Vulvovaginal Candida: a study of (a)symptomatic women

Abstract

The research described in this thesis concerns presence of asymptomatic vaginal Candida and vulvovaginal candidiasis. Vulvovaginal candidiasis (VVC) is an infection caused by abnormal growth of yeasts in the mucosa of the female genital tract. Acute vulvar pruritus and vaginal discharge are the usual presenting complaints, and vulvovaginal examination frequently reveals epithelial erythema and swelling of the labia and vulva together with adherent whitish discharge. However, due to lack of specificity of signs and symptoms, all patients with symptomatic vaginitis should be diagnosed on the basis of microscopic examination of their vaginal secretions. In the first chapters of this thesis, we examined how general practitioners (GPs) in The Netherlands diagnose and treat vaginal candidiasis, by sending questionnaires to 1160 Dutch GPs and by checking the microscopy performed by 324 Dutch GPs on stained vaginal smears of patients with symptomatic vaginitis. The questionnaires revealed that only 61 (16.1%) Dutch GPs always or often performs microscopy when diagnosing candidiasis, while 143 (37.6%) GPs never use a microscope to confirm their diagnosis. In addition, sensitivity and specificity of the microscopic diagnoses of the clinicians was only 52% and 89% respectively. This suggests that GPs often diagnose 'vulvovaginal candidiasis' in their practices, without (adequately) performing the laboratory examinations required to confirm their putative diagnosis, which could lead to wrong diagnoses and maltreatment. However, Candida (pseudo)hyphae and/or blastospores are also often discovered in cervical smears of asymptomatic women during their childbearing years. Since 1996 all women in the Netherlands between the ages of 30 and 60 receive an invitation once every five years to have a cervical smear taken. These smears are coded according to the Dutch national coding system for cervical cytology (KOPAC). KOPAC is an acronym, in which the O-category stands for ontsteking (inflammation) and the P-category reflects the status of the plaveiselcellen (squamous epithelium). The research described in this thesis involves cervical smears that were taken as part of the national screening program in the western region of The Netherlands and examined by the Leiden Cytology and Pathology Laboratory. The Leiden database, containing the results of the smears of almost 500,000 women, was used to study possible relationships between presence of asymptomatic Candida, immigrant status, (pre)neoplasia, and the incidence of acquiring other vaginal infections in time, by the cytological identification of Candida and other elements of the vaginal flora in smears. This research showed that presence of vaginal Candida is not associated with an increased risk for (pre)neoplastic cells in the same smear and in follow-up smears and does not predispose to an increased susceptibility for Trichomonas vaginalis, Gardnerella vaginalis and Actinomyces. In the last chapter of this thesis we evaluated the association between the bacterial flora and Candida overgrowth in symptomatic women. We noted that recurrent vulvovaginal candidiasis is associated with presence of lactobacilli and polymorphonuclear neutrophils in the vaginal smear, but with absence of Gardnerella. Future research should therefore focus on the effect of Candida on the vaginal ecosystem.