Women with non-albicans Candida (NAC) vulvovaginal candidiasis (VVC) were nearly twice as likely to have multiple physician visits for recurring infections compared to women who had C. albicans (CA) VVC, according to a retrospective chart review in the Journal of Women’s Health.
“The three questions we wanted to answer were the dominant specie of Candida for recurrence, any behavioral patterns associated with recurrence and any medications associated with recurrence,” said principal investigator Oluwatosin Goje, MD, an associate professor of ob/gyn and reproductive biology at the Cleveland Clinic Lerner College of Medicine (CCLCM), an affiliate of Case Western Reserve University in Cleveland.
The study comprised 174 women with a diagnosis of recurrent VVC and a positive vaginal fungal culture at CCLCM from 2010 to 2017.
Overall, 66% of women with NAC VVC had multiple physician visits for recurring infections compared to only 34% of women with CA VVC.
The women with numerous occurrences were significantly younger, had a lower body mass index (BMI), lower parity and endorsed high use of probiotics.
The NAC VVC group also had a higher percentage of postmenopausal women compared to women in the CA group: 87.5% vs. 61.3%, respectively.
“The discrepancy in postmenopausal rates was surprising,” Goje told Contemporary OB/GYN®. “On the other hand, it was reassuring that there was no significant difference between the CA group and the NAC group when we analyzed recent antibiotic use. After all, recent use of antibiotics is one of the risk factors for VVC.”
Still, the retrospective study has smaller numbers, so a larger prospective study is needed to delve further, according to Goje.
“CA remains the most prevalent species isolated in recurrent VVC, and recurrent VVC is more common in the premenopausal, sexually active woman,” said Goje, a staff ob-gyn and women’s health practitioner at the Cleveland Clinic in Ohio. “This is a very active woman who is busy with work, family, and life; thus having recurrent VVC may impact her quality of life adversely. Women with recurrent VVC report lower self-esteem, less social and physical activity, sexual discomfort, and poorer work outcome or missing work.”
To improve patient outcomes, Goje advocates early and proper diagnosis to prevent incorrect diagnosis. “Correct diagnosis would mean patients get the appropriate treatment on time,” she said. “Not every itch is yeast!”
A fungal culture for speciation and sensitivity is recommended in recurrent VVC if standard of care treatment (azoles) continues to fail, based on the frequency of recurrence. “Fungal culture is the gold standard in this cohort of patients with recurrent VVC,” Goje said. “This is the preferred line of management than continuous use of antifungal therapy if the patient has no resolution of symptoms.”
Patients with recurrent VVC may benefit from anti-fungal suppressive therapy for 6 months. “In my clinic, I have found it effective, with increased patient satisfaction compared to episodic treatment of VVC,” Goje said.
Because VVC is the second most common vaginitis, affecting millions of reproductive age women in the US, “more randomized controlled trials are needed to study the gaps in vaginitis; foremost, gaps in studying better therapeutics and looking at the relationship of the vaginal microbiome and VVC in the prevention of VVC. The microbiome changes with age and disease state,” she said.
Goje serves on the scientific advisory board of Evvy and Scynexis. She is also a contributor to Up-To-Date and the Merck Manuals.