Chronic Infection

Persistent or recurrent vaginal infections may cause daily or episodic symptoms of itching, irritation or burning. Not all women have persistent discharge from the vagina. Research supports that approximately 5% of women will suffer from recurrent infections.

The most common recurrent infections are:

1. Yeast 2. Bacterial Vaginosis 3. Trichomonas

Yeast Infection Yeast infections are common; approximately 20% of all women will experience one in their lifetime. Diabetes, pregnancy, antibiotic use and immuno-suppression are risk factors that predispose women to yeast infections. Yeast infections are not sexually transmitted. Although most women worry that their partner may be a source of re- infectivity, the penis is not a reservoir. In addition, a diet high in refined sugar does not put a woman at risk for recurrence. For some women with chronic yeast infections, the symptoms may flare at the same time during the menstrual cycle. Some experience burning with urination or vaginal dryness. Intercourse may be painful.

Recurrent infection is defined as 4 infections/year. Diagnosis is made from history and physical exam. Usually a special fungal culture is obtained to identify the yeast organism. If an acute infection is occurring, this is treated aggressively for 7-14days. Treatment is administered either orally or vaginally. Boric acid, a natural acid compound, can be used to effectively treat some resistant strains of yeast. Suppression may follow after treatment for the acute infection and may be recommended for up to 6 months. Most experience relief with long-term treatment, although the recurrence rate after suppression can be as high as 30%.

Many women are interested in the use of acidophilus products to prevent or treat chronic yeast infections. The research does not support that the administration of acidophilus orally, vaginally, rectally or douching is an effective means to treat fungal infections of the vagina. Active research is ongoing in hopes of identifying a successful way to replace the lactobacillus (“good bacteria”) of the vagina to prevent recurrent infection.

The Program in Vulvar Health • OHSU Center for Women’s Health Last updated Nov 2007 • www.ohsuwomenshealth.com/vulva/

Sobel, NEJM 1997, Vol 337:26, pp 1896

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Schuman, P., et al., Weekly fluconazole for the prevention of mucosal candidiasis in women with HIV infection. A randomized, double-blind, placebo-controlled trial. Terry Beirn Community Programs for Clinical Research on AIDS. Ann Intern Med, 1997. 126(9): p. 689-96.

Guaschino, S., et al., Efficacy of maintenance therapy with topical boric acid in comparison with oral itraconazole in the treatment of recurrent vulvovaginal candidiasis. Am J Obstet Gynecol, 2001. 184(4): p. 598-602

Sobel, J.D. and W. Chaim, Treatment of Torulopsis glabrata vaginitis: retrospective review of boric acid therapy. Clin Infect Dis, 1997. 24(4): p. 649-52.

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Bacterial Vaginosis Bacterial vaginosis (BV) represents a change in the ecosystem of the vagina. It is not a true infection but represents an imbalance in the bacterial environment. BV is not a sexually transmitted infection but has been associated with chronic douching, sexual activity, spermicides, young age, IUD, and African American race. Some women experience vaginal irritation accompanied with a thin, watery, yellow-green discharge. There can also be a characteristically fishy odor. Although there is a tie to sexual activity, treating the sexual partner has not been shown to reduce the risk of re-infection.

Chronic BV is defined as 3 episodes/year. Treatment is often with an oral or vaginal antibiotic called Flagyl (metronidazole) for 5-7days. For difficult cases, treatment may be extended to 14days. Only one study thus far has examined the use of prophylactic antibiotics for recurrent BV. Although Flagyl gel placed intravaginally twice weekly reduced the rate of recurrence, these women suffered more yeast infections due to the use of chronic antibiotics. Like other chronic infections, there has been great interest in products used to re-establish the vaginal bacterial environment. To this date, the use of probiotics has not been shown to be helpful but research continues in hopes of establishing an effective and successful way to promote normal bacterial colonization of the vagina.

2006 CDC STD Treatment Guideline Wilson, STI 2005, pp8-11 Larsson. Int J STD AIDS 1992; 39:220-3 Potter, BrJ Gen Pract, 1999; 49: 913-18 Sobel, AJOG, 2006; 194:1283.

The Program in Vulvar Health • OHSU Center for Women’s Health Last updated Nov 2007 • www.ohsuwomenshealth.com/vulva/

Trichomonas Trichamonas is a sexually transmitted infection caused by a single-celled organism. Women often experience a copious, yellow discharge that can lead to irritation and painful intercourse. Treatment of both the patient and her partner is important to avoid re-infection. Chronic infection with trichomonas is uncommon but can be troublesome. Typical treatment is with oral Flagyl (metronidazole). If recurrent infection occurs, treatment may be extended or sensitivity testing using a vaginal culture may be performed to ensure effective treatment with Flagyl.

2006 CDC STD Treatment Guideline

The Program in Vulvar Health • OHSU Center for Women’s Health Last updated Nov 2007 • www.ohsuwomenshealth.com/vulva/