Vulvovaginal Candidiasis and Atrophic Vaginitis

what shapes risk of vaginal infections?

• changes in normal flora

• changes in vaginal pH

• douching

• number of sex partners

goals of therapy for VVC

• relief of symptoms

• eradication of the infection

• reestablishment of normal vaginal flora

what is the mechanism underlying VVC and bacterial vaginosis?

estrogen → glycogen in vaginal lining → Lactobacillus eats glycogen -→ makes lactic acid → pH 4-4.5

pathophys of VVC

• antibiotics kill Lactobacillus

• pregnancy

• less Lactobacillus

• epithelium thins and dries → producing dryness, burning, and painful intercourse

atrophic vaginitis pathophys

• at menopause/postpartum/breastfeeding estrogen falls, so there is less glycogen, less Lactobacillus, and the epithelium thins & dries— producing dryness, burning, and painful intercourse

risk factors for VVC

• antibiotics = Kill normal flora, especially Lactobacillus → Candida overgrowth. 25–70% of women report VVC during/just after antibiotics; predictable post-antibiotic VVC is a classic self-care candidate.

• pregnancy/high-dose estrogen = Pregnancy, high-dose combined OCs, and estrogen therapy shift vaginal pH and susceptibility. (Low-dose OCs are unlikely contributors.)

• diabetes (poor control) = More glucose feeds yeast; frequent/recurrent VVC can be an early sign of undiagnosed diabetes

• immunocompromise = HIV, organ transplant, systemic corticosteroids, antineoplastics, immunosuppressants. Recurrent VVC can be an early sign of undiagnosed HIV.

10% of VVC cases may be _____-resistant

azole

odor of VVC

odorless

VVC discharge

thick, white, cottage cheese

vaginal pH

normal < 4.5

odor of BV

foul/”fishy”, worse after sex/menses

discharge of BV

thin, white/gray, sometimes foamy

pH of BV and trichomoniasis

>4.5

symptoms whose severity is tied to sexual intercourse, dysuria, vulvovaginal erythema/edema, or yellow discharge makes ______/__________ more likely

BV/trichomoniasis

• REFER

yeast produces __________

lactic acid

• not amines

BV and trichomoniasis replace acid-makers with ____________

amine-maker

• anaerobes overtake Lactobacillus, dropping lactic acid production and increasing pH >4.5

where does fishy odor of BV and trichomoniasis come from?

volatile amines released by bacteria overtaking Lactobacillus

requirement for self-care of VVC

prior, clinician-diagnosed epiode

what should you recommend for a patient with a first episode of VVC?

referral

self-care is appropriate for infrequent VVC, which is defined as…

< 3 infections in the past year and none in the past 2 month

• outside this window → REFER

what should you recommend for a patient whose symptom severity is worse with intercourse?

referral

what is classified as recurrent VVC?

> 4 documented infection in 1 year or symptom outside the self-care window

• may signal undiagnosed diabetes/HIV

what age must be referred for VVC?

< 12

what should you recommend for a patient with fever or pain in the lower abdomen/pelvis, back, or shoulder?

refer— suggests something beyond a local yeast infection

when do you refer for no improvement in VVC symptoms?

no improvement in 3 days or symptoms persisting beyond 7 days

exclusions for atrophic vaginitis

• Severe vaginal dryness or dyspareunia, or symptoms not localized to the vaginal area

• Any vaginal bleeding or spotting — postmenopausal bleeding must be evaluated to rule out endometrial cancer.

• Symptoms not relieved by lubricants — may need prescription vaginal estrogen.

class of drug used for uncomplicated VVC (mild-moderate, prior diagnosed episode, infrequent)

intravaginal imidazole

• clotrimazole

• miconazole

• tioconazole

1, 3, 7d course based on pt pref

counseling points for imidazoles

• relief in 2-3d

• full resolution ~1 week

• regimen length does not = speed of relief

• add external cream for vulvar itch

treatment for atrophic vaginitis

water or silicone based vaginal lubricant

why use lubrication for atrophic vaginitis?

replaces the lubrication lost when estrogen falls— symptom relief not a cure

why avoid oil-based products for atrophic vaginitis?

damage latex condoms/diaphragms

• refer for any bleeding

non-pharm management for VVC

• yogurt w live cultures/probiotics

• discontinuing a predisposing drug

first line for uncomplicated VVC and vulvar itching

imidazole

preference for drug delivery for imidazole

cream (or suppository/tablet plus the external cream)

does a 1, 3, or 7d imidazole regimen have a better cure rate?

overall cure rates are the same

• shorter courses may bring symptom relief faster by day 3

adverse effects for imidazoles

local

• vulvovaginal burning, itching, irritation (3-7%)

• most likely on the first application and easily confused with the infection itself

• headache can occur

avoid recommending vaginal products containing what 2 ingredient?

1. benzocaine

2. resorcinol

only mask itching, don’t treat cause, and carry local-reaction concerns

how do imidazoles kill yeast

inhibit a fungal CYP enzyme that the cell needs to make ergosterol — the sterol that holds the fungal cell membrane together (the fungal equivalent of cholesterol). Block it and ergosterol runs out while abnormal methylated sterols pile up, so the membrane loses integrity and the cell leaks and dies.

intravaginal miconazole can raise the INR in patients on _________; both go through ________

warfarin / CYP2C9

why are imidazoles a local, low-risk OTC drug?

human cell use cholesterol, not ergosterol, so the target is largely fungus-specific

• intravaginal dosing means almost nothing is absorbed

regimen for clotrimazole 1% cream

Insert cream into vagina daily for 7 days; apply to vulva BID PRN for itching.

clotrimazole 100mg vaginal tablet (+1% external cream) regimen

Insert tablet into vagina daily for 7 days; apply cream to vulva BID PRN for itching.

clotrimazole 2% regimen

Insert tablet into vagina daily for 7 days; apply cream to vulva BID PRN for itching.

miconazole (monistat 1) 1200mg suppository (+2% external cream) regimen

Insert suppository into vagina once for 1 day (morning or bedtime); apply cream to vulva BID PRN for itching up to 7 days.

miconazole (Monistat 3) 4% cream regimen

Insert cream into vagina daily for 3 days; apply to vulva BID PRN for itching.

miconazole (Monistat 7) 100 mg suppository regimen

Insert suppository into vagina daily for 7 days at bedtime.

miconazole (Monistat 7) 2% cream regimen

Insert cream into vagina daily for 7 days; apply to vulva BID PRN for itching.

Tioconazole (Vagistat-1 / Monistat-1 Day) 6.5% ointment regimen

Insert ointment into vagina once for 1 day.

what to recommend for VVC in pregnancy?

refer

• when treatment is indicated, a clinician uses a 7d clotrimazole, miconazole, or tioconazole regimen, ideally withholding the first trimester

VVC is rare before _______

menarche

are there any special considerations for otherwise-uncomplicated VVC in breastfeeding, older, or immunocompetent women?

no

atrophic vaginitis

inflammation of the vagina from atrophy of the mucosa when estrogen falls

• epithelium thins & lubrication declines, most commonly at menopause (also postpartum & during breastfeeding)

goals of self-care for atrophic vaginitis

reduce dryness, burning, itching, and dyspareunia

hallmark of atrophic vaginitis

dyspareunia (painful intercourses) with vaginal dryness, burning, or itching; symptom severity often tracks with intercourse

when is self-treatment appropriate for atrophic vaginitis?

mild to moderate, localized, and without bleeding

is petrolatum jelly a recommended vaginal lubricant?

no- hard to remove