Dr Lilianne Scholtz (MBBCh)

Dr Lilianne Scholtz (MBBCh)

I have a discharge. It s itchy and it burns. My urine burns too.

Diagnosis based on symptoms alone is accurate in ~34 % of women because symptoms are very non-specific Sobel JD. Lancet 2007;369:1961-71

Understand how women become infected with Candida and what the predisposing factors for infection are Differentiate between VVC and other vaginal infections Decide on appropriate treatment based on the type of VVC Answers to FAQs from patients Tips for prevention When to refer a patient

Other Trichomonas Bacterial vaginosis Mixed vvc Ries AJ. J Am Pharm Assoc 1997;NS37:563-9.

women experience 1 episode experience a 2 nd episode Sobel JD. Lancet 2007;369:1961-71

Sobel JD. Lancet 2007;369:1961-71

Cause recurrent VVC in 20 % of cases C. glabrata most common Diagnosis is by culture Does not respond to the usual antifungals Sobel JD. Lancet 2007;369:1961-71

Candida gains access mainly from the adjacent perianal area Effective anti-candida vaginal defence mechanisms allow it to remain dormant without any signs or symptoms

As long as the good bugs predominate Lactobacilli the bad bugs will remain dormant Candida Anaerobes Aerobes

Oestrogen glycogen in vaginal epithelium LACTOBACILLI Lactic acid & H 2 O 2 ph < 4.5 Immune system Keeps Candida & others in check Nyirjesy P. ACOG Practice Bulletin 2006;27:1195-1206

Pregnancy OCP + Oestrogen - Menopause Pre-diabetes Diabetes + glycogen in vaginal epithelium Antibiotics Spermicides Douching Vaginal perfumes - LACTOBACILLI Lactic acid & H 2 O 2 Cancer, HIV, cortisone ph < 4.7 - Immune system Keeps Candida & others in check Sobel JD. Lancet 2007;369:1961-71

Two most common causes of vaginitis, so it is important to differentiate between them Different bugs: BV is caused by an overgrowth of anaerobes, mainly Gardnerella vaginalis Different consequences: BV is linked to Increased risk of STDs, including HIV Increased replication and shedding of HIV Pelvic inflammatory disease Premature birth Late foetal death Different treatment: BV with metronidazole, VVC with an antifungal

S+S Examination Investigations Sobel JD. Lancet 2007;369:1961-71

Itch Most specific Burn Dysuria Dyspareunia Discharge Cottage cheese Not offensive Sobel JD. Lancet 2007;369:1961-71

VVC BV Itch x Burn x Discharge White, cottage-cheese, non-offensive Milky or gray, offensive fishy odour Ries AJ. J Am Pharm Assoc 1997;NS37:563-9.

Vulva appears erythematous and swollen

Satellite lesions

Discharge white, clumpy and sticks to walls

Discharge creamy, milky and homogenous, smoothly covers walls

Vulva & vagina Discharge VVC Erythematous, swollen Adherent, white, cottagecheese like BV Normal Smell Not offensive Fishy Creamy, milky or gray, smoothly coats vaginal walls Ries AJ. J Am Pharm Assoc 1997;NS37:563-9.

In a review of various studies, it was found that: Itching = VVC No itching = not VVC Inflammation = VVC Fishy odour = BV No odour = not BV

Wet mount microscopy is diagnostic

http://www.biosci.ohiostate.edu/~plantbio/osu_pcmb/pcmb_lab_resources/pcmb101_activities/plant_cells/plant_cells_wet_mount.htm

Sobel JD. Lancet 2007;369:1961-71

Hainer BL, et al. Am Fam Phys 2011;83(7):807-815

Eckert LO. NEJM 2006;355:1244-52

Sobel JD. NEJM 1997;337(26):1896-1903

KOH fishy odour (whiff test) Positive in BV infection Vaginal ph take sample from vaginal side wall ph < 4.5 in VVC ph > 4.5 in BV Vaginal culture If microscopy is negative or infection is recurrent Ries AJ. J Am Pharm Assoc 1997;NS37:563-9. Sobel JD. Lancet 2007;369:1961-71

Microscopy KOH whiff test VVC Budding yeasts Hyphae Negative BV Clue cells Positive ph < 4.5 > 4.5 Ries AJ. J Am Pharm Assoc 1997;NS37:563-9. Eckert LO. NEJM 2006;355:1244-52

Uncomplicated (80-90 %) Complicated (10-20 %) Infrequent Recurrent (4+) and or Mild-moderate Severe and or C. albicans Non-albicans and or Normal immunity Immunocompromised, debilitated, diabetic

cure rate with vaginal or oral azoles Trend towards shorter course treatment (1-3 days) Vaginal creams Vaginal tablets Vaginal suppositories Oral tablets CDC 2010 STD guidelines;59(rr-12)

Rx: Clotrimazole vaginal tablets 100 mg tab nocte X 6 nights Or 2 x 100 mg tabs nocte x 3 nights Or 500 mg nocte STAT BASHH = British Association of Sexual Health and HIV UK VVC guidelines (BASHH) 2007

Recurrent Severe Non-albicans Immunocompromised Double vaginal regimen (10-14 days) Or Triple oral regimen (3 doses, 72 hrs apart) Add 6 months maintenance for recurrent VVC

Initial treatment Double: Clotrimazole vaginal tablets 100 mg nocte x 12 nights Maintenance Add 6 months: Clotrimazole vaginal tablet 500 mg weekly x 6 months BASHH = British Association of Sexual Health and HIV UK VVC guidelines (BASHH) 2007

Initial regimen Triple: Fluconazole 150 mg x 3 doses, 72 hrs apart Maintenance Add 6 months: Fluconazole 150 mg weekly x 6 months BASHH = British Association of Sexual Health and HIV UK VVC guidelines (BASHH) 2007

CDC/BASH guidelines Severe VVC, immunocompromised, debilitated, diabetic, HIV Treatment regimen Double: Vaginal regimen (10-14 days) Triple: Oral regimen (3 doses, 72 hrs apart) Non-albicans spp. Boric acid vaginal capsules 600 mg x 14 days Pregnancy Vaginal azoles x 7 days BASHH = British Association of Sexual Health and HIV UK VVC guidelines (BASHH) 2007 CDC 2010 STD guidelines;59(rr-12)

Vaginal tablet/pessary Vaginal cream Oral tablet Effective Messy X X Drug wastage X X Precise dose X Systemic absorption X X Drug-drug interactions Systemic side effects X X X X Local side effects X Easy to see no. of doses administered X

Is VVC a sexually transmitted disease and should my partner get treated??

Candida is part of the normal vaginal flora However, incidence does increase in sexually active women (orogenital and anogenital transmission) No treatment of sex partner unless symptomatic

Why is my VVC recurrent? Real recurrence uncommon (< 5 % of women) Consider failure of treatment due to wrong diagnosis and treatment & non-compliance Correct diagnosis is NB, i.e. microscopy and culture Exclude underlying factors that promote Candida overgrowth

What about probiotics? Inhibit growth and adherence of vaginal pathogens, e.g. Candida Often used in conjunction with antibiotics or in women with recurrent VVC Efficacy controversial

Should I change my diet? Role of dietary factors in the treatment of recurrent VVC is limited Some evidence for an increased risk when consuming: a diet high in refined sugars 2 or more servings of bread/day

Opt for loose fitting clothes & cotton underwear Avoid douches, foam baths or vaginal perfumes Wipe from front to back Use a vaginal lubricant if suffering from vaginal dryness Souter J. SA Pharm Assist 2006

Patients younger than 16 and older than 65 Failure of treatment Complicated VVC (recurrent, severe, immunocompromised) Pregnant Suspected STD (smelly discharge, genital ulcers or blisters, swollen inguinal lymph nodes), previous STD or partner with STD Abnormal vaginal bleeding or blood stained discharge Lower abdominal pain Souter J. SA Pharm Assist 2006