II. Epidemiology

  1. Candida Vulvovaginitis accounts for 45% of Vaginitis
  2. Candida is cultured in 20-50% asymptomatic women
  3. Vaginitis often self diagnosed incorrectly

III. 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

IV. Risk 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 (and other hyperestrogenic states)
  5. Premenstrual phase of the Menstrual Cycle
  6. Depressed cell mediated immunity (e.g. HIV or AIDS)
  7. Obesity

V. 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)

VI. Signs

  1. Adherent white cottage-cheese discharge in vagina
    1. Sensitivity: 50%
    2. Specificity: 90%
  2. Vulvar erythema and edema (24% of cases)

VII. Labs: Initial

  1. KOH Preparation (10%)
    1. Test Sensitivity: 50%
    2. Pseudohyphae or budding yeast forms
    3. GynVaginitisYeast.jpg
  2. Vaginal pH <4.5 (Normal acidity)
  3. Absent Amine odor
  4. White Blood Cells not increased
  5. Wet-Prep is not sensitive or specific for yeast
    1. Bornstein (2001) Infect Dis Obstet Gynecol 9:105-11 [PubMed]
  6. Candida on Pap Smear
    1. Specific but not sensitive

VIII. Labs: Complicated cases

  1. Fungal PCR for candida strain
    1. Consider in cases refractory to standard therapy
  2. Fungal Culture positive
    1. Fungal Culture rarely performed (fungal PCR preferred)
    2. Fungal Culture may be very helpful in certain cases
      1. Confirm asymptomatic carrier of vaginal Candida
      2. Identify cause of recurrent Vaginitis

IX. Differential Diagnosis (Consider for refractory cases)

  1. Other Vaginitis cause
    1. Bacterial Vaginosis
    2. TrichomonasVaginitis
  2. Infectious Cervicitis (Sexually Transmitted Disease)
  3. Allergic Vaginitis or Vulvitis
  4. Vulvodynia
  5. Herpes Simplex Virus
    1. HSV presents with unilateral painful lesions
    2. Contrast with bilateral, symmetric involvement in Candida Vulvovaginitis

X. Management: Local First-Line Agents

  1. Miconazole
    1. Monistat 1200 mg vaginal tab PV qhs, 1 dose
    2. Monistat 4% cream, 5 g PV qhs for 3 days
    3. Monistat-3 200mg PV qhs for 3 days ($30)
    4. Monistat-7 2% cream PV qhs for 7 days ($15)
    5. Monistat Vag tabs 100mg PV qhs for 7 days ($15)
  2. Clotrimazole (Gyn-Lotrimin, Mycelex G)
    1. Clotrimazole 500 mg vaginal tab PV qhs, 1 dose ($19)
    2. Clotrimazole 200 mg vaginal tab PV qhs for 3 days
    3. Clotrimazole 2% cream qhs for 3 days ($14)
    4. Clotrimazole 100 mg vaginal tab PV qhs for 7 days ($14)
    5. Clotrimazole 1% cream qhs for 7 days ($14)
  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. Vagistat-1 6.5% ointment, 5 g intravaginally once
      1. Highly effective and less irritating than creams
    2. Terazol 80 mg vaginal suppository PV for 3 days
    3. Terazol-3 0.8%, 5 g vaginal cream for 3 days
    4. Terazol-7 0.4%, 5 g vaginal cream qhs for 7 days ($25)
  5. Nystatin
    1. Nystatin vaginal tablet (100,000 unit) PV daily for 14 days
    2. Nystatin ointment (100,000 units/g)
      1. Ointments are less irritating than creams

XI. Management: Oral Agents

  1. Fluconazole 150 mg PO for 1 dose
    1. As effective as Clotrimazole PV
    2. Do not use in pregnancy
      1. Evidence of Miscarriage risk, with even 1-2 doses
      2. Mølgaard-Nielsen (2016) JAMA 315(1):58-67 +PMID:26746458 [PubMed]
    3. Consider repeat scheduled treatment for persistent symptoms
      1. Consider prescribing Fluconazole 150 mg every 3 days for up to 3 doses for persistent Vaginitis symptoms
    4. Symptom improvement delayed for 24 hours with Fluconazole
      1. Consider concurrently treating with Nystatin ointment (100,000 units) for the first several days (least irritating)
  2. References
    1. (1994) Med Lett Drugs Ther 36(631): 1-2 [PubMed]

XII. Management: Recurrent or resistant Treatment

  1. Consider risk factors above
  2. 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
  3. 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. Consider a 3rd dose at 72 hours after second
    6. Sobel (2001) Am J Obstet Gynecol 185:363-9 [PubMed]
  4. 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

XIII. Management: Prophylaxis (more 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 351:876-83 [PubMed]

XIV. 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 orally once weekly to monthly
    3. Miconazole 100 mg vaginal tab qhs twice weekly
    4. Avoid oral Ketoconazole due to hepatotoxicity

XV. 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 329:548-51 [PubMed]

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