A 34-year-old nulligravid woman comes to the office due to vulvar itching and vaginal discharge. She has no other concerns. The patient is sexually active with her fiancé and takes oral contraceptives daily. She does not use barrier contraception. She took antibiotics 2 weeks ago for sinusitis but has no other medical problems. Pelvic examination shows an erythematous vulva and a thick white discharge that adheres to the vaginal wall. The rest of the physical examination is normal. Microscopic examination reveals budding cells. Which of the following is the most likely underlying cause of her current condition?

Question

A 34-year-old nulligravid woman comes to the office due to vulvar itching and vaginal discharge.  She has no other concerns.  The patient is sexually active with her fiancé and takes oral contraceptives daily.  She does not use barrier contraception.  She took antibiotics 2 weeks ago for sinusitis but has no other medical problems.  Pelvic examination shows an erythematous vulva and a thick white discharge that adheres to the vaginal wall.  The rest of the physical examination is normal.  Microscopic examination reveals budding cells.  Which of the following is the most likely underlying cause of her current condition?

Quizplus · Accepted Answer

11ec160b_37f5_32a3_9249_4f280feab479_MD0001_00 Gram-positive lactobacilli comprise a major part of the normal vaginal flora and exist in balance with other colonizers at a normal vaginal pH of 3.8-4.5. Changes in vaginal flora and epithelial injury can lead to overgrowth of yeast, most commonly Candida. Common triggers for Candida vaginitis include the following: Antibiotic use is the most common cause of Candida vaginitis due to reduction of the lactobacilli population, which facilitates Candida overgrowth. Patients with Candida vaginitis have vulvar/vaginal pruritus and erythema and a thick, white "cottage cheese-like" discharge. Vaginal pH is typically unchanged. Wet mount examination with potassium hydroxide (KOH) preparation is diagnostic and reveals budding yeast and pseudohyphae. (Choices A and C) Decreased thickness of the vaginal epithelium and decreased amounts of glycogen in epithelial cells are characteristic in postmenopausal and lactating women. These changes are caused by low estrogen levels and lead to atrophic vaginitis. (Choice D) Elevated pH of vaginal secretions (>4.5) is associated with bacterial vaginosis and Trichomonas vaginitis, not Candida vaginitis. (Choice E) Human papillomavirus (HPV) has a predilection for anogenital keratinized skin and mucous membranes. HPV can cause warts, dysplasia, and malignancy by incorporating its DNA into anogenital epithelial cells. Educational objective: Antibiotics suppress the normal vaginal flora and facilitate Candida overgrowth. Antibiotic use is the most common cause of Candida vaginitis. Other potential causes include pregnancy, systemic corticosteroid use, diabetes mellitus, and immunosuppression. __________ References: ACOG Practice Bulletin. Clinical management guidelines for obstetrician-gynecologists, Number 72, May 2006: Vaginitis. (http://www.ncbi.nlm.nih.gov/pubmed/16648432)

A 34-Year-Old Nulligravid Woman Comes to the Office Due to Vulvar