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Mitchell CM. Assessment and Treatment of Vaginitis. Obstet Gynecol 2024:00006250-990000000-01111. [PMID: 38991218 DOI: 10.1097/aog.0000000000005673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 04/11/2024] [Indexed: 07/13/2024]
Abstract
Vaginitis is the presenting symptom at millions of office visits each year in the United States. Although treatment of sporadic cases is often straightforward, recurrent cases present both diagnostic and treatment challenges. Molecular diagnostic tests are likely superior to in-office microscopy for most clinicians and most cases. In both recurrent bacterial vaginosis and recurrent vulvovaginal candidiasis, national treatment guidelines recommend an extended treatment duration with one of the first-line agents. In cases in which such treatment is not successful, vaginal boric acid is likely the cheapest and easiest alternative option. New antifungal medications offer additional but limited treatment options. Probiotics are not recommended for prevention of vulvovaginal candidiasis; however, vaginal products containing Lactobacillus crispatus may have promise for recurrent bacterial vaginosis. Trichomoniasis should be treated with a 1-week course of metronidazole; this is the only sexually transmitted infection for which treatment recommendations vary by sex. In cases in which patients do not respond to initial treatment, the diagnosis should be reconsidered, and other potential causes such as desquamative inflammatory vaginitis, genitourinary syndrome of menopause, or vulvodynia should be considered.
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Affiliation(s)
- Caroline M Mitchell
- Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, and the Vulvovaginal Disorders Program, Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, Massachusetts
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Roselletti E, Pericolini E, Nore A, Takacs P, Kozma B, Sala A, De Seta F, Comar M, Usher J, Brown GD, Wilson D. Zinc prevents vaginal candidiasis by inhibiting expression of an inflammatory fungal protein. Sci Transl Med 2023; 15:eadi3363. [PMID: 38055800 PMCID: PMC7616067 DOI: 10.1126/scitranslmed.adi3363] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 11/15/2023] [Indexed: 12/08/2023]
Abstract
Candida causes an estimated half-billion cases of vulvovaginal candidiasis (VVC) every year. VVC is most commonly caused by Candida albicans, which, in this setting, triggers nonprotective neutrophil infiltration, aggressive local inflammation, and symptomatic disease. Despite its prevalence, little is known about the molecular mechanisms underpinning the immunopathology of this fungal infection. In this study, we describe the molecular determinant of VVC immunopathology and a potentially straightforward way to prevent disease. In response to zinc limitation, C. albicans releases a trace mineral binding molecule called Pra1 (pH-regulated antigen). Here, we show that the PRA1 gene is strongly up-regulated during vaginal infections and that its expression positively correlated with proinflammatory cytokine concentrations in women. Genetic deletion of PRA1 prevented vaginal inflammation in mice, and application of a zinc solution down-regulated expression of the gene and also blocked immunopathology. We also show that treatment of women suffering from recurrent VVC with a zinc gel prevented reinfections. We have therefore identified a key mediator of symptomatic VVC, giving us an opportunity to develop a range of preventative measures for combatting this disease.
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Affiliation(s)
- Elena Roselletti
- Medical Research Council Centre for Medical Mycology at The University of Exeter, University of Exeter, Geoffrey Pope Building Stocker Road, Exeter, UK, EX4 4QD
| | - Eva Pericolini
- Department of Surgical, Medical, Dental and Morphological Sciences with Interest in Transplant, Oncological and Regenerative Medicine, University of Modena and Reggio Emilia, Modena, Italy, 41125
| | - Alexandre Nore
- Medical Research Council Centre for Medical Mycology at The University of Exeter, University of Exeter, Geoffrey Pope Building Stocker Road, Exeter, UK, EX4 4QD
| | - Peter Takacs
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary, 4032
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA, USA, 23507
| | - Bence Kozma
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary, 4032
| | - Arianna Sala
- Department of Surgical, Medical, Dental and Morphological Sciences with Interest in Transplant, Oncological and Regenerative Medicine, University of Modena and Reggio Emilia, Modena, Italy, 41125
| | - Francesco De Seta
- Department of Medical Sciences, University of Trieste, Institute for Maternal and Child Health-IRCCS, Burlo Garofolo, Trieste, Italy, 34137
| | - Manola Comar
- Unit of Advanced Microbiology Diagnosis and Translational Research, Institute for Maternal and Child Health—IRCCS “Burlo Garofolo”, University of Trieste, Trieste, Italy, 34137
| | - Jane Usher
- Medical Research Council Centre for Medical Mycology at The University of Exeter, University of Exeter, Geoffrey Pope Building Stocker Road, Exeter, UK, EX4 4QD
| | - Gordon D Brown
- Medical Research Council Centre for Medical Mycology at The University of Exeter, University of Exeter, Geoffrey Pope Building Stocker Road, Exeter, UK, EX4 4QD
| | - Duncan Wilson
- Medical Research Council Centre for Medical Mycology at The University of Exeter, University of Exeter, Geoffrey Pope Building Stocker Road, Exeter, UK, EX4 4QD
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