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Candida VulvovaginitisAka: Candida Vulvo-vaginitis, Vaginal Candidiasis, Vulvovaginal Candidiasis

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  1. See also
    1. Vaginitis
  2. Epidemiology
    1. Candida Vulvovaginitis accounts for 45% of Vaginitis
    2. Candida is cultured in 20-50% asymptomatic women
    3. Vaginitis often self diagnosed incorrectly
  3. Etiology
    1. Acute: Candida albicans (90%)
      1. Normal commensal organism in vagina
      2. Infection when Corynebacterium suppressed
    2. Recurrent Vulvovaginal Candidiasis
      1. Candida glabrata (increasing Incidence, now 15%)
      2. Candida tropicalis
      3. Candida parapsilosis
      4. Saccharomyces cerevisiae
  4. Predisposing Factors
    1. Diabetes Mellitus
    2. Medications
      1. Corticosteroids
      2. Immunosuppressant Medications
      3. Broad spectrum antibiotics
      4. Oral Contraceptives
        1. Increases frequency of Candida carrier state
        2. Does not increase symptomatic vulvovaginitis
    3. Heat and moisture retaining clothing (e.g. nylon)
    4. Pregnancy
    5. Premenstrual phase of the Menstrual Cycle
    6. Depressed cell mediated immunity (e.g. AIDS)
    7. Obesity
  5. Symptoms
    1. Asymptomatic in 20-50% of women
    2. Intense vaginal or Vulvar Pruritus (50% of cases)
    3. Vulvar Burning, soreness, or irritation
    4. Thick white curd-like or "cottage cheese" discharge
    5. No odor
    6. Dyspareunia
    7. Dysuria (33% of cases)
  6. Signs
    1. Adherent white cottage-cheese discharge in vagina
      1. Sensitivity: 50%
      2. Specificity: 90%
    2. Vulvar erythema and edema (24% of cases)
  7. Lab
    1. KOH Preparation (10%)
      1. Test Sensitivity: 50%
      2. Pseudohyphae or budding yeast forms
      3. GynVaginitisYeast.jpg
    2. Fungal Culture positive
      1. Fungal Culture rarely performed
      2. Fungal Culture may be very helpful in certain cases
        1. Confirm asymptomatic carrier of vaginal Candida
        2. Identify cause of recurrent Vaginitis
    3. Candida on Pap Smear
      1. Specific but not sensitive
    4. Vaginal pH <4.5 (Normal acidity)
    5. Absent Amine odor
    6. White Blood Cells not increased
    7. Wet-Prep is not sensitive or specific for yeast
      1. Bornstein (2001) Infect Dis Obstet Gynecol 9:105
  8. Differential Diagnosis (Consider for refractory cases)
    1. Other Vaginitis cause
      1. Bacterial Vaginosis
      2. Trichomonas Vaginitis
    2. Infectious Cervicitis (Sexually Transmitted Disease)
    3. Allergic Vaginitis or Vulvitis
    4. Vulvodynia
  9. Management: Local First-Line Agents
    1. Miconazole
      1. Monistat-3 200mg PV qhs for 3 days ($30)
      2. Monistat-7 2% cream PV qhs for 7 days ($15)
      3. Monistat Vag tabs 100mg PV qhs for 7 days ($15)
    2. Clotrimazole (Gyn-Lotrimin, Mycelex G)
      1. Clotrimazole 200 mg PV qhs for 3 days
      2. Clotrimazole 1% cream qhs for 7 days ($14)
      3. Clotrimazole 100 mg PV ghs for 7 days ($14)
      4. Clotrimazole 500 mg vaginal tab PV qhs, 1 dose ($19)
    3. Butoconazole (Femstat)
      1. Mycelex-3 5g of 2% Cream PV QHS for 3 days ($26)
      2. Gynezole-1 (sustained release) 5 g of 2% cream once
    4. Terconazole (Newer, binds better to Candida)
      1. Terazol-7 0.4% vag cream qhs for 7 days ($25)
      2. Terazol-3 0.8% vag cream for 3 days
      3. Terazol 80 mg vaginal suppository PV for 3 days
      4. Vagistat-1 6.5% ointment, 5 g intravaginally once
    5. Nystatin
      1. Vaginal tablet (100,000 unit) PV daily for 14 days
  10. Management: Oral Agents
    1. Fluconazole 150 mg PO for 1 dose
      1. As effective as Clotrimazole PV
    2. References
      1. (1994) Med Lett Drugs Ther 36(631):1
  11. Management: Recurrent or resistant Treatment
    1. Any of above intravaginal meds for 14-21 days ($28-$54)
      1. Consider maintenance after initial daily regimen
      2. Maintenance: Repeat application once weekly
        1. Consider using monthly at time of Menses
      3. Consider Terconazole (see above)
        1. More effective against other candida species
    2. Fluconazole (Diflucan) ($16-$22 for two dose protocol)
      1. See below for maintenance protocol
      2. Less effective for non-albicans Candida
      3. Dose 1: 150 mg PO
      4. Dose 2: 150 mg PO at 72 hours after first dose
      5. Sobel (2001) Am J Obstet Gynecol 185:363
    3. Other options
      1. Ketoconazole (Nizoral) 200mg PO bid for 5-14 days
      2. Itraconazole (Sporanox) 200 mg PO qd for 3 days ($40)
      3. Gentian Violet vaginal staining 1-2x (Office charge)
      4. Boric Acid 600 mg vaginal tab bid for 14 days ($14)
        1. Use is controversial
      5. Flucytosine (Ancobon) cream applied to affected area
  12. Management: Prophylaxis (recent protocol)
    1. Indication
      1. Four or mor yeast infections per year
    2. Initial treatment
      1. Fluconazole (Diflucan) 150 mg PO q3 days for 3 doses
    3. Maintenance
      1. Fluconazole (Diflucan) 150 mg PO each week
      2. Monitor liver enzymes (consider q1-2 months)
    4. Efficacy
      1. Suppression while on treatment: 90%
      2. Following treatment: Infection recurs in 60%
    5. References
      1. Sobel (2004) N Engl J Med 351:876
  13. Management: Prophylaxis (old protocol)
    1. Protocol for 6 month maintenance regimen
      1. Start with 2 week recurrent treatment option above
      2. Follow treatment with prophylaxis option below
      3. Fungal Culture and exam timing
        1. Baseline
        2. Two weeks (after treatment regimen above)
        3. Three months
        4. Six months (when stopping prophylaxis)
    2. Medications
      1. Clotrimazole 500 mg vaginal tab weekly to montly
      2. Fluconazole 150 mg PO once weekly to monthly
      3. Ketoconazole 200 mg PO bid five days monthly
      4. Miconazole 100 mg vaginal tab qhs twice weekly
  14. Prevention
    1. Control predisposing condition (e.g. Diabetes Mellitus)
    2. Reduce predisposing medications (e.g. Corticosteroid)
    3. Avoid moisture-retaining products near vagina
      1. Nylon underwear
      2. Panty-liners
      3. Vaginal lubricants or Spermicides
    4. Lactobacillus (probiotic) is not effective
      1. Does not prevent post-antibiotic Vaginitis
      2. Pirotta (2004) BMJ 329:548
  15. References
    1. Desai (1996) Am Fam Physician 54(4):1337
    2. Nyirjesy (2001) Am Fam Physician 63(4):697
    3. Sobel (1998) Am J Obstet Gynecol 178:203
    4. Tobin (1995) Am Fam Physician 51(7):1715

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