The Challenges of Diagnosing Recurrent Vulvovaginal Candidiasis


Michael L. Krychman, MD, and Jack D. Sobel, MD, review diagnostic criteria of diagnosis of RVVC and the impact of misdiagnosis.

Michael L. Krychman, MD: What are some of the challenges about diagnosing recurrent VVC [vulvovaginal candidiasis]? Do you think people are very aware in the community at large?

Jack D. Sobel, MD: The first issue really, as far as diagnosis is concerned, is so-called self-diagnosis. This is the ability of any individual woman to be able to diagnose with great certainty that her symptoms are attributable to a yeast. Self-diagnoses are remarkably inaccurate. I know there’s always going to be some argument from the people listening in on this, participants hearing this, watching this video, but really there are numerous good objective studies that show just how unreliable self-diagnosis is. That doesn’t mean patients, women, don’t have symptoms, it simply means that the symptoms are entirely nonspecific. There’s nothing unique to the symptoms that says, “Oh, I obviously do have a yeast infection.” Repeatedly, women are referred to me because of recurrent candida vaginitis, and when I start interrogating and talking to them, and getting a history, and we do the appropriate tests, we find that there’s a lot of overdiagnosis of recurrent infections and there are some elements of underdiagnosis, especially for chronic disease. But you’ve already outlined the various symptoms involved, so the next issue, as far as diagnosis is concerned, it’s not difficult to diagnose once the patient finds herself visiting a practitioner, and this is not a telehealth visit. Telehealth is a wonderful advance in medicine and science, but in the diagnosis of vaginitis it’s about 10 steps backwards. You cannot diagnose reliably any form of vulvovaginal disease without seeing a practitioner who takes a history and does a good physical examination as well as the appropriate immediate local tests that are available within the doctor’s office.

Michael L. Krychman, MD: I agree with you. The physical exam is invaluable and we’ll touch upon the concept of overdiagnosis, underdiagnosis in a little bit and how the impact of telehealth and teleprescribing, and you had mentioned that people are misdiagnosing or over the counter, we don’t have confirmation of diagnoses, so overdiagnosis. Every vaginitis is not yeast. Sometimes there’s BV [bacterial vaginosis]. Sometimes there’s a mixed infection. Sometimes it’s vulvovaginal atrophy. I think part of the issue that we are seeing is we have created this issue where there is a lot of telephone diagnosis and treatment because we didn’t have a choice with COVID-19, and then we’re overtreating. We’re seeing the emergence of resistance. We’re seeing more nonalbicans candidiasis. We’re seeing a variety of things that are changing in the landscape.

Transcript Edited for Clarity

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