A 52-year-old woman comes to the office due to vulvar pruritus for the past week. The patient also reports frequent urination, dysuria, and nocturia. She has had similar symptoms 4 times in the past 3 months. Each time previously, over-the-counter suppositories have provided symptom relief. However, symptoms recur within the next 1-2 weeks. The patient had irregular, heavy periods that improved after insertion of a progestin-containing intrauterine device. She has no other medical conditions or previous surgeries. Routine screening including a colonoscopy, mammogram, and Pap test was normal 2 years ago. She is sexually active and in a long-term, monogamous relationship. The patient does not use tobacco and drinks alcohol socially. Blood pressure is 130/80 mm Hg and pulse is 84/min. BMI is 25 kg/m². Pelvic examination reveals vulvar erythema and multiple excoriations. There is thick, white discharge throughout the vaginal vault. No cervical or vaginal lesions are noted. Microscopy reveals pseudohyphae and no motile organisms. Which of the following additional testing should be performed in this patient?

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11ec25c8_d9fb_13dc_bc81_b3788469dc78_MD0003_00 This patient has vulvovaginal candidiasis, characterized by white vaginal discharge and vulvovaginal pruritus, typically due to an overgrowth of Candida albicans. Other clinical features include dysuria and vulvar irritation, leading to vulvar and vaginal erythema and excoriations seen on physical examination. Further evaluation of the discharge typically reveals a normal pH; budding yeast and pseudohyphae are present on microscopy. vaginal erythema pseudohyphae Risk factors for vulvovaginal candidiasis include increased estrogen levels (eg, pregnancy), immunosuppression, and diabetes mellitus. Diabetes mellitus increases the risk of candidiasis as glucose facilitates the adhesion of Candida to the epithelial surface. Therefore, women with recurrent vulvovaginal candidiasis infections (≥4 episodes in a year) and other signs of diabetes mellitus (eg, nocturia, urinary frequency) should be evaluated with a hemoglobin A1c. Fluconazole is the treatment for vulvovaginal candidiasis, and improved glycemic control can reduce the risk of recurrence. (Choice A) FSH level may help in the diagnosis of menopause. The genitourinary syndrome of menopause (eg, vulvovaginal atrophy) may present with vaginal pruritus, dysuria, nocturia, and urinary frequency. However, examination reveals an atrophic vulva and thinning of vaginal mucosa with minimal rugation. In addition, menopause (decreased estrogen) reduces the risk of candidiasis. (Choice C) Nucleic acid amplification testing is used in the diagnosis of Chlamydia trachomatis or Neisseria gonorrhoeae cervicitis. Acute cervicitis presents with intermenstrual or postcoital spotting. Examination reveals mucopurulent discharge and cervical friability, which are not seen in this patient. (Choice D) Routine Pap test screening interval at age ≥30 is every 3 years with no HPV testing (or every 5 years with HPV testing). This patient had a normal Pap test 2 years ago and no indication (eg, cervical lesion, postcoital bleeding) for repeat testing. (Choice E) A vulvar biopsy may be indicated in patients with vulvar lesions unresponsive to therapy. Although this patient has recurrent candidiasis, previous infections resolved with over-the-counter suppositories. If her current symptoms do not resolve after management of diabetes mellitus and treatment of candidiasis, a biopsy may be performed to exclude other etiologies of her vulvar symptoms (eg, malignancy, lichen sclerosis). Educational objective: Vulvovaginal candidiasis is characterized by white vaginal discharge, pruritus, erythema, and excoriations. Risk factors include diabetes mellitus, immunosuppression, and antibiotic use. Recurrent candidiasis warrants evaluation for diabetes mellitus. References: Recurrent vulvovaginal candidiasis. (http://www.ncbi.nlm.nih.gov/pubmed/26164695) Vulvovaginal candidiasis: epidemiology, microbiology and risk factors. (http://www.ncbi.nlm.nih.gov/pubmed/26690853)

A 52-Year-Old Woman Comes to the Office Due to Vulvar