Controlling `yeast' infections

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Intense itching is usually the hallmark of a vaginal yeast infection. Once woman has experienced it, she's not likely to forget it.

Nearly 75 percent of all women will have at least one such infection in their lifetime. Many are plagued by recurring yeast infections, which are most frequent between the ages of 16 and 35.

Yeast is a term for single-celled fungi. The technical name for the variety of fungus often present in the human body is candida, and the technical name for infections caused by these fungi is candidiasis. Such infections occur not only in the vagina, but also in other parts of the body in both sexes (see accompanying article).

In December 1990, the Food and Drug Administration approved the over-the-counter (nonprescription) sale of the first of several products for treating vaginal yeast infections in women previously diagnosed by their doctors as having them.

A woman who has had one vaginal yeast infection can usually recognize its symptoms if it recurs. And a woman who has had several infections has no doubt about what's wrong when the next yeast infection starts.

There are several symptoms, but, according to Michael Spence, M.D., director of the Public Health and Preventive Medicine Program at Hahnemann University in Philadelphia, "If a woman does not itch, it's unlikely that she has a yeast infection."

Another symptom is a thick, mostly odorless discharge. But this can be misleading because, according to Spence, "Discharge in and of itself is not diagnostic. If you have a white discharge with an intense irritating itch, you may have an infection. Unfortunately, many women will, in response to increased estrogen at midcycle and the increased production of cervical mucus, develop a white, curdy discharge. That is not a yeast infection."

While not all women experience the following symptoms of a vaginal yeast infection, it's possible to have: vaginal soreness or irritation, a rash on the vulva around the vagina, pain or discomfort during intercourse, abdominal pain, soreness of the vulva or vagina, burning during urination, and even vaginal bleeding in some cases in addition to itching and discharge.
Causes of Yeast Infection

Candidiasis is caused by one of four varieties of candida: Candida albicans, Candida glabrata, Candida tropicalis, and Candida krusei. By far the most common-causing nearly 80 percent of vaginal yeast infections-is Candida albicans.

Most people have these organisms in the genital or intestinal tract to some degree at various times. It's the overgrowth of the fungus that causes problems.

According to Spence, there are a number of causes of the uncontrolled growth, usually related to some type of immune suppression. Sometimes there's been a significant change in diet. Other times it's due to use of antibiotics to treat another infection, such as strep throat or acne.

Broad-spectrum antibiotics such as penicillin or tetracycline can kill or suppress helpful bacteria in the genital tract, allowing yeast to grow unchecked, according to Philip Mead, M.D., Professor of Obstetrics and Gynecology at the University of Vermont College of Medicine.

It's even possible that an underlying disorder, like diabetes, is the root cause of the infection. "Whenever you see a fungal infection in a woman, these are the things that come immediately to mind," says Spence.

When physicians see recurrent yeast infections without another cause, they have to wonder about HIV disease. Because HIV (the virus that leads to AIDS) involves a lowering of the immune system, it could significantly impair a woman's ability to combat yeast, says Spence.

"Yeast infections can be passed back and forth between partners in unprotected intercourse, but because yeast is frequently present anyway, a sexual partner is more likely to pick up the infection if his or her immune system is also depressed," says Mead.

Immunity can become depressed by a number of factors besides HIV infection. Illness or infection of any kind weakens the immune system. Physical or mental stress can also wreak havoc, leaving the immune system less able to combat yeast infections. Lack of sleep, poor nutrition, and taking any medication, including birth control pills, can upset the body's balance, allowing yeast to thrive. Pregnant women also have a tendency to have more yeast infections, as the immune system becomes temporarily altered by hormonal surges.
Diagnosis

Diagnosing vaginal yeast infections can be tricky, especially at first. Several other disorders, including inflammation of the cervix or sexually transmitted diseases such as trichomoniasis (a parasitic infection) or herpes, can have similar symptoms.

According to Mead, clinical diagnosis of yeast infections starts with a slide of vaginal secretions examined under the microscope. "Those slides [can be] very specific. If you see the yeast organisms, you can assume that's the diagnosis."

(Slides are actually examined for a particular stage of the fungus form called mycelia. While yeast is a commonly present form of fungus, mycelia is the variation of the fungus type that can grow out of control and cause infection problems.)

It's possible to have a yeast infection that doesn't show up in the limited examination of a single slide smear. Mead says that if a woman has a negative slide smear, but still has significant symptoms, her physician is likely to order a culture.

For example, there is one variety of candida-Candida glabrata-that causes symptoms but does not characteristically show up under the microscope. For that, a culture may be necessary. "A culture is more sensitive," says Mead. "It should pick up virtually anything."

While studies have shown that women are able to correctly identify recurring vaginal yeast infections most of the time, there is still some concern about misdiagnosing and mistreating other problems that may mimic symptoms. Through package and product labeling of products sold without prescription, FDA and pharmaceutical companies are working to make sure that women with an infection that differs even slightly from the symptoms of a previous yeast infection return to their doctors.
OTC Availability-With Warnings

Until 1990, drugs to treat vaginal yeast infections were available only by prescription. In December 1990, after receiving the advice of a number of experts, FDA gave Schering-Plough HealthCare the go ahead to market and sell over-the-counter its antifungal medication Gyne-Lotrimin, a brand name for clotrimazole. It has been joined by several other products that are either clotrimazole or another antifungal, miconazole nitrate. (the first miconazole nitrate drug to be allowed to be sold OTC for vaginal yeast infections was Advanced Care Products' Monistat 7.)

Both clotrimazole and miconazole nitrate are from the same anti-fungal drug family and work very similarly by breaking down the cell wall of the yeast organism, causing it to dissolve completely.

The products are supplied in one of two ways: as vaginal inserts or suppositories or as a cream with a special applicator. Both formulations are for use at bedtime every night for seven nights.

While most women note improvement within just a few days, it's important to finish the seven-day treatment to make sure all of the troublemaking fungus has been disabled. Women who don't see rapid improvement of their symptoms are likely to have a problem other than a vaginal yeast infection.

"The benefit [of OTC sale of these products] is that they are readily available for women to purchase without having to go to a physician," says Joseph Winfield, M.D., a medical officer in FDA's antiinfective drugs division. Ready availability of OTC treatments means that women no longer have to suffer while waiting for an appointment, or rearrange work and family life to find time to go to the doctor's office for a recurrent infection.

"Vaginal candidiasis is a rather common occurrence," says Winfield. "It doesn't present any life-threatening condition to the individual [with an infection] and it's okay to treat over the counter-but only for women [who] have had an infection diagnosed by a physician previously. As those same symptoms recur, they should be able to treat themselves."

In October 1992, FDA required additions to printed information accompanying OTC products for vaginal yeast infections. One significant addition to the patient package insert was a notice that recurrent vaginal yeast infections, especially those that do not clear up easily with proper treatment, may also be the result of serious medical conditions, including HIV infection. The labeling also says:

If you experience vaginal yeast infections frequently (they recur within a two-month period) or if you have vaginal yeast infections that do not clear up easily with proper treatment, you should see your doctor promptly to determine the cause and to receive proper medical care.

"While it is true that women who are HIV-infected are much more likely to have chronic vaginal yeast infections," says Mead, "most women with recurrent vaginal yeast infections aren't HIV-positive [HIV-infected]."

In addition to the HIV notice, the following warnings also appear on information accompanying the products:

* Do not use if you have abdominal pain, fever, or foul-smelling vaginal discharge. You may have a condition that is more serious than a yeast infection. Contact your doctor immediately.
* Do not use if this is your first experience with vaginal itch and discomfort. See your doctor.
* If there is no improvement within three days, you may have a condition other than a yeast infection. Stop using this product and see your doctor.
* If symptoms recur within a two-month period, contact your doctor.
* Do not use during pregnancy except under the advice and supervision of a doctor.
* This medication is for vaginal yeast infections only. It is not for use in the mouth or the eyes. If accidentally swallowed, seek professional assistance or contact a Poison Control Center immediately.
* Keep this and all other drugs out of the reach of children. This product is not to be used in children less than 12 years of age.

Prevention

In general, candida likes warm, moist places. It's not possible to prevent every yeast infection, but a few simple steps can help reduce the number of infections women get.

Wear loose, natural-fiber clothing and underwear with a cotton crotch. As much as possible, avoid pantyhose, tights or leggings, nylon underwear, and tight jeans. Limit the use of deodorant tampons and feminine hygiene products if you feel an infection beginning, as they can interfere with the helpful bacteria in the vagina. Keep genitals dry after bathing or swimming (don't stay in a wet swimsuit for hours).

Seasonal changes can affect the likelihood of getting an infection, too. During high-heat, high-humidity periods, it's easier to get a yeast infection. Heavy winter clothing, which prevents easy release of perspiration and moisture, can also spell trouble.

PHOTO: Women who get vaginal yeast infections may want to limit their use of pantyhose and other tight garb, and instead wear loose, natural-fiber clothing.

PHOTO: Candida albicans

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By Amy Roffmann New

Amy Roffmann New is a writer in Chandler, Ariz.

OTHER YEAST INFECTIONS

Even though vaginal yeast infections are the most common type of candida infections, there are other ways in which yeast can cause problems.

Thrush is the name given to an oral yeast infection. It is most often seen in infants or in people with severely suppressed immune systems-as in AIDS. Its symptoms are painful sores in the mouth and throat that appear as creamy white patches and reveal red sores when scraped. Left untreated, thrush may spread to the throat and esophagus. (Other infections can cause similar symptoms, so anyone with these symptoms should have their condition accurately diagnosed by a health professional.)

Other candida infections can occur nearly anywhere on the body where there is a skin fold: under the arms, under the breasts, between the toes. The skin around the fingernails can be affected.

Candida infections have been reported in women who wear artificial fingernails. Fungal infections can start in the space between the artificial and natural nail if they become separated. The nails may become discolored by infection and may require drug treatment.

The drugs used to treat these other candida infections are similar, but not always identical to those used for vaginal yeast infections. Most of the treatments are from the "azole" drug family (clotrimazole, fluconazole). Some drugs are oral medications, although those are most often used only for stubborn or persistent infections. A fairly new drug (approved by FDA in January 1990), fluconazole is effective in a single dose by tablet or intravenous injection, but is most often used only in serious fungal infections, such as those in persons with HIV disease.

It's important to note that over-the-counter products for vaginal yeast infections are not appropriate for other types of fungal infections. Those products are only for the uses stated on the package. For any other yeast infection, see your doctor.

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