COL Yeast infections and the pitfalls of self-diagnosis
By Jane E. Brody
New York Times News Service
Just because a medication once sold only by prescription is now available over the counter does not mean that patients know how and when to use it properly. A good example involves the antifungal products now sold without prescriptions for the treatment of vaginitis -- not just any vaginitis, but the most common form, caused by the ubiquitous yeast of the genus Candida.
The fine print on the back of the box of the leading product, Monistat 3, warns, "Do not use if you have never had a vaginal yeast infection diagnosed by a doctor." That is meant to ensure that a woman who walks into a drugstore with a self-diagnosis will know that she indeed has a vaginal yeast infection and not something else -- something potentially more serious -- for which this product is inappropriate.
But as a new study of customers in pharmacies and grocery stores so clearly showed, only a third of the women buying over-the-counter vaginal antifungal product had accurately self-diagnosed their conditions.
An additional 21 percent of the customers studied did in fact have vaginal yeast infections but also had second infections for which the medication was not helpful.
Nearly 19 percent had bacterial vaginosis not amenable to antifungal therapy, 12 percent had other conditions and nearly 14 percent had no vaginal infections at all.
Thus, the study authors said, "half of the women who use over-the-counter products for self-diagnosed vulvovaginal candidiasis may eventually need to visit a clinician to receive proper therapy." An additional 14 percent, they continued, would also need medical examinations and laboratory tests to reassure them that they are normal and do not need treatment.
Furthermore, the women who had vaginal yeast infections that had been previously diagnosed by doctors and those who said they had read the package labels before purchase were no more likely to have arrived at correct self-diagnoses of pure vaginal yeast infection than were women lacking prior knowledge of the condition or the label guidelines.
The authors also found that giving women diagnoses over the telephone, a practice that has become increasingly common in prepaid health-care settings, was "fraught with inaccurate diagnoses."
The study, published in the March issue of Obstetrics and Gynecology, was directed by Dr. Daron G. Ferris of the Medical College of Georgia in Augusta and conducted in Augusta, Philadelphia, Detroit, Charleston and Omaha among 95 women who agreed to undergo medical examinations after choosing the antifungal product.
The findings imply "unnecessarily wasted financial expenditures, unfulfilled expectations, potential precipitation of lower-genital-tract allergic and contact dermatitis, and a delay in diagnosis and cure for the majority of women," the authors wrote.
Some women who applaud the self-empowerment that results from being able to treat themselves without medical assistance may think a misdiagnosis of vaginitis is no big deal: If they fail to improve with self-medication, they can always go to their doctors. But even with something as seemingly mundane as vaginitis, a delay in proper treatment can have serious consequences.
The infection, which could be herpes, can spread to sexual partners. Or if the cause is chlamydia, a bacterial infection, it may cause pelvic inflammatory disease and invade the woman's fallopian tubes, scarring them and possibly rendering her infertile. Also, untreated bacterial vaginosis can increase a woman's risk of acquiring HIV, the virus that causes AIDS.
A normal vagina contains many bacteria that help keep it healthy by raising the acid level and preventing the growth of harmful microorganisms that prefer a more alkaline environment. Especially prominent are Lactobacilli, bacteria from the genus used to turn milk into yogurt.
A number of conditions can tip the acid-base balance or otherwise allow an infection to take hold. They include a lowered resistance, from poor diet and sleep habits and undue stress; excessive douching; pregnancy; taking birth control pills or antibiotics, which can kill off the good bacteria; diabetes or prediabetes, with excess sugar in urine being the problem; vaginal abrasions; and the use of feminine hygiene sprays. Women who have sex with infected partners and postmenopausal women with thinned vaginal walls are especially prone to vaginitis.
How can you tell if the infection is caused by a yeast? The vagina is likely to be itchy, burning or red and hurt during intercourse and sting on urination. A thick, curdy, cottage-cheese-like discharge that is odorless or mildly yeasty may be present.
Unfortunately, other causes of vaginitis may produce similar symptoms. According to Dr. Sharon Hillier, director of reproductive infectious disease research at Magee-Women's Hospital in Pittsburgh, "Vaginal infections cannot be accurately diagnosed based on their symptoms."
A medical expert needs to sample the discharge and examine its contents under a microscope.
"We've empowered women with the ability to self-treat vaginal yeast infections, but we never gave them a way to diagnosis it," Hillier said. "We find that only about a quarter of women who come in saying they have a yeast infection actually have one."
Sometimes there are telltale signs that the cause is not a yeast. For example, a parasitic trichimonas infection may cause a thin, foamy, foul-smelling yellowish green or gray discharge. A Hemophilus bacterial infection may cause a creamy, very foul-smelling and often fishy discharge. Or a woman may have no discharge, only an inflammation of the vulva caused by an irritant or allergen like oral sex, fragrant soap, powders, synthetic underwear, sanitary napkins, pantyhose or tight jeans.
If you are self-treating a vaginal infection and do not improve sharply in the time period listed on the package, or if you have a recurrence a short time later, be sure to seek medical care without further delay.
Jane E. Brody is a New York Times staff writer and columnist who specializes in health and medical reporting.