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;85:11461148.

Up to 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.

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

Causative agent

C. albicans 85-90%
C. glabrata 5-10%
Others: C.tropicalis, C.krusei, C. kefyr,
& Saccharomyces cerevesiae (Brewers
yeast)

Symptoms

Vulval itching or soreness

Vaginal discharge
Superficial dysparenuia
External dysuria

Signs

Erythema
Fissuring
Non offensive discharge
Satellite lesions
Oedema

Investigations

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

Classification of VVC
.

Sobel JD et al, Am J Obs Gynecol 1998;178:203-211

1 Candida colonisation
2 Uncomplicated VVC
3 Complicated VVC

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 doesnt
distinguish between commensal and
pathogen

Uncomplicated VVC
mild
infrequent
non-persistent
non-pregnant women

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

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

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

Oral therapy

Fluconazole 150mg PO stat

Itraconazole 200mg PO BD 1 day

Choice of therapy

Oral
more acceptable to some
?quicker onset
systemic side effects
?not safe in pregnancy

Vaginal
messy
occasional irritation

Sexual partner

Grade A evidence to show treatment of

asymptomatic male sexual partners
is not required

Follow up

Unnecessary if symptoms resolve

Test of cure unnecessary

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

Differential diagnosis

Trichomonas vaginalis
Bacterial vaginosis
Herpes simplex virus
Vulval disease
Chlamydia
Gonorrhoea

125 women referred with problem

thrush to Dr David White at Hawthorn
House, Heartlands Hospital
Non albicans
4%

Nil of note
3%

Vestibulitis
4%

Other
18%

DN re-attend
40%

Eczema
12%

RVVC
19%

? 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
1998;102:939-944.
Give treatment to take after swab taken

Pediatrics

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

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

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.

Summary

No pathognomic feature
Itching is only predictive symptom/sign
Diagnosis needs laboratory confirmation
Symptoms/signs no guide to species
Asymptomatic male partners dont require
treatment
Remember to enclose copies of positive
swabs when referring
Consider differential diagnosis