Management of genital candidiasisBMJ 1995; 311 doi: https://doi.org/10.1136/bmj.311.7005.629a (Published 02 September 1995) Cite this as: BMJ 1995;311:629
- David J White,
- Susan M Drake
- Consultants in genitourinary medicine Department of Sexual Medicine, Birmingham Heartlands Hospital, Birmingham B9 5ST
Review omitted issues on recurrent thrush
EDITOR,--The British Society for Medical Mycology's review on the management of genital candidiasis fails to bring out some important points.1
Firstly, the vulval vestibulitis syndrome is not included in the section on differential diagnosis. This, however, is the commonest misdiagnosis in our clinic for patients with recurrent thrush and must be considered in any patient who complains of superficial dyspareunia.2
Secondly, the authors suggest that “recommended regimens are not clearly related to difference between drugs.” Neither are they clearly related to differences between patients. Unfortunately, almost all comparative treatment studies have been in unselected women. In the section on management of recurrent disease the authors mention that recurrence may be due to sequestration of fungal hyphae and spores in the deeper layers of the vaginal epithelium, which then regrow when conditions are favourable. This “vaginal relapse” hypothesis implies that it may be possible to prevent further attacks by intensive antifungal treatment. This needs to be tested in prospective comparative studies specifically in women with recurrent disease.
Evidence suggests that changing the contraceptive method to medroxyprogesterone acetate may be beneficial in recurrent disease.3 In our experience, medroxyprogesterone acetate is better than suppressive antifungal treatment in selected women. This is currently the subject of prospective study in our department. Requests for support from the pharmaceutical industry for both this and other studies of hormonal treatments for recurrent vaginal candidiasis have been successful.
The controversy over whether sexual transmission causes relapse in recurrent disease is discussed at some length in the article. The authors do not mention that sexual intercourse may predispose to the development of symptoms by causing epithelial damage. This is indicated by the common clinical entity of “honeymoon thrush” and the association between frequency of intercourse and symptomatic attacks of vaginal candidiasis.4 In women with recurrent vaginal candidiasis it is important to emphasise that intercourse should be slow and unhurried, with extra lubrication being applied to the penis. The possibility of sexual transmission should be “deemphasised” so that further damage does not occur in an already strained relationship.
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