Readers respond to articles on refractory vulvovaginitis and the bimanual pelvic examination.
Dr. Merida Miller’s review of recurrent vulvovaginitis ["Recurrent vulvovaginitis: Tips for treating a common condition," August 2014 Contemporary OB/GYN] is thorough and accurately reflects the standard thinking of the care of women with these problems. I would, however, like to point out two areas of disagreement.
1. Non-culture studies of the bacterial flora of the vagina of healthy women done in the laboratory of Dr. Larry Forney do not support the primacy of the role of H2O2-producing lactobacilli in maintaining a normal bacterial environment in the vagina. Instead, lactic acid-producing bacteria seem to be the key to vaginal health. This is important, for it calls into question the Nugent criteria for the diagnosis of bacterial vaginosis.
2. The notion that a culture for yeast should only be sent to the laboratory if the diagnosis is in question reflects the microscopic expertise of Dr. Miller, but not that of the practicing physician.
a. A number of observational studies indicate that about 42% of women who are sure they have a vaginal yeast infection have a positive culture for yeast. Many of these women feel this way for they have instructed by their doctors that their vaginal and vulvar symptoms are due to a yeast infection.
b. The brutal reality for physicians is that a number of observational studies indicate that only 46% of the women diagnosed by physicians as having a vaginal yeast infection actually had a positive culture for yeast. This sad reality was reinforced years ago by the observations of Dr. Paul Nyirjesy, who noted that only one in four patients sent to him with a presumed chronic or recurrent vaginal yeast infection had a positive culture for yeast when he evaluated them.
c. I have had this same experience in my own referral practice. In view of this, the current standard of care should be to obtain a fungal culture in every patient suspected by the physician of having a vaginal yeast infection. It would avoid the all-too-often repeated treatments for an infection that is not present.
William J. Ledger, MD
New York, NY
I would like to thank Dr. Ledger for his well-considered points regarding the article on recurrent vaginitis. I agree with the comments raised and thank him for bringing them to the attention of the readers. I would like to state, however, that despite considerable research by Dr. Ledger and others, understanding of the vaginal ecosystem still remains limited. I certainly agree with his comment about the Nugent criteria, but it is not generally used clinically given the requirement for a gram stain. I rely heavily on the Amsel criteria for diagnosis as microscopy is more cost-effective, less time-consuming and results have been shown to be highly accurate.
I would also like to clarify my diagnosis strategy for yeast. If there is positive microscopy, I believe treatment can be considered. If there is any question about the diagnosis or if this is a case referred for recurrent yeast, then a culture is necessary. I certainly agree that there is ample evidence that yeast is misdiagnosed both by providers and patients alike. The culture can also help identify the correct strain and help tailor the treatment plan.
My thanks again to Dr. Ledger for his thoughtful comments.
Merida Miller, MD
Praise to you for voicing out against the ACP Clinical Guideline against routine annual exams ["Whither the bimanual examination?" August 2014 Contemporary OB/GYN]. Why are other ob/gyns not speaking out and recommending against this ridiculous statement? Daily I see women from other practices presenting for consultations in regards to menopause and daily I hear them say, "My ob/gyn said I don't need a follow up but every 2 years"!
It is ludicrous that board-certified ob/gyns have conceded to the recommendations of ACP! Is it laziness from physicians who feel seeing fewer patients is beneficial for their own good and not the good of the patient? Is it the old "it's not cost effective" statement issued by ACP and insurance companies? Well it might not be "cost effective" unless it is their mother, wife, sister, or daughter!
Thank you for bringing this to light in Contemporary OB/GYN. Hopefully physicians will read it and take a second look at who the authors are heed your advice and stand on the issue!
James Mirabile, MD, FACOG
Overland Park, Kansas