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The objective of this study was to compare the effects of treatments for bacterial vaginosis (BV) on vaginal Mobiluncus morphotypes.Analyses were performed on Mobiluncus scores from similarly conducted studies evaluating clindamycin vaginal single-dose cream (CVSDC) or metronidazole vaginal gel (MVG) in 55 patients with BV and with Mobiluncus morphotypes at baseline.Both treatment groups demonstrated significant reductions in Mobiluncus score. However, the Mobiluncus score at test-of-cure was lower in the CVSDC than in the MVG group (P=0.0471). More patients in the CVSDC group than in the MVG group achieved microbiologic (57.5% vs. 26.7%; P=0.04), clinical (57.5% vs. 26.7%; P=0.04), and therapeutic cures of BV (45.0% vs. 20.0%; P=0.09).Clindamycin reduces vaginal Mobiluncus morphotypes to a greater extent than metronidazole in patients with BV; this correlates with a higher BV cure rate.

To compare women with different chronic vaginal symptoms with a wide variety of sociodemographic, health, behavioral, and psychosocial characteristics.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.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.Women with chronic vaginal symptoms have a variety of diagnoses, most of them noninfectious.II-3.

Objective This study was undertaken to assess if levels of interleukin-1β (IL-1β), IL-8, sialidase, prolidase and immunoglobulin A against Gardenerella vaginalis hemolysin (anti-Gvh IgA) in vaginal secretions differ between BV+ women with (M+) and without (M−) Mobiluncus spp. Study design Vaginal secretions were obtained from 265 women at their first prenatal care visit and assessed for all study parameters. Gram stain evaluation using Nugent criteria was performed and coinfection with sexually transmitted infections determined. Differences between BV+/M+ and BV+/M− women were evaluated using the χ 2 statistic or Mann-Whitney test. Results Of the 265 BV+ women, 43% (n = 113) were M+ of which 97% (n = 110) had Nugent scores of 9 or 10 . BV+/M+ women had elevated levels of sialidase (median value: 4.11 nmol vs 1.91 nmol of converted substrate; P = .003) but no difference in prolidase, anti-Gvh IgA, IL-1β, IL-8, levels were found between the two groups. BV+/M− women had significantly higher rates of coinfection with Trichomonas vaginalis. Conclusion BV+/M+ women have higher vaginal concentrations of sialidase and lower rates of T vaginalis compared with BV+/M− women. Further research is needed to assess the association of this, and other, microbiologic profiles to risk of adverse pregnancy outcome.

The current approach to diagnosing vulvovaginal symptoms is both flawed and inadequate. Mistakes occur at the level of the patient herself, her provider, and the sensitivity of office-based tests. Often, the differential diagnosis is so broad that providers may overlook some of the possibilities. A diagnostic algorithm which separates women into either a normal or elevated vaginal pH can successfully classify most women with vaginitis. Based on the amine test, vaginal leukocytes, and vaginal parabasal cells, those with an elevated pH can be placed into further diagnostic categories. Such an algorithm helps to prioritize different diagnoses and suggest appropriate ancillary tests.

Objective Efficacy study of suppressive vaginal metronidazole in reducing recurrent symptomatic episodes of bacterial vaginosis. Study design Multicenter prospective study with initial 10-day open-label metronidazole gel in which asymptomatic responders randomly assigned to receive twice weekly metronidazole vaginal gel or placebo for 16 weeks and off therapy for 12 weeks. Results Of 157 eligible women with recurrent bacterial vaginosis, 112 of 127 returning evaluable women (88.2%) responded clinically and were randomly assigned. During suppressive therapy, recurrent bacterial vaginosis occurred in 13 women (25.5%) receiving metronidazole and 26 (59.1%) receiving placebo (MITT analysis, relative risk [RR] 0.43, CI=0.25-0.73, P = .001). During the entire 28-week follow-up, recurrence occurred in 26 (51.0%) on treatment compared with 33 (75%) on placebo (RR 0.68, CI=0.49-0.93, P = .02). Probability for remaining cured was 70% for metronidazole compared with 39% on placebo, which declined to 34% and 18%, respectively, by 28 weeks follow-up. Adverse effects were uncommon; however, secondary vaginal candidiasis occurred significantly more often in metronidazole-treated women ( P = .02). Conclusion Suppressive therapy with twice-weekly metronidazole gel achieves a significant reduction in the recurrence rate of bacterial vaginosis; however, secondary vaginal candidiasis is common.

Objective The purpose of this study was to determine the effects of 3 intravaginal antibacterial treatments on vaginal lactobacilli in patients with bacterial vaginosis (BV). Study design Retrospective analyses were performed on Lactobacillus scores from 3 similar studies evaluating 2 2% clindamycin vaginal creams and 0.75% metronidazole gel at baseline and at 21 to 30 days in 408 patients with BV. Scores were compared using a 1-way global F test and McNemar's test. Results All groups had similar mean Lactobacillus scores at baseline ( P = 0.37) and at 21 to 30 days ( P = .71). The 3 groups were also comparable at both visits with respect to the distributions of scores within each group. In all groups, there was significant improvement in the percentages of patients with no lactobacilli present at 21 to 30 days compared with baseline ( P Conclusion Clindamycin and metronidazole promoted similar levels of restoration of vaginal lactobacilli at 21 to 30 days.

The purpose of this study was to determine if clinical findings and sociodemographic variables among bacterial vaginosis (BV)-positive pregnant women are associated with different microbiologic profiles.Pregnant women were assessed for BV by Nugent criteria. BV+ women were separated into 6 mutually exclusive microbiologic groups. In unadjusted analyses, we compared (1) sociodemographic and behavioral characteristics, and (2) 3 clinical characteristics among BV+ women with and without Mobiluncus (M+ vs M-). Unadjusted data were analyzed using the chi-square test. Multiple logistic regression was used to assess the likelihood of having clinical signs of BV in women with and without Mobiluncus spp while controlling for confounders.A total of 1756 BV+ pregnant women were followed. The M+ group (n=702) was significantly more likely than the M- group (n=1054) to be non-Hispanic black (80.9% vs 66.2%; P.0001), older than 21 years (61.7% vs 48.7%; P.0001), and to have had more than 3 lifetime sexual partners (66.4% vs 54.9%; P.0001). The M+ group was also more likely to have clue cells on wet mount (63.9% vs 47.2%; P.0001) and a positive amine odor after addition of KOH (57.2% vs 45.0%; P=.001). There was no difference in other demographic variables or physician diagnosis of abnormal vaginal discharge. In the adjusted analyses for each clinical outcome, all findings were consistent with the unadjusted analyses.BV+ pregnant women with Mobiluncus spp are more likely to have clue cells present on wet mount, a positive amine odor after KOH preparation, and to be older, non-Hispanic black, and have had more lifetime sexual partners compared to BV+ women without any Mobiluncus species.

Despite considerable evidence of azole resistance in oral candidiasis due to Candida species, little is known about the azole susceptibilities of the genital tract isolates responsible for vaginitis. The fluconazole susceptibilities of vaginal isolates obtained during a multicenter study of 556 women with complicated Candida vaginitis were determined by evaluating two fluconazole treatment regimens. Of 393 baseline isolates of Candida albicans , 377 (96%) were highly susceptible to fluconazole (MICs, n = 250) for which MICs were ≤1 μg/ml were compared with isolates ( n = 30) for which MICs were >1 μg/ml, although a trend toward an improved clinical outcome was noted on day 14 (odds ratio, >2.7; 95% confidence interval, 0.91, 8.30). Although clinical failure was uncommon, symptomatic recurrence or mycological relapse almost invariably occurred with highly sensitive strains (MICs, C. glabrata isolates following fluconazole exposure. Susceptibility testing for women with complicated Candida vaginitis appears to be unjustified.

For many women with chronic vulvovaginal symptoms, overdiagnosis of vulvovaginal candiasis (VVC) is an unfortunate tendency. In women with chronic vulvar itching or burning, a vulvar non-neoplastic epithelial disorder is a relatively frequent diagnosis. Although controversy persists about the nomenclature for these disorders, there seems to be a relatively clear consensus with lichen sclerosus. This chronic inflammatory skin disease affects primarily the female vulvar and perianal areas. Left untreated, it may lead to chronic scarring of the vulva with an associated loss of architecture. The etiology remains unknown, although infectious, genetic, and autoimmune causes have been suggested. Most patients will respond to potent topical corticosteroids. Treatment of associated conditions such as atrophic vaginitis or complicated VVC is sometimes necessary. Surgery should be considered in patients with severe scarring.

OBJECTIVE: To estimate what proportion of symptomatic women purchasing over-the-counter antifungal products for immediate treatment of presumed vulvovaginal candidiasis have vulvovaginal candidiasis or other genitourinary conditions. METHODS: A time-location sample of 95 symptomatic women who purchased and presented with an over-the-counter antifungal product for immediate and personal treatment of presumed vulvovaginal candidiasis were evaluated by clinical examination and pertinent laboratory tests. The percentage of women diagnosed having vulvovaginal candidiasis or other conditions, proportions of women with vulvovaginal candidiasis compared between groups with and without a prior diagnosis of vulvovaginal candidiasis, and groups that read or did not read the over-the-counter package label were assessed. RESULTS: The actual diagnoses for women who self-diagnosed vulvovaginal candidiasis were: vulvovaginal candidiasis 33.7%, bacterial vaginosis 18.9%, mixed vaginitis 21.1%, normal 13.7%, other diagnoses 10.5%, and trichomonas vaginitis 2.1%. Women with a previous clinically based diagnosis of vulvovaginal candidiasis were not more accurate in diagnosing vulvovaginal candidiasis than women without a prior clinical diagnosis (χ 2 = 0.27, P = .6). Women who read the package label were no more likely to have vulvovaginal candidiasis than were women who did not read the label (Fisher exact test, P = .39). CONCLUSION: Many women who self-diagnose and use an over-the-counter product for treatment of presumed vulvovaginal candidiasis do not have vulvovaginal candidiasis. A history of a previous clinically based diagnosis of vulvovaginal candidiasis and reading the package label do not help women self-diagnose vulvovaginal candidiasis properly. Ready access to these products is associated with wasted financial expenditures, unfulfilled expectations, and a delay in correct diagnosis for a substantial number of women.

Metronidazole-resistant vaginal trichomoniasis remains a major therapeutic challenge. Two women with symptomatic metronidazole-resistant trichomoniasis had multiple unsuccessful courses of therapy with a broad array of medications. Both patients finally responded to combination treatment with intravaginal paromomycin cream and high-dose oral tinidazole.

Cervicitis encompasses a variety of gynecologic conditions. Although inflammation on a Papanicolaou smear may be indicative of true cervical inflammation, establishing a diagnosis of mucopurulent cervicitis (MCP) is more clinically useful. MCP seems to be analogous to nongonococcal urethritis in men. Many cases of MCP are related to Chlamydia trachomatis infection, but the majority of cases have other potential causes. Other possible pathogens include Neisseria gonorrhoeae, Trichomonas vaginalis, Ureaplasma urealyticum, Mycoplasma genitalium, herpes simplex virus, and cytomegalovirus. Many cases may be related to cervical ectopy. MCP is a marker for endometritis, salpingitis, and adverse pregnancy outcomes. Given the current shortcomings in our understanding of this disease, an empiric approach to evaluation and treatment is suggested.

Persistent low back pain developed in a 51-year-old woman after she had undergone abdominal sacrocolpopexy. Four months postoperatively, necrotizing myofascitis developed in her gluteal muscles. The infected mesh, which had eroded into the vagina, was removed. Cultures of the infected mesh and abscesses grew common vaginal flora, including Gardnerella vaginalis and Actinomyces.

Objective: Patients with chronic idiopathic vulvar vestibulitis have increased mast cells when biopsied, and cromolyn has been suggested as a treatment. The purpose of this study was to assess the efficacy of 4% cromolyn cream in women with vulvar vestibulitis. Methods: A prospective, double blind, randomised, placebo controlled study was initiated at two centres. Patients with vulvar vestibulitis were assigned to apply cromolyn or placebo cream to the vestibule. Symptoms (burning, irritation) and signs (erythema, extent of erythema, tenderness) were recorded on a 0–3 scale. In the sexually active patient subgroup, dyspareunia was also evaluated. Results: 13 of the 26 evaluable patients received cromolyn. Patients in the cromolyn arm were more likely to have failed therapy with amitriptyline (p = 0.05), but the two groups were otherwise similar upon study entry. Overall, scores decreased from a median of 9 to 5 (p = 0.001) during the study, but the level of improvement was similar between both groups. Improvement was unrelated to duration of symptoms, fluconazole use, or sexual activity. Five patients (38%) taking cromolyn and six (46%) taking placebo felt they had a 50% or greater reduction in symptoms. In the 21 sexually active patients, the total score decreased from a mean of 12 to 8 (p = 0.005), but there was no statistically significant difference between study arms. Conclusions: Cromolyn cream did not confer a significant benefit in patients with vulvar vestibulitis. The large placebo response suggests the need for large well controlled studies of other treatment modalities.

Objective: Although it is FDA-approved for use in vulvovaginal candidiasis caused by non-Candida albicans species, terconazole cream has not been been studied in patients with these infections. We sought to assess the clinical and mycological efficacy of terconazole cream in women with non-C. albicans vaginitis.Methods: The records of patients who had received a 7-day course of terconazole cream for culture-proved non-C. albicans vaginitis were reviewed. Data with regard to patient demographics, clinical and mycologic response to therapy within 1 month of treatment, and outcome with other antifungal therapies were analyzed.Results: Twenty-eight patients received terconazole cream for non-C. albicans infections. Three patients did not return for follow-up. The median age was 45 years. Seven (28%) patients were nulliparous. The median duration of symptoms was 3 years. Nine patients (36%) had received terconazole within the 6 months prior to referral. Overall, there were 20 C. glabrata cases, 3 C. parapsilosis, and 2 C. lusitaniae. Fourteen (56%) patients achieved a mycologic cure; 11 (44%) noted a resolution of their symptoms. Prior terconazole use was not associated with treatment failure (P = 0.09). Ten failures received boric acid suppositories as subsequent treatment; a cure was effected in 4 (40%). Two of three patients (67%) were eventually cured with flucytosine cream. Five (20 %) patients remained uncured.Conclusions: Terconazole cream may be an appropriate first-line treatment for non C. albicans vaginitis, even in patients who have previously received the drug. Infect. Dis. Obstet. Gynecol. 8:240–243, 2000.

For any clinician involved in the health care of women, vaginitis remains an unavoidable problem. Vaginitis accounts for an estimated 10 million office visits each year, and it remains the most common reason for patient visits to obstetrician-gynecologists. 20 With the availability of over-the-counter antifungal therapies, these products now rank among the top 10 best-selling over-the-counter products in the United States, with approximately $160 million in sales. In the adolescent population, accurate numbers with regard to use of products for vaginal symptoms are not available, but some numbers suggest that such use is common. For example, in a college student population, 61% reported having experienced a vaginal yeast infection; 70% of these young women had relied on self-diagnosis and self-treatment for these yeast infections. 26 Despite extensive self-diagnosis and self-treatment for vaginal symptoms in all age groups, important questions persist about the accuracy of such an approach. The package insert for over-the-counter antifungal preparations recommends their use only in women who have been given a prior diagnosis of a yeast infection. Initial data suggested that, in women with a prior diagnosis of vulvovaginal candidiasis (VVC), as many as 82% could accurately diagnose themselves based on symptoms alone 8 ; however, this figure may represent an overestimate because patients in this study had been screened by telephone initially and were evaluated only if they had symptoms that sounded similar to VVC. In a questionnaire study of 634 women, Ferris and colleagues 11 found that only 11% of women could accurately recognize the classic symptoms for yeast infections; in women with a prior diagnosis of VVC, 34.5% rendered a correct diagnosis of VVC. Meanwhile, only 3% could identify bacterial vaginosis, vaginal trichomoniasis, or pelvic inflammatory disease (PID). If studies show such a poor ability to recognize and assign proper diagnoses to different vaginal infections even on theoretic grounds, it is doubtful that women, particularly adolescents, can accurately diagnose themselves. Finally, telephone diagnosis is probably no better than self-diagnosis. In a study of women who were assigned a nurse-administered telephone triage protocol diagnosis and then were physically evaluated, poor agreement was noted between the over-the-phone and in-office diagnoses, with κ coefficient scores that were marginally better than random chance alone. 1 Given the preceding information, the best chance at an accurate diagnosis seems to remain in the hands of clinicians. Although vaginitis is frequently trivialized by the medical community, it should be emphasized that women who present with vaginal symptoms deserve a thorough and complete evaluation. Some causes of vaginitis, such as trichomoniasis, are sexually transmitted infections, and these patients need further counseling about the prevention of sexually transmitted diseases (STDs) and the treatment of their partners. Other infections, such as bacterial vaginosis, are risk factors for more severe processes, such as PID. Even a local problem, such as VVC, may have important morbidities in terms of discomfort and pain, days lost from school or work, and sexual functioning and self-image, particularly if it becomes chronic and is not treated effectively. The vagina is one of the few sites of the body that, when infected, can be easily examined and accessed for diagnostic tests. With a standardized approach to the evaluation of vaginal symptoms, a cause can be identified in most cases, and the plethora of available treatment regimens allows selection of an appropriate agent that yields satisfactory results in most women.

Vaginal trichomoniasis poses a difficult therapeutic challenge when metronidazole is ineffective or contraindicated. We conducted a retrospective study of 6.25% paromomycin cream in the treatment of nine women referred with cases of vaginal trichomoniasis where metronidazole resistance or allergy was present. Results obtained immediately and 1 month after treatment were reviewed. The median age of the patients was 46 years; four women were nulliparous. The median symptom duration was 1 year. Five women were allergic to metronidazole. In four cases, resistance to high doses of metronidazole was demonstrated. Smears or cultures were positive immediately after treatment for three patients; a fourth relapsed 2 weeks later. Of these patients for whom treatment failed, one was cured with a 3-week course of paromomycin cream, and another was successfully treated with paromomycin cream and oral tinidazole. Three patients developed vaginal ulcerations that resolved spontaneously. Adverse effects may be a result of local formulation. Paromomycin cream was useful for treatment of cases of trichomonas infection where metronidazole resistance or allergy was encountered.

Although it is the second most common vaginal infection in North America, vulvovaginal candidiasis is a non-notifiable disease and has been excluded from the ranks of sexually transmitted diseases. Not surprisingly, vulvovaginal candidiasis has received scant attention by public health authorities, funding agencies, and researchers. Epidemiologic data on risk factors and pathogenic mechanisms remain inadequately studied. Most important, standards of care, including diagnosis and therapy, remain undefined. A conference was held in April 1996 to define and summarize what is known and supported by scientific data in the areas of epidemiology, diagnosis, and treatment of vulvovaginal candidiasis; but, more important, the conference aimed at defining what is not known, poorly studied, and controversial. Guidelines for the treatment and diagnosis of the different forms of vulvovaginal candidiasis are suggested.

Background Recurrent bacterial vaginosis is a difficult clinical condition. In women with recurrent bacterial vaginosis, relapses are common, even after prolonged courses of maintenance therapy. Because of its spectrum of activity, tinidazole was used in a patient with recurrent bacterial vaginosis. Case A 23-year-old woman taking oral contraceptives had a single sexual partner. She was treated for recurrent bacterial vaginosis with multiple courses of metronidazole gel 0.75%, including regimens of maintenance therapy. The patient experienced repeated recurrences shortly after stopping treatment. A single course of oral tinidazole resulted in a prolonged period where she was free of bacterial vaginosis. Conclusion Treatment options for recurrent bacterial vaginosis are currently limited. Tinidazole may be a useful option in women with recurrent bacterial vaginosis.

OBJECTIVE: Our purpose was to examine the importance of fungal cultures in evaluating patients with symptoms of chronic vaginitis by assessing the relative contribution of various yeast species and by comparing infections caused by Candida albicans with those caused by other species. STUDY DESIGN: A prospective observational study of patients referred with chronic vaginal symptoms was undertaken. In addition to a standard evaluation of symptoms, cultures for yeast were performed on modified Sabouraud agar plates. RESULTS: Seventy-seven isolates were obtained from 74 patients. A total of 68% were Candida albicans; 32% were other species. The clinical syndromes caused by non- Candida albicans isolates were indistinguishable from Candida albicans infections. Fluconazole gave a short-term mycologic cure in all Candida albicans but only 25% of non- Candida albicans cases ( p Candida albicans infections, boric acid suppositories achieved the best mycologic cure rate (85%). CONCLUSION: Because non- Candida albicans species are responsible for a significant number of chronic fungal vaginal infections and are more resistant to therapy with fluconazole, fungal cultures are a valuable aid in confirming the diagnosis and selecting appropriate therapy.

Objective: The objectives of this study were to assess the efficacy of medical management for vulvar vestibulitis and to examine several historical variables and determine their predictive values as to which treatments will be most successful.Methods: Seventy-four patients diagnosed with vulvar vestibulitis were evaluated. Each patient was treated using a sequence of consecutive medical therapies for vulvar vestibulitis. These therapies were topical aqueous 4% lidocaine with intercourse, topical corticosteroid therapy, oral amitriptyline, topical low-dose 5-fluorouracil (5-FU) cream, intralesional alpha-interferon, and a low-oxalate diet in combination with oral calcium citrate. The patients were followed over 3–30 months and their responses to therapy were assessed. In addition, a statistical analysis was performed to determine the positive predictive values of certain historical variables and specific treatment successes. Results: Forty-nine patients reported positive responses to one of the initiated therapies. More specifically, 18.1% of the patients who used lidocaine, 33.8% who used topical corticosteroids, 57.1% who used amitriptyline, 16.7% who used 5-FU, none who received interferon, and 50% who tried a low-oxalate diet had positive responses to therapy. No historical variables were predictive of which therapies would have the most successful outcome.Conclusions: Medical management is effective in alleviating the symptoms of vulvar vestibulitis. Various aspects of a patient's history are not helpful in selecting the therapy that will be most effective.

Candida vaginitis is commonly described as uncomplicated, for which the recommended treatment is single-dose antimycotic therapy, and complicated, for which the recommended dose is short-course antimycotic therapy. This study was performed to evaluate the necessity of multidose therapy in women with severe or recurrent Candida vaginitis. Severity of disease was determined using a semiquantitative scale in which a score of 1 to 10 was assigned according to the severity of pruritus and the presence of vulvar or vaginal erythema, edema, and excoriation or fissure formation. Only women with scores greater than 4 were included. For the purposes of this report, disease severity was rated mild in women with a score of 4 to 6 and severe in those with a score greater than 7. Of the 309 patients who met all of the study criteria, 157 women were identified with mild Candida vaginitis, and 152 had severe disease. Patients in each group were randomly assigned to receive either a single done of 150 mg fluconazole or two sequential doses of 150 mg fluconazole given 3 days apart. Follow-up examinations were conducted on day 14 and day 35 of the trial. There were no significant differences in the demographic or clinical characteristics of the two groups, with more 90% (N = 283, 91.6%) of all cases diagnosed as C. albicans. Other strains identified included 13 cases of C. glabrata, 7 of C. parapsilosi, 3 of C. tropicalis, and 1 each of C. guiliermondii, C. krusei, C. lipolytica, and C. zeylandoides. A greater number of patients with non-albicans lesions were randomly assigned to the two-dose group (N = 21) than to the single-dose group (N = 6). Of the 13 women with C. glabrata, which is resistant to fluconazole, 12 received two sequential doses and only 1 received a single dose of fluconazole. The one woman with C. krusei, another strain resistant to fluconazole, was in the two-dose group. The C. albicans species was eradicated on the day 14 visit in 78% of the patients in the single-dose group and 86% of the women in the two-dose group. Compared with C. albicans, non-albicans species were significantly more likely to be present in both the single- and dual-dose groups on the day 14 follow-up visit (79 vs. 46%, respectively; P = .097) and on the day 35 follow-up visit (65 vs. 23%, respectively; P

Objective To report the occurrence of Candida glabrata chorioamnionitis complicating an in vitro fertilization (IVF) pregnancy. Design Case report. Setting University hospital. Patient(s) A 30-year-old woman, primagravida, with an IVF dichorionic-diamniotic pregnancy who presented at 15 weeks with vaginal bleeding. Intervention(s) Before embryo transfer in next IVF cycle, vaginal culture from the patient revealed colonization with C. glabrata, which was treated with boric acid. Main Outcome Measure(s) Subsequent pregnancy after eradication of fungal organisms. Result(s) The patient's first pregnancy was treated with indomethacin and broad-spectrum antibiotics, but her membranes ruptured, and she delivered both twins at 16 weeks; the autopsy and pathology reports were consistent with C. glabrata chorioamnionitis. After boric acid treatment eradicated the organisms, two embryos were transferred in subsequent IVF treatment; the second pregnancy was uncomplicated, with dichorionic-diamniotic twins, delivered by cesarean section at 38 weeks. Conclusion(s) Eradication of vaginal colonization with C. glabrata may prevent infection of the next IVF pregnancy.

In malaria-endemic regions, the impact of malaria upon pregnancy and the value of chemoprophylaxis for malaria for pregnant women remain controversial. We prospectively studied 302 pregnant women who presented in labor to Centre Medical Evangelique, Nyankunde, Zaire. We evaluated the incidence of malarial infection in mothers, placentas, and neonates and examined the effect of infection on birth weight and perinatal mortality. We analyzed the outcome of pregnancy in relation to prophylaxis with chloroquine, controlling for parity and prenatal clinic attendance. Peripartum smears of maternal blood (21%), placentas (33%), cord blood (9%), and neonatal blood (7%) were positive for Plasmodium falciparum. Maternal malaria increased the risk of perinatal death (relative risk [RR] = 12.4) and low birth weight (RR = 3.7). Neonatal malaria increased the risk of perinatal death (RR = 7.2). Chloroquine prophylaxis protected against maternal (RR = 0.4) and fetal malaria (RR = 0.2), low birth weight (RR = 0.39), and perinatal death (RR = 0.38). Peripartum malaria increases the risk of perinatal death and low birth weight. Chemoprophylaxis with chloroquine during pregnancy may have a protective effect, even in certain areas where chloroquine-resistant P. falciparum is endemic.

Objective We evaluated whether vaginal concentrations of hyaluronan were altered in women with recurrent vulvovaginal candidiasis (RVVC). Study Design Lavage samples from 17 women with acute RVVC, 27 women who were receiving a maintenance antifungal regimen, and 24 control women were tested for hyaluronan and interleukin (IL)-6, IL-12, and IL-23 by enzyme-linked immunosorbent assay. Results Median vaginal hyaluronan concentrations were 33.8 ng/mL (range, 21.6-66.3 ng/mL) in women with acute RVVC, 15.0 ng/mL (range, 11.2-50.6 ng/mL) in women who were receiving maintenance therapy, and 4.2 ng/mL (range, 3.6-12.0 ng/mL) in control subjects ( P ≤ .02). The vaginal hyaluronan concentration was 27.4 ng/mL (range, 15.4-37.7 ng/mL) when Candida was detected by microscopy and 9.5 ng/mL (range, 7.7-14.6 ng/mL) in microscopy-negative cases ( P = .0354). Elevated hyaluronan levels were associated with itching plus burning (40.7 ng/mL) or itching plus discharge (42.1 ng/mL), as opposed to itching only (6.2 ng/mL; P = .0152). Hyaluronan and IL-6 levels were correlated ( P = .0009). Conclusion Hyaluronan release is a component of the host response to a candidal infection and may contribute to symptoms.

A silicone Gellhorn pessary, 3 inches in diameter, neglected for several years in an elderly woman, eroded through the anterior vaginal wall, ultimately to lie entirely within the bladder. General anesthesia and bilateral deep full-length Schuchardt's incisions were required to remove it. A Latzko procedure was done at a later date to close the large vesicovaginal fistula; similar Schuhardt's incisions were again used.

To the Editor: Trichomonal resistance to metronidazole was reported soon after its introduction and has been reported in many areas in the world. Although a sexually transmitted disease with dire consequences related to human immunodeficiency virus transmission, trichomoniasis is not a reportable infection, and epidemiologic data on its incidence in the United States are not available. Therefore, it is not surprising that accurate figures on metronidazole-resistant trichomoniasis are almost nonexistent. Nevertheless, clinically important resistance is considered rare, with estimates of high-level resistance to metronidazole occurring in only 1 in 2000 to 3000 cases.1 In clinics specializing in chronic vaginitis that . . .

This is the first published report of an incarcerated leiomyomatous uterus occurring as an acute abdominal condition in a nonpregnant patient. The patient had increasingly severe lower abd...

Objective To investigate the use of over-the-counter and alternative medicines in women with chronic vaginal symptoms. Methods One hundred five patients, referred by their gynecologists for evaluation of chronic vaginal symptoms, were interviewed about their use of over-the-counter and alternative medicines during the preceding year, the amount of money spent on each, and whether or not their physicians had been informed of these treatments. Results The mean age was 36 years, and one-half had finished college. The median symptom duration was 2 years. Seventy-seven (73.3%) patients had self-treated with over the-counter medications such as miconazole (74% of over-the-counter users), clotrimazole (38.2%), or povidone-iodine (13.2%). The median expenditure for over-the-counter use was $50 (range $2–1000). Forty-four (41.9%) had used alternative medicines, most frequently acidophilus pills orally (50%) or vaginally (11.4%), yogurt orally (20.5%) or vaginally (18.2%), vinegar douches (13.6%), and boric acid (13.6%). The median expenditure for alternative medicines was $35 (range $0-1200). Fewer physicians were aware of the use of alternative (70.5%) than of over-the-counter medicines (88.3%). Although most patients thought that vulvovaginal candidiasis was the cause of their symptoms, the most common diagnoses at initial presentation were candidiasis in 29 (27.6%), vulvar vestibulitis in 18 (17.1%), irritant dermatitis in 16 (15.2%), and bacterial vaginosis in 11 (10.5%). Women who actually had candidiasis were more likely to have used alternative medicines (odds ratio 2.31, 95% confidence interval 1.00, 5.42) than other patients. Conclusion Women with chronic vaginal symptoms often use over-the-counter and alternative medicines that add to health care costs and are unlikely to be of benefit.

Frequently ignored by the medical community, chronic vulvovaginal symptoms are relatively common and can frustrating for patients and physicians. Establishing a proper diagnosis will lay the foundation for an effective therapeutic therapeutic plan. Fungal cultures are an important component of the work-up. The most common causes of chronic vaginal symptoms are recurrent vulvovaginal candidiasis (RVVC), vulvar vestibulitis syndrome and irritant dermatitis. In patients with RVVC caused by Candida albicans, host factors may play an important role. Long-term oral antifungal therapy will break the pattern of recurrence in many patients. Infections caused by other species of yeast may be more resistant to standard treatment approaches.