Yeast not always the culprit in common vaginal infections

Vaginitis is probably the most common complaint, after pregnancy and well visits, among women who visit my office. Most of these patients present with vaginal itching, irritation and abnormal discharge or odor. 

Some women with vaginitis have already diagnosed themselves with a vaginal yeast infection, and have treated themselves unsuccessfully with over-the-counter (OTC) medication before coming into the office. 

But contrary to popular belief, not all vaginitis is caused by yeast, just as not all yeast infections can be alleviated with over-the-counter treatments.  This is why I'm hesitant to treat vaginitis over the phone, despite frequent patient requests that I just call in a prescription. 

It usually only takes a brief exam and a wet prep slide to distinguish between vaginal candidiasis and bacterial vaginosis (BV) — the most common vaginal infection in women of childbearing age. During this exam, other vaginitis culprits such as trichomoniasis or herpes can be ruled out, and STI testing can be performed if needed. 

Topical prescription treatment, with either an azole antifungal for candida or metronidazole for BV, is usually my first choice for uncomplicated vaginal infections. However, some patients prefer oral treatment.

I find that the greater challenge comes with treating recurrent infections. Many women who suffer from chronic vaginitis are frustrated when the standard treatments stop working or only briefly eliminate their symptoms.

Lab test are now available to determine which species are causing the yeast infection or BV. Utilizing these tests is often my initial action when standard treatments are ineffective, as not every organism is sensitive to commonly used medications. 

The CDC recommends a two-week intensive therapy regimen with an azole, followed by six months of maintenance therapy for chronic yeast infections. For chronic BV, the recommendation is six months of twice weekly metronidazole vaginal gel.   

While these regimes can be effective, I have found that in cases of chronic vaginitis, thinking outside the box often works best. Boric acid vaginal suppositories, which must be made in a compounding pharmacy, are highly effective in treating both chronic vaginal candida and chronic BV. 

I also recommend that women eliminate harsh soaps, avoid over-washing and sleep without underwear. Boosting the immune system with adequate sleep, proper nutrition and proper stress management are other key components in treating chronic vaginitis. Daily multivitamins that contain folic acid can also be helpful, and some midwife friends of mine advise increasing dietary garlic and acidophilous intake. 

Underlying causes for chronic vaginitis, such as diabetes and HIV should always be ruled out. Also be sure to review sexual habits, as BV is more common among women that have multiple sex partners.  

Vaginitis management is not always as simple as calling in a simple prescription. Patients should be educated that OTC treatment is often ineffective, and the “yeast infection” they are treating may not be yeast at all!

Robyn Carlisle, MSN, CNM, WHNP, is a full-scope midwife at University Doctors and Kennedy University Hospital in Sewell, N.J.

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