CASE 72-11, QUESTION 3: How can VVC be differentiated from other vaginal infections?
VVC should be differentiated from other vaginal infections because a
nonprescription antifungal agent could delay the appropriate treatment of other
vaginal infections. The physical appearance of the vaginal discharge may be useful in
predicting VVC if it is a viscous, nonodorous, white, curd-like discharge and the
patient has a normal vaginal pH (pH <4.5). The quantity of the discharge may be
scanty to profuse. Some women with VVC exhibit only vaginal erythema with
minimal discharge or an increased amount of normal vaginal secretion. Table 72-5
characterizes the vaginal discharges associated with VVC, BV, and trichomoniasis.
The vaginal discharge from a woman with signs and symptoms of VVC should be
examined for the microscopic presence of Candida using a wet-mount preparation
with 10% KOH or a Gram stain of the vaginal discharge. The use of KOH improves
the visualization of yeast or pseudohyphae that are seen in approximately 70% of
women diagnosed with VVC. If the wet mount is negative, the patient’s vaginal
discharge should be cultured for Candida in an appropriate growth medium. Isolation
o f Candida without signs and symptoms should not result in treatment, because
Candida is part of normal vaginal flora in approximately 10% to 20% of women. It is
the proliferation of C. albicans or other yeasts that lead to vulvovaginitis symptoms.
Nonprescription home screening tests are also available that measure pH levels
within the vaginal epithelium (e.g., Vagisil Screening Kit and Fem-V), which are
highly sensitive to pH changes but suffer from low specificity.
Physiologic Vaginal Discharge and Symptomatic Normal pH Vulvovaginitis
CASE 72-11, QUESTION 4: Do women such as L.L., who have an increased vaginal discharge and
symptoms consistent with VVC, necessarily have a vaginal infection?
Although the possibility of vaginal infection must be addressed when a woman
presents with an increased vaginal discharge with or without symptoms, other
conditions are associated with an increased discharge. First, a physiologic vaginal
discharge must be distinguished from a pathologic discharge. Physiologic discharges
(Table 72-5) characteristically are nonodorous, white or clear, highly viscous or
floccular, and acidic (pH ~4.5). Physiologic discharge may also become more
profuse at midcycle secondary to increased cervical mucus or vaginal epithelial
cells. Other conditions resulting in excessive vaginal discharge include retention of
foreign bodies (e.g., tampons) and allergic reactions or contact dermatitis secondary
to the use of vaginal spermicidal agents, soaps, deodorants, douches, vaginal
lubricants, and condoms. Episodes of vulvovaginitis-like symptoms can be
associated with frequent use of hot tubs, Jacuzzi baths, or swimming pools that
contain chemically treated water with high levels of chlorine.
Characteristics of Vaginal Discharge
Characteristics Normal Candidiasis Trichomoniasis
Color White or clear White Yellow–green White to gray
Odor Nonodorous Nonodorous Malodorous Fishy smell
Consistency Floccular Floccular Homogeneous Homogeneous
Other characteristics Thick, curd-like Frothy Thin
PL et al. Evaluation and management of vaginitis. J Gen Intern Med. 1998;13(5):335–346.
RISK FACTORS FOR VULVOVAGINAL CANDIDIASIS
CASE 72-11, QUESTION 5: What specific groups of women are most susceptible to VVC? Does L.L. fit
into any group at high risk for VVC?
C. albicans colonization and symptomatic VVC increases during pregnancy and
with use of high-estrogen containing oral contraceptives. Estrogens increase binding
affinity of vaginal epithelial cells to C. albicans.
concentrations (e.g., uncontrolled or poorly controlled diabetes mellitus); women
with depressed cell-mediated immunity secondary to disease (e.g., cancer, HIV
infection); and women receiving broad-spectrum antibiotics or immunosuppressive
drugs (e.g., cytotoxic agents, corticosteroids) are also at risk for VVC.
cases of VVC, although not related to intercourse, may be related to orogenital sex.
L.L. is taking tetracycline, which may increase her risk for VVC. Antibacterials
increase the risk for C. albicans overgrowth by suppressing the normal vaginal flora
(e.g., lactobacilli), which normally protect against C. albicans. L.L. is also taking a
low-estrogen–containing oral contraceptive; however, low-dose oral contraceptives
have not been consistently associated with an increased risk of VVC. The use of
diaphragms, vaginal sponges, and IUDs may also be risk factors for VVC.
Stress-induced VVC and an increased incidence of VVC before menstruation have
117 The cause of both is currently unknown. Although various dietary
factors have been postulated as a cause of vaginal yeast overgrowth, the role of diet
in the development of VVC remains inconclusive.
TREATMENT OF VULVOVAGINAL CANDIDIASIS
CASE 72-11, QUESTION 6: What vaginally administered therapy is effective for L.L.’s VVC?
L.L. is an appropriate candidate for nonprescription therapy (Table 72-6) because
she had previous vaginal yeast infections with symptoms similar to those she
currently is experiencing and her VVC is uncomplicated (defined as sporadic disease
with mild-to-moderate symptoms in an immunocompetent host). When a patient’s
VVC appears complicated (defined as a recurrent infection, severe symptoms, non–
C. albicans infection, presence of uncontrolled diabetes, immunosuppression, and/or
pregnancy), she should be referred to her medical practitioner.
well to short-term topical azole therapy. In addition, L.L. should ask her physician
whether continuation of antibiotics is truly needed. If L.L. had been evaluated by her
physician, a prescription for single-dose oral fluconazole or 3-day intravaginal
therapy might have been an option.
The available azole antifungals are equally effective in treating VVC with cure
rates between 80% to 90% when a full course of therapy is completed.
azole antifungal products listed in Table 72-6 are superior to nystatin, which is no
longer recommended by the CDC.
2 The medication used to treat L.L.’s VVC should
be selected based on response or failure to previous therapy, convenience, ease of
use, length of therapy, dosage form, and cost. L.L. should select a non–oil-based
product if a latex condom or a diaphragm is used as a form of contraception (Table
Other Treatments for ACUTE Vulvovaginal Candidiasis
Oral lactobacillus and lactobacillus-containing yogurt are advocated for the treatment
of VVC; however, evidence in support of this treatment is inconclusive.
600 mg capsules inserted in the vagina at bedtime for 14 days is effective for the
treatment of recurrent VVC with eradication rates of 70%, but vaginal burning and
irritation are common side effects and is poisonous if inadvertently ingested.
Gentian violet preparations also have limited use in the treatment of candidiasis
because they stain clothing and bed linens and cause local irritation and edema.
infection such as the one L.L. is experiencing?
Fluconazole is the only oral antifungal agent currently recommended by the CDC
for the treatment of acute VVC. A single 150 mg oral dose of fluconazole is as
effective as 3- to 6-day regimen of intravaginal clotrimazole.
women may prefer an orally administered drug to one that is administered
intravaginally, their use for mild-to-moderate VVC is of some concern because of the
possibility for systemic adverse effects and drug–drug interactions.
Adverse Effects Associated with Azoles
CASE 72-11, QUESTION 8: What adverse effects might L.L. experience from intravaginally or orally
When used intravaginally, azoles are associated with dose-dependent adverse
reactions similar to symptoms women report from VVC. Thus, it can be difficult to
differentiate disease symptoms from adverse drug reactions. If the vaginal symptoms
worsen after therapy is started, the patient should contact her health care provider. In
addition, if symptoms have not improved within 3 days after initiation of therapy or
continue past 7 days, the patient should contact her physician to rule out more severe
disease or treatment of the wrong disease.
117 Topical azole therapy has been
associated with a variety of adverse drug reactions, including headaches, allergic
contact dermatitis, vulvovaginal pruritus and irritation, dyspareunia, and general
burning, soreness, and genital pain. Oral fluconazole has been associated with
headaches, nausea, abdominal pain, diarrhea, dyspepsia, dizziness, taste perversion,
angioedema, and rare cases of anaphylactic reactions. In addition, intravaginal
miconazole has been reported to interact with warfarin, increasing the risk of
CASE 72-11, QUESTION 9: How should L.L. be counseled about the use of a nonprescription vaginal
Recommended Regimens for the Treatment of Candida Vulvovaginitis
Drug Availability Trade Names Dosing Regimens
a Femstat 3 Nonpregnant women: administer 1
applicatorful intravaginally QHS for 3
Pregnant women during second and third
trimesters: administer 1 applicatorful
intravaginally QHS for 7 consecutive days
Administer 1 applicatorful intravaginally
QHS for 7 to 14 consecutive days
Administer 1 applicatorful intravaginally
Administer 1 applicatorful intravaginally
Administer 1 applicatorful intravaginally
Monistat 7 Insert 1 suppository intravaginally QHS
Monistat 3 Insert 1 suppository intravaginally QHS
Monistat 1 daytime Ovule Insert 1 suppository intravaginally QHS
Tioconazole 6.5% vaginal ointment Vagistat-1 Administer 1 applicatorful intravaginally at
a Gynazole 1 Nonpregnant women: administer 1
applicatorful QHS for 1 dose only
Fluconazole 150-mg oral tablet Diflucan Take 1 tablet PO for 1 dose only
Terconazole 0.4% vaginal cream
a Terazol 7 Administer 1 applicatorful intravaginally
a Terazol 3 Administer 1 applicatorful intravaginally
Terazol 3 Insert 1 suppository intravaginally QHS
Adapted from Workowski KA, Berman S; Centers for Disease Control and Prevention (CDC). Sexually
transmitted diseases treatment guidelines, 2013. MMWR Recomm Rep. 2015;64(RR-03):1–137.
The details of intravaginal administration should be reviewed with L.L., including
instructions on how to clean the applicator. To minimize leakage and annoyance, L.L.
should apply the product at bedtime to increase retention in the vagina. She should be
advised that the nonprescription vaginal antifungal creams and suppositories are oil
based and thus may weaken condoms or diaphragms, thereby reducing their
L.L. should be informed about the importance of completing a full course of
therapy even if her symptoms subside beforehand and to continue her antifungal
treatment through her menstrual period should it occur. In addition, L.L. should be
instructed to see her physician if her symptoms persist, if she experiences symptoms
that signal a more serious problem (e.g., abdominal pain, fever, a foul-smelling or
bloody vaginal discharge), and/or if another yeast infection occurs within 2 months.
L.L. also should be advised to avoid wearing tight-fitting, unventilated underwear
(e.g., nylon panties or panty hose) and tight-fitting jeans because a warm, moist
environment can facilitate fungal growth. However, a study addressing risk factors
for VVC found no relation between type of underwear and the incidence of VVC.
In fact, many risk factors for VVC are not consistently associated with this
115 L.L. also could be alerted to the possible relation between candidiasis
and swimming in a heavily chlorinated pool or frequent use of a Jacuzzi or hot tub.
Complicated Vulvovaginal Candidiasis
CASE 72-11, QUESTION 10: How would management of L.L.’s VVC differ if she had poorly controlled
VVC in a woman with uncontrolled diabetes is usually considered to be
complicated VVC. A diagnosis of complicated VVC is also warranted when the VVC
is severe, recurrent (as defined), caused by non–C. albicans species or when VVC
occurs in an immunosuppressed, debilitated, or pregnant woman. The treatment of
complicated VVC varies depending on the underlying reason for the complication.
Severe VVC (e.g., extensive vulvar erythema, edema, excoriation, and fissures) may
be treated with either a 7- to 14-day course of topical azoles or two oral doses of
fluconazole 150 mg given 72 hours apart. Infection with non–C. albicans species
should be treated with a 7- to 14-day course of an oral or intravaginal azole;
however, the optimal treatment is unknown. Oral fluconazole has poor activity
against non–C. albicans species and should not be used. Boric acid 600 mg capsules
administered intravaginally once daily for 14 days can also be used, which has
shown eradication rates of 70%.
Recurrent Vulvovaginal Candidiasis
CASE 72-11, QUESTION 11: L.L. experiences another case of VVC 1 month later. Does she have
recurrent VVC? How should she be treated?
Most women have only occasional episodes of VVC, but approximately 5%
experience recurrent VVC infections defined as four or more episodes per year. To
determine whether L.L. has recurrent VVC, a diagnosis of Candida needs to be
confirmed by vaginal cultures. Then, underlying risk factors for VVC, such as
uncontrolled diabetes mellitus, consumption of excess sugars, IUD placement, and
use of antibiotics, must be ruled out.
124 Based on the timing of L.L.’s episodes and the
absence of risk factors, L.L. does not meet the definition for recurrent VVC. If a
patient meets the criteria for recurrent VVC, an underlying cause of the problem may
not be determined. In addition, the role of sexual transmission is not currently well
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