The Relationship Between Vulvovaginal Candidiasis and Provoked Vulvodynia: A Systematic Review

Nutritional and metabolic aspects related to vulvodynia: What do we really know?

OBJECTIVES

Vulvodynia is an emerging health problem, still insufficiently studied, that causes a significant reduction in quality of life in many women and individuals assigned female sex at birth. Little is known about the effects of diet and metabolic disorders on this condition. The objective of this study was to review currently available evidence on the diet and the nutritional and metabolic status of patients affected by vulvodynia.

METHODS

Published articles were systematically searched in the PubMed, Scopus, and Web of Science databases.

RESULTS

The few available studies that reported data on patients' body mass index (BMI) described a BMI within the normal range in most patients affected by vulvodynia, showing no difference or a slightly lower BMI with respect to control individuals. Data on the relationship between metabolic diseases and vulvodynia are lacking. Regarding nutrition, the few available data do not support the prescription of a low-oxalate diet in women with vulvodynia. To date, studies on other dietary behaviors are also lacking.

CONCLUSIONS

This review emphasizes-for the first time, to our knowledge-the lack of data and the importance of conducting prospective studies investigating the nutritional and metabolic aspects related to the onset, maintenance, and therapy of vulvodynia.

Treatment of Vulvovaginal Candidiasis-An Overview of Guidelines and the Latest Treatment Methods

Vulvovaginal candidiasis (VVC) is a common condition associated with discomfort in affected women. Due to the presence of different forms of the disease, diverse treatment regimens are developed; the newest ones include oteseconazole and ibrexafungerp. Here, we focus on the most up-to-date recommendations regarding VVC treatment, as well as novel treatment options. Topical and oral azoles are the drugs of choice in uncomplicated mycosis. The efficacy of probiotics and substances such as TOL-463 and chlorhexidine is indicated as satisfactory; however, there are no relevant guidelines. Although the majority of researchers agree that the treatment of non-albicans VVC should be long-lasting, the recommendations are inconsistent. Another clinical problem is the treatment of VVC with azole intolerance or resistance, for which literature proposes the use of several drugs including oteseconazole, ibrexafungerp, and voriconazole. The treatment schedules for recurrent VVC include mainly fluconazole; however, alternative options such as immunotherapeutic vaccine (NDV-3A) or designed antimicrobial peptides (dAMPs) were also described. We also focused on VVC affecting pregnant women, which is a substantial challenge in clinical practice, also due to the heterogeneous relevant guidelines. Thus far, few precise recommendations are available in the literature. Future studies should focus on atypical VVC forms to elucidate the inconsistent findings.

Chronic vulvar pain in gynecological outpatients

OBJECTIVES

Chronic vulvar pain (CVP) is pain in the vulvar area exceeding three months of duration. Previous studies have reported a prevalence of 7-8% in the general population and observed an association between CVP and other chronic pain, affective disorders and early life stressors. The aim of this study was to estimate the prevalence of CVP among gynecological outpatients and to explore its association with child sexual abuse, comorbid fibromyalgia and mental health.

METHODS

We conducted a questionnaire-based cross-sectional study among consecutive women attending an unselected general gynecological outpatient clinic at St Olav's University Hospital, Trondheim, Norway, during the period August 1st, 2017, to June 30th, 2018. CVP was defined as having experienced either vulvar burning, sharp pain or allodynia for three months or more within the previous year. Fibromyalgia was defined as widespread pain in the past six months in conjunction with a symptom severity score ≥5 on the fibromyalgia symptom severity score inventory, an ordinal scale from zero to 12. We collected information on sexual coercion experience and assessed mental health with the mental health inventory (MHI-5) of the SF-36 health survey, which yields a zero to five scale.

RESULTS

Of 1,125 questionnaires distributed, 810 (72%) were returned, and 762 (68%) included in final analyses. Among these, 130 (17.1%) reported CVP within the previous year and 92 (16.7%) were classified as suffering from fibromyalgia. Fibromyalgia was associated with CVP (adjusted OR of 1.8, 95% CI 1.1-3.1). Child sexual abuse was reported by 96 (13.1%) and was associated with CVP (adjusted OR 2.0, 95% CI 1.2-3.3). CVP and fibromyalgia were both associated with lower mental health scores; 0.51 and 0.58 points on the MHI-5 scale, respectively.

CONCLUSIONS

Chronic vulvar pain is common among women in a gynecological outpatient clinic and associated with child sexual abuse, comorbid fibromyalgia and worse mental health. Ethical committee number: REK Midt No. 2016/2150.

Changes in the Vaginal Microbiota of Women With Secondary Localized Provoked Vulvodynia

OBJECTIVE

The etiology of localized provoked vulvodynia (LPV) remains unknown, but observations suggest the involvement of the vaginal microbiota. We examined the vaginal microbiota of women with LPV and healthy controls, upon after a low-oxalate diet (LOD).

MATERIALS AND METHODS

A total of 9 women diagnosed with secondary LPV and 21 healthy controls were recruited from the Galilee Medical Center in Israel and subjected to prospective evaluations of their vaginal microbiota. Total DNA was extracted from vaginal discharge samples provided before and after following LOD for 3 weeks and was then subjected to 16S sequencing. Data obtained were then used to evaluate α and β diversity, identify differentially abundant bacterial taxa in LPV, and determine their impact on the metabolism.

RESULTS

These evaluations revealed decreased diversity in the vaginal microbiota of women with LPV and identified the Ochrobactrum genus and Pseudomonadaceae family as indicators for LPV. In addition, we identified 23 differentially expressed bacterial metabolic pathways between the LPV and control samples and revealed that LOD could induce changes in the β diversity of LPV vaginal microbiomes, which was further supported by some degree of pain reduction in patients.

CONCLUSIONS

Localized provoked vulvodynia and LOD were associated with shifts in the vaginal microbiota. However, the impact of these changes on the development of LPV requires additional studies with a larger cohort.

Relapsing Vulvovaginal Candidiasis: Treatment with Oxygen Therapy and Hyaluronic Acid

OBJECTIVE. The aim of our open, anecdotical, retrospective, spontaneous trial has been to evaluate the efficacy of the association between high concentration oxygen and hyaluronic acid for treatment of relapsing candidiasis.METHODS. 45 women (30.9 ±4.4 years) with relapsing candidiasis, and complaining of dryness, dyspareunia, pain, appealing to our Second Opinion Medical Consultation Network, signed an informed consent form and were treated with oxygen/hyaluronic acid therapy treatment, once a week, for a total of five weeks at the outpatient clinic (Healthy Center, Sirio, Fidenza, Italy). The physicians of the Second Opinion Network followed up weekly from remote (WhatsApp, Skype) each treated patient as to state the effectiveness, tolerability, and side effects of the treatment.RESULTS. The mean VAS and VuAS scores measured at first visit were 2,660 and 2,622 and significantly (p<0,0001) reduced to 1,311 and 0,77 at last visit. The measurements of the vaginal pH and of the vaginal swab after the last treatment session confirmed significantly (p<0.0001) the absence of candidiasis. Three months later in the follow-up, the percentage of patients who had had only one VVC relapse was 4,44% (2/45), a percentage that increased just to 8,8% at six months (4/45). The elastography index was significantly (p<0.0001) increased after the last treatment session (2,55 ± 0,545 vs 4,48 ± 0,505).CONCLUSIONS. The combined oxygen therapy with hyaluronic acid gave definite therapeutic benefits in this cohort of relapsing candidiasis in the acute phase of the infection. The 6-month follow up, also detected a lower reinfection rate compared with the historical available data. The procedure is totally painless with excellent compliance by patients and no untoward effects.

Provoked Vestibulodynia and Topical Treatment: A New Option

Background: Provoked vestibulodynia is commonly associated with dyspareunia and affects 7% to 15% of women. This pathology has major implications on sexual function and quality of life, and several types of treatments are available for its management. However, a consensus has not been reached concerning the best treatment of vulvar pain. The aim of this study was to assess the efficacy and safety of a brand-new product, the vulvar emulgel Meclon^® Lenex, for the management of provoked vestibulodynia and non-infective vulvitis. Methods: This was a monocentric, prospective, randomized, double-blind and placebo-controlled study. We enrolled 40 women with provoked vestibulodynia; 20 patients received Meclon^® Lenex, whereas the remaining received a placebo. Each woman was assessed subjectively (through questionnaires) and objectively by evaluating vaginal and vulvar symptoms (Friedrichs criteria and Marinoff dyspareunia grade). We evaluated efficacy, safety, compliance and tolerability of the brand-new product vulvar gel Meclon^® Lenex in provoked vestibulodynia. Results: After administration of Meclon^® Lenex, we evaluated all parameters of the Friedrichs criteria (burning, dyspareunia, erythema, vulvar pain at the 5 o’clock position and 7 o’clock position), as well as the levels of Marinoff dyspareunia. The active treatment showed to be statistically significantly effective (p value ≤ 0.05) in reducing all symptoms of Friedrichs criteria, vulvar pain and Marinoff dyspareunia. Conclusion: This prospective study showed that Meclon^® Lenex vulvar emulgel revealed an excellent tolerability and compliance, demonstrating to be a safe and effective option in the treatment of provoked vestibulodynia and non-infective vulvitis.

Vulvodynia Is Not Associated with Concurrent Candidal Vaginitis

Objective: The study purpose was to determine the prevalence of candida-positive vulvovaginal genital cultures among women with vulvodynia. Methods: This study was a retrospective analysis of data collected from 2017 to 2020. Eligible patients receiving care from an academic women's health practice in central Texas that employed value-based care pathways and who had a genital culture diagnostic test collected were included. Data were extracted from the electronic health record. Descriptive statistics, t-tests, and Fisher's exact test were used to complete the data analysis. Results: A total of 242 women met inclusion criteria and were included in the study. Of these, 64 (26.4%) had been diagnosed with vulvodynia and 178 (73.6%) had not. Of the 242 women, nearly one-third had confirmed yeast infections (29%) and 27 women (11%) met pathway criteria for polymerase chain reaction testing. There was no difference in the number of women with confirmed yeast infections during the study period among patients with or without a diagnosis of vulvodynia (75% vs. 70%, p = 0.718). Notably, among participants with vulvodynia, body mass index (BMI) was lower, and anxiety was more likely (t = 2.65, df = 120, p = 0.009; 78% vs. 55%, p = 0.002). Conclusions: The findings in this study showed no association between vulvodynia and yeast infection, a divergence from prior studies. In addition, vulvodynia was associated with low BMI and anxiety. Further research is needed to better understand the association between vulvovaginal candida infections and vulvodynia. Including women within and across more diverse races and ethnicities would improve generalizability.

Risks for Recurrent Vulvovaginal Candidiasis Caused by Non-Albicans Candida Versus Candida Albicans

Background: Vulvovaginal candidiasis (VVC) is the second most common vulvovaginitis (VV). About 20% of women will experience recurrent infections in their lifetime with non-albicans Candida (NAC) species being one of the causative agents. Although studies have looked at risk factors for recurrent VVC they are limited in scope. In this study, we explore whether risks of recurrent VVC are increased with NAC infections compared to Candida albicans infections. Methods: Through an institutional review board-approved retrospective chart review, we identified 174 women with positive yeast cultures and followed their charts to assess recurrent visits and treatments. We also assessed several baseline variables such as race, age, body mass index (BMI), obstetric history, probiotic use, contraceptive use, mycological therapy, steroid use, hormone replacement therapy, menopausal status, and medical comorbidities. Results: Women with NAC VV were more likely to have multiple visits for recurring infections compared to women who had C. albicans VV (66% vs. 34%). The women with multiple recurrences were younger, had a lower BMI, had lower parity, and endorsed higher use of probiotics. Conclusion: Women with positive NAC cultures were more likely to have multiple visits to their physicians for VV complaints. Identifying the causative species using vaginal fungal cultures can more accurately guide therapy and lead to better outcomes for these patients.

Localized Provoked Vulvodynia-An Ignored Vulvar Pain Syndrome

Localized provoked vulvodynia (LPV) causes dyspareunia among reproductive aged women. We review the pathogenesis of LPV and suggest that LPV is an inflammatory pain syndrome of the vestibular mucosa triggered by microbial antigens in a susceptible host. Tissue inflammation and hyperinnervation are characteristic findings which explain symptoms and clinical signs. Education of health care providers of LPV is important since this condition is common, often unrecognized, and patients often become frustrated users of health care. Research is needed on the antigen triggers of the syndrome. Randomized clinical trials are needed to evaluate treatment modalities.

Women's appraisal of the management of vulvodynia by their general practitioner: a qualitative study

BACKGROUND

Provoked Vulvodynia (PVD) is the most common cause of vulvar pain. General practitioners (GPs) are insufficiently familiar with it, causing a delay in many women receiving correct diagnosis and treatment. Besides patients factors, this delay can partly be explained by the reluctance of GPs to explore the sexual context of PVD and by their negative emotional reactions such as helplessness and frustration when consulted by patients with medically unexplained symptoms like PVD.

OBJECTIVE

To gain insight into how women with PVD perceive and evaluate condition management by their GP, in order to support GPs in the consultation of women with PVD.

METHODS

We performed face-to-face in-depth interviews with women diagnosed with PVD. The interviews were recorded, transcribed verbatim and thematically analysed. The Consolidated Criteria for reporting Qualitative Research (COREQ-criteria) were applied.

RESULTS

Analysis of the interviews generated four interrelated themes: Doctor-patient relationship, Lack of knowledge, Referral process and Addressing sexual issues. Empathy of the GP, involvement in decision-making and referral were important factors in the appreciation of the consultation for women with PVD who were referred to a specialist. Because women were reluctant to start a discussion about sexuality, they expected a proactive attitude from their GP. The communication with and the competence of the GP ultimately proved more important in the contact than the gender of the GP.

CONCLUSION

Women with PVD prefer a patient-centred approach and want GPs to acknowledge their autonomy and to address sexuality proactively.

Systematic analysis of protein expression in Candida albicans exposed to farnesol

BACKGROUND

The phenotypic switching of Candida spp. plays an important role in the development of vulvovaginal candidiasis (VVC). Farnesol, as a quorum-sensing molecule in Candida albicans, has the ability to prevent yeast-to-hyphal conversion in vitro. However, the mechanism underlying this ability is unclear. This study aimed to investigate changes in protein levels to better understand how farnesol impacts processes contributing to VVC.

METHODS

The isobaric tag for relative and absolute quantitation technique was used to detect protein expression in C. albicans strain SC5314 (ATCC MYA-2876) with or without farnesol exposure. Proteins with a threshold fold change greater than 1.5 were screened and considered differentially expressed proteins. All the altered proteins were analyzed using Gene Ontology annotation, Kyoto Encyclopedia of Genes and Genomes (KEGG) annotation, and metabolic pathway annotation.

RESULTS

Between the farnesol-exposed group and the farnesol-unexposd group, we detected 297 altered proteins among all 2047 tested proteins based on a threshold fold change of more than 1.5 (P < 0.05). Eighty-seven of the 297 altered proteins exhibited metabolic enzyme activity and participated in 85 metabolic pathways according to KEGG pathway analysis. Most of these metabolic pathways were associated with central carbon metabolism processes. In the sterol synthesis pathway, which involves the synthesis of farnesol, ERG25 (methylsterol monooxygenase) and ERG4 (delta 24(24(1))-sterol reductase) were both down-regulated in the farnesol-exposed group. All six altered proteases associated with the oxidative phosphorylation process were down-regulated in the farnesol-exposed group relative to the farnesol-unexposed group.

CONCLUSIONS

The mechanisms underlying farnesol-induced phenotype switching involves the adjustment of metabolic activities and epigenetic modification. Exogenous farnesol had an evident, but non-deterministic effect on the synthesis of ergosterol. The potential drug activity of farnesol warrants further investigation.

Emerging Evidence of Macrophage Contribution to Hyperinnervation and Nociceptor Sensitization in Vulvodynia

Vulvodynia is an idiopathic chronic pain disorder and a leading cause of dyspareunia, or pain associated with sexual intercourse, for women. The key pathophysiological features of vulvodynia are vaginal hyperinnervation and nociceptor sensitization. These features have been described consistently by research groups over the past 30 years, but currently there is no first-line recommended treatment that targets this pathophysiology. Instead, psychological interventions, pelvic floor physiotherapy and surgery to remove painful tissue are recommended, as these are the few interventions that have shown some benefit in clinical trials. Recurrence of vulvodynia is frequent, even after vestibulectomy and questions regarding etiology remain. Vestibular biopsies from women with vulvodynia contain increased abundance of immune cells including macrophages as well as increased numbers of nerve fibers. Macrophages have multiple roles in the induction and resolution of inflammation and their function can be broadly described as pro-inflammatory or anti-inflammatory depending on their polarization state. This state is not fixed and can alter rapidly in response to the microenvironment. Essentially, M1, or classically activated macrophages, produce pro-inflammatory cytokines and promote nociceptor sensitization and mechanical allodynia, whereas M2, or alternatively activated macrophages produce anti-inflammatory cytokines and promote functions such as wound healing. Signaling between macrophages and neurons has been shown to promote axonal sprouting and nociceptor sensitization. This mini review considers emerging evidence that macrophages may play a role in nociceptor sensitization and hyperinnervation relevant to vulvodynia and considers the implications for development of new therapeutic strategies.

Antifungal (oral and vaginal) therapy for recurrent vulvovaginal candidiasis: a systematic review protocol

INTRODUCTION

Vulvovaginal candidiasis (VVC) is frequent in women worldwide and usually responds rapidly to topical or oral antifungal therapy. However, some women develop recurrent vulvovaginal candidiasis (RVVC), which is arbitrarily defined as four or more episodes every year. RVVC is a debilitating, long-term condition that can severely affect the quality of life of women. Most VVC is diagnosed and treated empirically and women frequently self-treat with over-the-counter medications that could contribute to an increase in the antifungal resistance. The effective treatment of RVVC has been a challenge in daily clinical practice. This review aims to assess the efficacy of antifungal agents administered orally or intravaginally for the treatment of RVVC, in order to define clinical practices that will impact on the reduction of the morbidity and antifungal resistance.

METHODS AND ANALYSIS

A comprehensive search of the following databases will be carried out: PubMed, Embase, Scopus, Web of Science, Scientific Electronic Library Online (SciELO), the Cochrane Central Register of Controlled Trials (CENTRAL), Biblioteca Virtual em Saúde (Virtual Health Library)/Biblioteca Regional de Medicina (Regional Library of Medicine) (BVS/BIREME), Cumulative Index to Nursing and Allied Health Literature (CINAHL) and in the clinical trials databases (www.trialscentral.org; www.controlled-trials.com; www.clinicaltrials.gov). The risk of bias will be assessed according to the Cochrane Risk of Bias tool. We will perform data synthesis using the Review Manager (RevMan) software V.5.2.3. To assess heterogeneity, we will compute the I2 statistic.

ETHICS AND DISSEMINATION

This study will be a review of published data and it is not necessary to obtain ethical approval. Findings of this systematic review will be published in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

CRD42018093817.