Oestrogen, glycogen and vaginal candidiasis.

Our aim was to relate vaginal candidiasis to vaginal oestrogenisation. First, the incidence was determined (subjected to chi-square analysis) of vaginal Candida albicans infection in 339 consecutive dermogynaecology clinic patients aged 55 years and over, of whom 142 were using and 197 were not using oestrogen. Second, the ability of Candida species to utilise glycogen as a sole nutrient source was studied by performing assimilation tests using yeast nitrogen broth as a basal medium. infection on initial presentation compared with 4% in the cohort not using oestrogen (p < 0.001). All 34 isolates of C. albicans assimilated glycogen. Twenty-six non-albicans species of Candida tested did not assimilate glycogen. In this study of postmenopausal women, there was a highly significant relationship between the usage of oestrogen and the occurrence of C. albicans infection. The production of glycogen by oestrogen stimulated epithelial maturation provides an attractive substrate for C. albicans.

Adverse behavioral and sexual factors in chronic vulvar disease.

OBJECTIVE: We investigated the prevalence of adverse sexual, personal hygiene, and self-treatment behavior among women with chronic benign vulvar and vaginal disorders. STUDY DESIGN: This study was carried out by means of a scientific clinical audit producing actuarial data by way of a semistructured questionnaire. Subjects consisted of a sample of 530 cases treated at a specialist clinic for vulvar diseases. In addition to clinical and laboratory investigations, the patients were interviewed by the clinic's psychologist, who used a structured interview schedule developed specifically for the study. Descriptive analysis and analysis of variance were used to investigate data. RESULTS: Most patients remained sexually active in spite of arousal failure and discomfort and engaged in unlubricated and often painful sexual intercourse. Most women engaged in potentially harmful genital hygiene and self-treatment behavior. Adverse self-treatment practices but not adverse genital hygiene practices were associated with greater symptom duration. CONCLUSIONS: Adverse practices should be addressed during the management of cases of chronic vulvar disease.

Dyspareunia and vulvar disease.

OBJECTIVE: To determine the presence and frequency of contributing factors in functional dyspareunia and if these factors differ between patients with an epithelial disorder and those with apparently healthy genitalia. STUDY DESIGN: A psychologist assessed patients reporting dyspareunia at a vulvar diseases clinic by using a structured interview questionnaire, the Beck Depression Inventory, and the Spielberger State/Trait Anxiety Inventory. The questionnaire topics included sexual behavior, stresses and coping. Data were divided into two groups based on patients' functional diagnosis or epithelial disorder. RESULTS: Both groups recorded high levels of trauma-producing sexual behavior. Such behavior included unlubricated, unaroused and undesired sex. High levels of psychological and coping difficulties were also seen. Differences between the groups were seen in undesired sex, capacity to cope, stress factors coincidental with symptom onset and distress at the time of interview. CONCLUSION: Due to the high frequency of factors contributing to dyspareunia, such factors should be address regardless of the diagnosis. In all such patients it is recommended that a sexual and stress history be taken and counseling be considered.

Evaluation of patch testing in patients with chronic vulvar symptoms.

The Dermogynaecology Clinic was established at the Mercy Hospital for Women in 1989. Since its inception, 700 patients have been investigated and 15% were clinically diagnosed as having contact dermatitis. Primary irritant dermatitis was regarded as the common cause but to investigate the place of contact allergy 50 patients were patch tested to a standard battery, medicaments, preservatives, corticosteroids and miscellaneous allergens. Twenty-one patients (42%) had a total of 44 positive tests. The most common positive reactions were to nickel (22%), cobalt (6%), fragrances (12%), caine mix (6%) and ethylenediamine (8%). Medicaments and fragrances were regarded as important allergens. Corticosteroid and imidazole allergy was not a problem in this series of patients.

Human papillomavirus vulvitis: a new disease or an unfortunate mistake?

OBJECTIVE: To determine whether human papillomavirus (HPV) was responsible for symptoms in women with vulvar pruritus, pain and superficial dyspareunia who had been referred with a diagnosis of HPV vulvar disease made on clinical and/or colposcopic and/or histological grounds. DESIGN: In addition to standard clinical and laboratory investigations of the whole population, a sample of 15 test cases from the population of 71 women referred with a clinicopathological diagnosis of HPV vulvar disease, and two positive and 21 negative controls were assayed for HPV DNA. Polymerase chain reaction assays using L1 consensus primers were performed blinded to the clinicopathological diagnosis. SETTING: Dermogynaecology Clinic at Mercy Hospital for Women. SUBJECTS: Seventy-one women referred with a diagnosis of HPV vulvar disease. RESULTS: Thirteen cases which could be tested for HPV DNA were negative. Diagnoses other than HPV were found for the women's presentation in all cases. CONCLUSIONS: In the population studied, our investigations indicated that the clinicopathological diagnosis of HPV infection was incorrect and that HPV was not a cause of vulvar symptoms. We believe that the term HPV vulvitis is unfortunate as it has invited destructive treatments and drawn attention away from more likely causes of this difficult group of vulvar conditions.

Depo-Provera use in an Australian metropolitan practice.

OBJECTIVE: To review the characteristics and experience of Australian women treated with depot medroxyprogesterone acetate (DMPA) in one gynaecological practice in Melbourne since 1973. DESIGN: A detailed retrospective review of clinical data on 363 women treated with a total of 2298 injections of DMPA over the past 20 years. RESULTS: The main indication was contraception, although a substantial minority (20%) were treated with DMPA predominantly for medical indications such as endometriosis. No pregnancy occurred within three months of an injection. There was also high acceptability, with a mean of 6.3 injections per subject, and a mean overall follow-up of 43.3 months. The median delay in the return of fertility in those wishing to conceive immediately was 9.2 months. Only one patient complained of difficulty in conceiving. Menstrual bleeding disturbances only led to 7.3% of the discontinuations, although fairly frequent use of short courses of oral oestrogen (in 40% of women) was employed in the early months of DMPA treatment. Other side effects were relatively infrequent, the most common being superficial dyspareunia or reduced libido (in 8%). CONCLUSIONS: This much maligned drug merits a legitimate place among the contraceptive choices available for Australian women. Accurate, unbiased information about the extensive worldwide experience needs to be made available to all Australian medical practitioners.

PIP: In Australia, obstetrician-gynecologists analyzed records of 363 patients, 17-50 years old, from a private practice in the northern suburbs of Melbourne, who received injections of 150 mg Depo-Provera every 12 weeks, to determine the experience of these women. Over a 20-year period (1973-1993), the women had together received a total of 2298 injections. Most women (80%) used Depo-Provera for contraception. Other common indications for Depo-Provera use were treatment of endometriosis, recurrent candidiasis, and menorrhagia. No patient conceived within 3 months of injection. The mean number of injections per patient was 6.3. The mean overall follow-up was 43.3 months. Among women who wanted to become pregnant, the median contraception interval from the end of presumed contraceptive action and pregnancy was 9.2 months (range, 1.1-20.5 months). Just 1 woman complained that it was difficult for her to conceive after Depo-Provera treatment. The most common reason for discontinued use of Depo-Provera was no further need (e.g., sterilization) or change to oral contraception (41.6%). Side effects accounted for discontinuation in 23.4% of the women. Bleeding irregularities comprised 7.3% of discontinuations. Many women (40%) sometimes had light, prolonged bleeding and received ethinyl estradiol to treat it, usually in the 1st 6-12 months of treatment. Other side effects occurred rather infrequently, the most prevalent being reduced libido or difficulty with intercourse (8%). These findings confirm that Depo-Provera is a very effective and acceptable contraceptive method. It deserves a legitimate place among the contraceptive choices available for Australian women. Australian physicians should have access to accurate, unbiased information about the extensive worldwide experience of Depo-Provera.

Cytology of the vulva.

It was postulated that deficiencies in the technique of smear preparation are responsible for the fact that vulvar cytology lacks the frequent usage it deserves. Vulvar squamous and basal cell carcinoma, Paget's disease, intraepithelial neoplasia and podophyllin-resistant warts were sampled with vulvar cytology. In each case, smears were taken using a spatula, a swabstick and the technique of scraping with a scalpel blade held perpendicular to the tissue after cleaning the surface with saline. The slides were then compared after the abnormal cells had been indicated on the coverslip with an ink dot. Only when the scalpel blade was used was the preparation suitable for diagnosis in every case. Used correctly, vulvar cytology has considerable application for the gynecologist. It permits rapid diagnosis and delineation of lesions and is useful in the long-term follow-up of malignant and potentially malignant conditions.

Depo-Provera in the treatment of recurrent vulvovaginal candidiasis.

The long-acting injectable progestogen Depo-Provera appears to substantially reduce women's susceptibility to recurrent vulvovaginal candidiasis. Pregnancy and exogenous estrogen appear to counteract this effect of the drug. Evidence was derived from 15 patients studied for up to six years.

PIP: Patients with a history of recurrent candidiasis and who were using Depo-Provera (medroxyprogesterone acetate, DMPA) for contraception were reviewed in order to determine the time relationship between episodes of proven candidiasis, episodes of pruritus vulvae suggestive of this infection (but unproven), and injection of DMPA. Recently, patients were included in the study who had been given DMPA specifically to prevent recurrences of candidiasis even when the drug's contraceptive action was unnecessary, such as after sterilization. In all cases, the infection was initially treated with a vaginal candidacide, most commonly 1 week of an imidazole. The patients ranged in age from 19-37 years at the time of the 1st injection. Diabetes had been eliminated in all the cases. DMPA was given intramuscularly at a dose of 150 mg every 12 weeks. Prior to 1983, an estrogen supplement was prescribed in most cases in an effort to produce monthly menstrual periods. Estrogen supplementation is no longer used routinely, with amenorrhea the aim, although it is occasionally given to women who experience breakthrough bleeding. Candidal infection was considered proven when the branching filaments of the species were seen on a stained vaginal smear or when the species were cultured in a laboratory from a vaginal swab taken a symptomatic patient. With the exception of 2 patients, clinical candidiasis did not occur within the time in which 150 mg of intramuscular DMPA is known to suppress ovulation in all women, i.e., 12 weeks -- except in the presence of exogenous estrogen (cases 1, 2, and 14) and in one case (15) in which the patient had an unplanned conception prior to the injection. Both patients who experienced clinical despite the use of DMPA alone (cases 8 and 13) asked remain on the drug because believe it was responsible for their longest remissions in the past few years. The study seemed to provide evidence that DMPA will prevent a recurrence of clinical candidiasis in many women who are prone to this condition. The study further indicated that estrogens may predispose women to this infection.

Vulvovaginal candidiasis: treatment and recurrence.

This study compares the effectiveness of 6 treatment regimens for vulvovaginal candidiasis with 6 months' follow-up. 292 patients randomly allocated to the treatments completed the trial. Significant differences were found in the rates of recurrence within the different treatment groups. The most successful treatment was miconazole vaginal cream with oral nystatin, with a cure rate of 81%. The high rate of recurrence of this condition is noted and the need for at least 6 months' follow-up in future trials of candidacides is emphasized.