very important.Dr. Susan Hoffstetter:And hopefully you're able to do microscopy, because I think it's really a very helpful tool. Unfortunately, a lot of offices are moving away from that, with the PCR DNA probes, which are acceptable if you don't have microscopy, but sometimes there's nothing better than looking under that microscope with the little saline and KOH, seeing what that pH is.Dr. Susan Hoffstetter:I would encourage you, even if you're using PCR DNA probes in your practice, to get some pH paper. It's very objective and it can help you educate the patient about the health of their vaginal microbiome. pH paper is a very inexpensive... It costs about $9 on Amazon for a little roll of pH paper. I think it would really guide you to help in your diagnosis and also in educating your patient about that healthy pH level that we want to obtain for her vaginal microbiome.Dr. Susan Hoffstetter:So let's move into recurrent vulvovaginal candidiasis. To have a diagnosis of recurrent candidiasis, we're really looking at four or more distinct episodes over the course of one year. The worldwide prevalence of recurrent candidiasis is approximately 138 million women annually. That's a lot. And an additional 372 million will have an episode over one's lifetime. So it's a really huge morbidity and economic cost to us. It is considered the second most common infection that women will ever have, just generally speaking about candidiasis.Dr. Susan Hoffstetter:Looking at patterns and triggers. Again, treatment compliance, I think is critical. Have they been sexually active during previous treatments? Again, what's their immune status? Have they been on oral topical cortical steroids? HIV status? Antibiotics?Dr. Susan Hoffstetter:I think here in Missouri, we see a lot of people who have recurrent sinusitis who are on antibiotics for weeks at a time, and that can certainly challenge the vaginal microbiome. For our women who are diabetic, the use of the glycosuria inducing agents for their treatment is certainly increasing the prevalence of candidiasis, particularly Candida glabrata. If a woman is not diabetic, but has a strong family history, I routinely will screen them for diabetes if they're having recurrent candidiasis.Dr. Susan Hoffstetter:Pregnancy offers challenges for women with candidiasis and our treatment options are limited when our women are pregnant. I also see women who are not diabetic, but have a diet rich in carbs and sugars that can actually contribute to their recurrent episodes of candidiasis.Dr. Susan Hoffstetter:And then another group is our post-menopausal women on hormone therapy. I have seen where the hormone therapy is actually contributing to some of the candidiasis, particularly if they had issues prior to the onset of menopause and hormone therapy. So sometimes stopping their therapy might just be an interesting trial if you can break their recurrent pattern. So something to think about there.Dr. Susan Hoffstetter:Other patterns and triggers that might come out in your conversation with your patient. Is it her period? I commonly hear women who say, "I have a yeast infection every month", and that coincides with the onset of their period. Do they have any kind of other dermatitis or reaction to their products?Dr. Susan Hoffstetter:Looking at skincare products, clothing, what they do for exercise, because these things can serve as triggers. You really want to encourage your patients to avoid a lot of the over-the-counter sexual lubrications. A lot of preservatives and chemicals that can aggravate and challenge the vaginal microbiome. The very tight Spanx, lycra leggings. Clothing. Some of that exercise clothing now really creates an abnormal environment with heat and sweat. Thong underwear is again very tight and occlusive to the vulva. Even ones made out of cotton are things I tell my patients not to do.Dr. Susan Hoffstetter:Sometimes biking, which is great exercise, but it has its risks for our women. I see issues for those who spin, because spinning usually is an exercise that these people are very motivated about and do multiple times a week. It's intense and there's a lot of heat, sweating, and then adding the tight clothes. Long distance bike riders can also run into issues. Some of the bike shorts with all the extra padding builds up a lot of heat. Then those can be issues for women who are very athletic.Dr. Susan Hoffstetter:Other contact irritants in products and soaps can contribute and act as a trigger for women who are vulnerable.Dr. Susan Hoffstetter:Stress is always a factor that I like to include with my patients. Stress challenges us. Certainly we all live in interesting times, but stress lowers your immune system and it enables us to acquire things that perhaps we wouldn't, if we were not under such a chronic level of stress.Dr. Susan Hoffstetter:Persistent self-treatment with over-the-counter antifungals. Plethora of products, again, at the drug store, on the internet, on how to treat your vagina. Things are easy and available. They're not necessarily inexpensive, so I really try to discourage the use of over-the-counter products with my patients.Dr. Susan Hoffstetter:And then again, inappropriate treatments. The patient might think she has one thing, maybe he has another. They call the office. We might hear one thing, they might have another. So we can get into some misdiagnosis. So I really encourage, obviously, evaluation, if at all possible, when our patients call.Dr. Susan Hoffstetter:So what are those symptoms your woman's going to tell you of? With candidiasis, you're going to hear the pruritis, burning, soreness. Sometimes it's just a sense of irritation or dryness or rawness. I actually find dryness to be a very sensitive indicator of a symptom of yeast. Dyspareunia certainly will result. They could have external dysuria from the irritated skin.Dr. Susan Hoffstetter:And I think it's important to realize when we have women with recurrent infections, it can actually cause or deepen their depression and worsen their anxiety. So we need to keep in mind, this is something that truly needs to be evaluated appropriately, and guided this patient into treatment, because we don't want to challenge her mental health stability.Dr. Susan Hoffstetter:When we do an exam and we look at our patient, she could be erythematous. Tissues could be swollen. Women who have more chronic issues will develop fissures, areas that are just excoriated. They can even have satellite lesions moving out from the primary area of infection. Their discharge can be white, thick and curd-like, however, vaginal discharge was shown in a study that we did in our center to be one of the least predictive of a positive yeast culture. So we have to always be a little suspect of that classic description of yeast, because sometimes it's true and sometimes it's not.Dr. Susan Hoffstetter:How do we make the diagnosis? Again, doing that wet mount is a really wonderful thing. With candidiasis. Your pH level can be normal. Probably is. You're going to look under that microscope. On the bottom screen at the left, you'll see the hifi and some buds, and on the bottom screen at the right, you're going to see what Candida glabrata looks like.Dr. Susan Hoffstetter:Some people will say that glabrata looks like little snowmen because you can have these buds stacked together. That picture doesn't particularly look like a snowman to me, but you will see that in the literature of how it's described.Dr. Susan Hoffstetter:You can see if there's any lactobacilli present, just so you can learn what the health of that vaginal microbiome is. Obviously you can do gram stains if you can do that, or the yeast culture. All these things would be appropriate ways of diagnosing candidiasis.Dr. Susan Hoffstetter:With the yeast culture... With my patient population, my women have all come with lots of treatment, lots of issues for a long period of time. A yeast culture is very important to obtain. It helps us to identify the species of candida that they have. It helps us to identify medication sensitivity. Women who have been treated over and over tend to develop non-albicans candidiasis. Those species are hard to see under a microscope. And most importantly, they tend to be resistant to the [ESAL 00:14:54] therapies. We are also seeing an increase in the resistance of typical Candida albicans to the fluconazole. So that can be a worrisome trend, but we'll have to keep an eye on that as we go forward.Dr. Susan Hoffstetter:Pitfalls of diagnosis. I think it's really important that we understand that pap tests are not reliable to diagnose candidiasis. So when we're looking at that, how many episodes have you had, don't count what's on that pap smear. Asymptomatic women who have yeast on their pap do not need an evaluation or treatment. If they're symptomatic, you really should bring them in and do a confirmatory test. That sensitivity is really low.Dr. Susan Hoffstetter:We know that of just women in general, 20 to 30% will have vaginal candida that's identifiable, but if they're asymptomatic, we do not need to treat. So you're treating your patient. You're not treating a piece of paper or a lab test. Always, always keep that in mind, because we can get into an over-treatment issue by saying, "Oh, you have yeast on your pap. Treat you." And then we sort of go down that path of that they have a problem with chronic yeast. So always remember pap tests are really not good to diagnose other infections.Dr. Susan Hoffstetter:So what are we going to do for our woman with recurrent candidiasis? What are our treatment options? I always start with good skin care guidelines. Avoiding those contact irritants, helping them take care of their vaginal and vulvar skin. Support that vaginal microbiome. That's always step number one.Dr. Susan Hoffstetter:There are some guidelines that are CDC and [ACAT 00:16:38] supported for our fluconazole 150 milligrams weekly for six months. That'll be fine unless you have Candida krusei, which is normally resistant and will require other treatments. After the six months, 40 to 50% of women will remain in remission for that time, so that's a pretty good response rate.Dr. Susan Hoffstetter:Sobel is a physician who has done a lot of research in recurrent candidiasis. He uses itraconazole 200 milligrams twice a day for three days, and then 100, 200 milligrams a day for six months.Dr. Susan Hoffstetter:Boric acid is quite the popular item. It's available online in drug stores now, so a lot of people are using boric acid. There's really very little data to support any of the use of boric acid, however it is commonly being used. You can use it vaginally up to about two weeks and you can maintain then twice weekly. But again, that's more observational personal experience by clinicians who will use that.Dr. Susan Hoffstetter:Patient selection is very important. Boric acid can not be used if you're attempting pregnancy or pregnant. It is toxic or considered a poison if you were to have oral ingestion. So you really need to know who you're picking to put on that as well as if there's small children or that they understand that they have to keep this medication away from other oral medications.Dr. Susan Hoffstetter:Nystatin 100,000 units, intra vaginal capsules can be used nightly for 14 nights. You could have it compounded as a capsule or in a suppository. Nystatin is considered very safe and has been used even with pregnant patients. And then amphotericin b cream or suppositories can be used for 14 days. So those are just some of the options we have available.Dr. Susan Hoffstetter:Other things when you're considering treatment for your patient with recurrent yeast is, should you treat the partner? In my practice, if the male partner is not circumcised, or if the partner is symptomatic, we go ahead and treat. But I just want to tell you that in randomized studies, the partner treatment has really failed to show a decrease in the risk of recurrence. So that's kind of just an individual decision that you'll need to make.Dr. Susan Hoffstetter:The other thing that's very common is a lot of the over-the-counter products, lactobacillus, really not effective in treatment or prevention for recurrent candidiasis. And again, we can go to Dr. Google on the internet. Yogurt, garlic, tea tree oil, low carb diet, douching. There's really very little data on any of these things.Dr. Susan Hoffstetter:If your patient is still with symptoms after you've tried some of these treatment options, really the next best step is to refer her to a specialty center where they can really help understand the etiology, what's going on with this patient, to interrupt that cycle.Dr. Susan Hoffstetter:Again, this is a quality of life issue. It's a mental health issue for our patients. So we do want to do the right thing. We try. If it doesn't work, the best thing we can do for our patient is to move them onto someone who could offer them more or different options.Dr. Susan Hoffstetter:So let's move on to bacterial vaginosis. BV. Prevalence rates of BV, I'm sure you're all very aware of this very frequent common condition. Affects about 21 million women in the US. We hear BV talked about a lot because the recurrence rates are at least 30% at three months and 58% by one year.Dr. Susan Hoffstetter:There are strong ethnic differences in who has BV. Our African-American women have a burden of 51% of this, followed by Mexican-American women at 32%, Caucasian at 23%. So we don't really understand why there's ethnic differences, but we see it every day in our clinical practices. Recurrent BV is considered more than three documented separate episodes per year.Dr. Susan Hoffstetter:Symptoms. I'm sure you're all very familiar. Discharge. It has that amine odor. Fishy smell. They can be asymptomatic, or they can have symptoms of irritation, burning, itching. Symptoms can worsen after intercourse, menses or oral sex due to the pH change from those alkaline fluids.Dr. Susan Hoffstetter:Why do women have BV? It's really considered an imbalance of the vaginal microbiome or a dysbiosis of that vaginal environment. The imbalance can be caused by intrinsic factors, such as genetics, age, hormone status, obesity, emotional status, immune status,Dr. Susan Hoffstetter:Extrinsic factors. I think we focus on these a lot because we can impact them. Sexual activities, douching, abnormal bleeding, male circumcision at times can cause a role, perinatal hygiene, and even smoking.Dr. Susan Hoffstetter:When we have an imbalance, no matter which factor is behind that change, you have a decrease in the lactobacillus types as listed below. When we lose our lactobacillus, that causes an overgrowth of our anaerobic species, and then we have that pH rising to greater than 4.5, resulting in BV.Dr. Susan Hoffstetter:There are special populations in which BV is more of an issue. For women who have sex with women, prevalence rate can be 25 to 50%. If a woman has BV, 94% of her female partners will also have it. There are some who think that BV should be considered a sexually transmitted infection for women who have sex with women. That's subject for discussion.Dr. Susan Hoffstetter:Another group that I want just to give a little shout out to is our menopausal population. BV really becomes less common after menopause. So if you have a post-menopausal woman who you are continuing to treat for BV over and over, you really want to start to think, is that really what she has? Is there something else going on? There is an inflammatory vaginal discharge that has a very alkaline pH, and it can be associated with a skin condition of lichen planus. So when you, again, see that post-menopausal woman, think outside the box, or have her see someone else for just another evaluation before you just keep treating her over and over for bacterial vaginosis.Dr. Susan Hoffstetter:How do you make the diagnosis of BV? Amsel's criteria is standard. You want to have three of the following symptoms or signs. One is the discharge. Again, it's that thin gray discharge. It just kind of coats everything. Sometimes you'll just see it on the tissues at the introitus. You have your elevated pH. It has to be greater than 4.5. You have your whiff test. You can have the fishy odor before or after you add the 10% KOH. And then when you look with your wet mounts under the microscope, you're going to see clue cells greater than 20% of the field, but you should not expect to see white blood cells. Again, rapid testing is an alternative if you don't have the ability to have a microscope in your office practice.Dr. Susan Hoffstetter:Pitfalls. There's really no role to obtain a routine vaginal culture. It is not specific for BV, and it will lead you down a path. Think back to all the organisms that are in a healthy vagina. So you're going to grow something, but whether or not that is important, no one knows that answer, but a routine vaginal culture is not specific for BV, and you really should not do that.Dr. Susan Hoffstetter:Pap tests are also not reliable to diagnose BV. If they suggest that there's BV and the woman is asymptomatic, you do not need to evaluate or treat her. If she is symptomatic, you need to bring her back in and do confirmatory testing before you treat her. So again, don't rely on that pap test. That can put people into the treatment cycle inappropriately.Dr. Susan Hoffstetter:Standard treatments for BV... Not recurrent BV, but just BV... Are what's listed. So we have metronidazole the oral, the gel. Of course, there's no alcohol with the metronidazole. We have Tindamax. It has fewer side effects, but it can be more expensive. Clindamycin comes in some different forms, either oral, cream or ovules. [inaudible 00:25:31] does degrade latex or rubber condoms and diaphragms for five days, so be sure you're doing that. If you use the Cleocin ovules, it's three days. It is considered a category B drug, but it's not recommended during pregnancy.Dr. Susan Hoffstetter:The newer treatment is secnidazole. It's a single dose granule. Patients stir it into a little soft food. It's one dose, which is a benefit. No alcohol restrictions, which is easier from a patient compliance standing.Dr. Susan Hoffstetter:So I'm talking about regular [inaudible 00:26:03] because when we talk about, what do we do for recurrent BV, you can actually re treat with one of the standard agents, you can extend the course of treatment with it, switch it up. So those are some of the first steps that you're going to use when you have patients who are meeting the criteria for recurrent.Dr. Susan Hoffstetter:I always, of course, put in the vulvar skincare guidelines. In studying our patient population, we have had a great decrease in symptoms just from good skincare guidelines. So don't minimize that.Dr. Susan Hoffstetter:We can do other things to suppress or prevent BV. There's a standard regimen of using the MetroGel vaginally, twice weekly for four to six months after that initial standard treatment was given. A monthly oral metronidazole or tinidazole with a monthly fluconazole. That's another extended treatment regimen by CDC.Dr. Susan Hoffstetter:I'm going to bring up boric acid again. There's very minimal data on this, but it's commonly being used again. Since it's gone over-the-counter now, it's becoming, I think, even more popular. Using it vaginally nightly for two weeks and then a couple of times a week, it will give some decrease in the pH, which can help, but I just want to stress there's really little data about it. And then patient selection is important as we've discussed when we used it for candidiasis.Dr. Susan Hoffstetter:There are other products such as Aci-Jel. I just picked that one just to tell you there's really no data to support the use of these products. So when we're looking at what's the best thing, we really want to pick treatment regimens for patients that at least have some research to back them up, some data to support them, that they were going to help them. Sometimes we give them products because we don't know what else to do. But just remember we want to help our patients. We want to help them return to a healthy vaginal microbiome, and sometimes the use of more and more of these things, just delays that return to normal.Dr. Susan Hoffstetter:Other treatment considerations. Probiotics. Oral, vaginal. Really not recommended for the treatment of BV, or to augment anti-microbial treatment, or to maintain the vaginal microbiome. There's just a plethora of probiotics for vaginal health. So important to remember, there's really not data to support them. These are products that have no FDA regulation. They're out there on the internet and they're expensive. So if we're recommending treatments for our patients, we want to be sure we're doing things that we know will work, and that they're just not spending their hard earned money on things that are not going to be helpful.Dr. Susan Hoffstetter:As far as treating sexual partners, the data really do not support that. There's no impact on rates of relapse or remission. And there's really been no studies to address the simultaneous treatment for female partners, for women who have sex with women, to decrease recurrent rates. So the whole issue, should you treat the partner? There's no data to support that.Dr. Susan Hoffstetter:So in summary, recurrent infections are very troubling to women. It impacts the quality of their life, their mental health, their relationships. We want to be sure we're evaluating them carefully. We don't want to be mistreating them, but we also don't want to be over-treating them.Dr. Susan Hoffstetter:I think my take home message is that if you have tried some things and you're not getting better, try to find a specialty center or somewhere where you can send your recurrent... Or those difficult cases, because this is very important to your woman's day-to-day life, again, her health, the health of her vagina, and we want to do the right things for our patients.Dr. Susan Hoffstetter:I hope this presentation will be useful to you in your clinical practice. I appreciate all your attention during the presentation, and I will conclude at this point. Thank you. ................
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