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Vulvovaginal candidiasis (VVC)

Vulvovaginal candidiasis (VVC). Louise Oliver GP Extension Registrar GU Medicine. Size of the problem. 55% of women by mid 20s have had VVC Geiger AM, Foxman B, Gillespie BW. AmJ Pub Hlth 1995; 85 :1146-1148. Up to ¾ of all women at least 1 lifetime episode

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Vulvovaginal candidiasis (VVC)

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  1. Vulvovaginal candidiasis (VVC) Louise Oliver GP Extension Registrar GU Medicine

  2. Size of the problem • 55% of women by mid 20s have had VVC Geiger AM, Foxman B, Gillespie BW. AmJ Pub Hlth 1995;85:1146-1148. • Up to ¾ of all women at least 1 lifetime episode • $58.4 million per year $19.8 in medication costs Foxman B, et al STDs 2000;27:230-235.

  3. Consequences • Not directly life threatening but….. • Poor self esteem. • Psychosexual problems.Stewart DE, Whelan CI, et al Obstetrics & Gynecology 1990;76 :852-856. Irving G et al. STIs. 74(5):334-8, 1998 Oct. 99210932 • Socially unacceptable to discuss • Often misunderstood/dismissed by health professionals

  4. Causative agent • C. albicans 85-90% • C. glabrata 5-10% • Others: C.tropicalis, C.krusei, C. kefyr, & Saccharomyces cerevesiae (Brewer’s yeast)

  5. Symptoms • Vulval itching or soreness • Vaginal discharge • Superficial dysparenuia • External dysuria

  6. Signs • Erythema • Fissuring • Non offensive discharge • Satellite lesions • Oedema

  7. Investigations • GUM setting: • Gram stain or saline microscopy of anterior fornix or lateral vaginal wall discharge • Culture • GP setting: • Charcoal swab for culture

  8. Classification of VVC Sobel JD et al, Am J Obs Gynecol 1998;178:203-211. • 1 Candida colonisation • 2 Uncomplicated VVC • 3 Complicated VVC

  9. 1 Candida colonisation • Candida is an opportunist pathogen • Normal vaginal flora in many women • 27% in longitudinal studyPriestley CJ et Genitourin Med1997;73:23-28. • Higher in pregnancy (30-40%) • Positive HVS for Candida doesn’t distinguish between commensal and pathogen

  10. 2 Uncomplicated VVC • mild • infrequent • non-persistent • non-pregnant women

  11. 3 Complicated VVC • severe, persistent, recurrent VVC or underlying host abnormality • Divided into: • 1 severe vulvovaginal candidiasis • 2 persistent non- albicans infection • 3 recurrent vaginal candidiasis

  12. Treatment • National guidelines www.mssvd.org.uk • General advice • Topical & oral azole therapy 80-95% cure rate (non-pregnant women) • Oral azole therapy avoid in pregnancy & breast feeding • Do not treat asymptomatic Candida colonisation

  13. Topical therapy( given PV) • Clotrimazole 500mg stat/ 200mg x 3/7 / 100mg x 6/7 / 10% vaginal cream 5g stat • Econazole 150mg stat/ 150mg x 3/7 • Fenticonazole 600mg stat/ 200mg x 3/7 • Isoconazole 2 x 300mg stat • Miconazole 1.2g stat/ 100mg x 14/7 • Nystatin 4g cream x 14/7 / 1-2 pessaries x 14/7

  14. Oral therapy • Fluconazole 150mg PO stat • Itraconazole 200mg PO BD 1 day

  15. Choice of therapy • Oral • more acceptable to some • ?quicker onset • systemic side effects • ?not safe in pregnancy • Vaginal • messy • occasional irritation

  16. Sexual partner • Grade A evidence to show treatment of asymptomatic male sexual partnersis not required

  17. Follow up • Unnecessary if symptoms resolve • Test of cure unnecessary

  18. Symptoms fail to settle • Severe VVC - repeat fluconazole 150mgs after 3 days Sobel JD et al Am J Obs Gynae 2001;185:363-369. • ? Non albicans infection • ? Recurrent VVC • ? Irritation secondary to topical therapy • ? Wrong diagnosis

  19. Differential diagnosis • Trichomonas vaginalis • Bacterial vaginosis • Herpes simplex virus • Vulval disease • Chlamydia • Gonorrhoea

  20. 125 women referred with “problem thrush” to Dr David White at Hawthorn House, Heartlands Hospital

  21. ? Recurrent VVC • Research area • Speciated fungal culture • ??FBC and random glucose • ??HIV test only mandatory if other indication • Symptom diary • Self taken swabs • equivalent to doctor/nurse swabs Blake DR, et al Pediatrics 1998;102:939-944. • Give treatment to take after swab taken

  22. Recurrent VVC • ? GUM referral • Could try regime recommended by MSSVD but unlicenced! • Fluconazole PO 100mg weekly x 6/12 • Clotrimazole PV 500mg weekly x 6/12 • Itraconazole PO 400mg monthly x 6/12

  23. Contraception & recurrent VVC • Whether pill causes VVC unclear • DepoProvera protective • small retrospective study • reduced Candida colonisation in prospective study • Norplant associated with reduced incidence of vaginitis

  24. “Alternative” treatment • Due to “overgrowth of Candida in bowel”????? • Yoghurt and lactobacillus acidophilus • lactobacillus vaginal flora not protective • intravaginal ineffective but soothing Bisschop MP, et al Ned Tijdsch Geneesk 1987;131:159-161 • yoghurt effective growth media for Candida • Oral lactobacilli may be effective Hilton E et al Ann Int Med 1992;116:353-357. • ??atopy mediated Isolauri E et al Am J Clin Nutr 2001;73:444S-450S. Kalliomaki M, et al Lancet 2001;357:1076-1079.

  25. Summary • No pathognomic feature • Itching is only predictive symptom/sign • Diagnosis needs laboratory confirmation • Symptoms/signs no guide to species • Asymptomatic male partners don’t require treatment • Remember to enclose copies of positive swabs when referring • Consider differential diagnosis

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