"Not thrush again!" Women's experience of post-antibiotic vulvovaginitis

Vulvovaginal candidiasis (VVC) is a common problem, causing significant morbidity and affecting women's wellbeing. It results in major costs to the healthcare system,1-3 with annual costs in the United States estimated at $US1.8 billion.4

Access to over-the-counter (OTC) medications allows women to self-diagnose and treat vaginal symptoms.5,6 Although this increases women's autonomy, there are concerns about the accuracy of self-diagnosis and the appropriateness of OTC medication choice,7 as well as fears of cross-resistance of Candida spp to imidazoles resulting from inappropriate use.8

Studies of the extent of the impact of symptoms of VVC on women and how they manage them are limited by this difficulty of accurate self-diagnosis.7 Given this limitation, studies in the United States have shown that a high proportion of women use OTC antifungal agents or alternative treatments for chronic vaginal symptoms,9,10 and that more than half of a group of white women consulted a doctor for their most recent episode of vulvovaginitis.11 A study in the United Kingdom found that a third of women had bought OTC antifungal medications for vulvovaginitis,2 and that women often used alternative treatments in addition to OTC antifungal agents.3

Cohort and case–control studies have found a significant association between taking antibiotics and developing VVC.12-14 A comprehensive literature search found only one US prospective community-based study in which 28% of 78 women developed symptomatic microbiologically proven candidal post-antibiotic vulvovaginitis (PAV).15

Australian community data are lacking. We found no published research of how women specifically manage the problem of PAV. We report here a cross-sectional study exploring how often symptoms of PAV occur, how women manage these symptoms, and whether concern about PAV affects their decisions regarding antibiotic use.

Of the 16 practices approached, four were ineligible (one solo practitioner was on holidays, one clinic had closed and two had populations unsuitable for the subject of the study — one was for army personnel and the other had elderly, non-English speaking patients). Of the remaining 12 practices, five agreed to participate. The location of these five clinics ranged from inner city to outer suburban Melbourne. Their patients had a mixture of ages from young families and students to elderly people, with SEIFA codes ranging from 3 to 9 (Socio Economic Indexes For Areas: 1 = lowest socioeconomic group and 11 = highest).21

Reliance on self-reported symptoms, with no confirming microbiological data, has limitations.17 However, the symptoms of vaginal itch and discharge have a high positive predictive value for VVC (91%) in women taking anti-biotics.15 Self-diagnosis of VVC in other settings may be inaccurate, so our study can only claim to report symptoms suggestive of and interpreted by women as VVC. Certainly, a large number of women in our survey reported symptoms of VVC in the previous month. However, as their treatment decisions were based on their perceived symptoms, these findings have clinical relevance for both the women and their practitioners.

Australian women use a wide range of medications to prevent and treat PAV, as did UK women for VVC.3 Surprisingly, 49% of women with a history of symptoms suggestive of VVC, after taking prescribed antibiotics, would use an antifungal agent as prophylaxis. The women in our sample used OTC antifungal agents more commonly than women in a UK study,2 but less frequently than those in US studies in which the context was chronic vaginal symptoms.9,10 As in the US studies, about 40% of the women used yoghurt or lactobacillus products to prevent or treat PAV. Women in our sample preferred the oral route; however, at the time of our survey there were no convenient per-vaginum forms of these therapies commercially available. Despite the popularity among women of complementary and alternative products for this indication, there is no evidence that any of these treatments are effective. The limited research in this area has shown promising but inconclusive results for the effectiveness of lactobacillus in treating recurrent VVC.22-25

The prevalence of PAV we found (23%) is similar to that found in a previous US study (28%).15 However, the reliability of this estimate is limited by the variability between practices and the small numbers of surveyed women who had taken antibiotics in the previous month. The self-reported prevalence of symptoms of recurrent VVC in our study (7%), and the reported rate of a history of VVC (72%), are consistent with previously reported rates.17

The 19% of women with a history of vulvovaginitis who would not take prescribed antibiotics because of concerns about developing PAV have important implications for practice, as have the 7% of women with a history of vulvovaginitis who would consult a complementary therapist about prevention or treatment of PAV. Because women can now self-medicate with OTC and other remedies, general practitioners may be less aware of women's concerns about PAV. When prescribing antibiotics, they should enquire about a history of PAV and offer advice about its prevention. We are currently undertaking a randomised controlled trial to determine the effectiveness of the commonly used complementary therapy, lactobacillus, for prevention of PAV (<http: //www.pav.unimelb.edu.au>).