Recurrent vulvovaginitis is on the rise.

Although it is not a serious condition, it can affect the quality of a woman’s life to a large extent.
I am not going to write a complete essay on how to manage recurrent vulvovaginitis as I am sure most of my fellow gynecologists are very versed with it.

The reason for writing on this topic is to share some of the salient points in the management and add a few rarer things which some of you might or might not be used in the management of this highly uncomfortable ailment.

1. History and Examination
   Getting a detailed history of the color, consistency, smell of the discharge and its timing in relation to the menstrual cycle is imperative to clearly diagnose the causative agent which could range from fungal to bacterial to dermatological condition or hormonal imbalance

It is mandatory that vaginal swabs are taken for culture at the first visit when a woman presents with vaginal discharge, as this forms a baseline later to ‘test for the cure’ after completion of the treatment.

2. Is your patient on Antibiotics or hormonal contraception?
   Do not forget to check if your patient is on antibiotics or hormonal contraception. If she is, counsel her that your efforts might not yield the same results.
3. Is she a diabetic?
   I am sure you are all ruling out diabetes in these women. Please do a GTT, not just random sugar as they might be impaired glucose tolerance and not overtly diabetic.
4. What treatment are you advising her ?
   Depending on the causative organism, she will need treatment with Metronidazole/Clindamycin for Bacterial vaginosis/Trichomoniasis and Fluconazole for fungal infection.

However, it is important to note here, local treatment alone has lesser cure rates than combined oral and local treatment.So it is preferable to prescribe both oral and local treatment.

This removes the colonization in the bowel and hence chances of reinfection.

5. Test for cure
   It might be beneficial to follow up with your patient after the treatment course is completed and recheck vaginal swabs to test for a cure. This way, the risk of incomplete treatment and emergence of resistant strain is reduced.
6. Long term treatment
   All those who have a persistent or recurrent infection after the initial treatment should be treated with once a week oral Fluconazole and Metronidazole for at least 3 to 6 months.

Consider post-coital or post-menstrual prophylaxis if symptoms coincide with coitus or menstruation.

7. Treating the partner
   In recurrent vulvovaginitis, it is essential to advise the woman to follow safe sexual practices and to treat the partner as well with long-term oral Fluconazole and Metronidazole.
8. Is it Candida Glabrata infection?
   The majority of the yeast infections are due to the common Candida Albicans species. However, recently there is an increased emergence of resistant species such as Candida Glabrata.

Routine Fluconazole may not be effective in such cases. Either higher Azoles such as Teraconazole or Itraconazole might help.

In those with resistance to all Azoles, local Boric acid application for 7-14 days might be beneficial.

If no relief with even this, higher anti-fungal drugs such as Amphotericin or Flucytosine might be considered but with caution.

In this day and age of resistant species what other life style measures can we advise our patients to prevent getting these infections.

9. Have you heard of the Anti Candida diet?
   Did you know that diet rich in sugars and starchy foods can predispose women to recurrent candidiasis?
   Likewise, diet rich in probiotics (such as probiotic yogurt) can reduce the recurrence rates.
10. Have you asked the Wiping habits of your patient?
    Wiping from back to front can increase the chances of reinfection of the vagina with bacteria or fungus as these could have colonized in the bowel.
11. Is your patient routinely douching herself?
    These days women have developed a trend of douching themselves on a regular basis. I do not blame them. Pharmacological company adverts are partly responsible for this.

Counsel your patient that normal body odors are acceptable. Only if they are excessive and foul-smelling, she needs treatment and even that after consulting her gynecologist.

Routine douching is not only unnecessary but can even harm the vaginal epithelial cells and alter the vaginal milieu, hence increasing her risk of vaginitis, This applies to repeated washing the area with soap as well.

12. Does Coconut oil help?
    There is some evidence to suggest either oral or local coconut oil can help combat and prevent vaginal infections. It contains fatty acids such as lauric acid/capric/caprylic acid which have both fungicidal and antibacterial properties.
13. Do not ignore the hormonal imbalance or dermatological condition.
    For all you know her symptoms might not be due to infection at all. So make sure that she is not suffering from a dermatological condition that is causing vaginitis-like symptoms.

In addition to this, perimenopausal or postpartum women might be more prone to vaginal infections due to relative or absolute estrogen deficiency. A short course of topical estrogen might be considered in such cases with caution.