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ORIGINAL RESEARCH |
From the Department of Obstetrics and Gynecology, Drexel University College of Medicine, Philadelphia, Pennsylvania.
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ABSTRACT |
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 ABSTRACT MATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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METHODS: Serially recruited subjects answered a questionnaire that asks about demographic information and symptoms and measures depression and stress scores. Patients underwent a standardized history, physical examination, and laboratory examination. Patients with recurrent vulvovaginal candidiasis, vulvar vestibulitis syndrome, desquamative inflammatory vaginitis, physiologic leukorrhea, and other diagnoses were compared with one another. Chi-square tests and one-way analysis of variance with Tukey honestly significant difference (HSD) post hoc analyses were used for categorical and continuous data analysis.
RESULTS: Two hundred patients were enrolled in this study. The most common diagnoses were contact dermatitis (21%), recurrent vulvovaginal candidiasis (20.5%), atrophic vaginitis (14.5%), and vulvar vestibulitis syndrome (12.5%); 18% of women had 2 or more diagnoses. In the overall study sample, the mean age was 38.4 years, 78% were white, and 55% were college educated. Sixty-two percent had symptoms for over a year. Desquamative inflammatory vaginitis patients were older and less likely to be menstruating. Those with vulvar vestibulitis syndrome had more frequent complaints of dyspareunia. Recurrent vulvovaginal candidiasis patients felt that their symptoms had the greatest negative impact on work and social life. There were high rates of psychiatric disorder (43.5%), atopic disease (42.5%), and pain syndrome (56%) in all groups.
CONCLUSION: Women with chronic vaginal symptoms have a variety of diagnoses, most of them noninfectious.
LEVEL OF EVIDENCE: II-3
Women with chronic vaginitis represent a challenging patient population. They often will self-medicate with a variety of over-the-counter and alternative medicines to get symptom control. Unfortunately, in some instances, the self-treatment may end up exacerbating the condition.3 In our experience, affected women will often speak eloquently of how disruptive these problems are to their quality of life and of how frustrated they are by the refractory nature of their conditions. Although frequently trivialized, chronic vaginal problems have a significant impact in the overall health and well-being of affected women.
As noted elsewhere, the causes of chronic vulvovaginal symptoms as seen in tertiary care vaginitis or vulvar clinics include a broad differential diagnosis, including infectious causes such as recurrent vulvovaginal candidiasis and a variety of vulvar disorders.3,4 Within these broad groups of conditions, there are few data about the relative frequency of these conditions. Furthermore, although there may be good insights into the populations of women with specific causes of chronic vaginal symptoms, such as, for example, those with vulvar vestibulitis syndrome,5 a broader understanding of the characteristics of the general population of women with chronic vaginitis is missing from the literature. The purposes of this study were to estimate what conditions are responsible for chronic vaginitis, to compare patient characteristics between women in different diagnostic categories, and to examine the effect of the conditions on work, social, and sexual functioning.
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MATERIALS AND METHODS |
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Informed consent was obtained from each patient before enrollment in the study. Enrolled patients were given a self-administered questionnaire requesting information about their conditions as well as overall health. Broad categories of questions were as follows: general demographics, description of symptoms, prior treatments, and general health questions. The questionnaires also included the Center for Epidemiologic Studies Depression scale,6 the Cohen Perceived Stress scale (maximum score=56),7 and the John Henry scale (maximum score=60).8 This last scale was developed to assess the extent to which a person actively copes with psychosocial stressors in her environment, with higher scores reflecting a greater feeling of control over one's life. Although these three scales have been validated in other patient populations, none have been used in a population of women with chronic vaginal symptoms. After completing the questionnaire, each patient underwent an evaluation that included a standardized history and examination, a vaginal pH measurement, amine test, smears for saline and potassium hydroxide microscopy, and yeast cultures. Cultures and polymerase chain reaction testing for other pathogens, including Nesseria gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis, and herpes simplex virus, were obtained if clinically indicated. Vulvar or vaginal biopsies were performed in patients with vulvar or vaginal findings where the diagnosis was in question (eg, hyperpigmented thickened skin suggestive of either lichen simplex or vulvar intraepithelial neoplasia). The clinicians who evaluated the patients entered the results of the examination and clinical tests onto a clinical findings data sheet. Diagnoses that best fit the overall clinical situation were then assigned to each patient. For the purposes of these analyses, in the case of women with multiple diagnoses, a primary diagnosis that clinicians felt accounted for the bulk of the symptoms was assigned. The other diagnoses were considered secondary.
The study population was then categorized into five mutually exclusive diagnostic groups: vulvar vestibulitis syndrome, recurrent vulvovaginal candidiasis, desquamative inflammatory vaginitis, physiologic discharge (ie, leukorrhea), and other conditions. The box "Criteria for Entering Patients Into the Diagnostic Groups" lists the criteria for entering the patients into the vulvar vestibulitis syndrome, recurrent vulvovaginal candidiasis, desquamative inflammatory vaginitis, and physiologic leukorrhea groups. Although desquamative inflammatory vaginitis and atrophic vaginitis may appear initially similar to one another, the main characteristics that distinguish the two conditions are the abnormal purulent discharge and the presence of copious leukocytes on microscopy. The additional criterion of a negative culture for T vaginalis was added to ensure that none of these patients had trichomoniasis that was missed by microscopy.
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Data analysis was performed with the SPSS 13.0 statistical software package (SPSS Inc, Chicago, IL). Continuous data were evaluated using one-way analysis of variance and Tukey honestly significant difference (HSD) post hoc tests. Categorical data were analyzed with 
2 tests. Fisher exact tests were used if the cells had fewer than five subjects. Fisher exact tests were used if the expected frequencies in the cells had fewer than five subjects. Multiple tests of proportions with Bonferroni correction were conducted after the 2 tests to ascertain differences between the specific groups.
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RESULTS |
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In the study population, the mean age was 38.4 years, with a standard deviation (SD) of 13. The patient population consisted of 156 (78%) white, 28 (14%) African-American, 6 (3%) Asian, and 6 (3%) Hispanic women. Most patients had completed a college education (n=110, 55%), were married or living with a partner (n=117, 59%), worked outside of the home at least part time (n=148, 74%), and had a household income of $40,000 or greater annually (n=150, 75%). One hundred twenty-four (62%) women described a duration of symptoms of a year or more. A measure of their eagerness to get specialized care for their problems is reflected in the 63% of women traveling for more than 1 hour to reach the center. Table 1 lists the most common diagnoses attributed to the 200 patients. Thirty-six (18%) patients had two or more diagnoses. In many of these patients, the additional diagnoses were felt to be only minor contributors to the patient symptoms. In women with multiple diagnoses, the most common secondary diagnosis was vaginal atrophy, which was found in 12 (33%) women.
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Table 2 compares the demographics between our five different patient subpopulations. Apart from women in the physiologic leukorrhea group, all groups exhibited relatively high (56% of total) rates of diagnoses for conditions that cause pain, defined here as fibromyalgia, chronic fatigue syndrome, chronic back pain, interstitial cystitis, irritable bowel syndrome, or migraine headaches. A relatively large number of patients noted concomitant psychiatric diagnoses (43.5%), primarily depression, obsessive-compulsive disorder, and panic/anxiety attacks. In addition, 42.5% had a history of allergic or atopic disease, defined as a history of asthma, "significant" seasonal allergies, or eczema. Symptoms and their effect on social and sexual functioning are shown in Table 3. Patients who answered that their vaginal or vulvar condition affected their social or work life moderately or worse were listed as affirmative responses for these categories. Vaginal or vulvar pain in daily activities and with sexual activity over the past four weeks was scored on a visual analog scale, which was then recalibrated from 0 to 100, with the worst pain being scored as 100. Of the 200 patients, 148 (74%) were currently in a sexual relationship and completed the scale for pain with sexual activity. In comparison with the physiologic leukorrhea group, women in the other groups had nore complaints of pain with sexual activity.
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For most health care providers, women with chronic vulvovaginal symptoms appear to be very similar to one another. However, differences noted in our analyses allow us to draw certain profiles of women with certain vulvovaginal conditions. For example, although more than 50% of women with desquamative inflammatory vaginitis and vulvar vestibulitis syndrome complained of dyspareunia, those with vulvar vestibulitis syndrome were younger, had fewer pregnancies and children, and were much less likely to complain of discharge. Not surprisingly, women with vulvar vestibulitis syndrome had more complaints of dyspareunia, scored higher on visual analog scales for sexual pain, but had fewer complaints of an abnormal discharge than women in the physiologic leukorrhea group.
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DISCUSSION |
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Recurrent bacterial vaginosis patients accounted for only 6.5% of our patient population. We found this result surprising and feel that it may represent referral or patient bias. Because bacterial vaginosis tends to be relatively easy to diagnose and tends to cause fairly mild symptoms, it may be that providers were reluctant to refer patients with recurrent bacterial vaginosis or that women with recurrent bacterial vaginosis are less likely to seek tertiary care for their symptoms. On the other hand, to our surprise, desquamative inflammatory vaginitis, present in 8% of our patients, was slightly more common than recurrent bacterial vaginosis. Universally described as rare,9,10 desquamative inflammatory vaginitis is a condition that causes a profuse purulent vaginal discharge and severe vulvovaginal inflammation. The etiology remains unknown although it has been associated with erosive lichen planus, pemphigus vulgaris, and mucous membrane pemphigoid. In a case-control study of 47 women with desquamative inflammatory vaginitis, Newbern and colleagues10 noted that patients with desquamative inflammatory vaginitis had similar demographics to friend controls. Not surprisingly, they were more likely to describe a previous diagnosis of other vaginal infections (possibly because of previous misdiagnosis). In our current study, we found that women with desquamative inflammatory vaginitis tended to be older and less likely to be menstruating than other patient groups. Apart from the physiologic leukorrhea group, women with desquamative inflammatory vaginitis were more likely to complain of an abnormal discharge but had lower scores on the daily pain scale. Because of the referral biases that are inherent in our patient population, we are unable to comment on the prevalence of desquamative inflammatory vaginitis in a broader population of women.
In a population of women with chronic vulvovaginal symptoms, we found differences between our diagnostic groups. For example, as one would expect, women with vulvar vestibulitis syndrome tended to be younger and better educated and to have a lower household income and fewer children than other groups. These last two findings would be expected in a population that is younger. Not surprisingly, the women with vulvar vestibulitis syndrome had the highest visual analog score for pain with sexual activity. Although dyspareunia is considered a hallmark of vulvar vestibulitis syndrome, we found that about half of patients with recurrent vulvovaginal candidiasis, desquamative inflammatory vaginitis, and other vulvovaginal conditions also complained of dyspareunia, and their rating of pain with intercourse on a visual analog scale was similar to that of women with vulvar vestibulitis syndrome. This finding underscores the fact that many conditions other than vulvar vestibulitis syndrome can cause dyspareunia and that women with this complaint need a careful diagnostic evaluation to ensure that they are properly identified.
It has been suggested that women with vulvodynia, including those with vulvar vestibulitis syndrome (also known as localized provoked vestibulodynia), may have a greater rate of other associated pain syndromes such as interstitial cystitis, fibromyalgia. Some authors have suggested that women with vulvar vestibulitis syndrome are at higher risk of having these comorbidities.11,12 In an earlier report, Fitzpatrick and colleagues11 reported three cases of women with vulvar vestibulitis syndrome and interstitial cystitis, and hypothesized that, because the vestibule and bladder shared common embryonic origins, the cause of both conditions might be similar. In an Internet-based survey of women with vulvar pain disorders, Gordon and colleagues12 found that 35% of their respondents had irritable bowel syndrome, 21% had fibromyalgia, and 18% had migraine headaches. However, because these investigators could not independently confirm each subject's diagnosis, it is not clear that these "comorbid" pain syndromes were indeed related to vulvar vestibulitis syndrome. More recently, in a case-control survey of women with vulvodynia, Arnold and colleagues13 found that fibromyalgia and irritable bowel syndrome were significantly associated with vulvodynia, with odds ratios of 3.84 and 3.11, respectively. Giesecke and colleagues14 found that women with vulvodynia also exhibited increased peripheral pressure pain sensitivity. They hypothesized that this finding was an example of central sensitization as a mechanism contributing to the patient's overall pain. Although their study suggests links between vulvodynia and other pain syndromes, our finding that women with a range of conditions that cause vulvar pain all exhibited similarly high (50–63%) rates of chronic pain syndromes implies that these "comorbid" pain syndromes are not associated with vulvar vestibulitis syndrome alone, but rather that they occur to a similar degree in women with other chronic vulvovaginal diseases.
As noted by Foxman and colleagues15 in their survey of 2000 women selected by a United States random-digit dialing survey, vulvovaginal candidiasis causes significant health care costs, with an estimated $1.8 billion spent on medical and treatment expenses, travel costs, and time missed from work. Our results show that, on a personal level, recurrent vulvovaginal candidiasis is also disruptive to the quality of life. In our study, recurrent vulvovaginal candidiasis patients were most likely to report that their condition affected their social or work life moderately or severely, and they reported high levels of daily pain. Thus, our study confirms that recurrent vulvovaginal candidiasis is a problem with significant social costs to the women who suffer from it. What is less clear is whether recurrent vulvovaginal candidiasis is associated with other diseases. Neves and colleagues16 have recently found in a Brazilian population that women with recurrent vulvovaginal candidiasis had a greater history of atopic disease (68%) than women with sporadic vulvovaginal candidiasis (15%). They hypothesize that the allergic response to other antigens in the vaginal area might cause changes at the mucosal level that facilitate the occurrence of a symptomatic infection by Candida albicans. It is estimated that the overall prevalences of asthma, allergic rhinitis, and atopic disease in the United States are 5–8%, 8–16%, and 15–20%,17,18 with much overlap among these three conditions. The relatively high rates of atopic disease (42.5% overall) in all of our patient groups, with the exception of the desquamative inflammatory vaginitis patients, highlight the role that atopy and allergy may play, not just in recurrent vulvovaginal candidiasis, but also in many different vulvovaginal conditions.
Across the board, our patient population exhibited a high rate of previously diagnosed psychiatric conditions, with 87 (43.5%) women noting a previous diagnosis of a psychiatric condition. This number seems quite high compared with estimated rates of 5–9% for depression and 3% for generalized anxiety disorder.19 In a Swedish study of 1,013 consecutive gynecologic outpatients who were administered a diagnostic tool for evaluating mood, anxiety, and eating disorders, Sundström and colleagues20 found that psychiatric disorders were present in 30.5% of women. However, they further noted that 79% of their patients had been previously undiagnosed and untreated. Because the rate of psychiatric disorders in our study represents women who had been previously diagnosed, our finding implies that the actual rate of psychiatric disorders is greater than what we report here. With a lack of a control group and given the self-reporting nature of our data, it is difficult to ascertain whether the rates of psychiatric disorders are higher in women with chronic vaginal symptoms than in other women. It is also possible that psychiatric disorders such as anxiety disorders and obsessive-compulsive disorder may make affected women more likely to focus on disturbing vaginal symptoms and thus more likely to request referral to a specialty clinic.
Our findings are limited by the lack of a matched control group of normal healthy women, the self-administered nature of our study questionnaires, the self-reporting of other health problems, and the inherent bias in a referral population. Because this analysis hinged on the diagnosis assigned at the initial visit, it is possible that referred patients may have had other diagnoses that were difficult to establish during the course of just one visit. Our focus on a primary diagnosis in women with multiple diagnoses may also have affected our findings. Finally, the small subgroup sample sizes may have limited our ability to detect differences between various groups. However, we wish to emphasize that our findings underscore that there is a broad range of conditions that can cause vulvovaginal symptoms, that a relatively broad differential diagnosis must be entertained when evaluating women with chronic symptoms, and that most of the causes of chronic "vaginitis" in a referral population are noninfectious. Finally, the finding that patients with these conditions report a significant negative impact on social, work, and sexual quality of life underscores the fact that these problems should not be trivialized.
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Footnotes |
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Presented as an oral presentation at the 2006 Annual Meeting of the Infectious Disease Society for Obstetrics and Gynecology, August 3–5, 2006, Monterey, California.
Corresponding author: Paul Nyirjesy, MD, 245 North 15th Street, New College Building-16th Floor, Philadelphia, PA 19102; e-mail: pnyirjes{at}drexelmed.edu.
doi:10.1097/01.AOG.0000239103.67452.1a
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REFERENCES |
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